How good is your mammogram?

Not all mammograms are created equal. Outdated equipment, untrained technicians, and slow follow-up make some breast screening centers a haven for undetected breast cancer.

When Sue Greenaway-Schultz stepped into the shower one day she had no idea she was embarking on a yearlong odyssey that would pit her against her physician, a surgeon, and a national health problem.

On that chilly November day Sue discovered a small lump on her left breast. A no-nonsense woman, she assumed the lump was excess skin and fat, and went about her daily business. However, when the lump persisted for a month, and her breast began feeling unusually tender, she decided to see a doctor.

Like most women, Greenaway-Schultz--a 38-year-old mother of two--didn't ask questions when the doctor suggested she undergo a mammogram at another doctor's office. Although it struck her as odd that the equipment used by the second physician seemed outdated, she completed the mammogram and forgot about the test--until the doctor phoned a week later to say something had shown up on her screening.

In less than two weeks Sue had gone from enjoying her health, her family, and her job to facing the fact that she could lose her breast, or worse, her life. After plunging into a deep depression, Sue gathered her thoughts and plotted her next step.

"The mammogram said there was something wrong. The doctor said it could be cancer. What else could I do but think ... This is it ... I could die?" Sue said. "At first I was worried about losing my breast. But then I realized what was at stake. I could lose my life."

What Sue didn't know was that she didn't have cancer. Her mammogram, conducted with an older machine, had detected some abnormal tissue. Although the tissue was unusual, it wasn't life-threatening.

After seeking a second opinion and undergoing another mammogram, Sue was given a clean bill of health. Today she has regular mammograms and consultations with a breast cancer expert, and tries to put the whole experience out of her mind.

Protecting from disease. Breast cancer is a serious concern for all women, especially those over the age of 50 or with a family history of the disease. In 1993 alone, an estimated 180,000 women in the United States will be diagnosed with breast cancer. Approximately 46,300 of these women will die from breast cancer this year.

According to the American Cancer Society, a woman's chance of contracting breast cancer has increased in recent years. Today women face a one-in-eight chance of being diagnosed with breast cancer.

However, by following a three-part program that includes breast self-examinations, professional breast examinations, and mammograms every one to two years for women 40 to 49 and annual mammograms for those over the age of 50, women can protect themselves from this devastating disease.

Problems with mammograms.

While this is sound advice, breast cancer experts warn that women should be cautious--not all mammograms are created equal. Outdated equipment, untrained technicians, and slow follow-up make some breast screening centers a haven for undetected breast cancer.

Some 10,000 locations across the nation perform mammograms, including hospitals, free-standing clinics, private physician offices, and mobile units. Given the scope of the industry, one would assume that a government body polices these facilities to ensure that their personnel are properly trained, that the equipment is safe and designed specifically for breast imaging, and that follow-up is timely. In some areas, this is simply not the case.

"It's a little scary because some places probably are not using qualified radiologic technologists," said Francine Knutson, R.T., former director of medical imaging for the American Society of Radiologic Technologists. "So they may employ people who have no idea of radiologic safety. Plus, we really don't know the exact number of places in this country performing mammograms."

Given the potential for problems, what can women do to make certain their mammograms are safe and accurate?

Accredited centers. According to Dr. John Link, medical director of the breast center at Long Beach Memorial Medical Center in California and a national renowned expert in breast cancer, women should look foremost for accreditation by the American College of Radiology (ACR), a physician organization that reviews radiologic facilities.

"We look for several things when accrediting a center," noted Pamela Wilcox, R.N., manager of the mammography accreditation program at ACR, "including staff qualifications, equipment, quality assurance programs, image quality, breast dose, and processing quality control. Each part of the link is vital--otherwise, the image is worthless."

The ACR accreditation is voluntary, and as of November 2, 1992, 4,902 facilities had been accredited. Some 2,476 more applications are pending.

Why should women care if the center they visit for their annual mammogram is accredited? First, accreditation ensures that the technician performing the mammogram is registered with the American Registry of Radiologic Technologists (ARRT). This registration is for general radiologic technologists only.

Women should never assume that all centers employ personnel with the ARRT designation. According to John Wade, director of member services and information for the American Society of Radiologic Technologists, the result could be untested technicians performing a highly skilled procedure.

"In those states where registration with the ARRT is voluntary, it is possible that you could see technologists who have literally been trained on the job," Wade says. "Particularly in rural areas, where there is a shortage of technologists, this could be the case."

A technologist's skill guarantees two things: a quality breast image from which a radiologist can accurately diagnose, and safe application of a potentially harmful substance--radiation.

Equipment. Another concern is that the equipment used be "dedicated," that is specifically designed for mammography. In a routine mammogram, two views of the breast are taken. To get an optimal image, the breast should be compressed using a flattening device manufactured specifically for this purpose.

According to Don Honey, supervising health physicist for the radiologic branch of the Department of Health Services, some facilities may still be using general radiologic equipment without the compression device.

"And that's not a good idea," he noted. "It may be better than no mammogram at all, but it won't be entirely adequate."

Beyond offering compression, the breast screening center should have a dedicated processor used only for mammographic films. Because of differences in the type of film used for mammograms and the time spent processing the film, a dedicated processor is essential. One quick way to determine whether a center had dedicated equipment is to look at its volume. Facilities that do around 50 mammograms a week probably have the funds to purchase this extra equipment.

"Anyone can call a breast screening center and ask about the number of mammograms it performs per week," Honey said. "You don't want a facility that does just one or two a week; you want one with lots of clients, special equipment, and radiologists who are used to reading many mammograms, so they know what to look for."

The physician who interprets the X-rays should be board-certified in radiology and read at least 480 mammograms a year.

When it comes to radiologic safety, each state has radiologic health branches that test the mammography equipment a minimum of once every three years. And with the recent passage of federal legislation that frequency is to be increased to once every year for any facility that bills for Medicare, which includes most facilities. Again, if in doubt about the safety of equipment used during your mammogram, look for ACR accreditation, which ensures that your exposure to radiation is within acceptable limits.

Don't let price fool you. An expensive mammogram is not necessarily a better one. "Mammograms range anywhere from $50 to $200," says Dr. Link, "depending on what someone wants to charge. But it doesn't mean that the $200 mammogram is any better. In fact, some people who are charging $200 are using the older equipment."

"In the past five years we've tried to get women to have mammograms, regardless of the quality," Dr. Link noted. "But we're shooting ourselves in the foot. It is not helping the cause if we are not doing good mammography. Now the emphasis needs to be on quality."

Perhaps the best argument for quality mammography is this fact: breast cancer tumors grow over a period of 3 to 10 years; a screening mammogram can detect a tumor at the third or fourth year, when the chance for recovery is excellent. It makes all the sense in the world for women to seek out quality, safe mammograms.

If you have questions about breast screening facilities in your area, contact the American Cancer Society office nearest you, or call the National Cancer Institute at 1-800-4-CANCER.