WASHINGTON, DC, February 20, 2002 (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.

Breast cancer is the second most common cancer affecting women in the United States, with over 200,000 new cases diagnosed each year.

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.

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.

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.

"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.

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.

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.

New experimental findings reported this week by Lawrence Berkeley National Laboratory cell biologist Mary Helen Barcellos-Hoff support Dr. Epstein's warnings.

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.

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.

"Our data is pointing to the tissue surrounding breast cells as a primary target of ionizing radiation damage," Barcellos-Hoff said.

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.

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."

"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.

"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.

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.

"Overdiagnosis and subsequent overtreatment are among the major risks of mammography," he warns.

"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.

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.

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.

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."

"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."

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.

"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.

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.