Pursuing Health Equity: Radiology’s Commitment to Eliminating Preventable Differences in the Burden of Disease

Ashley Wilson

The ability for all people to attain their full health potential through the elimination of disparities in health and healthcare, also known as health equity, has been a consistent challenge worldwide. The COVID-19 pandemic brought additional exposure to the pervasive inequalities in healthcare for racial and ethnic minority groups and amplified focus on healthcare infrastructures that were not built with equal accessibility and care for all individuals. According to the US Centers of Disease Control and Prevention (CDC), health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment[1].

Radiologists who specialize in detecting cancers such as breast cancer, where systematic screening recommendations already exist, are aware of the inequities that are prevalent in women’s health. As health disparities became further apparent during the COVID-19 global health crisis, calls from patient coalitions and support groups to eliminate health inequalities across all of healthcare and enlist support for global health equity have motivated responses from leaders across the healthcare industry. New initiatives from pharmaceutical giants, insurance providers, and medical imaging and technology manufacturers have begun to promote increased awareness, build patient and provider support programs, help improve accessibility, and generate more mindful innovation.

Addressing disparities in health and health care is important not only from an equity standpoint but is a moral imperative for contributing to improving population health and economic prosperity in all patient communities. As the gateway to diagnosis, radiologist’s roles in challenging traditional bias in data and inequality in care is front and center and can be a key influencer of change. Understanding the health risks or commonalities associated with specific patient communities, cultures, or geographic areas and how they may affect prevalence of disease, detection and treatment is key, as is building trust with patients in communities where the disparities are greatest. Bringing in interpreters or specialized staff to eliminate language barriers and understand cultural influences can help build trust with patients. Ensuring these patients have access to information in local languages, high-quality screening, genetic testing, treatment, and clinical trials are important steps on the path to health equity for all individuals.

Eliminating equity-specific challenges in breast imaging and breast cancer screening

In 2020, there were 2.3 million women diagnosed with breast cancer and 685 000 deaths globally. As of the end of 2020, there were 7.8 million women alive who were diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer.[2]  The mortality rate from breast cancer has decreased in recent years due to increased emphasis on early detection and more effective treatments in white women and some ethnic populations, but the overall cancer incidence among African American and Hispanic populations has continued to grow[3]. According to data compiled by the American Cancer Society, the incidence rate for women of color is similar to that of white women, but the mortality rates are markedly different. African American women have a 40 percent higher mortality rate from breast cancer. Among women under 50, the disparity is even greater: deaths among young women of color are double that of young white women. African American women are also often diagnosed with breast cancer at more advanced stages, when treatment options are limited, costly and the prognosis is poor[4]. Delays in breast cancer diagnosis and treatment have also been recorded across different patient subpopulations and are associated with adverse outcomes[5],[6]. Delayed time to treatment is another category where racial disparity persists, as highlighted in a recent study reporting that women of color waited nearly 17 days longer for treatment initiation compared with white women[7].

Further inequities in breast cancer screening were revealed during the COVID-19 pandemic, which is already responsible for nearly four million missed breast cancer screenings in the US[8]. The research, conducted at Washington State University Health Sciences Spokane reported that not only did the number of completed screening mammograms across Washington state fall by 49 percent, but when researchers analyzed the data by race and geographic variables, they reported that the most significant decreases in screenings were seen in non-white populations and those living in rural communities.

Patient advocacy groups like the Brem Foundation, The Susan G. Komen Foundation and world renown cancer organizations such as the Union for International Cancer Control UICC) believe that all women should have equal access to quality breast healthcare, and they are working to bridge the gap. 

Addressing the socioeconomic factors that cause ill health and result in health inequities is crucial for everyone to attain the highest standard of health, regardless of race, religion, political beliefs, social or economic situation. This right is enshrined in both the WHO Constitution and the UN Declaration of Human Rights.

--Dr. Sonali Johnson, Head of Advocacy, UICC

In cooperation with medical imaging manufacturers such as GE Healthcare and other industry partners, patient advocacy organizations are working tirelessly to try to improve access for women who are unable to access tests. Between organizing mobile mammography units into underserved communities or helping to fund diagnostic and screening exams for women who otherwise cannot afford them, patients are getting connected with improved access to breast cancer screening, education, and information, and in some cases, navigators, who identify and assist those women who might be experiencing challenges with childcare, time off work, or transportation. Several ways that have been suggested by caregivers to successfully challenge health inequities in breast cancer care include improving access to education in local languages, increasing access to care and screening, improving early breast cancer detection in underserved communities and reducing the time to breast cancer treatment to improve outcomes[9].

It’s our job as physicians to identify barriers to patient comprehension and to use all resources available, whether that includes medical interpreters, ancillary staff, or online educational materials to ensure patients fully understand their conditions and treatment options. This is a big step in helping to address existing disparities in care."

--Randy C. Miles, MD, MPH, Interim Service Chief, Breast Imaging, Massachusetts General Hospital in Boston

Bridging long-standing disparities in care

The challenge to improve health equity by eliminating disparities based on socioeconomic factors such as poverty, race, insured status and education levels is, unfortunately, not unique to women’s breast health. These disparities are prevalent across healthcare and patient communities, but now that the issue of disparities in healthcare has become front and center, the onus is on leaders in government, industry, and healthcare providers to take action to eliminate preventable differences in the burden of disease.

According to the Institute of Medicine US Committee on Understanding and Eliminating Racial and Ethnic Disparities in Healthcare, for the efforts to reduce disparities in healthcare to be most effective, they should be applied in a systemic, simultaneous, coordinated fashion[10]. US insurance giant, Blue Cross Blue Shield (BCBS) has announced major goals for tackling disparities in care, such as reducing racial disparities in maternal health by 50 percent in five years. As part of a plan to address these issues, the company is bringing visibility to major areas of inequity or disease prevalence in certain communities such as in diabetes, where African American adults are 60 percent more likely than non-Hispanic white adults to be diagnosed with diabetes. In cardiovascular health, BCBS reports, black men are 70 percent more likely to die from a stroke as compared to non-Hispanic white men[11].

To address some of these clinical areas and instances of racial and ethnic variation in disease incidence and prevalence, clinical organizations and professional societies in the US and globally have also shifted their focus to improving health equity. The Radiology Society of North America (RSNA) has recently established the Radiology Health Equity Coalition to address health disparities and measurably change outcomes. The RSNA’s network of patient-focused radiologists will collect and disseminate resources and best practices, advocate for and connect with patients and community members, and collaborate on programs and services to empower their colleagues to improve health care equity[12]. It is clear that clinicians such as radiologists are progressively taking the opportunity to understand the nuances and context surrounding a patient’s health and life circumstances at the point of care to optimize the health outcomes for each individual patient.

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[1] https://www.cdc.gov/chronicdisease/healthequity/index.htm#:~:text=Health%20equity%20is%20achieved%20when,length%20of%20life%3B%20quality%20of

[2] World Health Organization March 2021 - https://www.who.int/news-room/fact-sheets/detail/breast-cancer

[3] Yedjou CG, Sims JN, Miele L, et al. Health and Racial Disparity in Breast Cancer. Adv Exp Med Biol. 2019;1152:31-49. doi:10.1007/978-3-030-20301-6_3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6941147/

[4] https://ww5.komen.org/end-breast-cancer-health-disparities/

[5] Bleicher RJ, Ruth K, Sigurdson ER, et al. Time to surgery and breast cancer survival in the United States. JAMA Oncol 2016;2:330-9.

[6] Gagliato DeM, Gonzalez-Angulo AM, Lei X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol 2014;32:735-44.

[7] Selove R, Kilbourne B, Fadden MK, et al. Time from screening mammography to biopsy and from biopsy to breast cancer treatment among black and white, women Medicare beneficiaries not participating in a health maintenance organization. Womens Health Issues 2016;26:642-7.

[8] https://jamanetwork.com/journals/jamaoncology/fullarticle/2778916?resultClick=1

[9] Ann Mootz, MD, Firouzeh Arjmandi, MD, Basak E Dogan, MD, FSBI, W Phil Evans, MD, FSBI, FACR, Health Care Disparities in Breast Cancer: The Economics of Access to Screening, Diagnosis, and Treatment, Journal of Breast Imaging, Volume 2, Issue 6, November/December 2020, Pages 524–529, https://doi.org/10.1093/jbi/wbaa093

[10] Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Washington (DC): National Academies Press (US); 2003. PMID: 25032386.

[12] https://www.rsna.org/news/2021/may/RHEC%20Scott%20Appointment