Government highlights barriers to mammography in rural and some urban areas

A new government report claims access to mammography services is adequate nationwide, though troubling barriers persist in some parts of the country, particularly rural areas. But a representative from the American College of Radiology says the report is actually a wake-up call about the potential for a crisis in access unless action is taken to boost the supply of mammography personnel.

The report, released publicly last Wednesday by the Government Accountability Office, could influence the development of the Mammography Quality Standards Act, which is now being reviewed and updated, prior to reauthorization in 2007.

MQSA author Sen. Barbara Mikulski (D-MD) hailed the GAO report findings, saying they showed that the quality control legislation has leveled the playing field for mammography services.

But Dr. Carol Lee, head of the ACR's breast imaging commission, had a rather different take on the GAO report conclusions.

"The trend of all the measured parameters for delivering mammography services is going in the wrong direction. The numbers of technologists, machines, and radiologists have all declined. Rather than being happy that capacity is adequate, we should take it as a wake-up call," Lee said in an interview with Diagnostic Imaging.

Between 2001 and 2004, more mammography facilities closed than new centers opened. About one-third of facility closures were due to financial factors. Providers also reported problems in recruiting and retaining staff.

Yet the GAO report concludes that, broadly speaking, current supply is sufficient. It notes that the number of women who received an annual screening mammogram in a given year from 2001 to 2003 was about 33 million. This compares with 68 million women over 40 who were actually eligible for an annual mammogram in 2003.

To estimate the national capacity to provide mammograms, the authors multiplied the number of machines across the country by the number of possible mammograms per piece of equipment per year. This yielded a total capacity of 81 million mammograms per year, which would be more than enough to serve the current number of women over 40, according to the report.

That broad figure of 81 million, however, does not appear to take regional supply and demand into account. As of Oct. 1, 2004, 25% (865) of the total number of U.S. counties (accounting for 3.4% of the population) had no mammography machines, not including mobile services, according to the report.

"If you average it out nationwide, the numbers sound great. I don't know that it reflects the true situation. Someone needs to pay attention to the fact that the numbers are going in the wrong direction," Lee said.

The finding that supply is adequate is based on a simple equation derived from the number of machines and average capacity per piece of equipment. It does not take into account availability of technologists and radiologists to interpret the exams, she said.

"The best quality mammography machines won't do a whole lot of good if there is no one around to take them or read them. I am worried that this is where we are headed unless something changes in this country," Lee said.

The report notes that access problems are encountered in some parts of the U.S., mainly in midwestern, southern, and western states. Lack of access hits women in thinly populated areas particularly hard.

Between 2001 and 2004, the number of mammography machines decreased dramatically in some pockets of the country: 117 counties lost more than 25% of their machines, though these counties accounted for only 2.6% of the 2004 population .

As of Oct. 1, 2004, 50 out of 115 counties in Missouri lacked any mammography machines, as did 60% of North Dakota counties.

Where machines were lost or facilities closed, women still had access to mammography but, in some cases, faced excessive waiting times and long-distance travel for services. Appropriate wait times were defined as up to 30 days for screening and up to two days for a follow-up diagnostic test.

Problems were also reported in some urban areas. In Brooklyn, for example, the loss of machines led to screening wait times that averaged two months, increasing to three or four months during busy periods.

This does not bode well for mammography in the future.

"A crisis in access will not be a sudden catastrophic event. Gradually, wait times and travel distances will increase, and fewer women will have mammograms. I am concerned that we may see a reversal of the mortality gains we have seen with screening," Lee said.

The report does concede that while current capacity is adequate, supply problems could occur in the future. The population of women over 40 is projected to increase by 50% by 2025, while the number of practitioners per 10,000 women over 40 will dip by 23% during that period, according to a 2005 report from the Institute of Medicine, Improving Breast Imaging Quality Standards.

The IOM report urged a number of changes to improve mammography quality and ensure access in the future:

• higher reimbursement for providers

• advanced auditing

• development of centers of excellence

• incentives for attracting more practitioners to the field

• possible expansion of MQSA to other types of breast imaging modalities

However, the GAO report could be interpreted as supporting the status quo for MQSA reauthorization, according to Lee.

For more information from the Diagnostic Imaging archives

Technology changes drive new x-ray standards

Mammography system helps keep breast centers on track

MQSA: Historic success becomes regulatory threat

Report urging changes to breast standards draws fire