The 1980s and 1990s have witnessed a remarkable increase in resources devoted to women's health and, in particular, the early detection of breast cancer. These improvements have included: expanded insurance coverage of screening mammography, new federal funds earmarked specifically for breast cancer research, the creation of new medical facilities designated as women's health centers, the institution of federally mandated guidelines for standardization and quality control of mammography facilities, technical improvements in mammography, stereotactic breast biopsy as an alternative to surgical biopsy, the development of new breast imaging modalities, and improved awareness of women's health issues through increased media exposure.

Despite the dramatic expansion of breast imaging services available to women and the emphasis in the media on breast cancer awareness, too many women continue to present for their initial mammogram with advanced clinical disease. Two recent disturbing examples from our breast service bring this to mind. The first, a well-dressed 78-year-old woman with diabetes who was status-post two cataract surgeries and a retinal laser within the year, presented with a 15 cm ulcerating cancer of her left breast. She stated that she had had a small bruise for some time and had come in to be seen because it had begun to bleed. The second, a 63-year-old recently retired woman, was referred from her family practitioner for an itching, inflamed right breast. Physical examination at the time of her mammogram showed a markedly deformed breast, with nipple retraction and numerous erythematous skin nodules consistent with an advanced breast cancer. She could not recall the date of her last mammogram. Her cheerful disposition at the time of her visit reflected the depth of her denial.

Screening mammography has consistently enabled the detection of significantly smaller and potentially curable breast cancers. Although many advances have been made in services available and in making the public aware of the fact that early detection of breast cancer saves lives, the current system occasionally fails, as in the two cases described above. These examples support the continued need for educational programs and for patient-friendly medical services. We must actively and enthusiastically emphasize the positive aspects of screening mammography. We must tear down the barriers that may prevent women from taking this all too important step to ensure their own health and well-being.

Dr. Hogge is an Assistant Professor in the Breast Imaging Section of Radiology at the Medical College of Virginia of Virginia Commonwealth University, Richmond, VA.