Most women know that at a certain age they should start getting mammograms. The screenings find breast cancer early, when it is most treatable, and they save lives.
A decade ago, 70 percent of American women in the recommended age group got mammograms.
Last, year, only half did.
What's going on?
There are scores of reasons women avoid mammograms, from economics to fear of cancer to lack of time.
The federal health care reform law last year tried to get at the money issue by requiring insurance plans to cover routine annual screening mammograms. If you pay out-of-pocket, they cost $75 to $100 at many centers.
But if that screening uncovers a potential problem, follow-up testing and treatment may be costly even for the insured, because of high copayments and deductibles.
And, as unemployment rises, more women lose insurance entirely.
The result: Tampa Bay area doctors say more and more women are fearful of finding trouble they can't afford to fix.
They want to get the word out that even in these tight times, there's help available.
Janel Smith of Belleair Bluffs lost her full-time job and health insurance three years ago. She had started annual mammograms before age 40, because her mother had been diagnosed with breast cancer.
So Smith started looking for an affordable alternative and found the Pinellas County Mammography Voucher Program, which helps uninsured women like her.
The voucher program covered Smith's mammogram in 2010. Then in January this year, she found a lump in her left breast during a monthly breast self examination. She panicked.
"I had no insurance," said Smith, who is now 41. "My very first thought was, 'Oh my God, I'm gonna die.' "
For months, she worried, thinking that even though she got help with the mammogram, she had nowhere to go for treatment.
Then, in June, she received a reminder letter from the voucher program that it was time for her annual screening.
"And I thought, somebody's going to help me get through it," Smith said.
She found out that the lump was indeed cancer, and opted for a mastectomy in August.
"The program was a godsend, such a blessing. They took care of me totally," Smith said. "If it weren't for the voucher program, I wouldn't be sitting here right now, happy and cancer-free."
The program, started in 2000, receives funding from the Florida Suncoast Affiliate of Susan G. Komen for the Cure and the Avon Foundation to provide free and low cost mammograms to uninsured women in need. Physicians and hospitals donate their services for follow-up testing and treatment.
"We don't have funding to cover every woman," said Dr. Barbara Bourland, program founder and director of the Susan Cheek Needler Breast Imaging Centers at Morton Plant Hospital in Clearwater. "But last year we provided 800 free screening and diagnostic mammograms."
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Another barrier to mammography is confusion over screening guidelines.
In 2009, the U.S. Preventive Services Task Force, an independent group of medical experts who review preventive health practices to guide primary care physicians, recommended raising the age to begin mammograms from 40 to 50 and called for screening every two years rather than annually, based on evidence that for most women, the risk of breast cancer rises after 50.
Still, groups including the American Cancer Society, the American College of Obstetricians and Gynecologists and the American College of Radiology continue to recommend starting the annual test at age 40 for most women. Those at high risk, including women whose mother or sister had been diagnosed with breast cancer, are urged to begin even younger.
Some doctors think that the confusion has given women an excuse to reject screening altogether. Further, it has clouded what had been a simple message: After 40, get an annual mammogram.
"Since the task force report came out there has been a remarkable dropoff in people going for mammograms," said Dr. Chris Flowers, director of breast imaging and research at Moffitt Cancer Center in Tampa. "It's scary that only 50 percent are having mammograms regularly. Really, the task force guidelines in 2009 hammered a nail in the coffin of mammography screening."
Flowers' biggest worry is for women younger than 50. Statistically, Flowers agrees they are less likely to get cancer. But younger women tend to have more aggressive, faster growing tumors that are more likely to spread to other organs.
"It's a real worry,'' Flowers said. "Nearly 95 percent of women can be cured when their cancer is picked up in annual screening."
Bourland agrees the differing recommendations have hurt mammogram rates. "Women are truly confused about what to do now," she said.
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Another hurdle is fear of pain. To get a clear image, breast tissue must be compressed between a large plastic plate and fixed platform while an X-ray image is made.
Most women report only a mild to moderate twinge lasting a few seconds, but the discomfort tends to be greater for women with dense breasts.
"Compression spreads out the tissue so we can see all the way through the breast," explained Dr. Tracy Halme, a radiologist at the Shimberg Breast Center at St. Joseph's Women's Hospital in Tampa.
"The better the compression, the better the visualization of the breast to see small calcifications or early signs of cancer."
Halme said it may help some women to schedule their mammogram a week or so after their menstrual period, when breast tissue may be less sensitive. "Or if you do have tender breasts, take a Tylenol an hour before the exam," Halme recommended.
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More reasons women don't get screened:
• Fear. Flowers said some women avoid getting mammograms because they've had abnormal results in the past — which may have been benign cysts or even nothing at all, but the anxiety from being "recalled," as doctors refer to a second round of testing, is just too much. "They think, 'I don't want to go through that again' and so avoid screening," Flowers said. "But about 20 percent who are recalled turn out to have cancer, so it's important to be rechecked."
• Concern over radiation. Mammograms use a low dose of radiation that does not place most women at higher risk of cancer.
• Having to take time off from work or family obligations. Mammograms take only moments, yet Halme hears from lots of women who think they're too busy to get one.
"Women are usually the family caregivers and tend to put themselves last. That thinking has to change," she said.
"It's not selfish to take care of yourself. You have to be healthy to take care of your family."
Irene Maher may be contacted at firstname.lastname@example.org.