Reaching Out

Radiologists are working to increase access to life-saving breast imaging in nations throughout the world.reaching out

When it comes to breast cancer, the difference between access to screening and treatment resources from one nation to another can be striking. The Bulletin caught up with three radiologists working in countries across the globe to explore efforts to increase imaging, understand cultural barriers, and cut breast cancer rates.

Uganda

Background. The only available mammography in Uganda is located in the capital city, Kampala. For most of the population, if there is any breast cancer screening, it is done only by physical exam. In addition, recent data shows Ugandan women are developing breast cancer at a younger age than women in the United States. And because of the lack of screening, women generally present at more advanced stages, greatly reducing survival rates.

Cultural attitudes toward breast cancer and breast exams present additional challenges. "Breast cancer is difficult for women to talk about because there is a strong sense of modesty in the country," says Ginger Merry, MD, MPH, who works with Imaging the World, a nonprofit dedicated to improving global health through imaging. "And due to a variety of cultural and economic carriers, women don't necessarily seek care early on for a breast mass." In Uganda, community education is stressing early detection is key to boosting survival rates.Uganda

Efforts. While mammography is the gold standards for breast cancer screening, most agree that it's not currently a realistic option for most of Uganda. "Mammography is an expensive modality that requires equipment and technical expertise that is currently not practical for the rural setting of Uganda," says Merry. "Ultrasound is a much more practical option due to its lower cost, smaller size, fewer requirements for supporting infrastructure, and lower power demands compared to mammography."

So while screening continues to center around the physical exam, imaging is playing a valuable role in diagnostic evaluation through the use of ultrasound. If something suspicious is discovered during the physical exam, an ultrasound study can provide valuable clues about the nature of the mass and the next steps for treatment. "It's portable, it's more cost efficient, and it can be used for multiple different types of studies," says Merry, explaining the rationale behind the selection of ultrasound.

Outlook. While bringing mammography to rural Uganda will most likely be a long-term objective, Merry reports that ultrasound has been received positively and is adding valuable options in diagnosing not only breast cancer but also a variety of other clinical conditions. And ultrasound may well be a stepping stone on the path to mammography. "The first step to getting there is creating a diagnostic and treatment pathway for these women," says Merry. From there, the goal is to expand to more proactive measures in combating breast cancer.

Guatemala

Background. Income distribution is highly unequal in Guatemala and greatly affects access to health care. With more than half of the population living below the poverty line and mammography affordable only for members of the relatively small upper- and middle-classes, the average woman has little or no access to this vital screening exam. In addition to the logistical obstacles, preventative medical treatment is not yet ingrained in the culture. Since women often wait to seek medical treatment until the notice a problem, demonstrating the value of screening becomes just as important as making such screening available.

Efforts. A variety of nonprofit organizations operate in Guatemala, taking on a range of health issues. Radiology Mammography International (RMI), founded by Richard N. Hirsh, MD, FACR, focuses on increasing Guatemalan women's access to mammography. "Are there more deadly diseases than breast cancer? Perhaps there are," says Hirsh, "but mammography is a service that we feel women are entitled to, especially as breast cancer has become the most common cancer affecting women in the entire world."guatemala

RMI works to increase screening rates by boosting access and increasing awareness about the importance of mammography. In August, Hirsh headed to Guatemala with a team of three radiologists, six technologists, one equipment engineer, and two women's health educators. Each member of the team played a valuable role in installing two donated machines, training the local medical staff, reading the resulting exams, and reaching out to the community.

Outlook. In terms of general health care and access to more modern imaging technologies, such as mammography, Guatemala remains among the most underserved countries in the region, with one of the lowest life expectancies at birth. In recent years, public health attention has increased the focus on preventative care across the health-care spectrum, including breast cancer screening. While a variety of NGOs work to increase breast cancer awareness and access to screening, much work remains to be done.

Chile

Background. Mammography is routinely available in Chile, particularly in the capital, Santiago. In rural areas, however, access is somewhat more limited.

Prior to 2005, the national program for breast cancer prevention centered around breast self-exams. Nevertheless, in the eight years since then Chilean women have been encouraged to seek imaging, and mammography has made great strides, though barriers still exist. Mary F. Wood, MD, a radiology resident at Eastern Virginia Medical School, conducted a survey of Santiago women and found that 35 percent perceive cost as a barrier to getting screening, followed by lack of time and "self-neglect" (translated from the Spanish term flojera, which refers to a lack of energy for things not considered essential). The study also found that women who reported higher incomes and those who were privately insured were more likely to get screening than those with lower incomes and other forms of insurance.chile

Efforts. A nationwide public-awareness campaign seeks to educate women about the benefits of mammography. October is Breast Cancer Awareness Month, and campaigns are very similar to those found in the United States. The National Breast Cancer Screening Program offers free mammograms to women between the ages of 50 and 54, in hopes of encouraging women to form the habit of seeking mammograms.

In Santiago, where most of the available data originates, a 2008 study found screening rates around 12 percent. Wood's study, done at the end of 2012, showed the rate at 55 percent. "A lot of improvement has been seen over a short period of time with the initiation of national health campaigns and public awareness," says Wood.

Outlook. "The future of mammography is Chile is very promising," says Wood. "From my experience, there is a great interest in public health in Chile. And there are a lot of proactive people in multiple fields working towards increasing screening and improving national health."


By Lyndsee Cordes

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