Immediate-read mammography program reduces disparities, ‘eliminates a huge barrier’
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The problem of racial disparities in cancer care is multifaceted, and clinicians or institutions seeking to address the issue may not know where to begin.
However, research scheduled for presentation at the virtual ASCO Annual Meeting suggests that even slight adaptations to cancer screening approaches can result in measurable improvements in health care equity.
The study by Constance D. Lehman, MD, PhD, professor of radiology at Harvard Medical School and chief of breast imaging at Massachusetts General Hospital, and colleagues evaluated the potential of an “immediate-read” mammography program to reduce racial disparities in time to diagnostic imaging following an abnormal screening result.
“There are many barriers to women coming in for screening mammograms, and there are many barriers to them coming back if they need a diagnostic workup,” Lehman said in an interview with Healio. “When we read and interpret the results with the patient at the time of the mammogram, it removes so many of those barriers.”
Lehman and colleagues implemented the immediate-read program in May of 2020, in response to the COVID-19 pandemic. They compared the time from screening exam to diagnostic mammography between 8,222 exams conducted before implementation of the program, from June through October of 2019, and 7,235 conducted after implementation, from June through October of 2020.
Median time to report finalization decreased from 61 minutes (interquartile range [IQR], 24-152) before implementation of the program to 4 minutes (IQR, 2-7) after implementation. Diagnostic accuracy of interpretation, as measured by abnormal interpretation rate, cancer detection rate and positive predictive value, all stayed within recommended quality metrics for screening mammography.
“Before we implemented this commitment, our patients of color were significantly less likely to have a same-day diagnostic mammogram when they had an abnormal screening mammogram,” said Janeiro U. Achibiri, MD, breast imaging and intervention clinical fellow at Massachusetts General Hospital and lead study author, adding that results showed an age-adjusted OR for patients of color vs. white patients of 0.28 (95% CI, 0.1-0.78). “That completely went away when we implemented the program. It has really opened our eyes to the fact that there’s so much we can fix, and there’s so much we can fix quickly.”
Lehman and study co-author Brian Dontchos, MD, radiologist at Massachusetts General Hospital, spoke with Healio about the improvements brought about by the program, what it might mean for the future and the value of making small shifts to produce big changes.
Healio: What inspired you to develop this program?
Lehman: The COVID-19 pandemic played a significant role. We thought the practice of “immediate reads” was too often reserved for a selected subset of patients and thought we could do better. That was always in the background, and then when we reopened our doors for screening after our COVID-19 shutdown, we realized how helpful it would be for patients to have their results before they left to conserve resources and avoid return trips to the clinics and added exposures to patients and to staff. So, that caused us to think, “why not offer our immediate-read program for all our patients coming in?”
We knew that this would particularly help our patients with more barriers to care. You hear people hypothesize about why people of color have delayed diagnoses. “Is it because they don’t trust the medical system?” “Maybe they’re more concerned about diabetes or hypertension.” “Maybe they don’t focus as much on wellness.” But, these explanations don’t account for the disparities at the institutional level. After the COVID-19 screening-clinic closings, we reopened our clinics across the country more rapidly in neighborhoods where typically our white patients and those with higher socioeconomic status have access. We were slower to open across the country in neighborhoods of what we think of as our traditionally underserved, most vulnerable patient populations.
Dontchos: In 2019, we published a study showing that same-day biopsy services for women with suspicious breast findings eliminated patient subgroup disparities in their time to tissue diagnosis, so we knew the potential of an immediate-read screening mammography program. Implementing this type of service can be challenging given the inherent unpredictability of when a patient will require additional imaging following an abnormal screening mammogram. However, if we truly want to impact systemic barriers to vulnerable populations, health care leaders must step up and make real change.
Healio: How might immediate-read mammography benefit Black women in particular?
Lehman: We know that Black women tend to be diagnosed with breast cancer at younger ages than white women. In terms of our screening recommendations, we hear arguments all the time about starting mammograms at age 40, 45 or 50 years, but these don’t consider a patient’s race. All of us — health care providers, insurers, hospitals, clinics, committees making guidelines — need to be more careful about these recommendations that were developed from studies of almost exclusively white women. If Black women develop cancer at earlier ages, but recommendations state that they should start at the same ages as white women, there is the possibility more cancers in younger Black women will be diagnosed at more advanced stages.
We have so many recommendations that are based on white women, recommendations that may or may not apply to Black women. Why haven’t we learned? There was a time when treatment for heart disease was based on studies of white men. And then we discovered that the risk factors, the presentation and targeted treatments for white men did not apply as well to white women, Black men or Black women. We learned from this and made some changes, but there are many areas, such as breast cancer screening and diagnosis, where we have a great deal of work to do to translate our high-level aspirations to our on-the-ground actions and results.
Dontchos: In a typical screening mammography practice, most abnormal screening exams do not result in a cancer diagnosis. Yet, an abnormal screening exam causes great patient anxiety and distress until a definitive diagnosis is made. Resolving abnormal screening exams in real time during the same visit ultimately benefits all our patients, but to a greater extent benefits our most vulnerable. Studies have shown time and time again that removing barriers to screening mammography improves participation. Offering same-day services eliminates a huge barrier.
Healio: Does physician bias play a role in breast cancer screening disparities?
Lehman: Yes. I think we’re all trying hard to wake up. I have been asked, “Do you think we have challenges with racism in health care?” I say yes, of course we do. Yes, there’s implicit bias. Yes, it’s ubiquitous. For example, as we implemented the immediate reads, as well as a same-day biopsy program, we wanted to make sure that everyone — our doctors, technologists, receptionists, schedulers — understood this is a good thing we can offer to all our patients. Because when we have unconscious bias and we see someone who seems a bit different, we might make assumptions. We might think, “Oh, she doesn’t really want to have the biopsy today,” or, “She probably needs to get back to her kids; she seemed worried about child care. I’m going to find another time this week when she can come back in.” That might or might not be true for that specific patient. I think we just need to check ourselves all the time, and we need to hold ourselves accountable by our data across all our quality metrics. We need to study our quality metrics across the diversity of patients we serve — by race and socioeconomic status. Collectively, we need to ask ourselves: Are we providing quality health care to the full diversity of the patients we serve? Do we have disparities in our service provision? Do we know? Our overall metrics may look fine, but not so great if we study them in our more vulnerable populations. That is where we can really start to identify our opportunities and challenges and develop strategies to effect real, measurable change.
What I liked most about this project and this practice change at our institution was it worked better for all of our patients. It was another great example of how health care teams could rapidly respond to the new challenges of the pandemic and also bring fresh perspective and creative solutions to age-old problems.
For more information:
Janeiro U. Achibiri, MD, Brian Dontchos, MD, and Constance D. Lehman, MD, PhD, can be reached at Massachusetts General Hospital, 15 Parkman St., Boston, MA 02114-3117; email for Lehman: clehman@partners.org.
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Achibiri J, et al. Presented at: ASCO Annual Meeting (virtual meeting); June 4-8, 2021.
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