Examination Anxiety

JEANNE RICHARDS is an ardent believer in mammography. During a routine mammogram in 1995, doctors discovered a lump deep in her left breast. It turned out to be a benign cyst. But since then Mrs. Richards, 57, has received a mammogram twice a year though the American Cancer Society recommends only one annually.

"When I go to any doctor, I am a nervous basket case until I find out I am O.K.," she said. Recently, Mrs. Richards has begun noticing a troubling decline in service at her clinic.

"In the last three years it has totally changed to the point where I felt I was a piece of cattle," she said. "I literally would stand in the hall, not in the waiting room. It was so packed it was like they were herding people in."

She had to wait six months for her last appointment at the clinic, the Jacqueline M. Wilentz Comprehensive Breast Screening Center at Monmouth Medical Center in Long Branch, considered one of the premier breast centers in the state.

While the experience of Mrs. Richards, the vice president of a financial planning company in Toms River and the co-host of a radio show on financial planning, is not universal, medical experts say it points to a troubling direction in mammography services. Even as an aging and increasingly educated baby boom generation is demanding more mammograms, the number of breast screening centers -- in New Jersey and nationwide -- is dropping. For some patients, the changes are already translating into longer waiting times and declining service.

"There is a crisis brewing," said Dr. Robert A. Smith, director of cancer screening for the American Cancer Society at its headquarters in Atlanta. "If you were to say 'How hard is it to get a mammogram?' I think at this point you would say it is not very hard. But it's a little bit like facing floodwaters and saying, 'It's no big deal, it's only up to the front door it's not into the house yet.' "

New Jersey lost 7 percent of its mammography centers over the last 18 months alone, going to 263 facilities from 283. Since 1994, there has been an overall drop of 9.6 percent in the state, mirroring national declines.

By contrast, the number of women in the state receiving mammograms is increasing. About 451,000 women in the state turn 40 each year, the age at which health officials advise women to begin mammogram testing. Most authorities regard mammograms as the best available tool for early cancer detection despite some widely reported -- and widely disputed -- studies suggesting that regular mammograms do not lower the risk of dying from cancer.

"With more and more women becoming eligible and more and more facilities closing it doesn't take a rocket scientist to realize that pretty soon there will be a vast access problem," said Joshua J. Cooper, the Congressional relations director for the American College of Radiology, a professional society for radiologists, radiation oncologists and medical physicists.

Health officials do not really have a gauge of whether there are enough mammography centers to serve current and future demand. Neither the Food and Drug Administration nor the State Department of Environmental Protection's Bureau of Radiological Health, which regulate mammography centers, compare the capacity of each clinic with the needs of the public.

"It would not be difficult at all to carefully scrutinize what the resources presently available are to make sure the capacity does not erode to the point where public health begins to suffer," said Dr. Smith of the American Cancer Society. "It's only when it gets to be crisis,when they begin hearing from constituents that they can't get services they need, that they begin looking at broader issues of capacity."

Low Reimbursement for Tests

The main reason for the shrinking resources, doctors say, is low reimbursement by health insurers. Nationwide, it costs an average of $86 to perform a screening mammography in a doctor's office, according to the American College of Radiology. But Medicare reimburses an average of only $81 and private insurers tend to follow suit. Until January, the rate was $69 but it was increased after growing pressure from groups like the college of radiology. Physicians say it still is not enough.

"It is certainly a very undervalued procedure as far as insurance companies are concerned," said Julie Timins, a radiologist at Christ Hospital in Jersey City and JFK Medical Center in Edison. "In most practices, mammography is a break-even or money-losing venture."

Costs are even higher in New Jersey. Some doctors say it costs as much as $175 to perform a mammogram. Medicare reimbursement is $86.74 in most southern counties and $91.80 in the north.

"It is so under-reimbursed that it would almost take doubling," said Beth Deutch, a radiologist. "Obviously there is a problem." Dr. Deutch was so dismayed by what she felt was the second-class status of her specialty that she left her job as medical director of the Jacqueline M. Wilentz Center after eight years to open a private fee-for-service clinic nearby.

"When I got there we did 3,000 mammograms," she said of the hospital. "Last year we did 30,000 studies -- that includes other things -- all done in the same square footage. When I left, the waiting time was five to six months for a routine mammogram, six weeks if you had a problem, which is just bad medicine."

Frank Vozos, the executive director of Monmouth Medical Center, acknowledged that the hospital clinic had outgrown its space. But, he said, it is in the midst of a $5 million expansion plan. It has also reduced waiting times to between two and five weeks by increasing the radiologists' schedule to five days a week from three and a half, and he is hiring a third radiologist. The clinic has also adopted fast-track screening procedures in which mammograms are read in batches and women are called back with results within 72 hours.

"There's no question it was a crowded place because people wanted to be there," he said.

The hospital has suffered from poor reimbursement; mammography barely breaks even, he said. But administrators offset losses through other services, like breast surgery and diagnostic procedures.

Not all clinics are so fortunate.

The American College of Radiology surveyed 21 mammography facilities that closed in New Jersey between April 2001 and January 2002. Eight said they folded for financial reasons, two merged with other clinics, two cited staffing problems and nine listed other reasons or failed to reply.

"It shows me that we've got a problem with reimbursement, and if that problem isn't fixed, you're going to continue to have a growing access problem," Mr. Cooper said.

Lobbyists are working to raise the reimbursement rate through provisions in a prescription drug bill now under consideration by the United States Senate.

But more than just reimbursement is plaguing radiologists these days. Missed cancer diagnoses are among the most commonly litigated malpractice claims in medicine.

"The stress is so high because there is an unrealistic expectation that this is 100 percent accurate when it's well known that 10 percent of breast cancers don't even show up on a mammography," said Dr. Lawrence C. Swayne, a radiologist at Morristown Memorial Hospital.

Decreasing Number of Specialists

As a result, there is a growing shortage of radiologists specializing in breast imaging. A study of physicians completing radiology residencies last year found that 64 percent said they would not specialize in breast imaging because of lawsuits, low pay, high stress and the fact that breast imaging is perceived as a female field.

"Residents have a feeling that breast imaging is not valued as much by hospitals, by radiology department chairmen and by other members of the radiology group," said Dr. Stephen A. Feig, the director of breast imaging at Mount Sinai Hospital in New York and a co-author of the study.

The solutions, he said are complex, requiring the medical establishment to rethink the way it views mammography.

In the meantime, his clinic has a three-month backlog partly because of closings and staff shortages at other clinics in New York City.

In New Jersey, stories like Mrs. Richards's still tend to be limited to the more prestigious clinics. In general, waiting times for an appointment are usually short, from one day to two weeks, and most offices offer same-day services for patients who have discovered a lump.

"Right now we are not experiencing a shortage of mammography facilities and there is little evidence that women are waiting a longer time for mammograms," said Evelyn Dries, the vice president for prevention and early detection for the American Cancer Society's New York and New Jersey region.

Despite that statement, one does not have to look far to find anecdotal evidence of poor service.

Loretta Weinberg, the 67-year-old chairwoman of the State Assembly's health committee, said that this summer she had to wait six weeks for a mammogram, much longer than usual. And then she had to make several phone calls to her insurance company to argue over payment for a new screening tool called computer-assisted diagnosis, in which a computer looks for abnormalities on a breast X-ray.

"I'm concerned about access to health care and early diagnosis screenings of all kinds for all our residents," she said. "I am particularly concerned for the availability for women."

In a traditional screening mammogram, the breast is compressed between a platform that contains X-ray film and a plastic plate. Technicians take two X-rays of each breast. Women with dense breast tissue or those with suspected tumors usually require additional views or ultrasound. Digital mammography, which is becoming increasingly popular, uses photo receptors rather than X-ray film. Images are easier to process, store and transmit via computer but as yet there is no evidence that the method works better than traditional mammography.
 
An Imperfect Science

To be sure, mammography is an imperfect science, relying on the quality of film and the skill of the radiologist. It does not detect all cancers, and abnormal results often turn out to be benign.

"Mammography, when it is done well, is quite effective," said Dr. Smith of the American Cancer Society. "Under some circumstances of poor quality and attention, mammograms can be quite ineffective."

For Jeanne Richards, who lives in fear of breast cancer, mammography is still the best option. But she has turned her back on the world of managed care. She became the first patient at a new $2.5 million private clinic, HerSpace in West Long Branch, which Dr. Deutch opened with her husband, Larry Rubin, a wireless software entrepreneur, in August.

There, Mrs. Richards waits for her mammogram in a white waffled robe surrounded by bubbling fountains and elegant furniture. She receives the results in person, by Dr. Deutch, within 30 minutes of the procedure. It costs her $250 out of pocket.

"It was very comforting, very smooth and the whole objective is to make a frightening, uncertain time into a comfortable, pleasant visit," Mrs. Richards said.

She acknowledged she was lucky to be able to afford the service. But, she added, her housekeeper also switched to Dr. Deutch even though her insurance covered only 80 percent as an out-of-network cost.

"The shame of it," Mrs. Richards said, "this is the type of facility that should be the common, not the unusual."

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Copyright 2002, The New York Times Company. This article originally appeared in the October 6, 2002, Sunday, Late Edition of The New York Times on the first page of the New Jersey section.