By Matt Skoufalos
Throughout the United States, health care, like many other resources, is unevenly distributed. In eastern Tennessee, at the foothills of the Appalachian Mountains, that truth is plainly spelled out in some of the most needy communities in the state. There, surgical oncologist John Bell has worked to drive down the disproportionate incidence of advanced-stage diseases among residents of the region, a staggering fact that manifested itself in epidemiological data he first explored 25 years ago.
Bell runs the University of Tennessee Medical Center (UTMC) Cancer Institute Breast Health Outreach Program (BHOP), a community outreach health initiative that he said sprang from a conversation with the then-director of the UTMC pastoral care program, the Reverend George Dobbler.
“Since he was clergy, and we live in the Bible Belt, we thought the best way to start this program was through the churches, where people generally listen to what the pastor has to say,” Bell said. “I began to look at different counties that touched our service area, and identified some that we thought were not meeting, from a statistical point of view, anticipated numbers of new cases.”
With financial backing from cosmetics companies Avon and Revlon, Bell launched the BHOP mobile mammography service in two east Tennessee counties. Today, it serves about 20 of them with a combination of health education and cancer screening services. With the help of community outreach organizations, BHOP seeks opportunities to deliver those services to some of the people least likely, for reasons of time and financial resources, to get them. Their common barriers to access are financial, emotional and, often, physical.
“The education level here is not generally what you’re going to find in an more ‘sophisticated’ urban area,” Bell said. “You’re going to find a high percentage of working-poor women, who don’t have the means, time, or knowledge to get to an imaging facility – if they’re trying to go to a facility – and then they often have to overcome their initial fears.”
In addition to its dedicated technical and medical staff, BHOP breast health educators are versed in early warning signs of breast cancer and self-examination techniques. They can teach patients how to identify breast abnormalities, and they provide didactic, hands-on education that Bell described as better than “throwing some brochures on a table” at a health fair.
“Our employees are some of the most dedicated people I’ve ever come in contact with,” he said. “What they do and what they give up, being ready to teach a class at 6 a.m. after these women get off the night shift … I cannot say enough about the staff that supports this program. It’s a full, comprehensive service.”
Many women most in need of breast cancer screenings can’t take time off work to schedule a mammogram. This includes shift workers and single parents upon whom households depend financially. Given a cancer diagnosis, many also wouldn’t be able to take time off work to receive appropriate treatment. So they avoid mammography for fear of discovering a problem.
“I think it boils down to one word: fear. They are afraid of what they’re going to find out,” Bell said.
“They’re afraid of what treatment they might have to undergo because there’s still a lot of antiquated thoughts in some of these rural areas,” he said. “They think about the side-effects of treatment, and it’s hard for them to understand that the diagnosis of breast cancer is not a death sentence; that early diagnosis leads to care. Treatment options have come so far that surgery is not mutilating; oral anti-cancer agents have minimal-to-no side effects and allow people to continue to work and care for their families while they’re being treated.”
“It’s overcoming this fear of what they might find and talking them off the ledge that leads them to obtain the education and screening that can be life-saving,” Bell said.
More than talking women off the ledge, however, BHOP has made a noticeable dent in the number of cancers that otherwise wouldn’t have been detected among a population least equipped, resource-wise, to face the disease. In its early days as a two-county pilot project, BHOP screened 60 women and found two cancers. Of those cases, many were in their advanced stages. After 25 years, “it’s pretty rare that we find anybody that’s beyond a Stage I or II,” Bell said.
Since 2002, BHOP has averaged approximately 2,200 mobile mammograms per year, with 2018, in which 3,548 mobile studies were conducted, its busiest yet. Anywhere between 6 and 10 percent of those studies are the first mammograms patients have ever undergone – about 200 per year, Bell said – and many of the women screened today are return customers, which demonstrates the need for those services.
At the heart of the mobile program is a 3D tomography system. Bell estimates the mobile units have traveled about a quarter-of-a-million miles since 2005. Soon, the 3D equipment will be transferred to a new vehicle, “and we’re going to keep working,” he said. Operating with a state-of-the-art diagnostic tool offers a multitude of benefits, Bell said. It enables BHOP screeners to find cancers earlier and yields better-quality images, reducing the rate of callbacks, lowering the cost of performing the studies, and offering a higher likelihood of detecting multiple tumors. It’s kept in tip-top shape by a dedicated service staff, Bell said.
“We QA that piece of equipment every time we roll it out, we digitally transmit those images back to our home center, and the images are read within 24 to 48 hours,” he said. In the event that a study reveals the need for follow-up, BHOP nurse navigators “reach out to each patient and make sure they don’t fall through the cracks,” Bell said.
“In the final analysis, all the program is trying to do is to provide a service to women that are otherwise underserved, hoping to find breast cancers early and save lives,” Bell said.
Similar to the efforts undertaken by BHOP, Texas-based nonprofit The Rose has been working to improve awareness of breast cancer and access to diagnostic screening tools since 1986. Headquartered out of Houston, The Rose focuses on delivering breast imaging services to women who lack the ability to pay for those services, especially those living in rural communities.
Chief Operating Officer Bernice Joseph estimates that its mobile mammography program, which has been operating since 2006, performs anywhere from 8,500 to 10,000 mammograms a year, backed in part by state funds and those from independent foundations, like the Susan G. Komen Foundation.
The Rose started out with a small van containing portable imaging equipment; today, the organization operates a fleet of 40-foot coaches equipped with mobile mammography systems on par with those in its fixed-site, ACR-accredited breast centers of excellence. Onboard counselors provide a network of additional support services, from clinical education to follow-up services, for the women screened at The Rose outreach events. Today, of the 40,000 patients seen annually by the agency, roughly a quarter of them are screened through its mobile mammography program.
“We believe that all women, regardless of whether they are insured or uninsured, should have access to 3D imaging,” Joseph said.
Jessica Duckworth, The Rose’s director of imaging and mobile services, estimates that its mobile units cover a geographic area of more than 30,000 square miles in a 40-county radius. It’s not uncommon for the mobile coach and its staff to spend six hours a day on the road, out and back, to communities where 3D mammography and computer-aided cancer detection systems may otherwise be inaccessible to locals. When using such high-end technology to deliver high-stakes screenings, “one of the first and foremost things you have to be able to do is create trust,” Joseph said.
Just like with BHOP, a lot of that work is done through a network of partners on the ground. Community organizations – federally qualified health centers, charity clinics, physician’s offices, United Way chapters, employers – not only help drive attendance on the days the vehicle is in town, but they also identify which patients might need help covering the cost of the studies.
“Here we are driving up from the big city of Houston,” Joseph said. “We have the funding to be able to provide those services at no cost to the patient, but what we need is a community partner to get the women there.”
“We also find people who want to support us by helping us fund that uninsured care,” she said. “If [Duckworth] finds something on that screened mammogram, we can take the patients back to our centers.”
“It doesn’t help to tell an uninsured woman we saw something that needs more study,” Joseph said. “We have a place for her to get that care.”
In the future, Joseph anticipates forming additional clinical partnerships with practitioners who can provide other health screening services “that many women may never have the opportunity to take advantage of,” from gynecological care to mental health; even genetic counseling.
“We talk to a lot of different organizations about what they think might work in their community, but our biggest challenge is what do they think they might need, and how do we improve the health of the community,” she said. “For us, the evaluating process is just as important as the screening process.”
Economically vulnerable women don’t only exist in rural areas, as Laurie Margolies, chief of breast imaging for Mount Sinai Health Systems, can attest.
In 2016, when the New York State Department of Health and Health Research Inc. announced a multi-million-dollar funding opportunity to create six mobile mammography vans, Margolies drafted a winning proposal on behalf of Mount Sinai Hospital. In October 2018, the health system rolled out its mobile mammography program (MMP); inside a year, it’s connected with 1,600 patients and identified six cancers that may have otherwise gone undiagnosed.
“We go out, five or six days a week,” Margolies said; “to every borough of New York City at least once a month.”
“In the urban areas, just like in the rural areas, there are many barriers to health care access, and screening mammography is one of those areas that can be greatly impacted by bringing a mobile mammography van to an area,” she said.
The Mount Sinai MMP van is equipped with the same high-quality imaging equipment the organization uses in its fixed site, a Hologic 3Dimensions mammography system. A team of drivers, technologists and patient navigators offers a complete suite of services for women seen through the service, and Margolies oversees 14 radiologists who interpret the studies the MMP generates. Mount Sinai coordinates follow-up services for patients whose mammograms show a need for further investigation.
“It reaches people who are distressed or unable to access care otherwise, and in a very cost-efficient way,” Margolies said.
The cost of an annual mammogram typically is covered by health insurance, and CDC grants administered by the New York state cancer services program are available to help those patients who are uninsured. The MMP “really addresses some of the patients’ needs by not having to travel, by not having to make an appointment or have a prescription, and without concern for their insurance status, for the most part,” Margolies said.
As in other mobile mammography programs, Mount Sinai’s leverages partnerships with community organizations to identify vulnerable audiences that otherwise might not have access to breast cancer screening services. Those community connections bridge service providers and the populations they support, and also help acclimate patients to the MMP who have never participated in a mobile health care screening.
“Allowing the mobile bus to be partnered with people they trust, be it a health care facility, a religious organization or a community center, really helps patients who may have a distrust of the whole medical health care infrastructure to overcome that and get the necessary screening,” Margolies said.
“Community organizations have been incredibly grateful that this service is available for their constituents,” she said. “Sometimes people are a little bit hesitant to get their medical care on a mobile unit, but once they’ve done it, the research shows that they are uniformly very happy with the care they’ve received.”
Vitally, the MMP has helped individual patients who were reluctant to be screened for breast health, or who had dismissed mammography as unnecessary because they had no family history of breast cancer. Unfortunately, as Margolies noted, most breast cancer patients have no family history of the disease.
“They were very afraid, but they are incredibly grateful that things are caught,” she said.
Perhaps most importantly, Margolies said, the very presence of a mobile mammography unit can remove barriers to screening that are self-imposed by patients.
“One woman knew that she needed a mammogram, and her doctor was telling her to get one, and when the bus was in front of her, she didn’t have any excuse any more,” she said.
“It’s invaluable to the patient, and in health care, helping patients is our goal.”