By: Jean Johnson for Uterus1“The last time I had a mammogram, they found a tiny lump way inside my breast close to the chest wall by my ribs,” said Beth Schabacher of Flagstaff, Arizona. “My physician said the chances that the lump was benign were high but that most women opted for a biopsy just to make sure.” Schabacher went through the surgery, but was not at all pleased at the outcome.
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“Once they got in, they couldn’t even find a lump. So they took an extra scoop of breast tissue out just to be on the safe side. Now I have a dent in my breast that looks like a small ping pong ball.” That was in 1995 and 57 year old Schabacher hasn’t had a mammogram since. “I sort of soured on the whole medical world after that. They talk so big at the beginning of things, and then when something turns out badly, they don’t even have the grace to apologize.”Schabacher isn’t alone in her mixed feelings about mammograms according to two new studies. Still, given that research consistently demonstrates that regular annual or biannual mammograms dramatically lessens the chances of women succumbing to breast cancer, experts are exploring obstacles that seem to stand in the way of women going for this state-of-the-art x-ray.
Fortunately, most women don’t encounter a breakdown in the system to the extent Schabacher did. So, instead of biopsies gone awry, two independent research teams chose to look at first emotional reactions to false positive mammography results and then cost considerations.
The team that examined mammography costs – that range between $100 and $125 across the nation, dropping to as low as $60 in some rural areas – essentially concluded that if women were more informed about coverage offered by their health insurance plans, they would be more inclined to go in for a mammogram.
In 1998, professor of epidemiology and biostatistics in the Ohio State University School of Public Health, Electra Paskett, Ph.D., initiated a project designed to improve mammography screening rates in Robeson County, North Carolina. “We know that even though African American women are less likely than white women to get breast cancer, they die of it more frequently,” said Paskett. “Anything we can do to help early detection would be helpful.”
Most recently, Ann McAlearney, Ph.D. in the Division of Health Services Management & Policy in OSU’s School of Public Health examined the data that had accumulated over time in the Paskett project. Information from interviews with 897 women age 40 and older contained comment about the women’s attitudes toward mammography including questions concerning costs. What McAlearney found was that while over half of the respondents said they felt cost was a barrier to getting screened, 40 percent of these were under-informed about the extent to which their insurance would defray their out-of-pocket expense.
More McAlearney found that women on Medicaid or Medicare were more aware of their coverage than those on private insurance plans. “This suggests a significant role for private insurers,” said McAlearney. “We feel private insurers could be very helpful in reducing the perception of cost as a barrier if they would step up their education efforts and help these women to become more familiar with the details of their policies.”
The medical community is not the only one looking at factors influencing women’s rates of mammography. Indeed, the nation’s $1.5 trillion healthcare market is not something that’s escaped the notice of marketing professors at the University of Pennsylvania at Wharton, Barbara Kahn, Ph.D. and Mary Frances Luce, Ph.D. That the National Cancer Institute estimates 31 million women a year currently having mammograms at an average cost of $100 only sharpened the pair’s interest.
Operating on a premise that women are increasingly engaged in their own healthcare decisions, Kahn and Luce looked at the interface between emotions associated with false positive tests and the frequency with which women have the breast screening.
“We used to have a more paternal society where the doctor or the benefits officer made these decisions for you,” said Kahn. “More and more the consumer is becoming empowered – which is good. But the question is, ‘how do the emotional aspects frame their decisions?’”
To answer this, Kahn and Luce tracked women who received false positive results from their mammogram. With industry rates estimated to run as high as 20 percent for false positives, candidates for their survey were not difficult to find. What they discovered was that women who have had a false positive do tend to procrastinate and delay when time for another mammogram rolls around. “There are lingering effects from the time spent thinking about why it might be positive. They’re thinking, ‘I smoke’ or ‘my aunt had breast cancer.’ Some of that tends to stick around and create further anxiety, so we do think there are likely to be some lasting negative effects.”
Luce did underscore that their study “did not indicate that the women would never be tested again, only that they might put it off.” The research by Kahn and Luce also suggested that the effects of false positive breast screening tests could be offset in two ways. Women who received information about preventative care like breast-self examinations, were less likely to delay, they said. Similarly, those who were made aware of the 20 percent false positive rate before they learned their own results and had time to worry, also were more likely to follow up with regular mammograms.
How does all this information play with Beth Schabacher of Flagstaff? “Cost was never an issue for me, so I can’t comment there,” she said. “But on the emotional part I think I can relate. So I think if I’d known that breast screening isn’t an exact science I might have been able to tolerate my experience better. Also, now that I revisit the subject 10 years down the road and am reminded that 1) mammograms do seem to important, and 2) that we can’t expect medicine to get it right every time, I guess I’ll relent and schedule myself an appointment. It’s the least I can do for myself I guess.”
