As reported by The New York Times, January 9, 2005.

Rell's Treatment Highlights Hurdles for Screenings Faced by Many

By Avi Salzman

For Gov. M. Jodi Rell, breast cancer was a public battle before it became a personal one. Over the past decade Mrs. Rell, who was well enough after her breast cancer surgery on Dec. 27 to open the Legislature with her State of the State address on Wednesday, became personally involved in numerous efforts to encourage early detection and search for a cure. When she was lieutenant governor, she offered free mammograms at the Capitol every October and lobbied to create a check-off box on the state income tax form that allowed people to donate money to breast cancer research.

But women with breast cancer, and the doctors who care for them, still have major concerns about mammography and breast cancer treatment in the state. The governor has been successful with improving breast cancer services, but many of the concerns facing practitioners and patients cannot be fixed in Mrs. Rell's office. Indeed, for numerous reasons, many women in the state cannot get the kind of treatment given the governor, advocates said

"That was an ideal situation: Jodi Rell was diagnosed and treated quickly," said Marilyn Moore, executive director of the Witness Project, which encourages black women to get mammograms. "Every women should have the same speed of services. Right now, it's not available to everyone."

In recent years, women in Connecticut have been more likely than those in almost any other state to get breast cancer, making early detection particularly crucial. An American Cancer Society study that looked at data from 1996 to 2000 showed that the state had one of the highest incidence rates in the country, though breast cancer death rates were average. The high incidence rate could be caused by numerous factors, including the state's aging population and the concentration of groups at high risk for the disease, according to Dr. Carolyn Runowicz, the director of the Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center. The death rate statistics, she said, are encouraging.

"That's good, because that shows you that the quality of care is good in Connecticut," she said.

But if breast cancer treatment, at least in terms of death rates, is strong in the state, detection is still a concern for doctors and treatment advocates. A mammogram, a kind of breast X-ray, is still the most common way to check women for irregularities, doctors said, but it isn't easily available to everyone.

The number of offices offering mammograms in Connecticut continues to decline, from 166 on Jan. 1, 2000 to 140 last month, according to the federal Food and Drug Administration. It is part of a nationwide trend, as the total number of certified centers offering mammograms has dropped from 9,558 on Jan. 1, 2000, to 8,999 last month. The numbers of centers has been decreasing for at least a decade. In 1994, 10,119 were authorized by the F.D.A. to offer mammograms. So as the demand for mammograms increases, spurred by aggressive outreach efforts and a change in the recommended age for a first mammogram from 50 to 40, women have had to wait longer to get the procedure done, doctors said. And the people needed to take and review the X-rays are leaving the field, or choosing specialties with less oversight and lower malpractice premiums, doctors said.

It is hard to gauge the severity of the problem of long waits for mammograms, waits that some doctors said can discourage women from making an appointment. Doctors and technicians interviewed for this article said they had heard of offices where the wait for a mammogram was at least two months, but at their own offices the waiting period was never more than a few weeks. Generally, doctors said, the waiting periods are still a problem, but not as much as they were a few years ago.

Heather Gilligan, the head technician at Hartford Hospital's Breast Diagnostic Center, said women seem to prefer the smaller doctor's offices for mammograms. The hospital has no waiting list for mammograms, she said, and women can generally make same-day appointments, but they choose instead to go to offices where they may have to wait months for an appointment. Women simply prefer a comfortable, quiet office to have a procedure as nerve-wracking as a mammogram. "Patients just don't like coming to a hospital for a mammogram," she said. "They don't want a hospital setting, which seems sort of sterile and cold."

Dr. Judy Destouet, the chairwoman of the American College of Radiology's Mammography Accreditation Commission, said the procedure is often a money-loser in the short run. Her Virginia-based organization represents about 30,000 radiologists, radiation oncologists and clinical medical physicists.

But the more efficiently doctors run their mammography offices, the more money they can expect to make from the procedure, doctors said. Providers make about $4 on each mammogram, said Ms. Gilligan of Hartford Hospital.

Dr. Edward Cronin, director of breast imaging at Jefferson X-Ray Group, which has offices in the Hartford area, said he had spent the past year and a half trying to make his office efficient to increase the number of mammograms technicians can process in a day. By his calculations, Jefferson X-Ray has reduced the time patients wait for an appointment. In 2003, the five offices were doing 115 to 125 mammograms a day. Now, 200 women are able to get mammograms every day. The wait for an appointment used to be three to six weeks, but it has been cut to about two weeks or less, he said.

"The big issue for us is to accommodate all people who want mammograms and have enough personnel so we can do it efficiently," he said.

Dr. Cronin said insurance companies reimburse anywhere from $70 to $110 for mammograms. Congress raised the Medicare reimbursement rate for mammograms from $69 to $81.81 in 2001, but hasn't raised it since, and insurance companies often look to the government to determine whether to raise or lower reimbursement rates, doctors said. To make ends meet, some doctors said, volume is key. It can be hard for new providers to break into the field, because the cost of the equipment is high, Dr. Cronin said.

"You can cover expenses, but it takes a lot of money up front," Dr. Cronin said. "It is not a well-reimbursed procedure unless you work very hard at trying to be very efficient at doing it."

Keith Stover, a lobbyist for the Connecticut Association of Health Plans, which represents eight health insurers in the state, said doctors needed to negotiate with the insurers if they are concerned about reimbursement. Mammography, he added, is not a procedure health insurers take lightly.

"Early detection is something we consider essential," he said. Doctors also said they were concerned about the rate of malpractice lawsuits against breast cancer specialists who fail to diagnose tumors after studying a mammogram. Reading a mammogram is notoriously difficult. Different doctors, studies have found, often come to different conclusions about the same mammogram. And mammograms aren't fail-safe; the cancer didn't show up on Mrs. Rell's routine mammogram, but came up during a biopsy of another non-cancerous calcium deposit that was discovered in the mammogram.

New digital technology has made the process a bit more precise, said Dr. Cronin of Jefferson X-Ray, by allowing doctors to magnify high-resolution digital images and giving doctors a better view.

Still, "malignant neoplasms of the female breast" generated the most malpractice claims against members of the Physician Insurers Association of America, a trade association for doctor-owned malpractice insurers, since the organization began collecting such figures in 1985. Payouts to plaintiffs average more than $200,000, according to the association. That organization, along with many breast cancer specialists and radiologists, is advocating for caps on payouts in malpractice cases.

The industry cited malpractice and reimbursement concerns, and the overall stress, to explain why radiology residents shy away from mammography. According to a study conducted by Dr. Lawrence Bassett at U.C.L.A. in 2003, 87 percent of the radiology residents he surveyed said they considered mammography to be the most stressful kind of imaging to interpret. Even the technicians who administer the X-rays, nearly all of whom are women, are difficult to find, Dr. Cronin said.

"There's definitely a shortage in technologists trained in mammography," said Dr. Howard Lee, a radiologist with Northeast Radiology of Connecticut and Westchester, N.Y. "It's a more stressful job than, for instance, shooting X-rays of kids' ankles." Doctors said the job is difficult because technicians deal with women under particularly high stress, the job is technically demanding and the technicians have few breaks during the day.

Dr. Cronin said some of his technicians left the field to raise families, so he pays them to come back in the evenings to conduct mammograms.

These sorts of economic and personnel challenges have changed the industry in fundamental ways. As more small mammography practices go out of business, the field is increasingly being dominated by larger mammography practices that can generate a high enough volume of mammograms to make money, Dr. Destouet said.

Even as some offices close, others, including those dedicated to serving the poor, are opening. Various organizations have tried to increase the availability of mammograms in the state. Using money from its annual Swim Across the Sound charity event, the St. Vincent's Foundation in Bridgeport recently opened the Women's Imaging Center, which offers digital mammograms, ultrasound and bone-density testing.

Women who make appointments at the imaging center have been waiting about two weeks for screenings, said Ron Bianchi, president of the St. Vincent's Foundation and corporate senior vice president of the St. Vincent's Health Services.

The federal Centers for Disease Control and the state finance a $3 million program called the Connecticut Breast and Cervical Cancer Early Detection Program. The program, available at 18 centers around the state and managed by the Department of Public Health, offers free mammograms and other services to women who are uninsured or underinsured.

Women are less likely to be screened if they are poor, said Susan Davis, the president of the Connecticut Breast Cancer Coalition and Foundation. Single women raising children often fear getting mammograms, because if they have a tumor, they can't afford the treatment, Ms. Davis said.

"Once you've been screened, you have a pre-existing condition," she said. "Then I don't know how you would go about getting insurance."

Hospital officials said they would help patients who qualify get Medicaid or free or reduced treatment. But Ms. Davis said a woman who is a household's sole breadwinner often can't afford to take time off. The number of visits can become prohibitively expensive, even if the patient has insurance and is simply paying co-pays, she said. Ms. Davis's coalition acts as a network for patients and survivors and offers various services, including a fund that can help people stay afloat financially as they deal with the disease.

"I'm sitting here with people's heat bills," she said. "This can be a very expensive disease."

With the governor recovering from surgery, people in the state are talking about breast cancer these days, Ms. Davis said. There's hope in that.

"This sort of underscores a lot of issues that every woman goes through and people don't generally think about these issues," she said. "I hope this will raise some of the issues we've been working on for a long time."