- WASHINGTON, DC (ENS)
- Mammography centers around the country have been scaling back operations
and closing their doors for the past two years because of inadequate insurance
reimbursements. The trend comes at a time when a growing population of
older women is increasing the demand for the radiological breast exams.
But a prominent cancer prevention physician warns that mammography is a
risky, unreliable, profit driven technology.
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- Breast cancer is the second most common cancer affecting
women in the United States, with over 200,000 new cases diagnosed each
year.
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- Currently, the average cost of a mammogram is between
$90 and $100, and Medicare only reimburses $82 for the procedure. The private
insurance reimbursement rate is somewhat lower. According to the American
College of Radiology, nearly 400 mammography programs nationwide have been
forced to close since March of last year, 40 of them in New York State.
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- New York Senator Chuck Schumer (Photo courtesy Office
of the Senator) "Thousands of women across Westchester County could
be forced to wait months for mammograms because there aren't enough radiology
centers that can afford to screen them," said New York Senator Chuck
Schumer, a Democrat. The New York senator is co-sponsoring legislation
with Senator Tom Harkin, an Iowa Democrat, that would raise Medicare reimbursement
rates to more accurately reflect the cost of the procedure. "The bottom
line is that we need to raise reimbursement rates, which would keep mammography
centers open and provide incentives to attract the next generation of radiologists,"
Schumer said.
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- But cancer prevention physician Dr. Samuel Epstein, professor
of environmental and occupational medicine at the University of Illinois-Chicago
School of Public Health, says mammograms are at best ineffective in detecting
cancers, and at worst, may themselves trigger cancers. The safe, effective,
low cost route to cancer prevention, he says, is monthly breast self examinations
(BSE) coupled with annual clinical breast examinations (CBE) and education
about the avoidable causes of cancer.
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- "Mammography poses a wide range of risks of which
women worldwide still remain uninformed," warns Dr. Epstein who is
chairman of the Cancer Prevention Coalition.
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- Dr. Samuel Epstein (Photo courtesy Naturally Healthy)
In a September 2001 article published in the International Journal of Health
Services, Dr. Epstein claims that radiation from mammography "poses
significant cumulative risks of initiating and promoting breast cancer."
"Contrary to conventional assurances that radiation exposure from
mammography is trivial - and similar to that from a chest X-ray or spending
one week in Denver - about 1/1,000 of a radiation absorbed dose (rad) -
the routine practice of taking four films for each breast results in some
1,000 fold greater exposure, one rad, focused on each breast rather than
the entire chest," Dr. Epstein writes.
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- Premenopausal women who get annual mammograms for 10
years are exposed to a total of about 10 rads for each breast, "each
rad of exposure increasing breast cancer risk by one percent," he
writes.
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- New experimental findings reported this week by Lawrence
Berkeley National Laboratory cell biologist Mary Helen Barcellos-Hoff support
Dr. Epstein's warnings.
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- Barcellos-Hoff showed that exposure to ionizing radiation
creates a microenvironment in the tissue surrounding breast cells that
can cause even nonirradiated cells and their progeny to become cancerous.
"Radiation exposure can cause breast cancer by pathways other than
genetic mutations," said Barcellos-Hoff who presented her study in
Boston this week at the annual meeting of the American Association for
the Advancement of Science.
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- Barcellos-Hoff and her team focused on the signaling
- crucial to normal functioning - that takes place between a cell and the
microenvironment of its surrounding tissue. The director of Berkeley Lab's
Life Sciences Division, Mina Bissell, has shown that breakdown in these
communications can initiate the cancer process.
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- "Our data is pointing to the tissue surrounding
breast cells as a primary target of ionizing radiation damage," Barcellos-Hoff
said.
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- Radiation damage to this surrounding tissue generated
signals that changed how the breast cells' genomes were expressed. A new
cell type was created with physical characteristics that were cued to act
cancerous by the signals coming from outside the cell.
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- A normal breast as it appears in a mammogram (Photo courtesy
McGill University School of Medicine) The discovery suggests new and possibly
more effective means for preventing breast cancer. "Repairing damaged
tissue so that it once again suppresses instead of promotes carcinogenesis
is a simpler strategy for stopping the cancer process, compared to trying
to repair individual damaged cells," says Barcellos-Hoff. But Senator
Schumer says he is concerned for the health of New York women who must
wait as long as four or five months to get a mammogram. "Early detection
is the key to treating the disease effectively and routine mammograms reduce
the risk of dying from breast cancer by 40 percent."
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- "These shortages are putting thousands of Westchester
County women at risk because delayed diagnoses often result in tumors being
detected at less treatable stages," the senator says.
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- "We need to push this bill through Congress and
get it to the President's desk immediately because when it comes to treating
breast cancer, every day counts," Schumer said of the Assure Access
to Mammography Act, first introduced in March 2001.
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- But mammography is "not a technique for early diagnosis,"
says Dr. Epstein, who points out that the radiological screenings miss
many cancers, and mistakenly diagnose other conditions as cancer, particularly
in premenopausal women.
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- "Overdiagnosis and subsequent overtreatment are
among the major risks of mammography," he warns.
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- "Despite long-standing claims, the evidence that
routine mammography screening allows early detection and treatment of breast
cancer, thereby reducing mortality, is at best highly questionable,"
writes Dr. Epstein.
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- This is a fine needle aspirate of a breast mass that
contains both benign (left) and malignant (right) cell clumps. The benign
cells are small, uniformly sized and shaped. The cancerous cells are larger
and vary in size and shape. (Photo courtesy University of Wisconsin-Madison,
Dept. of Surgery, Dr. William Wolberg Tutorial ) No nation other than the
United States routinely screens premenopausal women by mammography, although
professional associations are divided on the need to do so. The American
Cancer Society acknowledged in 1985 that most breast cancers are found
by the women affected. "We must keep in mind the fact that at least
90 percent of the women who develop breast carcinoma discover the tumors
themselves," the society said. Effective self examination for breast
cancers "critically depends on careful training by skilled professionals,"
and confidence is enhanced with annual clinical breast exams by experienced
professionals, Dr. Epstein emphasizes.
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- A "large-scale crash program" for training
nurses in how to perform clinical breast exams and how to teach breast
self examination is immediately needed, particularly for underinsured and
uninsured women in the United States and in developing countries, he urges.
Clinics offering this training "could be established nationwide, and
eventually worldwide" in schools, community hospitals, churches, synagogues
and mosques, he envisions.
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- These clinics could also serve as sources of reliable
information on how to reduce the risks of breast cancer. "From an
environmental standpoint," says Dr. Epstein, "the most important
thing is the contamination of animal and dairy fats with carcinogenic industrial
pollutants. That's a very major source. Living near hazardous waste sites
in another major thing, living near industry."
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- "In your body fat and in my body fat, there's probably
about 150 to 200 carcinogenic industrial pollutants," he said. "And
animal and dairy fats, they concentrate the stuff. They are mainly chlorinated
hydrocarbon pesticides, PCBs, they're aldrin, dieldrin, chlordane, heptachor,
DDT which have permeated the totality of our environment, our air, our
water, our workplace, in the North Pole you find them."
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- GE 800T mammogram system at Memphis, Tennessee's Delta
Medical Center (DMC) (Photo courtesy DMC) In the senator's view, the problem
is financial. "The average increase in the Medicare rate - 1.5 percent
per year between 1997 and 2000 - has lagged far behind the medical inflation
rate. Since other government insurance programs and private insurers base
their reimbursement rates on Medicare, low Medicare rates create a ripple
effect which lead mammography clinics to receive insufficient reimbursements
from private and government insurers alike," he said. Dr. Epstein
too acknowledges that the costs of mammography are high and rising. "The
dangers and unreliability of mammography screening are compounded by its
growing and inflationary costs," he writes, citing an annual cost
of $10 billion if all women, both before and after menopause were screened
annually.
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- "Such costs will further increase some fourfold
if the industry, enthusiastically supported by radiologists, succeeds in
its efforts to replace film machines, costing about $100,000, with the
latest high tech digital machines, approved by the FDA [Food and Drug Administration]
in November 2000, costing about $400,000," he writes.
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- But while the senator would fund the increasing costs
of mammography, the doctor would have women utilize low cost breast self
examinations supplemented by annual clinical exams and education about
the environmental factors that contribute to the disease.
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