Jeannie Marcom* knows the value of health screenings more than most women. The 53-year-old NJ woman is a medical writer; she documents the consequences of skipped screenings all the time. And yet, she admits, "I hate doing medical screenings." For instance, she's never had a colonoscopy, recommended for everyone at average risk of colon cancer every 10 years beginning at age 50.

* not her real name

"Every year my doctor fills out papers for me to have a colonoscopy. Then when I go back for my annual checkup, she does it again and says, 'Let's try again this year,'" she says. Now Ms. Marcom is three years overdue. "My experience is that medical screenings are a huge waste of time in a schedule that is jam-packed. I suppose it is fortunate that they have been a waste of time. But I hate everything about them—the drive, the wait and the process."

Nonetheless, it doesn't take much to snap her back to the importance of screenings. One year, Ms. Marcom was eight months late for her annual mammogram. Then her niece was diagnosed with breast cancer. "So that put me right back on track," she says.

Nationwide, women tend to put preventive care like screening mammograms, colonoscopies, Pap smears and other such testing on the back burner, even if they have good health insurance.¹ They do it for a variety of reasons: not enough time, not enough money, not enough interest, not enough knowledge.

One recent national survey of 1,600 women found that nearly two-thirds mistakenly believed that if they had no family history of cancer, they were at low risk for developing cancer (most people diagnosed with cancer have no family history of that cancer). The survey, from the American College of Obstetricians and Gynecologists (ACOG), also found that nearly one-third (29 percent) of women have neither seen a health care provider on a regular basis nor had a Pap test or mammogram in the past year. When asked why they missed these important screenings, 18 percent said they didn't think it was necessary; 7 percent said they didn't know how to get screened; and 7 percent thought it was a waste of time.²

What they and other women don't understand is that getting recommended preventive health care services can do more for your overall health and longevity than nearly any other health-related behavior. Among the benefits:

• Screening mammograms are the primary reason for the significant drop in the death rate from breast cancer among women 40 and older that's occurred in the past 20 years.³

• An initial screening colonoscopy in which polyps (precancerous growths) are removed is responsible for a dramatic reduction in colon cancer deaths in recent years. When colon cancers are detected in their earliest stage, the five-year survival rate is 90 percent; however, the overall five-year survival rate for colon cancer in the United States is 39 percent, primarily because of a lack of screening.⁴

• Cervical cancer rates have plummeted 70 percent since the Pap test was introduced in the 1950s.⁴

But cancer screenings aren't the only recommended preventive tests. Today, answering a few questions as part of the Framingham Risk Assessment (http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof) can determine your risk of a heart attack in the next 10 years. That's important, but even more important is the fact that once people find their risk is high, they're much likelier to make lifestyle and other changes to reduce it. One study found that 90 percent of those with an elevated risk made such changes. Five years later, those who had the cardiovascular risk screening and had a higher risk of heart attack reduced their average risk by half compared to those who never got the screening.⁵

Given the potential benefits of preventive screenings, here's what you need to know about what you need and when you need it.

Mammograms: What's New?

Catherine Lauro has lumpy, or cystic, breasts, the kind that make reading a mammogram a real challenge. Still, the 50-year-old nurse from Middletown, NJ, has always been good about getting her annual breast cancer screenings. But in late 2005 when Ms. Lauro went for her regular screening, it just wasn't clear what were cysts and what might be something to worry about. So the radiologist recommended an ultrasound. That test showed something suspicious on the left side, and Ms. Lauro went for a biopsy. While the suspicious site on the left breast turned out to be just another cyst, the breast exam the surgeon gave Ms. Lauro turned up another lump on the right side—and that one turned out to be cancer.

In February 2006, Ms. Lauro elected to have both breasts removed in a bilateral mastectomy, figuring that given their lumpy nature, she'd rather be safe than sorry. She underwent radiation and chemotherapy and has been cancer-free for nearly two years now, thanks in part to her reliance on regular screenings.

Screening mammograms can reduce the risk of death from breast cancer between 15 percent and 40 percent in women 40 and older, with greater risk reductions in older women.⁸ Yet rates of breast cancer screenings have dropped in recent years. One study found rates in insured women dropped from 67 percent in 1999 to 62.5 percent in 2002, even though the health insurance company studied sent reminder notices to its members.⁸

"I haven't actually skipped," says one 52-year-old woman whose mother died of breast cancer. "But I have put it off for quite a few months." Ask her why and she shrugs. "Who knows? I don't get around to making the appointment, forget that it's time, secretly hope that if I don't go I won't get any bad news, don't know what to do with the kids while I'm getting my mammogram."

Screening rates are even lower among women who do not have health insurance coverage. Yet low-income, uninsured women ages 18 to 64 can get free mammograms and cervical cancer screenings in all 50 states, the District of Columbia, four U.S. territories and 13 American Indian/Alaskan Native organizations under the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). However, of the 4 million women eligible for screening mammograms under the program between 2002 and 2003, only about 13.2 percent, or 528,622 women, received them.⁹

Missing screening mammograms can have serious effects. One reason African-American women are more likely to be diagnosed with more advanced breast cancers than Caucasian women is thought to be the lower rates of screening mammograms in African-American women. This could also explain the fact that African-American women have a 36 percent higher death rate from breast cancer than Caucasian women, even though they have an overall lower incidence of breast cancer.^10,11

Bottom line: The strongest predictor of breast cancer survival is the stage of the disease at diagnosis. Screening mammograms diagnose breast cancer at an earlier stage. Plus, women whose breast cancer is diagnosed on screening mammography have better long-term survival rates than those with tumors of the same stage found in other ways.^12,13

All of which begs the question: If the benefits of mammograms are so clear, why do so many women forego this important test?

One reason is financial, says Katherine Sherif, MD, who directs the Drexel Center for Women's Health at Drexel University College of Medicine in Philadelphia. "More non-elderly women are slipping through the cracks because fewer employers are providing health insurance."

When she finds a woman who is behind on her screenings, whether mammogram or otherwise, she's careful not to make them feel bad. Instead, she says, "Although I'd like you to get a mammogram, colonoscopy and Pap smear, what can you commit to now?" Then she goes through the woman's risk factors for each of the conditions those screenings pick up—breast, colon or cervical cancer—and determines which is most important given the woman's personal medical history. So, for instance, if the woman had an abnormal Pap smear in the past, it might be most important to repeat that test. If the woman's mother died of breast cancer, a mammogram might be first on the list. "We prioritize and then I work with her step by step," says Dr. Sherif.

Breast Cancer Screenings Today and Tomorrow

Some women skip mammograms because they say they hurt. And yes, having your breast squished between two paddles in a futile attempt to make it flat as a pancake can be uncomfortable. But the compression lasts less than a minute; the results can be life changing.

And, let's face it—screening centers are doing what they can to make the whole mammogram experience less onerous. They're setting up mammography centers separate from general diagnostic centers; gussying them up with soft music and lighting and spa-like amenities. Some encourage you to book "mammogram parties" with friends and then go out for a nice lunch or dinner after.

But what's really important about a mammogram center isn't its looks or even its customer service, says Ari Brooks, MD, an associate professor in the department of surgery at Drexel University College of Medicine. It's volume. Studies find that the more mammograms radiologists read, the less likely they are to miss a potential cancer. However, this benefit is a two-edged sword; studies also find that the more mammograms the radiologist reads, the greater the risk of a false/positive reading.¹⁴

Also try to find a center that employs a dedicated breast radiologist, Dr. Brooks advises, someone who only deals with mammograms and other breast-related radiographic tests. Sometimes the radiologist will have completed a fellowship in breast radiology; other times, this person is simply a doctor who does nothing else.

Then comes a decision you may have only thought you had to make with your camera: film or digital? Film, or analog, mammograms are developed like photographs used to be developed. They tend to be less sensitive for women with dense breasts, with studies suggesting that between 10 percent and 20 percent of cancers identified by breast exam in these women were not detected on film mammograms. Like photographs from film, analog mammograms can't be altered once developed, so you can't zoom in on a certain site, make one part darker to get better contrast, etc.

Digital mammograms are like the photos you take with that nifty new camera you got for your birthday. They can be uploaded and stored on computers, transmitted electronically and digitally manipulated to improve the view, just as you use computer enhancement to remove red eyes from your vacation photos. This reduces the risk that you'll have to return and redo the mammogram. Digital mammograms also use less radiation than film mammography.¹⁵

So which is better? Depends on your age and breasts. If you're over 50, either is just as good at identifying potential problems. If you're under 50, pre- or perimenopausal, or have dense breasts, a major national study comparing the two in nearly 50,000 women found digital mammography was significantly more accurate.¹⁶

The problem is that only about 11 percent of the nation's 8,800 mammography facilities are digital, although it's just a matter of time (and money) before all convert. In the meantime, however, don't put off your mammogram because you're waiting for your center to convert to digital, especially if you're over 50.¹⁷

Other Breast Cancer Screening Options

If you have a high risk of breast cancer, your health care professional may recommend that you undergo a screening ultrasound or MRI in addition to a mammogram. Neither is recommended for routine screening at any age, and the American Cancer Society is the only organization to recommend MRI plus mammogram for screening high-risk women.¹⁸ Dr. Brooks says he uses MRI only for younger women who test positive for genetic mutations that increase their risk of breast cancer or who have three family members who had breast cancer. "The problem with MRI is that it finds too much; it puts women through torture because the negative biopsy rate is very high," he says.

Another option you may have heard about but that isn't yet ready for prime time is thermography. This technology identifies areas of heat within the breast to highlight suspected cancers, since studies find that women with breast cancer have a higher breast skin temperature. However, although the U.S. Food and Drug Administration approved one company's thermography equipment for use in 2004, studies find the test is just not specific enough for routine use, and few centers offer it.¹⁹

And don't forget the low-tech approach. About five percent of breast cancers are identified solely by clinical breast examination, in which the health care professional carefully feels your breast for any abnormalities.²⁰ You should have a clinical breast exam every year. You should also be conducting your own breast exam every month; although fewer breast cancers are identified with self-examination than with clinical examination, it's still worth doing.

If it's any consolation, know that someday the discomfort of today's mammograms will be a thing of the past. In 10 years or so, a simple blood test might be all that's needed to identify early signs of breast cancer. Even before then, newer mammogram technology that doesn't require as much compression will likely be available. But in the meantime, don't put yours off any longer!X

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© 2007 NWHRC. All rights reserved. Reproduction of material published in the National Women's Health Report is encouraged with written permission from NWHRC. Write to NWHRC, 157 Broad Street, Suite 315, Red Bank, NJ 07701, call 1-877-986-9472 (toll-free) or e-mail info@healthywomen.org.

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