Overcoming Obstacles

OCT overcome

Many underrepresented minorities do not seek preventative screening, putting them at a higher risk.

Screening awareness season is upon us. This month, the world will light up pink in order to remind patients about the importance of breast cancer prevention. In November, those pink ribbons turn blue for lung cancer. Yet despite the movement to make preventative screening more accessible to all patients, a large swath of the community remains unscreened and at risk.

High Rates

Although breast cancer is the second leading cause of death in American women and occurs at a higher rate in Caucasian women, mortality is considerably higher in underrepresented minorities (URMs).1 Other cancers present the same issues for URMs. For example, URMs in the United States more frequently present with later stages of lung cancer, meaning these patients are also at risk for higher mortality rates.2 One of the reasons for these numbers is although screening utilization has increased over the years, many women, especially minority women, do not seek or undergo preventative screening.3
URMs may not seek screening for a variety of reasons, ranging from financial to cultural to educational. But these barriers are not unbreakable. Radiologists can play a key role in helping to make screening more accessible. “It’s vital patients seek and have equal access to screening,” says Debra L. Monticciolo, MD, FACR, chair of the ACR Commission on Breast Imaging. “It’s a proven life-saver, and we as physicians owe it to our patients."

(Mis)Information Station

One reason patients may not seek out screening is lack of education or misunderstandings about procedures. One study of late-stage lung cancer patients found a variety of misconceptions among its minority population, including the belief that stress and joint pain are causes of lung cancer and if they left it alone, “it would eventually go away.”2
Another study found Mexican patients believed they should not seek screening as a preventative measure; rather, they should only get a mammogram if they experienced pain or found a lump in their breasts.1
There are a variety of ways to combat this issue. Efren J. Flores, MD, director of radiology community health improvement at Massachusetts General Hospital, recommends providing multilingual patient educational materials as well as enlisting the help of patient navigators, whose sole job is to aid patients throughout their health care process. Patients respond better to one-on-one counseling, telephone coaching, and other tailored methods.1,3 He acknowledges that although his practice has seen significant gains through patient navigators, the resources needed to make them effective may be too much for a smaller practice.

Although paid patient navigators may be costly, radiologists can also combat misinformation about screening through community advocates. Radiologists can encourage patients to convince their friends and family to seek screening and share their experiences.1

The Money Factor

Another barrier URM patients may face involves their socioeconomic situation. Factors such as not having health insurance, not being able to take time from work, or even lacking childcare during appointments can cause a patient not to seek screening.3

Monticciolo adds distance may also factor into the burden of health care for URMs: “Patients in non-urban areas have fewer facility options to choose from. That means they often have to travel much greater distances to receive the services they need,” she says. Since screening is proactive rather than reactive, it may be harder for patients to justify the cost or time.3
To help these patients, Monticciolo recommends encouraging facilities to offer financial help or programs to make imaging more accessible. Her practice combats some of the socioeconomic barriers by offering a free clinic; they also periodically offer breast care days that are cost-free for physical exams and imaging. Flores’ department offers same day cancer examinations and has increased the availability of evening appointments.

Flores also recommends partnering with primary care physicians. “They work closely with these patients and are trusted, so they can help pass along important information,” he says. “Primary care physicians will also know which of their patients are more at risk to skip preventative appointments and can help remind patients of the importance of screenings.”
Monticciolo also notes dismantling barriers cannot only be done at the local level; there is important work to be done nationally so all patients get the screening they need. “We need to speak out to our members of Congress to demand fair coverage,” she says. “For breast cancer patients, this means advocating for insurance coverage without co-pays or cost-sharing and fighting for annual screening mammography starting at age 40, should the patient choose it.”

Fighting the battle to ensure screening for all patients is multifactorial and may seem daunting. But Flores and Monticciolo encourage all radiologists to embrace the difficulty. “Patients deserve safe, quality healthcare, and it’s important physicians do their part in helping that happen,” says Flores. Adds Monticciolo, “It’s a challenge we should all embrace.”

 By Meghan Edwards, freelance writer, ACR Press

1. Alexandraki IA, Mooradian AD. Barriers related to mammography use for breast cancer screening amongst minority women. JAMA. 2010;102(3):207–218.
2. Bergamo C, Lin JJ, Smith C., et al. Evaluating beliefs associated with late-stage lung cancer presentation in minorities. J Thor Onc. 2013;8(1):12–18.
3. Ahmed AT, Welch BT, Brinjikji W, et al. Racial disparities in screening mammography in the United States: a systematic review and meta-analysis. J Am Coll Radiol. 2016;14(2):159–165.

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