Patient Diversity in Breast Imaging: Barriers and Potential Solutions

Raising Cultural Awareness and Addressing Barriers to Breast Imaging Care for Black Women

Health care disparities, which are differences in the attainment of full health potential among population groups, have been documented across medical conditions, clinical settings, and diagnostic and treatment modalities. Deeply rooted health care disparities due to many factors have affected how Black women (BW) view medical care including screening mammography. This article explores health care disparities around breast cancer in BW and how patient distrust, provider biases, race, and social determinants of health continue to have negative effects on breast cancer outcomes in BW, despite medical advances in breast cancer detection and management. In addition, this article addresses the importance of culturally competent care for BW around breast cancer awareness, screening, and treatment, and offers strategies to address disparities and rebuild trust.

Community Outreach in Breast Imaging: What Radiologists Can Do to Close the Gap for the Uninsured Population

After implementation of the Affordable Care Act in 2010, the uninsured population of the United States decreased significantly. As of 2022, there were approximately 26.4 million uninsured individuals in the United States. The lack of coverage and access to services disproportionally affect minority groups in the country, reflecting the influence of the social determinants of health in their uninsured status. Use of screening mammography, an effective modality that results in early detection of and decreased mortality from breast cancer, was delayed or postponed by women of all races due to lockdowns and fear during the COVID-19 pandemic. Since then, the return to mammographic screening has lagged among minorities, further increasing their disproportionate screening gap. Radiologists-and more specifically breast imagers-must recognize these issues, as people who are uninsured and part of minority groups are diagnosed with breast cancer at later stages and have higher mortality rates, less continuity of care, and overall lower survival. The purpose of this article is to familiarize radiologists with the uninsured population, explain how they are disproportionally affected by breast cancer, and propose strategies that breast imagers can pursue to improve screening access and decrease compliance gaps for this patient population. ©RSNA, 2023 See the invited commentary by Nguyen in this issue. Quiz questions for this article are available through the Online Learning Center.

Patient-centered Care: Value Added by Breast Radiologists in the Management of Breast Pain

With the shift of the healthcare system toward patient-centered, value-based care, the role of the breast radiologist is essential and increasingly multifaceted. Beyond sole image interpreters, breast radiologists serve as subject matter experts within multidisciplinary care teams, acting as advocates and initiators into the healthcare system and providing patient-centered care through effective communication and patient education. These vital roles are well demonstrated through the imaging evaluation and management of the most common breast symptom that affects the majority of the patient population-mastalgia. By leveraging the opportunities provided during the evaluation of the symptomatic breast to optimize patient communication and education, as well as integration of care delivery, breast radiologists add significant value to patient care and ultimately improve patient outcomes.

Cultural Competence in the Care of LGBTQ+ Patients: A Primer for Breast/Chest Centers

The number of individuals identifying as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) has doubled over the past 10 years, and this figure continues to rise. The LGBTQ+ community is diverse, encompassing a vast array of differences in gender identity and sexual orientation. Additionally, it is inclusive of people from all races, ethnicities, religions, and socioeconomic backgrounds. This intersectionality of identities and experiences impacts both access to health care and its delivery. Barriers to care for this population are multifactorial and include stigma, discrimination, bias, limited role models, issues with insurance coverage, lack of education and training for health care providers, and lack of research on LGBTQ+ health-related issues. Specific to breast cancer, the screening recommendations for this group are influenced not only by risk but also by gender-affirming hormonal and surgical therapies. This article will provide an overview of the LGBTQ+ population, review breast cancer screening compliance and recommendations, summarize the multitude of health disparities, and offer potential interventions to improve care delivery at the individual, facility, organizational, and health policy levels.

Identifying and Reducing Barriers to Breast Imaging

Purpose of Review

The purpose of this review is to discuss disparities in breast health care access and outcomes related to race, gender, cultural diversity, sexual orientation, socioeconomic status, geographic location, and disability. The authors recognize the complexity of eliminating inequalities in health care but are optimistic that all patients will one day have equal access to care through dialogue, acknowledgment, recognition, and action.

Recent Findings

After lung cancer, breast cancer is the second leading cause of death among American women. Mammography as a preventative screening tool has resulted in significant reductions in breast cancer mortality. Despite existing breast cancer recommendations, it has been projected that 43,250 women will die from breast cancer in 2022.

Summary

Disparities in healthcare outcomes exist for many reasons including inequalities based on race, gender, cultural diversity, religion, sexual orientation, and socioeconomic status. Disparities, no matter how large or complex, are not insurmountable.

Surveillance Imaging after Primary Diagnosis of Ductal Carcinoma in Situ

Background Guidelines recommend annual surveillance imaging after diagnosis of ductal carcinoma in situ (DCIS). Guideline adherence has not been characterized in a contemporary cohort. Purpose To identify uptake and determinants of surveillance imaging in women who underwent treatment for DCIS. Materials and Methods A stratified random sample of women who underwent breast-conserving surgery for primary DCIS between 2008 and 2014 was retrospectively selected from 1330 facilities in the United States. Imaging examinations were recorded from date of diagnosis until first distant recurrence, death, loss to follow-up, or end of study (November 2018). Imaging after treatment was categorized into 10 12-month periods starting 6 months after diagnosis. Primary outcome was per-period receipt of asymptomatic surveillance imaging (mammography, MRI, or US). Secondary outcome was diagnosis of ipsilateral invasive breast cancer. Multivariable logistic regression with repeated measures and generalized estimating equations was used to model receipt of imaging. Rates of diagnosis with ipsilateral invasive breast cancer were compared between women who did and those who did not undergo imaging in the 6-18-month period after diagnosis using inverse probability-weighted Kaplan-Meier estimators. Results A total of 12 559 women (median age, 60 years; IQR, 52-69 years) were evaluated. Uptake of surveillance imaging was 75% in the first period and decreased over time (P < .001). Across the first 5 years after treatment, 52% of women participated in consistent annual surveillance. Surveillance was lower in Black (adjusted odds ratio [OR], 0.80; 95% CI: 0.74, 0.88; P < .001) and Hispanic (OR, 0.82; 95% CI: 0.72, 0.94; P = .004) women than in White women. Women who underwent surveillance in the first period had a higher 6-year rate of diagnosis of invasive cancer (1.6%; 95% CI: 1.3, 1.9) than those who did not (1.1%; 95% CI: 0.7, 1.4; difference: 0.5%; 95% CI: 0.1, 1.0; P = .03). Conclusion Half of women did not consistently adhere to imaging surveillance guidelines across the first 5 years after treatment, with racial disparities in adherence rates. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Rahbar and Dontchos in this issue.

Culturally Competent Care in the Breast Imaging Clinic: Hispanic/Latino Patients

Hispanic/Latino people represent 19% of the U.S. population, and this proportion is expected to increase to 26% by 2050. Hispanic/Latino people comprise a diverse ethnic group that includes individuals from all races, religions, languages, cultural identities, and nationalities. Barriers to health care that have created significant disparities in this community include language, low socioeconomic status, and inability to afford health insurance. Health coverage for Hispanic/Latino people has been a longstanding problem in the U.S., stopping many of these patients from seeking preventive care such as screening mammography. Breast cancer is the most common cancer among Hispanic/Latino women in the U.S. and the leading cause of cancer death in this group. Five-year breast cancer survival in Hispanic/Latino women is slightly lower than that in non-Hispanic White women. Some of the factors that account for the ethnic disparities in breast cancer include lower levels of adherence to screening mammography of Hispanic/Latino women as a consequence of inadequate insurance coverage, language barriers, lack of transportation, being unable to leave work, and lack of childcare. By promoting a culturally sensitive clinical environment, breast radiologists can increase patient engagement, utilization of preventive services, treatment adherence rates, and overall health status.

Disparities in the use of screening breast magnetic resonance imaging persist in Louisiana after the Affordable Care Act: A question of access, policy, institutional support, or something else?

BACKGROUND

Louisiana continues to have one of the highest breast cancer mortality rates in the nation, and Black women are disproportionally affected. Louisiana has made advances in improving access to breast cancer screening through the expansion of Medicaid. There remains, however, broad underuse of advanced imaging technology such as screening breast magnetic resonance imaging (MRI), particularly for Black women.

METHODS

Breast MRI has been proven to be very sensitive for the early detection of breast cancer in women at high risk. MRI is more sensitive than mammography for aggressive, invasive breast cancer types, which disproportionally affect Black women. Here the authors identify potential barriers to breast MRI screening in Black women, propose strategies to address disparities in access, and advocate for specific recommendations for change.

RESULTS

Cost was identified as one of the greatest barriers to screening breast MRI. The authors propose implementation of cost-saving, abbreviated protocols to address cost along with lobbying for further expansion of the Affordable Care Act (ACA) to include coverage for screening breast MRI. In addition, addressing gaps in communication and knowledge and facilitating providers' ability to readily identify women who might benefit from MRI could be particularly impactful for high-risk Black women in Louisiana communities.

CONCLUSIONS

Since the adoption of the ACA in Louisiana, Black women have continued to have disproportionally high breast cancer mortality rates. This persistent disparity provides evidence that additional change is needed. This change should include exploring innovative ways to make advanced imaging technology such as breast MRI more accessible and expanding research to specifically address community and culturally specific barriers.

Breast Cancer Screening and Outcomes Disparities Persist for Native American Women

Over the past three decades, mortality rates from breast cancer have decreased for multiple racial groups but have remained constant for American Indian and Alaskan Native (AI/AN) women. Additionally, AI/AN women are less likely to receive timely breast cancer screening and are more likely to be diagnosed with advanced stage breast cancer at younger ages than their White counterparts. These disparities can be explained, in part, by the unique barriers to accessing care faced by AI/AN women. The Indian Health Service provides care to many AI/AN patients; however, their scope of practice is limited, and the service is chronically underfunded, leaving many women without appropriate and timely care. Additionally, geographic access to care is limited because of the sparsity of clinics and limited transportation resources. American Indian and Alaskan Native patients also harbor a history of mistrust in health care systems, and there is a paucity of culturally sensitive education regarding the importance of screening. There have been some grassroots efforts to address these barriers; however, large-scale coordinated efforts are lacking. In order to provide equitable breast health care, more awareness and widescale initiatives are needed and can be championed by breast radiologists.

A Needs Assessment for Inclusion, Diversity, and Equity: Survey Results of the Society of Breast Imaging

OBJECTIVE

To assess and understand the inclusion, diversity, and equity (IDE) needs of the Society of Breast Imaging (SBI) membership to guide development of a strategic plan and goals for the Inclusion, Diversity, Equity Alliance (IDEA) of SBI.

METHODS

A 23-question survey developed by IDEA was distributed electronically to all SBI members in November 2020 to assess and understand the society's IDE needs. Descriptive statistics were used to summarize the responses. Open-ended responses were reviewed by the authors and sorted into three categories: supportive, nonsupportive, or neutral suggestions.

RESULTS

The response rate was 12% (453/3686). Only 55% (238/429) of respondents agreed that the diversity of SBI leadership reflected the diversity of the society, with stronger agreement that actions of SBI aligned with their core values of collaboration and collegiality (327/249,75%), and of respect for diversity and inclusiveness (303/429, 70%). Overall, 65% (172/264) of respondents were satisfied with the quality and diversity of speakers at the annual symposium; however, White respondents agreed more compared to non-White respondents (P = 0.035), and those practicing greater than 20 years agreed more compared to those practicing 6 to 10 years (P = 0.023). Of 88 total suggestions, three common themes were: more resources for recruitment, retention, and education for a diverse staff; further increase in diversity among leadership and membership; and more patient care resources.

CONCLUSION

In addition to showing areas of agreement by SBI members, this survey also identified opportunities for SBI and IDEA to further incorporate IDE into our initiatives and organization.