Fewer women are getting mammograms. Facilities offering mammograms are closing. Mammogram machine usage is declining. And we don't really know why.

"We're heading in the wrong direction," says Carol Lee, professor of radiology at Yale University School of Medicine and chair of the American College of Radiology's commission on breast imaging.

"If this decline holds up, it will be very worrisome," she says.

"We're looking at a possible increase in deaths if we see this continue," according to Diana Balma, vice president of public policy at Susan G. Komen for the Cure.

Studies don't show which women -- rich or poor, young or old, educated or uneducated -- are skipping these critical screenings, but there are a few possible reasons for this dangerous drop.

Think about this:

Perhaps there are fewer facilities, staffed by fewer radiologists and technologists due to high lawsuit rates and modest reimbursement. This is scary -- because the number of women old enough to get screened is increasing.

Women may be missing out on all sorts of necessary medical care because of inadequate health insurance or other access problems.

Women may be choosing, for whatever reasons, not to get mammograms, despite strong public urging that women age 40 and older get screened one time every year.

And now think about this:

Recent news about declining breast cancer rates may not be all that good. It may not be that fewer women are developing breast cancer. It may simply be that fewer women are getting early diagnoses because of irregular or nonexistent screening.

New Zealand Christchurch Hospital radiation therapists are in a dispute over pay and have threatened to stage a strike beginning the first week of January. According to the hospital's clinical director of radiation oncologist Dr. Chris Wynne, the amount of money being argued over is so small that the other doctors have offered to pitch in and make up the difference to end the dispute and avert a strike that would affect 250 cancer patients.

Because Dr. Wynne has not received a response from the District Health Board or the radiologists regarding the monetary offer made by the doctors, he has decided to bring attention to the dispute by doing something even he admits is stupid -- he has started smoking. That's right. He is standing outside the hospital smoking cigarettes in a play for media attention. Obviously, it is working, as the story has been picked up around the globe.

But surely, was this the only way he could think to bring attention to the dispute? Who knows -- you and I might have chosen a different course of action -- but Dr. Wynne thinks it is the only thing left to do to bring attention to the innocent victims who will be affected by the strike -- the cancer patients who will have to go without timely treatment. Dr. Wynne says he will continue doing a stupid thing by smoking for as long as it takes until the stupidity of the entire situation ends.

Computer-assisted detection (CAD) technology uses computer software to identify and mark areas of concern on mammograms. Radiologists typically review the CAD-marked images after they interpret the original film.

Radiologists can see lesions that CAD sometimes misses so they should not become too dependent on the technology when reading mammograms.

A study was done by the researchers at Group Health to determine the effectiveness of CAD assistance. They found that CAD increased radiologists' ability to determine that the women did not have any cancerous lesions. CAD did not however affect the radiologists' ability to spot cancer when it was present. The physicians performed equally well with and without CAD.

CAD did not mark all visible abnormalities and the doctors could be influenced by the computer's interpretation rather than their own interpretation. Its hard to ignore the technology but the authors of the study recommend training radiologists on characteristics that CAD may miss.

CAD assistance can help radiologists but should not replace their own judgment in reading mammograms.

There may be another explanation for the recently announced decline in breast cancer rates. And it's not nearly as promising as the first explanation may be.

A day after researchers announced that the significant drop in breast cancer cases is primarily due to fewer women using hormone replacement therapy (HRT), some experts suggest breast cancer rates are not dropping at all. Just as many women may have breast cancer, they say. They just aren't being screened for it.

"We have been aware for several years that the number of radiologists who specialize in mammography have been decreasing, and that there are places in the United States where women have difficulty getting access to mammography," Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, wrote on the society's blog just after the public announcement.

"If mammography use has reached a peak and is now decreasing, we may actually be diagnosing fewer cancers when they can be most effectively treated, Lichtenfeld said. "If you don't get a mammogram, you don't diagnose a cancer."

The research linking the decline in HRT to the drop in breast cancer came from the M.D. Anderson Cancer Center in Houston and was discussed at a breast cancer conference in San Antonio on Thursday. The research, based on a report by the National Cancer Institute, showed a seven percent drop in new breast cancer cases between July 2002 and August 2003, corresponding with the results of a 2002 Women's Health Initiative study.

With media reports citing HRT as the direct cause of the drop, some worry the public is getting the wrong message -- specifically women still taking hormones or those who have taken them in the past. While women not taking hormones are breathing a sigh of relief, others are in a panic.

Dr. Katherine Sherif, director of the Drexel Center for Women's Health at Drexel University College of Medicine in Philadelphia, has spoken already with 15 patients worried about this news.

"What I have told them is that three years is too short of a time to measure the effects of a drug on breast cancer," she said. "Cancers take decades to develop, and conversely, withdrawing hormones could not result in a decrease in breast cancer in three years -- it's actually absurdly short." There are also concerns women will experience anxiety about other therapies using estrogen, such as in vitro fertilization (IVF).

The study on HRT and breast cancer may be raising more questions than answers -- which could be a good thing. More questions prompt more investigation, more study, more research. And this will hopefully help us figure out one facet of the mystery of breast cancer.

Previous posts on the topic of HRT and breast cancer are as follows.

• HRT use drops breast cancer rates drop
• Hooray for HRT!?
• HRT and smoking dramatically increases breast cancer risk
• HRT increases breast cancer risks

I started my breast cancer treatment under the care of one oncologist. And then in a search for more warmth and compassion, I landed in a new relationship with a new oncologist. He offered me just what I was seeking. Plus something I didn't expect.

My new oncologist offered me a new treatment plan -- a new course of action that better suited my specific disease.

U.S. researchers reported yesterday that breast cancer patients were urged to change their treatment plan more than half the time when they received a second opinion from a multidisciplinary panel of surgeons, radiation oncologists, medical oncologists, radiologists, and pathologists.

Researchers at the University of Michigan Comprehensive Cancer Center believe second-opinion changes are a result of different interpretations of breast imaging and pathology results, consideration of new techniques and treatments, discovery of undiagnosed second cancers, and emerging medical research.

It wasn't a formal multidisciplinary team that delivered me a new, better opinion for my own cancer care. It was one man, who merged instinct and science and then consulted a well-know oncologist friend who agreed with the approach I ended up following.

I am thankful for everything I gained from my second opinion -- the warmth, the compassion, the treatment plan that has served me well for two years.