There's no shortage of controversy when it comes to mammography-based breast cancer screening. Most recently, investigators at the Cochrane Centre in Copenhagen published yet another analysis of screening programs and declared that there was no evidence that screening saves lives.
Mammography screening advocates were quick to point out flaws in the Nordic research, just as they were quick to criticize the U.S. Preventive Task Force last year when it recommended raising the beginning screening age from 40 to 50 (British Medical Journal online, March 24, 2010, and March 30, 2010).
But this debate may be academic if women don't have access to any screening services at all: The prolonged U.S. recession has put mammogram and other cancer screening programs at risk for closure. Rhode Island's free screening program ran out of money in early 2010, forcing it to discontinue offering services until federal funding for the program is replenished in July. California eliminated its no-cost "Every Woman Counts" mammograms to low-income women under age 50 in 2010 and placed a six-month freeze on new enrollments. The screening program run by the state of New York also saw its funding shrink in 2009 because of $3.5 million in cuts to the state's budget.
Compounding the problem is that more women, because of job losses, loss of healthcare insurance, or other financial hardships, are now eligible for free screening. One of the factors in the temporary closure of the Rhode Island program was that the state was faced with a 50% rise in demand for screenings that it could not support.
There is no national database to compile information on the states that have reduced or eliminated breast cancer screening programs, but cuts are definitely taking place from coast to coast.
While lack of finances is the main reason for closure, free screening programs are also looking at scientific evidence and expert guidelines to help them determine if screening programs are worthwhile.
"Most states are looking at new evidence, especially that having to do with mammograms," said Joseph Bailes, MD, chair of the ASCO government relations committee.
But "whether states implement the U.S. Preventive Task Force's guidelines remains up in the air." he said.
Minnesota: A case study
The Sage Screening Program in Minnesota is a perfect example of a program that is experiencing major ups and downs because of tough economic times. Free screenings barely survived state budget cuts and severe midyear "unallotments" made by the governor to some Minnesota Department of Health (MDH) programs.
The Sage Screening Program covers the cost of mammograms and cervical cancer screenings that are free to uninsured women or those who have copays through their private insurer. Sage is funded by the CDC's National Breast and Cervical Cancer Early Detection Program, the Susan G. Komen Foundation, and other charitable organizations as well as the state.
Sage follows the American Cancer Society (ACS) guidelines that call for annual mammograms for women 40 and over and for younger women with symptoms or special health risks, including a family history of breast cancer. Sage also receives in-kind support from the ACS.
According to Jonathan Slater, PhD, chief of the MDH Cancer Control Section, 137 cases of breast cancer were detected among the more than 18,200 Minnesota women screened through the Sage program in 2009. Thus about 1 in every 138 screening mammograms resulted in a diagnosis of cancer.
David Arons, government relations director for the ACS in Minnesota, was among the advocates who helped shield Sage from larger state budget cuts. He said MDH Commissioner Sanne Magnan, MD, also deserved kudos. "She stood up for [Sage] last year during the budget process," he said.
Cutting screening to save money is very "short-sighted" thinking, Dr. Bailes said. "Diagnosing a tumor early is a lot less costly to the healthcare system compared with treating someone with an advanced disease," he noted. In 2007, the CDC's National Breast and Cervical Cancer Early Detection Program was reauthorized through fiscal year 2011. The program provides Pap tests and other screenings for qualified women aged 18 to 64 and mammograms for qualified women aged 40 to 64. To qualify, women must be uninsured and have annual incomes lower than 250% of the federal poverty level.
It remains to be seen what effect the healthcare reform law will have on breast cancer screening. The law will not be fully implemented until 2014, but some provisions, such as the elimination of private plan copays for screening tests, take effect sooner. How the law is implemented will also impact screening availability.