Is the future of cancer screening at your local shopping mall?

That’s the question sticking in my mind after reading a recent report about a local radiology practice opening a large mammography center in an upscale shopping mall in Long Island, New York.

Let’s face it: Medical care is changing. And with changes come new ideas. Some will work, some won’t. The thought of getting a mammogram while on a shopping trip may just be what the doctor ordered and the consumer needs, or it may not. I don’t know the answer, and only time will tell.

I grew up in a world — which is now fading away — where patients and doctors had relationships. You had your doctor, and your doctor knew the other doctors who would be best for your care, and that primary doctor followed you and cared for you for years. As you aged, someone knew you well — maybe even became a family friend or someone you interacted with in your community.

Today we have mega hospitals, mega practices, and failing long-term primary care relationships in many parts of the country. Having those relationships was once thought to be a key to successful health strategies. Now we are handing over those relationships to systems and networks. Maybe those networks will indeed invest in keeping people healthy and improving quality, but for large parts of the consumer nation, the jury is still out on that one. No matter: How we deliver the care we need is becoming more fragmented than it was in the past.

As we evolve our new and perhaps less personal approaches to healthcare, there are important questions to ask: By making screening for breast cancer more readily available and convenient aren’t we, in fact, helping to improve the health of our communities? Or is “ready access” going to take us in directions that may prove problematic in the long run?

Given the subtly different recommendations from several respected organizations, including the American Cancer Society, that decision may not be a simple one. In fact, some recommendations, including those from the ACS, include the important advice that some women (in our case women ages 40 to 44, for example) learn the pros and cons and carefully decide, with their clinician, whether getting screened at that particular time in their lives is right for them. If we are going to embrace more convenient and direct-to-consumer health services, then we need to work on better ways to assure that women receive the information they need to make that choice.

Getting screened for breast cancers is not like getting your blood pressure checked or getting a flu shot. It is an important decision that requires some thought and discussion based on your age, your risk, and your personal values. You should know what the next steps might be — from having a not-infrequent false positive, which can lead to a number of additional medical procedures, to what to do next when a breast cancer is found early (which of course is the goal of having a mammogram in the first place).

The article goes on to say that uninsured women can get a screening mammogram for $45. That’s admirable and may be very important for women who would otherwise not have access to mammography services.  Access to a screening test becomes more complicated when uninsured women have a suspicious finding, or require more tests to prove that a cancer is or is not present. What safety nets do we have if these women do have cancer and need treatment?

There are all sorts of rules and pathways in different states as to what services are available for women who have breast cancer and no insurance. However, there are also circumstances in the past and currently with certain screen-detected cancers where uninsured folks have nowhere to go, or have significant delays in getting the care they need. Sometimes they go without any care at all. Follow-on care is sometimes complex, and having plans and options in place is important. Having a suspicious mammogram without options for treatment can be a difficult — and heartbreaking — situation.

So here is a tip of the hat to consumer engagement, and better access to health care services that are appropriate, medically necessary and consistent with the evidence as we know it. Hopefully, this new approach to getting a screening mammogram will work well for consumers and the docs. If it’s a success, everyone benefits.

However, there is a larger story here, one that goes beyond the headline and the particulars of how women are screened for breast cancer.

I can’t help but ponder if the changes in how we receive and deliver health care portends something not so great: a move away from one of the most important (perhaps even more important than ever) aspects of medicine: a strong, continuous, personal relationship between consumers/patients and health professionals.

You never know how important that relationship can be — until you really need it.

J. Leonard Lichtenfeld is deputy chief medical officer, American Cancer Society. He blogs at Dr. Len’s Cancer Blog.

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