At one point in 2024, a backlog of mammogram results for women receiving care through the U.S. Department of Veterans Affairs’ topped 4,800, delaying an unknown number of surgeries, .
In February 2024, the only mammographer at the Aurora VA facility left, forcing it to close its breast-cancer screening program and refer any veterans needing mammograms to community providers. The community care program connects patients to someone outside the VA system when they need services that the VA doesn’t offer in their area.
The VA’s Office of the Inspector General found that community care staff in Aurora couldn’t keep up with the deluge of images submitted by other centers, and that outside providers also created delays by not sending images promptly. The system didn’t have a reliable way of tracking which women were due for mammograms and sending them reminders, .
The report didn’t determine whether the processing delays caused any harm, such as late cancer diagnoses.
The VA Eastern Colorado Health Care System said it determined none of the women with abnormal mammogram results were hurt by the delay, and that it has cleared the backlog.
In a statement, the VA said it was in the process of implementing all the auditors’ recommendations, and the percentage of veterans due for mammograms who actually completed them is now in line with the national average.
While the majority of veterans are men, about 15,600 women received health care through the Aurora facility in the fiscal year ending in September 2024, according to the OIG.
It didn’t specify how many of them were between 40 and 74, the ages when the U.S. Preventive Services Task Force . Men also occasionally need mammograms if they have symptoms suggesting breast cancer.
At least 4,815 sets of images got caught in backlogs when staff didn’t upload them to their electronic health records, according to the report. Surgical staff at the facility told the auditors they had to spend time chasing down images so they could prepare before removing lumps, and sometimes had to postpone surgeries because they didn’t have the images in time.
Auditors said part of the problem was that the number of images needing to be uploaded increased by 5,000 in one year, while staffing didn’t. The complexity of the process and the fact that some providers sent the images on disks also contributed, they said.
In other cases, the images didn’t even make it to the VA. The Aurora facility recorded that it didn’t receive images for 524 women’s mammograms in March and April 2025. The inspectors couldn’t tell if any of them had cancer, and if so, what the delay meant for their diagnosis and treatment.
About 10% of the women who get a mammogram in a typical year will get a call to come in for additional testing, with a slightly higher rate for those getting a first mammogram, . Only about 0.5% have cancer, though.
Community providers interviewed by the inspectors said they didn’t know they were supposed to send the actual mammogram images, and thought a report on their findings would be enough. Some thought they needed special authorization to share the images.
The VA was supposed to follow up three times if they didn’t get the images, but did so less than 10% of the time because of a lack of support staff, according to the OIG.
Inspectors also found problems with the systems for tracking if patients completed their follow-up testing and for notifying women due for mammograms, increasing the odds that someone could fall through the cracks.
The Veterans Health Administration and the undersecretary for health agreed with the inspectors’ recommendations, which included improving image-sharing technology and adding staff. They said it could be difficult to ensure community providers understand the VA’s expectations, however, since a third-party administrator works with them.
