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Disparities in Access to Multimodality Breast Imaging Before and During the COVID-19 Pandemic

Published:September 04, 2022DOI:https://doi.org/10.1016/j.acra.2022.08.036
      The COVID-19 pandemic brought into the spotlight significant preexisting disparities in care throughout medicine, including Radiology; they most adversely affect racial minorities, patients of lower socioeconomic status, and those with no or inadequate health insurance (
      • Abraham P
      • Williams E
      • Bishay AE
      • et al.
      the roots of structural racism in the United States and their manifestations during the COVID-19 pandemic.
      ,
      • Abraham P
      • Bishay AE
      • Farah I
      • et al.
      Reducing health disparities in radiology through social determinants of health: lessons from the COVID-19 pandemic.
      ). The article by Nguyen et al., entitled “Addressing Disparities Related to Access of Multimodality Breast Imaging Services Before and During the COVID-19 Pandemic” explores the disparities specific to access of breast imaging services due to the pandemic (
      • Nguyen DL
      • Ambinder EB
      • Myers KS
      • et al.
      Addressing disparities related to access of multimodality breast imaging services before and during the COVID-19 pandemic.
      ). Sixty percent of breast imaging services were delayed for all populations during the first 6 months of the pandemic, and it is projected that this will have a small negative impact on breast cancer mortality by 2030 (
      • Nguyen DL
      • Ambinder EB
      • Myers KS
      • et al.
      Addressing disparities related to access of multimodality breast imaging services before and during the COVID-19 pandemic.
      ). This data is for overall populations but given some racial and ethnic minority populations (Blacks, Hispanics, and Native Americans) already have increased mortality from breast cancer it can be assumed that this will only compound the difference. In addition, breast cancer is the leading cause of cancer death in Hispanic women, but they had one of the lowest rebound screening mammography rates after the pandemic which is very concerning (
      • Sprague BL
      • Lowry KP
      • Miglioretti DL
      • et al.
      Changes in mammography use by women's characteristics during the first 5 months of the COVID-19 pandemic.
      ). This article is extremely important and should be used as a call to action for breast imaging departments to focus on addressing these now exacerbated disparities in these select populations.
      While we know that prior to the pandemic racial and ethnic minority groups utilized screening mammography at lower rates than whites. The reasons cited for this are cultural barriers, knowledge gaps, access, and transportation. We also know that rebound rates for screening in some racial and ethnic minorities were lower than for white women. Thus, we need to encourage these women back to regular mammography screening through aggressive interventions that address these barriers. As this article suggests we need to address cultural and knowledge barriers, which can be done with outreach activities to target knowledge gaps and cultural barriers in certain populations (
      • Nguyen DL
      • Ambinder EB
      • Myers KS
      • et al.
      Addressing disparities related to access of multimodality breast imaging services before and during the COVID-19 pandemic.
      ). Breast imagers need to mobilize and bring educational programing to churches and community centers where at risk populations are more common. Since access and transportation are issues for many minority and low socioeconomic status communities, breast imaging providers should consider using mobile mammography units to reach both urban and rural communities with limited access or difficulty with transportation. Mobile mammography units have previously been shown to increased adherence to screening in American Indian women in rural settings, a group that has not seen as decline in breast cancer mortality like other groups did with the advent of screening (
      • Roubidoux MA
      • Richards B
      • Honey NE
      • et al.
      Adherence to screening among American Indian women accessing a mobile mammography unit.
      ). In addition to screening mammography, Nguyen and colleagues also advocate for equal access to advance imaging technologies, such as screening MRI and ultrasound, which suffer from the same barriers to access in these populations (
      • Miles RC
      • Onega T
      • Lee CI
      • et al.
      Addressing potential health disparities in the adoption of advanced breast imaging technologies.
      ). Given that some of these populations are at increased risk for breast cancer, access to supplement screening can help with early detection and the resulting decreased mortality.
      Prompt follow up from screening mammography is essential, and this paper points out two ways for improvement in these populations; (1) ensure readability of patient letters from screening mammography facilities, (2) use patient navigators, and (3) offer same day work ups. Breast imaging departments need to make sure screening mammography result letters are readable for all literacy levels and available in all languages so that patients can understand the results of their screening mammogram and why they need to return for more imaging. Patient navigators play an important part in calling patients who need to come back for diagnostic imaging to both remind patients they need an appoint and to answer questions. This has been shown to increase the likelihood of follow up by a factor of three (
      • Nguyen DL
      • Oluyemi E
      • Myers KS
      • et al.
      Impact of telephone communication on patient adherence with follow-up recommendations after an abnormal screening mammogram.
      ). Lastly, if possible, performing same day interpretations of screening studies, and, if needed, same day diagnostic breast imaging and biopsy has been shown to mitigate disparities in racial/ethnic minority populations (
      • Dontchos BN
      • Achibiri J
      • Mercaldo SF
      • et al.
      Disparities in same-day diagnostic imaging in breast cancer screening: impact of an immediate-read screening mammography program implemented during the COVID-19 pandemic.
      ,
      • Dontchos BN
      • Narayan AK
      • Seidler M
      • et al.
      Impact of a same-day breast biopsy program on disparities in time to biopsy.
      ). All these interventions can help decrease the time from diagnosis to treatment of breast cancer in these vulnerable groups, which in turn can help decrease mortality from breast cancer in these populations (
      • Nguyen DL
      • Ambinder EB
      • Myers KS
      • et al.
      Addressing disparities related to access of multimodality breast imaging services before and during the COVID-19 pandemic.
      ).
      This review paper by Nguyen et al. is of great importance as it spotlights on not only the preexisting disparities in breast imaging that we must address, but it also demonstrates how the COVI-19 pandemic has exacerbated those differences, making it vital for breast imaging providers to start addressing these disparities now. All breast imaging departments should do a deep dive into their data to see where disparities exist at their institutions and use interventions like patient navigators, same day work ups, and other innovative ways to address disparities to ensure equitable breast imaging for all patients.

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