By Matt Skoufalos
At the best of times, bringing at-risk and underserved patients in for routine breast cancer screening can be a complex proposition. But during the novel coronavirus (COVID-19) pandemic, when elective imaging procedures were shelved as all of the health care world shifted to battling the virus, a new wrinkle emerged.
A pre- and post-COVID (March 2019 through May 2021) analysis of the U.S. National Mammography Database published in the Journal of the American College of Radiology (ACR) in August 2022 identified the impact of these shutdown. Screening mammograms were down 37 percent, diagnostic mammograms down 58 percent, breast biopsies down 47 percent, and cancer diagnoses down 49 percent, all as compared with pre-pandemic levels.
“Although diagnostic mammogram levels returned to near pre-pandemic levels … screening mammograms, breast biopsies and, most importantly, cancer diagnoses continue to lag,” wrote Dr. Lars Grimm of the ACR National Mammography Database (NMD) Committee in a summary.
“These findings are likely to have a major impact on future breast cancer outcomes,” Grimm wrote. “The cancer diagnosis deficit that started in the acute phase of the pandemic continues to grow in parallel with lower screening mammography utilization rates. Failure to diagnose smaller, screen-detected cancers will lead to more late-stage cancers in the future. Initial cancer registry data demonstrates a stage shift to later-stage breast cancers, and multiple modeling studies predict a corresponding increase in patient morbidity and mortality.”
As the nation recovers from the myriad impacts of the pandemic, there are specific concerns as to how breast imaging practitioners are handling the specific needs of their patient populations, particularly those who face barriers to accessing routine screenings.
Henry Izawa is president and chief executive officer of FUJIFILM Healthcare Americas Corporation. Izawa said that its clinical partners reported that some of their biggest post-pandemic breast imaging challenges have as much to do with roadblocks in staffing as with generating return visits from hard-to-reach, at-risk patients.
“There’s a lot of people who are not coming back to work among our clinician partners, especially the technicians,” Izawa said. “It’s a very big problem. I talk to a lot of rural and critical access hospitals, and the CEOs say, ‘My biggest fear is not money; it’s the fact that I can’t get staff.’ A lot of federally qualified health center (FQHC) facilities want to provide a line of service [like cancer screening], but they worry about staffing, so they don’t bother. Our fear is that if they stop providing services, the [screening] rate is going to go down more and more.”
The FUJIFILM response to short-staffed practice environments has been to focus on technological solutions that drive volume through efficiency and a consistency in image quality, with the intention of delivering reproducible results independent of staffing changes. By studying patient callback ratios and monitoring physician practices, the company found that its clinical partners could improve their study outcomes by re-training them to best position patients for their mammograms. Making those technical adjustments to how practitioners compress and position the breast helped improve efficiency while also helping patients feel more comfortable during the process.
“I think some of the work we’ve done has provided our customers with confidence that, regardless of personnel, they’ll be able to provide that efficiency, or spend more time with patients as they come back in order to build their relationship,” Izawa said.
FUJIFILM is also working in partnership with its potential customers to develop community health events that can drive awareness of the importance of annual breast cancer screenings while emphasizing technological solutions that promote patient comfort and confidence during the exams. DNA methylation-based liquid biopsy technology allows physicians to screen patients for cancer with a blood draw rather than a tissue sample, as in traditional biopsies. Technological advancements in digital breast tomosynthesis provide dense-breasted patients with additional insight into their cancer risk. Genetic profiling can help women with a family history of breast cancer to identify their risk levels on an individual level. FUJIFILM is also exploring dual-energy, contrast-enhanced, digital subtraction mammography technology, which offer a greater degree of accuracy in breast imaging. Discovering which patient groups are the best fit for which specific technological solutions helps improve their outcomes as well.
“There’s a lot of awareness of known technology that’s being used to provide personalized care for dense-breast patients, or higher-risk patients,” Izawa said. “There’s also a lot of newer technologies that are being introduced into the market. People are transitioning into how we use these technologies to drive more of a personalized care approach to screening.”
All these high-end technologies are leveraged in service of early cancer detection, but they can’t be put to use if patients aren’t able to access them. To that end, Izawa also spoke about the need for mammography vendors to support clinical outreach programs that help connect women who should be screened for breast cancer with the health systems that can facilitate those studies.
“We’re partnering with our potential customers and holding events to create more awareness of how important annual screening is,” he said. “The most important thing is driving early detection.”
As critical as public outreach is to bringing women in for breast imaging studies, Tricia Trammell, imaging operations manager at the UT Southwestern Medical Center of Dallas, Texas, believes that getting them to come back year after year means employing staff who can manage patient anxiety with sensitivity to the emotional intensity of their experiences. This is particularly significant given the lapse in studies conducted during the pandemic: patients either had to reckon with the fear of skipping a routine screening, and thus, potentially missing a chance for early detection of an abnormality, or else weighing the risk of contracting COVID-19 for a non-urgent health visit.
“After the height of the pandemic was over, when imaging services really ramped up again, many patients had a perceived sense of, ‘I didn’t have any testing done for this year and a half, and everything was fine,’ ” Trammell said. “ ‘Nothing happened to me while I didn’t have imaging, so what’s going to happen now? Will they find something because I didn’t stick to my annual screening schedule?’ ”
“Conversely, patients wondered if they were risking getting COVID from coming to the hospital or outpatient centers and being around other people, or should they delay longer and not be on their annual schedule and see what happens,” she continued. “Either way, you’re playing with fire, so that adds to the whole emotional factor that’s already underlying when you’re caring for and communicating with patients who are getting a mammogram.”
Trammell believes that the physical discomfort that patients experience during a mammogram is secondary to the psychological discomfort they may be more intensely feeling during the lead-up to the study and during the study. As important as the results of the test are, the heightened emotionality of the experience around the cancer screening process puts an even higher premium on patient interactions.
“Often when a patient states that she doesn’t want a mammogram because it hurts, or when she delays in scheduling the exam, what she’s really uncomfortable about it is the unknown,” Trammell said. “Until they receive a benign or no-findings result, they’re emotionally uncomfortable. The story hasn’t changed in the 22 years that I’ve been doing mammography: it’s about early detection, access to care, technology and great compassion for people.”
“I did breast ultrasound imaging this morning, and two of my patients were crying and shaking with fear,” she said. “I held their hands and hugged them and had an opportunity to remember why I am in this field; why I am in this industry. It’s to care for people and to help them through very scary situations.”
In addition to her imaging leadership role, Trammell is a certified patient navigator, a process that she believes plays a critical role in removing the barriers to care that keep patients from accessing the imaging technologies that can save their lives through cancer screening.
“If a patient doesn’t know or have access to that technology because nobody navigated them to that technology, the technology doesn’t mean anything,” Trammell said. “An imaging navigator is going to call when there’s an irregular mammogram, schedule a biopsy, hold their hand through that biopsy, call the patient with biopsy results and coordinate follow up care. It’s a game-changer as it relates to time between screening and diagnostic mammography, time between diagnostic and biopsy, and time between biopsy and surgical referral.”
Trammell points out that access to care has been a historic problem for some segments of the imaging patient population, and likely will continue to be so. For those reasons, she values community outreach programs that help either bring patients to imaging centers, or take the modalities into the community. But many mobile mammography programs were shut down or limited during the pandemic, which underscores the deficit that communities lacking access to imaging technologies continue to face.
“Most programs are now fully back up and running, and going full speed, but there’s no way to recover that year and a half that was lost,” Trammell said. “There’s no way to get it back. Now the focus is getting people back on their annual schedules, and finding any interval cancers that may have developed throughout that pandemic.”
Dr. Linda White Nunes is the University of Pennsylvania vice chair for inclusion, diversity and equity in the department of radiology as well as the division chief of abdominal imaging, Pennsylvania Hospital. She described the impact of “dual pandemics” — one that has chronically kept patients away from hospitals, and another that acutely limited the lines of service that hospitals were equipped to offer amid virus surges — on community health initiatives aimed at improving breast cancer screening for people who struggle to access imaging services.
“Sometimes it’s hard for us to separate the effects of the two pandemics,” Nunes said. “There’s a well-described delay in care associated with COVID. Even after that acute six to 12 months, people were fearful of coming back for things that weren’t urgent for fear of contracting COVID. We feel that we are just now making up for that time, and catching cancers that may have developed during that period.”
Nunes cited CDC reports of approximately 41 percent of American adults avoiding medical care, and 32 percent avoiding routing care during the pandemic; an in-house survey of patients presenting to a University of Pennsylvania breast imaging center found that 26 percent reported delaying care during the pandemic. Those affected were younger people who often had household responsibilities, or had contracted COVID themselves, she noted. In addition to the impact of the pandemic, Nunes also described the weight of the social unrest following the murder of George Floyd in police custody, which led to broader, louder discussions about health disparities and social determinants of health.
“People were not presenting at hospitals to get the screenings they should,” she said. “We chose to try to combine a community partner, a corporate partner, and ourselves, to see if we could get beyond the social determinants of health.”
Those partnerships proved fruitful. Siemens Healthineers North America provided the mobile imaging suite, delivered on a semi-trailer affectionately nicknamed “Mammo Mandy.” The Murrell Dobbins Career & Technical Education High School in the West Lehigh neighborhood of Philadelphia hosted one event, and the Community of Compassion CDC, a 5,000-member congregation in West Philadelphia, hosted another.
The first event was dedicated specifically to breast imaging, while the second provided breast, colon, and prostate cancer screenings, followed by another two weeks of onsite breast cancer screenings with the mobile unit. At Community of Compassion, the larger health fair also included opportunities for residents to undergo lung cancer risk assessments, familial or genetic risk assessments, and education about clinical trials and research.
“We wanted to both educate and screen on that day,” Nunes said. “Their leadership is really in touch and in tune with their community, and their community really trusts them.”
The events were both successful not only for their locations, which were well-known within the community, but also because of the connections their community partners had built within the neighborhoods. Nunes described the reach that the Community of Compassion has within the community as extensive and meaningful. In addition to the guests in the sanctuary, the church also livestreams its services to congregants, which brought in women from throughout the city.
“One of the people at the mammography van that day said she was home watching the livestream of the service,” Nunes said. “Between the pastor and the physicians saying how important it was, she said, ‘I’ve got to get out of this house, and get down there and get screened.’ Other people said a friend said the same thing to them.
“Having friends, community leaders and people you trust telling you, ‘You’ve got to do this and I’ll walk down there with you,’ that’s important,” she said.
Abigail Weldon, senior director of women’s health at Siemens Healthineers North America, said the partnerships proved fruitful for everyone involved.
“Penn Medicine is one of our most valued partners, especially in the Philadelphia area,” Weldon said. “We located the space, and provided the equipment and the project management – and 241 women got their mammograms in a two-week span with very little marketing.”
“That solidified for both Penn Med and Siemens that there is a need that I don’t think we’ve even quantified yet for us to be in inner cities,” she said. “Mobile mammography is not just for rural areas that don’t have access.”
When it comes time to measure the success of community initiatives like these, there are quantitative and qualitative takeaways, Nunes said. She pointed to the higher-than-expected number of cancers among patients post-pandemic as evidence that the programs are reaching people who do not ordinarily come in for routine screenings. Penn Medicine is working to create a program using a smaller mobile unit – one capable of rotating through the city on a regular schedule – to expand upon their successes.
“There are health centers that are not doing breast imaging, and you could roll up to their parking lot,” she said. “So we definitely see a lot of potential, and hopefully we’ll be able to give that type of program a try soon.”
Weldon also believes that any efforts that can be made to address health care disparities in general aree significant, and specifically those that have been exacerbated by the pandemic.
“We won’t know the true effect of the pandemic for years to come,” she said. “We are seeing health care providers also pivot to make up for the lost screening. I think that’s where we can have a sense of hope. There’s a lot of movement around getting these screening services to the non-traditional space.
“We were on a good path when it came to screening, and seeing less deadly effects of breast cancer,” Weldon said. “We need to be in more spaces when it comes to screening.”
