Need A Mammogram? It Could Take A While

Paula Sperling, 56, a new york city saleswoman, prides herself on being well organized. Whenever she has to schedule an appointment at New York University's Breast Imaging Center for her annual mammogram, she usually calls three to four weeks in advance. But the native New Yorker was surprised to learn last December that the next available opening wasn't until sometime in April. Sperling reminded the office staff that she has a family history of breast cancer. "Three or four months could mean the difference between a tumor that's localized and one that's spread into the lymph nodes," she recalls thinking. "I called them every day for a week, and they kept saying there were no exceptions."

If it's any comfort to her, Sperling is not alone. While conditions in Manhattan may be extreme, many women across the U.S. are finding it increasingly difficult to schedule routine mammograms in anything less than four to eight weeks. Some major imaging centers--notably in New York and Florida--have shut their doors. Others, squeezed by fee structures set by Medicare or managed care, are curtailing services. If you have a suspicious lump or other symptoms, you will usually be seen within a few days, but if you want to spot the smallest tumors--those that give you a 90% or better chance of long-term survival--you are simply going to have to wait your turn.

The crisis in mammography comes just as the benefits of regular breast scans for women ages 40 and older are starting to be widely recognized--and as new advances in digital technology are beginning to come on line (see following story). How serious the problem seems, though, depends a lot on whom you talk to.

Radiologists worry loudly that their field is being eviscerated. They point to the growing number of licensed physicians who have abandoned mammography, forced out of their practices by low reimbursement rates and high malpractice costs. They have a powerful ally in Senator Tom Harkin of Iowa, who lost two sisters to breast cancer and is scheduled to introduce a bill in Congress this week that would boost payments for mammograms and provide incentives for radiologists to stay in the field. "Women in New York City have had to wait five months for mammography, and three months if they have an abnormality that needed to be checked out," Harkin says. "That's just unconscionable."

Not everyone is convinced that the situation is so dire. "We're not sure if it's a crisis," says Fran Visco, head of the National Breast Cancer Coalition, "or if it's something generated by the radiologists' trade association." Indeed, Visco believes the reimbursement issue has shifted focus away from other, more important issues in breast cancer, such as expanded funding for research and providing better protection against genetic discrimination.

Some answers may be forthcoming in the next few weeks. The American Cancer Society and the Society of Breast Imaging are busy analyzing data from a recently completed survey of radiologists and their waiting times. Harkin also hopes to hold hearings on the issue in May.

To understand why the radiologists feel so threatened, it helps to have a little background. In 1990 Congress directed Medicare to extend its coverage to mammography screenings. The move had broad impact, since many insurance companies use the Medicare rate as a starting point for their reimbursement schedules. But while Medicare payments took into account increases in the cost of living, no provisions were made to cover improvements in quality and technology that raised the cost of administering the tests.

Over the years, the gap between cost and reimbursement has only grown wider. Today the Medicare rate for a mammogram stands at about $69, yet the cost incurred by the imaging centers can run anywhere from $100 to $150. "We're basically operating a charity," says Dr. Mark Dennis, a radiologist at the Sally Jobe Breast Center in Englewood, Colo., whose six clinics performed more than 50,000 mammograms last year and reportedly lost $120,000, most of it on mammograms. "We can afford to keep our doors open only because our mammography sites perform other types of services as well."

As if the dismal economics were not enough to scare off would-be radiologists, "failure to diagnose breast cancer" has become the profession's No. 1 malpractice expense. Mammograms, by their very nature, miss 10% to 15% of all breast cancers. That means that even the best radiologists won't spot one cancer for every nine they detect. (Adopting more advanced techniques like magnetic resonance imaging doesn't solve the problem. mri scans are far more expensive than mammograms, take three times as long and are much more labor intensive.)

With the benefit of hindsight, another radiologist--say, one hired by a patient's lawyer--might very well be able to pick out the trace of an incipient malignancy on a mammogram that was previously marked clean. But that's hardly a fair test, say most practitioners. "You can't expect people to go into a field knowing they could be pulled into court for 10% of the cancer patients that they see," says Dr. David Dershaw, director of breast imaging at Memorial Sloan-Kettering in New York City. Indeed, the number of applicants for Sloan-Kettering's five training positions in breast radiology fell from an average of 40 a few years ago to 12 last year.