Dismantling Disparities
By Rebecca Montz, EdD, MBA, CNMT, PET, RT(N)(CT), NMTCB RS
Radiology Today
Vol. 25 No. 4 P. 18

Persistent inequalities in women’s health demand solutions.

In the realm of women’s health, a glaring truth emerges: Undeniable variances in breast cancer outcomes compel health care professionals to navigate these inequities, steering toward a healthier future for all women. Disparities in breast cancer encompass variances in incidence, diagnosis, treatment, and outcomes, and they are influenced by factors such as race, ethnicity, socioeconomic status, and health care accessibility. It is imperative to confront and address these inequities to guarantee fair and effective breast health care for every woman.

The existing statistical data illuminates how these disparities affect women. Per the American Cancer Society, there are significant inequities in breast cancer mortality, with Black women facing a mortality rate approximately 40% higher than their white counterparts. This discrepancy is likely attributed to delayed diagnosis, despite similar incidence rates. Reports further emphasize that Black women often receive a breast cancer diagnosis at a younger age, in advanced stages, and with more aggressive forms of the disease, compared with their white counterparts. A concerning statistic from the American Cancer Society indicates that Black women have the lowest five-year relative breast cancer survival rate among all racial or ethnic groups. Additionally, Hispanic women face a higher likelihood than white women of being diagnosed with breast cancer at later stages, when treatment becomes more challenging, making breast cancer the leading cause of cancer death for Hispanic women.

Stamatia V. Destounis, MD, FACR, a breast imaging specialist at Elizabeth Wende Breast Care in Rochester, New York, advocates the importance of initiating breast screenings at a young age for Black women due to their higher rates of advanced disease and mortality. Destounis advocates for the ACR recommendation, which suggests a risk assessment evaluation for all patients by the age of 25. This allows radiologists to make appropriate screening recommendations, determining when to start, how screening imaging tests are necessary for patients at a higher risk of breast cancer.

Barriers to Access
Breast cancer disparities among underserved women are influenced by a multitude of factors. Significant obstacles include restricted access to health care services, including screenings and treatments. Challenges such as insufficient medical insurance coverage and financial hardships exacerbate these disparities, impeding routine check-ups and timely medical interventions. Tchaiko Parris, breast section lead and diagnostic and interventional breast radiologist at Radiology Chartered – Bellin Hospital in Green Bay, Wisconsin, cites a December 2023 data analysis from the Kaiser Family Foundation. The results highlight that individuals from racial and ethnic backgrounds face a higher likelihood of being uninsured, compared with their white counterparts. The absence or insufficiency of insurance coverage typically heightens the risk of encountering delays or interruptions in both the diagnosis and treatment phases.

Claire L. Streibert, the site chief of breast imaging at Fox Chase Cancer Center in Philadelphia, says the issues related to insurance access and financial challenges were heightened during the COVID-19 pandemic. She says a significant number of individuals facing job losses delayed addressing their breast health, even when experiencing pain and discomfort. Literature confirms the detrimental impact of the pandemic on mammography screenings and breast cancer diagnoses, documenting declines of up to 99% in screening mammography and 50% in breast cancer diagnoses across various health care systems nationwide, during the initial peak in the spring of 2020. Constance D. Lehman, a professor of radiology at Harvard Medical School and a breast imaging specialist at Massachusetts General Hospital in Boston, and colleagues conducted a study addressing racial and ethnic screening disparities during the COVID- 19 pandemic. The findings revealed a disproportionate decrease in screening for patients of races other than white, coupled with initial delayed access at facilities serving underserved populations, exacerbating existing disparities.

Residing in areas with limited access to specialized breast cancer services can create geographical barriers, impacting the ability to receive prompt and adequate care. Evelyn Gonzalez, MA, the senior director of community outreach at Fox Chase Cancer Center, delves into the complexities of geographical barriers and emphasizes the significance of reaching underserved women in their communities. Fox Chase Cancer Center took proactive steps by being among the first in Pennsylvania to deploy mobile units to underserved communities, ensuring optimal patient service. Data shared by Gonzalez reveals that in the past year alone, 51% of screened women in underserved communities stated they wouldn’t have completed their mammogram without the mobile unit. Effectively reaching underserved women will necessitate broader implementation of tactics, such as improving transportation access, deploying more mobile units in underserved communities, extending screening mammogram availability to after-hours and weekends, and providing incentives for patients completing their annual doctors’ review (including blood work, medication review, imaging, etc), as highlighted by Parris.

Lehman notes that cultural and language barriers present additional challenges, impeding effective communication between health care providers and underserved women, potentially impacting their comprehension of preventive measures and treatment options. Lehman, Parris, and Streibert highlight the inherent racial biases within conventional breast cancer risk models, resulting in an underestimation of future risks for nonwhite women, as the existing traditional risk models were built almost exclusively on white women. Consequently, recommendations and policies often fall short of addressing the unique needs and experiences of underserved women. Encouragingly, there is a growing initiative to diversify clinical trials. However, to ensure success, addressing root causes of underrepresentation, such as medical system distrust, fear of discrimination, logistical hurdles, and financial barriers hindering underserved women’s participation, must be addressed, Parris emphasizes.

Focused Approach Needed
Gary J. Whitman, a professor of breast imaging and breast radiation oncology and medical director of the Mobile Mammography Program at The University of Texas MD Anderson Cancer Center in Houston, says patient perceptions of organized health care systems may be shaped by beliefs or feelings of distrust, particularly if a patient’s family member has had an adverse experience. He also highlights biological factors, such as genetic predispositions and hormonal influences, contributing to the risk of breast cancer. Whitman says underserved women, including populations more susceptible to certain types of cancer, might encounter limited access to genetic testing and counseling services.

The general lack of awareness and education regarding breast cancer, along with social determinants of health like education and employment, contributes to disparities among underserved women. Racial and ethnic discrepancies are apparent, with specific groups encountering higher rates of breast cancer or facing obstacles in accessing health care, leading to variations in health outcomes. Parris emphasizes the pivotal role imaging professionals play in addressing underserved women, stating, “As imaging professionals, we play an important role in combating disparities in breast cancer care. We have an immense opportunity to educate and encourage women in the populations we serve to get screened for breast cancer.” Destounis notes that factors such as low income, limited education levels, inadequate health literacy, lack of insurance or underinsurance, race, ethnicity, and residing in rural areas can collectively contribute to the formation of vulnerable or at-risk populations.

Tackling these multifaceted factors necessitates a thorough and focused approach to health care delivery, education, and community outreach, ensuring equitable access for all women, irrespective of their socioeconomic status. Lehman stresses the immediate need to diminish breast cancer disparities in underserved communities.

“We can’t claim quality care in domains where we have inequitable care,” Lehman says. “Equity needs to be a key component of defining quality. Until our quality commitment is demonstrated for traditionally underserved patients, we have not achieved our goal of, or frankly our right to, claim high quality care at our health centers.”

Technology’s Role
Underserved communities encounter challenges in accessing the latest technological advancements in breast cancer detection and treatment, perpetuating disparities in health care outcomes. These advances may not be uniformly accessible to underserved communities, contributing to health care inequalities. Factors such as limited financial resources, inadequate health care infrastructure, and geographical barriers can hinder the availability of cutting-edge diagnostic tools and innovative treatment options. Additionally, a lack of awareness and education within these communities may impede the adoption of advanced technologies that could significantly enhance early detection and personalized treatment approaches for breast cancer.

Restrictions in accessing screening procedures, such as digital mammography, 3D mammography, or breast MRI, which are pivotal for early detection, pose challenges. Parris says disparities in the adoption of advanced technologies such as 3D mammography, indicating a higher likelihood of implementation in areas with greater incomes and predominantly white populations. This discrepancy creates barriers for some individuals to access superior screening options for early breast cancer detection. The implications are particularly severe, given studies demonstrating that Black women are diagnosed with more aggressive breast cancers compared with their white counterparts. Parris highlights that even when Black women undergo screening, they are more likely to be served by facilities with fewer resources, potentially leading to longer delays between detection, diagnosis, and treatment. A study by Alsheik et al in the Journal of the American College of Radiology affirmed these disparities, revealing that Black women were less likely to receive 3D mammography screening and were also less frequently screened multiple times over the observed five-year period compared with white women.

Implementing AI in health care, specifically for improving diagnostic accuracy through the interpretation of medical images, may face challenges in communities with limited resources and infrastructure. The obstacles include the requirement for robust computing systems and high-speed internet, which may be lacking in certain underserved areas. Additionally, the adoption of AI technologies may be hindered by associated costs and the need for specialized training among health care professionals, particularly in resource-constrained communities.

Destounis is optimistic about AI aiding radiologists but also emphasizes the critical need to validate AI algorithms across diverse populations for unbiased and equitable health care outcomes. Addressing these challenges necessitates concentrated efforts to improve technological infrastructure, cut costs, and implement comprehensive training programs, ensuring widespread accessibility of AI benefits in medical image interpretation across diverse health care settings. Lehman is optimistic about the advancements in telemedicine and AI integration within underserved communities, stating, “It is particularly encouraging to see increased awareness and commitment to equity during this time of extraordinary advances in telemedicine and AI,” she says. “I am confident these advances will support higher quality and more equitable outcomes for our traditionally underserved patients.”

Risk Assessment
Underserved populations may encounter barriers in accessing advancements in genetic testing for breast cancer risk assessment, as previously mentioned by Whitman. Financial constraints, coupled with limited awareness and restricted access to genetic counseling services, contribute to the underutilization of these crucial testing services. The potential impact extends to the adoption of personalized medicine for breast cancer treatment, as tailoring therapies based on individual characteristics and genetic makeup becomes less accessible in these communities.

Progress is being achieved in risk assessment, with the National Accreditation Program for Breast Centers (NAPBC) implementing standards (NAPBC Standard 5.1 and NAPBC Standard 5.4) as of January 1, 2024. These standards mandate accredited breast programs to incorporate risk assessment seamlessly into the screening process tailored to the needs of their patient population. Streibert believes this proactive outreach in educating individuals about their lifetime risk will aid in identifying those at higher risk across diverse populations, enabling them to access additional screening tools. Gonzalez says this initiative would empower health care professionals to address disparities more effectively, leading to the development of more sensitive and appropriate tools for underserved communities and, ultimately, enhancing overall health care through personalized treatment.

Mitigating the technological advancement disparities in breast cancer care necessitates a holistic approach, encompassing improvements in health care infrastructure, awareness campaigns, educational programs, and policy initiatives. The goal is to guarantee fair access to the latest innovations in breast cancer detection and treatment for all communities.

Awareness and Outreach
Outreach and awareness initiatives are instrumental in addressing disparities, promoting preventive measures and empowering underserved women to take charge of their breast health. By encouraging women to prioritize screenings, these campaigns contribute to earlier diagnoses and improved treatment outcomes. These programs go beyond information dissemination, providing valuable resources such as financial assistance and community programs to alleviate economic burdens associated with breast health services.

Outreach endeavors directly deliver information and services to underserved communities, striving for equal access to breast health resources. Health facilities adopt navigator programs, offer subsidized transportation, and provide translation assistance to enhance outreach. Some utilize mobile mammography units, extending services with after-hours and weekend programs for increased accessibility. Collaborative initiatives within the breast health sector, particularly partnerships with organizations such as the Black Women’s Health Imperative or RAD-AID, are instrumental in comprehending and addressing the distinctive needs of these communities, as outlined by Parris.

Moreover, outreach programs play a crucial role in dispelling myths, addressing cultural sensitivities, and fostering open conversations to facilitate appropriate care-seeking behaviors. Support groups, educational workshops, and community engagement activities create supportive environments for women to share experiences, seek guidance, and collectively prioritize their health. Building trust is a cornerstone of outreach initiatives, establishing relationships between health care providers and underserved communities. This involves addressing concerns, promoting cultural competence, and delivering health care in a manner that aligns with the values of the community. In essence, these comprehensive outreach and awareness efforts aim to create an equitable and informed approach to breast health, ensuring that all women can access and benefit from available resources and services.

Additionally, outreach endeavors play a key role in fostering awareness regarding the significance of advocating for policies that promote equity in breast health. By empowering women to become advocates for their health, communities can collaboratively strive for systemic changes that mitigate health care disparities. Destounis notes the pivotal role of radiologists in leading the charge for policy changes and legislation, to ensure equitable access to essential screening services. Parris reiterates this viewpoint, “It’s imperative that health care professionals, policymakers, and community organizations join forces to reach underserved women in breast cancer care,” Parris says. “Together, we can help underserved women not only gain equal access but also reap the benefits of advancements in breast cancer screening.”

“Historically, we placed a lot of responsibility on the patients themselves rather than our own practices and policies that favored white, higher income patient populations and contributed to the poor outcomes in our patients of color and lower income patients,” Lehman says. “It is exciting to see the change in attitudes and perspectives on how, as radiologists, we can support quality outcomes for the full diversity of our patients.”

Rebecca Montz, EdD, MBA, CNMT, PET, RT(N) (CT), NMTCB RS, has worked at the Mayo Clinic Jacksonville and University of Texas MD Anderson Cancer Center in Houston as a nuclear medicine and PET technologist.