Breast Health Series: Advocating for Equity in Breast Care
In this 4-part series, I sit down with Dr. Amy Patel and discuss the importance of prioritizing breast health.
We explore the challenges women face in managing their breast health, potential solutions for these challenges and we look to the future and the role technology can play in optimizing breast care.
Are confusing screening recommendations and COVID care delays a factor in the rising incidence of breast cancer?
Earlier this year the Centers for Disease Control and Prevention reported an 87% decrease in breast cancer screenings due to COVID. This information is for one month! It reflects data from April 2020 compared to the same month over the previous 5 years. It makes you wonder what that data looks like for all of 2020.
A quick Google search highlights a long list of studies and articles that tell us the same thing – screenings for the early detection of breast cancer are down due to COVID, especially in underserved communities. Combine this with confusing breast screening recommendations and we have a perfect storm leading to higher rates of breast cancer.
October, breast cancer awareness month, provides an opportunity to assess the larger scope of challenges women and the breast cancer community face in managing breast health. Earlier this month I interviewed Dr. Amy Patel, Medical Director of the Breast Care Center at Liberty Hospital. During our discussion she called out access to care, reaching underserved communities, care equity for women of color, breast cancer screening recommendations, COVID delays, and the increasing incidence of breast cancer as specific challenges that need to be addressed.
Each week during the month of October, I’ll share my conversation with Dr. Patel. My hope is that this information will motivate women to get their screening mammograms and inspire healthcare professionals to use their voices to raise awareness and drive change.
This week, in Part 2 of the Breast Health Series: Advocating for Equity in Breast Care, we’ll talk with Dr. Patel about solutions to address confusing breast cancer screening recommendations, COVID screening delays, and the increasing incidence of breast cancer.
Part one of the series, It takes a village… the breast cancer community, focused on the importance of breast health and the need for federal legislation to ensure equal access to breast care.
Breast Health Series: Advocating for Equity in Breast Care
Part 2: Are confusing screening recommendations and COVID care delays a factor in the rising incidence of breast cancer?
Kathleen: Building on your comment that breast health is multifactorial, let’s talk about the challenges women and the breast cancer community are currently facing.
Earlier in our conversation, you outlined three interrelated challenges that are concerning to the breast cancer community – inconsistent breast screening recommendations, the impact of COVID-19 on preventative screening, and an increase in the incidence of breast cancer.
When looking at breast screening recommendations, what can we do as a breast cancer community to get on the same page?
Dr. Patel: A lack of agreement on screening recommendations can be very conflicting and confusing for women. You have subspecialty groups like the American College of Radiology, the Society of Breast Imaging, the American College of Breast Surgeons, OB-GYNs, and ACOG recommending annual screening mammography in average-risk women starting at age 40 and continuing if you’re in good health and have a seven-to-10-year life expectancy. But then you have groups like the USPSTF (United States Preventative Services Taskforce) recommending mammography every two years starting at age 50, although they are revisiting those recommendations. Then the American Cancer Society says you should start routine screening at 45, but from 40 to 44, maybe have a discussion with your physician to see if you should start screening before age 45.
This is very confusing for women and that’s disconcerting in our world, especially if we have a patient that comes in at 50 plus, she’s got a pretty advanced cancer, and she was always told to start screening at 50. We could have potentially caught her cancer earlier. Also, it’s challenging because we, as a breast cancer community, are becoming more aggressive about screening recommendations. In 2018, the American College of Radiology and Society of Breast Imaging came out with recommendations for heightened surveillance in women beginning at age 30. Recommending that any woman of any color is risk assessed by 30.
I’d mentioned the USPSTF is revisiting its recommendations. They’re looking at more recent data and they’re particularly looking at data involving women of color. It’s really a great step that they’re revisiting these recommendations. And from a national level, the Society of Breast Imaging and the American College of Radiology put together letters to send to the task force, commending them for doing this and hopeful that we can get on the same page.
Making sure these national organizations are in touch with USPSTF and the major governing bodies in the house of medicine, I think is extremely important. That is why our lobbyists on Capitol Hill, for particularly the radiologists, the radiation oncologists, really are invaluable. They are there in D.C., and they’re able to be our voice when we are not able to physically be present. So that’s important.
Then, of course, organizations like the American Cancer Society, it’s important for us to get involved. I’m vice-chair of our American Cancer Society, Kansas City board; and although I don’t agree with the recommendations for screening, and my chair knows that my board knows that, our staff knows that, I feel like I’m in a position now where I have a seat at the table. I’ve been in discussions with the chief medical officer of the American Cancer Society, and I’ll be talking to the CEO soon. We need more clinicians like me to kind of go out on a limb. Do I think I will make a change by myself? Probably not. But if I can get more people to join me in this effort, and particularly again, people in positions of power, organizations in power, like ACR, SBI, I do think that we can get there someday.
We really do need to get on the same page for our patients. This will also help in terms of insurance coverage. If we can all get on the same page, CMS, private payers, they’re more likely to cover these things if we can all get on the same page together.
Kathleen: You talked about COVID as a challenge, noting that breast screenings dipped significantly during COVID? What can we do to reverse this trend and bring women back in for their breast screening?
Dr. Patel: I have heard many breast centers after we paused screenings in the spring and early summer of 2020, have built registries to flag patients that missed their screening during that period. They do outreach to these flagged patients to try to get them back in for follow-up care. And although some practices are still experiencing a backlog of patients, there are some breast centers around the country where they are caught up. However, women are still not coming in the door, even though we’ve resumed screenings. And I think recent statistics shared by the American Cancer Society show screenings are still down 13% compared to pre-pandemic levels. So, we still most certainly have work to do.
What we have tried to do, particularly with my practice, there are a lot of people still not feeling safe getting together, so we’re not doing in-person events, we’re trying to reach patients virtually. One of my other additional passions is social media. We’ve been doing a lot of social media outreach, for example, we teamed up with the American Cancer Society, Kansas City, and my chief medical officer who’s also an infectious disease specialist and head of our COVID task force. He did a video to talk about the safety measures that are in place in the breast centers. Not just ours, but other breast centers as well, and highlighted how important it is to get your mammogram and not to delay life-saving screenings.
Diacom Dialogues Podcast: Taking Control of Your Breast Health
If we can have people in positions of leadership, such as our CMO, experts in the field of infectious disease, or experts on the virus, to give that sort of reassurance, or if you’re a CEO of a hospital system or if you are a medical director or a section chief of breast, to get out there and say… this is what we’re doing to keep you safe, so come in for your routine screening. I think that provides a lot of reassurance. For us, that has definitely helped. Also, what’s been beneficial is making sure we have good relationships with our primary care providers. We know that our patients have a very strong relationship with their OB-GYNs, with family practice, internal medicine, and that patients listen to their guidance in terms of getting screened.
So really forging relationships with our primary care doctors, with the OB-GYNs is very, very important so that they can work together with us to talk to patients, to counsel them, and let them know it’s safe to go and get your mammogram.
Kathleen: One of the other challenges you mentioned was an increase in the incidence of breast cancer. Why do you think that’s happening and what can we do to address this increase?
Dr. Patel: The incidence of breast cancer is going up, which is worrisome. Back in the 1980s and 1990s, we saw an uptick in cases. In the 2000s however, with the advent of new treatments, particularly in the field of medical oncology, we started to see the numbers coming down. And so, we’ve had a good 10 to 15 years where numbers are coming down, but now we’re seeing an increase in the incidence of breast cancer of about 0.3% a year. So that is also a challenge.
Again, I think there are multiple layers to the increase we are seeing. I think women not coming in for their screening is one component and COVID is, unfortunately, exacerbating that. Patients losing their jobs and therefore insurance coverage may not be going to get the examinations that they need. That’s one component.
I also think that we’ve got to continue to devise imaging that can detect cancers at the earliest point. I think we’ve done great work in the advent of digital breast tomosynthesis; we see across the board an increase in the cancer detection rate. This has been really, really wonderful across various practice types and geographical locations. I think even novel technologies such as abbreviated breast MRI (AB-MRI), which is a more comfortable exam for a woman, have also been amazing and I think will be another game-changer in early detection and help address the increase we are seeing in breast cancer rates.
Abbreviated Breast MRI from Holland Hospital
And then technologies like artificial intelligence will, of course, be an important part of the future. On the oncology side, continuously working on inventing therapeutic agents that can combat very aggressive cancers. I would say 10 to 15 years ago, for a woman who had triple-negative breast cancer, there was not much hope nor treatments options. But now, today in 2021, we have options for women with triple-negative breast cancer and they can do well. So just in a short amount of time, we’ve come up with new, inventive therapeutic agents for our patients.
We’re going to have to work together, whether it’s medical oncology, the radiology side, the surgical side, we’re going to have to continue to come up with more and more innovative tools to better serve our patients and manage the increase we’re seeing in the incidence of breast cancer.
What are your thoughts on ways to increase routine breast screening? Has your facility implemented a program that’s worked well to get women in for screening appointments post COVID? Share your ideas and questions in the comments below, as Dr. Patel told us last week, it takes a village.
In Part 3 of the Breast Health Series, I’ll talk with Dr. Patel about access to care, reaching underserved communities, and driving care equity for women of color.
Join us here next week, there’s lots more to discuss!
This series is based on an interview with Dr. Amy Patel and has been lightly edited for written clarity.