The pursuit of equitable breast care for all patients is a key focus of providers around the world. However, it remains an uphill battle. For example, in the US, a zip code can be a better predictor of life expectancy than genetics, according to the Robert Wood Johnson Foundation.^[1] The goal of driving health equity is to create an environment where all people can attain their full health potential by reducing disparities in care. In some hospitals that are designated as “safety net” hospitals, health equity is part of a mission to provide high-quality care to all patients, embrace the role of caring for the most vulnerable populations, and work to eliminate health disparities.^[2]

Improving access is key to equitable breast care

Improving access is key to equitable breast care delivery for all patients, and safety net facilities aim to promote programs that reach out to populations that are underserved. Dr. Randy Miles, chief of breast imaging and advocate for women’s health equity in breast care, recently discussed his experience with improving access for underserved patient groups with a dedicated women’s health and breast care program. The effort incorporated coordinated clinical care, 3D mammography technology, data analysis, and, most importantly, metrics.

“Improving access to screenings for breast cancer in underserved populations is essential,” Miles says. “It requires valuing everyone equally while focusing efforts to address inequalities, historical and contemporary injustices, and the elimination of healthcare disparities. The identification and removal of barriers to care is only a first step in transforming breast care in the safety net setting.”

Dr. Miles explains that “engaging stakeholders to change systems, policies, and practices to impact change is key along with identifying metrics that can be used to evaluate and measure progress. Having this information is critically important to reassess, build iteratively, and continuously improve on your efforts.”

Understanding barriers in breast care

Health disparities have been an ongoing challenge in women’s health, particularly in breast cancer. In 2020, there were 2.3 million women diagnosed with breast cancer and 685,000 deaths globally, making it the world’s most prevalent cancer.^[3]Though the mortality rate from breast cancer has decreased in recent years due to increased emphasis on early detection and more effective treatments, cancer incidence in some ethnic populations continues to grow.^[4] These statistics can be tied to the ability of these patients to access breast cancer screenings.

Women in Black and Hispanic populations are often diagnosed with breast cancer at more advanced stages, when the treatment options can be limited and costly, often leading to poor prognoses.^[5] According to a recent study, women of color also often experience delayed time to treatment.^[6] Black women still have a 4% lower incidence rate of breast cancer than White women but a 40% higher breast cancer death rate.^[7] Further inequities in breast cancer screening were revealed during the COVID-19 pandemic. Screenings across all patient populations dropped severely, with the most significant declines in non-white populations and those living in rural communities.^[8]

The social determinants of a patient’s health are the nonmedical factors that can influence their health outcomes, such as the conditions in which they are born, work, live, and age.^[9] These factors include economic stability, education, housing, and community environment, and they play an important role in the health inequities seen in women’s breast cancer statistics. Combined with economic policies, social and cultural norms, and public development plans, these attributes influence the underlying causes of barriers to equitable healthcare.

According to Dr. Miles, the first step in improving health equity in women’s breast care is Identifying which determinants affect the patient population served by a local facility.

“Basic demographic information on the patient population combined with data regarding social determinants to care gave me a great place to start,” Dr. Miles says. “For example, I found that 33 percent of our patients spoke Spanish as their primary language. Therefore, cultural competency would be extremely important to impact change in our patient community. You cannot make the needed changes without a solid understanding of your patient community.”

Accessing advanced mammography can impact breast cancer statistics

Better access to care can help increase health equity. However, ensuring each patient has access to quality care is key to impacting the statistics on breast cancer detection and mortality rates affecting certain populations. Since medical imaging is involved in many disease care pathways, radiologists have an opportunity to influence and improve access to high-quality care in breast cancer screenings, according to Miles.

The introduction and adoption of 3D mammography in breast cancer screening has been swift.^[10] Improving access to this technology could increase the quality of care available in underserved communities. Clinicians—especially radiologists—understand the benefits of this technology.

“In our facility, we have made changes to improve access to care and quality, including offering 3D mammography,” Dr. Miles notes. “We were contributing to the solution of health equity by ensuring our patients have access to high quality of care.”

With the installation of 3D tomosynthesis mammography systems, Dr. Miles and his team were able to ensure that patients were receiving high-quality care. 3D tomosynthesis not only accelerates breast screening exam times but also provides superior image quality and diagnostic accuracy.^[11]

High patient throughput in breast care

By implementing a streamlined workflow, it helped Dr. Miles and his team achieve high patient throughput. One of the key adjustments was increasing scanning hours, including initial screenings, supplemental diagnostic exams, and procedures. With all-day screening on certain days of the week, wait times have gone from 2 months to 2 days. His group has also implemented a same day biopsy program. This practice can help reduce the risk of patients potentially not attending a secondary appointment due to issues with arranging time off, transportation, or childcare.

With extended hours, clinicians also had the flexibility to spend extra time with patients experiencing linguistic barriers or health literacy issues. They provided resources such as materials printed in the patients’ primary languages and focused on improving the service environment to ensure that care was well-coordinated.

Before Dr. Miles’ workflow efficiencies were implemented, patients waited approximately two months for a screening appointment. The current availability is now within a few days for initial screening as well as for supplemental diagnostic exams. Results are also reported much faster—two hours rather than two days—significantly decreasing the time from diagnosis to biopsy.

Elevating patient care for underserved patients

In cooperation with medical imaging manufacturers and other industry partners, patient advocates like Dr. Miles are working tirelessly to improve breast cancer care access. Because of collaborative efforts, patients are getting better breast cancer screening and education. Some of the ways that can successfully mitigate health inequities in breast cancer care include:

Providing information in patients’ primary languages
Increasing access to same-day breast screening and reporting
Reducing the time between screening and the start of treatment to help improve outcomes

“It’s our job as physicians to identify barriers to care and to use all resources available to ensure patients have access and fully understand their conditions and treatment options,” Dr. Miles says. “This is a big step in helping to address existing disparities in care.”

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REFERENCES

[1] Life expectancy: Could where you live influence how long you live? Robert Wood Johnson Foundation. https://www.rwjf.org/en/insights/our-research/interactives/whereyouliveaffectshowlongyoulive.html. Accessed February 24, 2023.

[2] Crown A, Ramiah K, Siegel B, et al. The role of safety-net hospitals in reducing disparities in breast cancer care. Annals of Surgical Oncology. March 31, 2022. (Epub ahead of print.) doi: 10.1245/s10434-022-11576-3.

[3] Breast cancer. World Health Organization. Published March 26, 2021. https://www.who.int/news-room/fact-sheets/detail/breast-cancer. Accessed February 24, 2023.

[4] Yedjou CG, Sims JN, Miele L, et al. Health and racial disparity in breast cancer. Advances in Experimental Medicine and Biology. 2019;1152:31-49. doi: 10.1007/978-3-030-20301-6_3.

[5] Stand for H.E.R. Susan G. Komen. https://www.komen.org/about-komen/our-impact/breast-cancer/stand-for-h-e-r/. Accessed February 24, 2023.

[6] 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. Women’s Health Issues. November 2016;26(6):642-647. doi: 10.1016/j.whi.2016.09.003.

[7] Breast Cancer Death Rates Are Highest for Black Women—Again

[8] Chen RC, Haynes K, Du S, et al. Association of cancer screening deficit in the United States with the COVID-19 pandemic. JAMA Oncology. April 29, 2021;7(6):878–884. doi: 10.1001/jamaoncol.2021.0884.

[9] Social determinants of health. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. Accessed February 24, 2023.

[10] Bernardi D, Macaskill P, Pellegrini M, et al. Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM-2): A population-based prospective study. The Lancet Oncology. August 2016;17(8):1105-1113. doi: 10.1016/S1470-2045(16)30101-2.

[11] Superior diagnostic accuracy demonstrated in a reader study comparing the ROC AUC of GE screening protocol (V-Preview + 3D CC/MLO with 3D in STD mode) to that of 2D FFDM alone. V-Preview is the 2D synthesized image generated by GE Seno Iris mammography software from GE DBT images. FDA PMA P130020 http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P130020

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