The emergence of newer breast screening technologies, such as digital breast tomosynthesis and breast MRI, has helped lower mortality rates, by improving detection and therapy treatments.
However, this has also raised the concern that existing disparities amongst vulnerable populations regarding access and appropriate utilization of breast screening technologies will only get worse, according to a recent study published in the May issue of Academic Radiology.
Breast cancer mortality rates have been steadily declining due to increased mammography screening, but not all women have benefitted from it equally, wrote lead author Randy Miles, MD, MPH, from the department of radiology at Massachusetts General Hospital, and colleagues.
"Racial and ethnic minorities, women from low socioeconomic backgrounds, those living in rural areas, and the elderly bear a disproportionate burden of breast cancer morbidity and mortality," Miles et al. wrote. " These vulnerable populations often contend with barriers to screening, experience delays in diagnosis, and present with a more advanced stage of disease at the time of diagnosis."
Contributing disparities and advanced imaging
Despite having a lower incidence rate than white women, black and subgroups of Hispanic women have higher breast cancer mortality rate, according to the researchers.
The differences in outcomes, the researchers wrote, is due to many factors seen among these vulnerable populations, including advanced disease at diagnosis, worse biological features of the disease, low income, limited education, lack of health insurance, living in a geographical area rural area, language barriers and cultural differences.
New and emerging breast cancer screening technologies and new state mammography laws passed in the U.S. have changed the field of imaging, making mammography more widespread and common routine for women. However, the researchers explained, these new advancements for women who need it most may come at a hefty price.
Insurance companies are not required to cover supplemental screening modalities, unlike mammography screening that has benefited from mandatory health insurance coverage from the Affordable Care Act (ACA), which many vulnerable populations use.
"Given the known financial pressures on mammography facilities, these emerging technologies offer the opportunity to increase revenue through either higher reimbursement for MRI or higher out-of-pocket payments for tomosynthesis and screening ultrasound. As a consequence, the adoption of adjunct technologies may inadvertently cause decreased availability and access to imaging services for those unable to afford them," the researchers wrote. "Furthermore, vulnerable women may be displaced from routine screening if there are fixed or decreasing imaging capacity and preference for accommodating more financially sustainable examinations among facilities."
Patient-level factors
Decreasing the number of women who do not benefit from advanced breast cancer screening include three categories of patient-level factors, according to the researchers.
They include insurance coverage or financial support to undergo breast cancer screening, community-based outreach programs to increase breast screening awareness, and mobile mammography unites to remove geographic access barriers.
Regarding financial support, Latina and black women report the most cost concerns as a barrier to screening, specifically. The researchers also discussed that community-outreach programs, programs designed to address barriers (as previously mentioned) and educate women about policy and patient provider relationships are sparse in underserved communities though critical to increasing access to care and close the breast cancer screening gap.
System-level factors
Breast cancer screening access in general largely depends on the health care system—specifically, appropriate distribution of mammography unites and personnel. However, functioning mammography facilities and machines have declined by 10 percent over the past decade, the researchers explained.
"Declines in mammography capacity over the past few decades because of increased financial strain may be disproportionately impacting women from traditionally underserved backgrounds, Miles et al. Wrote.
Additionally, increased financial costs, required travel time due to living in a rural setting and limited access to primary care are also contributing factors for underserved populations unable to access advanced screening modalities.
Next steps
The researchers believe that further research specializing in patient-level factors and system-levels factors are needed to understand the determinants of appropriate advanced imaging use among vulnerable populations, as well as policies ensuring access. Ultimately, these efforts may lead to more personalized, multimodality breast cancer screening approaches adopted into clinical practice, according to the researchers.
"Particular areas of need in these populations are increased access to risk- based screening and a regular source of primary care, availability of insurance coverage for advanced imaging services beyond mammography, and patient education about the potential benefits of more aggressive multimodality screening regimens among vulnerable women at high lifetime risk of developing breast cancer," the researchers concluded.
A recent graduate from Dominican University (IL) with a bachelor’s in journalism, Melissa joined TriMed’s Chicago team in 2017 covering all aspects of health imaging. She’s a fan of singing and playing guitar, elephants, a good cup of tea, and her golden retriever Cooper.