Pictures of Health

Though it looks like an overcrowded kitchen bulletin board, it is, in fact, a complex family triage system, the kind you’ll find in many homes with minivans parked at the curb. Life-saving phone numbers (police, poison control, pizza places that deliver in thirty minutes or less) are arrayed across the top. Immunization records, reminders of which kid is allergic to what medicine, and receipts for a flexible spending account are arranged below. The priority position in the middle is given to the yellow forms warning of the latest scourges at school—norovirus, strep throat, head lice. Buried beneath all of it are the items that don’t seem as urgent: my husband’s new eyeglass prescription, a six-month reminder for a dental checkup now six weeks overdue—and a note about the mammogram I was supposed to schedule the moment I turned forty, but haven’t.

It’s not that I’ve forgotten about the mammogram. In truth, I’ve thought about the brochure on breast cancer screening and the accompanying referral form nearly every day since my trusted nurse practitioner pressed them into my hand five months ago. At first, I put the screening off because I’d been told to wait six months after breastfeeding so the radiologist could get a clear reading. When that date came and went, I told myself I was waiting for a free afternoon and a good babysitter—a rare harmonic convergence that seemed better suited to a haircut instead.

When I start to feel guilty about putting it off, I tell myself that plenty of other women can’t find time for their exams either. A study conducted for the American College of Obstetricians and Gynecologists found that about one out of three women hadn’t seen their health care provider on a regular basis or gotten a Pap smear or mammogram during the previous year. That puts me in pretty good company—though not the company I know I should be in.

After all, I’ve raced for the cure, written checks for cancer research, and received my share of worried calls from friends awaiting biopsy results. I know full well that not having a family history of breast cancer doesn’t guarantee I won’t get it. Actually, about 80 percent of the women who have been diagnosed with breast cancer have no known family history of the disease. And while exercising regularly, eating right, and nursing my kids may help reduce my risk, I know that an estimated 3,000 women in Minnesota will find out they have breast cancer this year—though many of them have done “everything right” too. Research hasn’t uncovered all the causes of breast cancer or the cure, but it has shown that regular mammograms can cut your risk of dying from the disease by 30 to 40 percent.

Still, my mammogram referral form remains pinned to the kitchen bulletin board. Maybe it’s time to pin down what exactly is keeping me from making that appointment before another five months go by.

Researchers are asking similar questions in the wake of recent National Cancer Institute findings that fewer women are getting screening mammograms, which are recommended annually for women over forty. Between 1987 and 2000, the mammogram rate jumped from 39 to 70 percent for American women over forty. Then, in 2005, the rate declined by 4 percent across all age groups and by 7 percent among women aged fifty to sixty-four—the group with the most breast cancer cases and those most likely to benefit from a screening.

“It was a big flag that made us ask what’s going on,” says Amy Stella, an oncologist who specializes in breast cancer at the Humphrey Cancer Center at North Memorial Medical Center in Robbinsdale. While lack of health insurance and rising copays have been blamed for some of the decrease, a closer look at the findings reveals that women fifty to sixty-four tend to be the group most likely to have health insurance and access to physicians. “Is [the decline] a trend or is it just a blip?” asks Stella. “I don’t think anyone knows the answer yet, but it’s troubling.”

When that ACOG survey asked women what kept them from getting the recommended mammogram and Pap smear screenings, two-thirds said they believed—mistakenly—that if they had no family history they faced little risk. Another 18 percent said they thought the tests were unnecessary, and 7 percent said the screenings were a “waste of time.”

Though he obviously disagrees, Jonathan Slater, director of the Minnesota Department of Health’s Cancer Control Section, says he can understand why many women—with crowded kitchen bulletin boards of their own—might come to such conclusions. “Who wants a mammogram?” he says. “In the best of cases, you go to all of that trouble, inconvenience, and discomfort and find out it was for nothing. Or, in the worst cases, you find out it’s what no one wants to hear.”

According to Tim Emory, director of breast imaging at the University of Minnesota Medical Center, Fairview, a thousand screening mammograms will typically result in fifty to a hundred women being asked to return for additional “screening call-backs.” Of that group, ten to fifteen may need a biopsy, and five of them—or half a percent of the original screening group—may learn they have breast cancer.

“Lack of time is one of the justifications given [for not getting screened], but often the underlying reason is fear,” Slater says. “But these are the psychological barriers that have to be overcome if you want to live a long and healthy life.”

Fortunately, a majority of Minnesota women over the age of forty seem to be clearing that hurdle. In 2006, almost seven out of ten had a mammogram in the previous year and eight of ten had one in the previous two years—which makes for one of the highest mammogram screening rates in the country. Some of the credit goes to the Sage Screening Program, a comprehensive breast and cervical cancer initiative concentrated on women who are uninsured or underinsured and is funded by the state, the U.S. Centers for Disease Control and Prevention, and money raised by the Twin Cities Race for the Cure.

Though demand for screenings is up 12 percent over the previous year, with more than 17,000 free mammograms offered through the program, Shelly Madigan, former Sage director and now section manager of MDH’s Cancer Control Section, says she still encounters women who aren’t sure they want to know what a screening might tell them. “I don’t have time to have breast cancer,” women frequently tell her.

Madigan understands the sentiment; she received her own breast cancer diagnosis in 2001. “It was a total surprise to me as it is to many women,” she explains. “I was a single mother with no time either and all of a sudden you’re put into a treatment schedule that takes over your life.”

Madigan’s diagnosis might have come earlier had she gotten a mammogram every year—the current recommendation for women over forty. But following the prevailing advice at the time—that women with no family history get screened only every couple of years—she and her doctor decided to wait. “I really regret not having that annual mammogram, because my cancer would have been smaller and I probably wouldn’t have had to go through everything I went through,” she says, adding that she has since learned, through her brother’s genealogical research, that breast cancer has been in her family. “It just skipped two generations.”

As for women who think they don’t have time to get a mammogram, Madigan says the time they save now may steal from the time they have left.

According to ancient female wisdom,  a woman waiting for a period that’s late to arrive will be aware of an unusually large number of babies. Postponing a mammogram may create a similar effect: Every other headline I see in the weeks before I schedule my mammogram seems to have something to do with breast cancer. I read, for instance, that anxiety is linked to breast cancer—which makes me more anxious, until I read another study debunking the link. Breast cancer screening comes up in an early presidential candidate debate and again when John Edwards drops out of the race, his own wife’s breast cancer now classified as incurable. I read about new research into an alleged connection between incandescent lighting and breast tumors—and then turn off all the lights. I hear about “mammogram parties,” where groups of friends schedule their appointments en masse and later relax with a glass of wine and an Advil. Unfortunately, when I propose this safety-in-numbers strategy to friends who also turn forty this year, they tell me that mammogram and party are two words they’d rather not hear in the same sentence. Which is how I now feel about the phrase breast compression.

“The way the equipment is set up, you have to pull the breast away from the chest a little bit in order to see it,” says the U of M’s Tim Emory, who’s also a radiologist at the clinic where I eventually make my appointment. “It’s a balance between getting the highest-quality image with the least radiation exposure and not hurting anyone too much.”

Mammography is not a perfect tool: One-fourth of all breast cancers are discovered through breast examinations alone and don’t show up on a mammogram. Magnetic resonance imaging is another screening technology that women may be reading about lately, but, because of its high false-positive incidence, the American Cancer Society recommends an annual breast MRI only for women who know they have a greater than 20 percent lifetime risk of contracting the disease. For someone like me—a first-timer in her early forties—and those under age fifty or with dense breast tissue, digital mammography is considered the best tool, somewhat more sensitive than high-quality film-screen mammography in detecting cancer.

“You all ready?” the technician asks when I walk in, wearing jeans and a hospital gown—sadly, not the premium waffle-weave robe I hear is part of the trend to make breast-imagining centers more like spas. Oh, well. Though her hands are cold, the tech’s demeanor is warm as she adjusts me to the equipment. She asks me to grab a small handle, lean forward, lift my chin, and put my breast onto a glass sheet that really doesn’t seem suited for the purpose. “Ow! Ow!” I say to myself as the top half of the machine comes down on me like a panini press. But before I get to the third “Ow!” the pressure subsides, and we move on to the next image. She takes four images, two of each breast from different angles. After a quick check of the images on her monitor, she tells me I can go. 

“That’s it?” I ask. Three minutes have elapsed, according to my watch. Three minutes, five months, and thirteen days.

A week later, I receive a letter from the lab saying everything looks fine, and, for the first time in five months, I stop thinking about it.

Says Emory, “That’s really what you get for your money and your trouble by getting a mammogram every year”—a better chance at a longer life, a little peace of mind, more time to worry about other things. And he’s right, of course. It’s such a good return on a three-minute investment that I know I won’t postpone my next one.

And maybe next time I’ll get my friends to come with me.

Contact contributing writer Laura Billings at edit@mspmag.com.

RESOURCES • For more information about free mammograms offered through Minnesota’s Sage program, call 1-888-643-2584. • To learn more about the Susan G. Komen Twin Cities Race for the Cure,  visit racecure.org or call 952-746-1760.