Part I: Breast cancer screening in Romania

Oct 20, 2003

AuntMinnie.com is pleased to present the first installment of a three-part series on breast cancer issues in the international community.

By Dr. Ana Roxana Covali

Romania does not currently have a formal breast cancer screening program in place. It is up to the individual woman to undergo an annual mammogram, or any kind of preventive imaging at all.

In addition, very few Romanian radiologists specialize in reading mammograms. There is a five-year residency in radiology that includes a two-year rotation in general radiology, with two to four months devoted to mammography. Two years ago, two university hospitals in Bucharest began offering month-long courses in mammography for junior or senior radiologists. However, these courses are only held once or twice a year.

Romanian radiologists have two options for employment: practicing at a private clinic or a state facility. Depending on the hospital profile, radiologists are required to perform general imaging tasks. So, in an obstetrics and gynecology hospital, the radiologist interprets all film, whether it’s for women (mammography, hysterosalpingography) or for babies. As there is no such position as an ultrasound technologist, radiologists may perform ultrasound exams of the abdomen, pelvis, and breast.

Recently, a high-profile mass-media campaign was launched for mammographic breast cancer screening for women 45-65 years of age. This was in addition to an ongoing public awareness campaign wherein a number of state-run university hospitals offered free mammograms for a two-week period in September.

These campaigns seemed to be effective. Anecdotally, a 60-year-old neighbor of mine, after seeing the mass-media emphasis on breast cancer screening, asked me where she should have a mammogram. She said that she had not felt anything abnormal on self-palpation, but she wanted to take breast cancer off her mind.

But there is a problem. Iasi is a major city, with around half a million inhabitants. It also has the oldest university in Romania, as well as two obstetrics and gynecology university hospitals.

However, there are only two state-owned mammography units available at the university hospitals. One became non-functional and had to be uninstalled. The second one is still in use at one ob/gyn university hospital, but its days are numbered. The third unit is in working order at the central university hospital, but cannot keep up with the number of women who need to undergo both screening and diagnostic mammograms.

My ob/gyn hospital has no mammography unit. Instead, I work with a general x-ray unit that has been adapted to some degree for breast imaging, but really only allows me to image larger breasts.

Ironically, a couple of years ago a breast imaging machine was installed in a private medical facility, staffed with highly qualified personnel, and advertised with much fanfare. The unit was subsequently removed because of a lack of patients.

The problem is not specifically related to money. In-patients do not pay for radiographs, but out-patients do. For example, if a woman is admitted to my ob/gyn hospital for possible uterine carcinoma, and her breasts seem abnormal, she is sent to me. I perform the mammogram for free, if it is possible on my x-ray unit. The same holds true at other ob/gyn facilites, provided their mammography equipment is functional.

If a patient is admitted to the central hospital (i.e. for pneumonia, peptic ulcer, or other non-ob/gyn issues) she would have to pay about $10 (U.S.) for the mammogram. The same fee is charged if a healthy woman wants to undergo a screening mammogram, outside of those two free weeks in September.

But again, encouraging women to undergo regular breast cancer screening is not easy, and hospitals may not have the budget to even install mammography machines.

In private practice, if the radiologist owns the equipment outright, he can keep the majority of his income (after taxes) and could make a screening program viable. This is fine if one has many patients, although that is rarely the case.

Meanwhile, radiologists at state hospitals have fixed wages that depend on years of experience, the number of exams performed, and their level of education. But the number of radiologists employed by a hospital depends on the number of beds. And as previously mentioned, equipment is sorely lacking. Every young radiologist dreams of working on a CT or MRI unit, but unfortunately there are few available.

Without a screening program, the issue of malpractice is almost nonexistent. Malpractice insurance isn’t expensive, and, to my knowledge, patients rarely sue physicians.

In fact, patients have a powerful weapon against doctors if they feel they have been wronged: the mass media. If an angry patient can explain in enough details what he thinks went wrong with his procedure or treatment, then local newspapers and television are willing to make it headline news. No physician wants that.

By Dr. Ana Roxana Covali
AuntMinnie.com contributing writer
October 21, 2003
Dr. Covali serves as a junior radiologist at the Elena Doamna Obstetrics and Gynecology University Hospital in Iasi, Romania. She also is a teaching assistant in the histology department at Gr. T. Popa University of Medicine and Pharmacy in Iasi. Dr. Covali is currently pursuing a Ph.D. in histology at Carol Davila University of Medicine and Pharmacy in Bucharest.

Flag courtesy of CIA - The World Flag Book

Calif. Asians, Latinos miss cancer screening-study, September 18, 2003

Diverse Los Angeles population gives cancer clues, August 22, 2003

Statistics suggest strategies for cancer reduction among Hispanics, August 11, 2003