Shortly before her 40th birthday, a woman visits her primary care physician and is advised she should schedule her first mammogram. The patient is puzzled and says she “read somewhere” that she can wait a few years. The physician has heard this before and kindly convinces the patient to comply with the recommendation. She agrees, schedules the mammogram and receives her results before even leaving the imaging facility.
Scenarios like this happen all the time in healthcare and are representative of how patient engagement strategies are being leveraged to bolster patients’ receptiveness to cancer screening, in turn increasing scanning utilization rates.
“Several factors currently keep these rates from being what they should be, but patient engagement has the potential to change things,” says Debra Monticciolo, MD, professor of radiology at Texas A&M Health Science Center College of Medicine in Bryan, Texas, vice-chair for research and section chief of breast imaging in the department of radiology at Baylor Scott & White Healthcare in Temple, Texas, and chairman of the American College of Radiology (ACR) Breast Imaging Commission.
Statistics indicate that breast cancer screening utilization rates are neither on an upswing nor what they could be. For example, a Mammography Quality Standards Act (MQSA) and Program Scorecard released by the U.S. Food and Drug Administration (FDA) last year pegs the total number of annual mammography procedures reported as of Jan. 1, 2016 at 39.1 million. The number edged up to 39.2 million as of Jan. 1, 2017.
Additionally, racial disparities remain in the use of screening mammography in the U.S. According to a study published in the Journal of the American College of Radiology, African American and Hispanic populations have lower odds of utilizing screening mammography when compared with the white population (J Am Coll Radiol. 2017 Feb;14(2):157-165.e9). The authors cited odds ratios of 0.81 for African American women and 0.83 for Hispanic women, both with a confidence level of 95 percent. Their review and meta-analysis was based on more than 5.8 million patients across 39 different studies; of these patients, more than 43 percent were Caucasian, more than 33 percent were African American, more than 17 percent were Hispanic, and more than 6 percent were Asian/Pacific Islander.
Factors Working Against Better Engagement
Multiple obstacles appear to preclude improvements in these rates, with disparate scanning recommendations and guidelines topping the list. When it comes to mammography, “conflicting information is a major catalyst in keeping women away from having an initial scan and often subsequent ones,” says Elizabeth A. Morris, MD, chief of the breast imaging service and Larry Norton Chair at Memorial Sloan Kettering Cancer Center in New York City and professor of radiology at Weill Cornell Medical College, also in New York City. Morris, who serves as president of the Society of Breast Imaging (SBI), adds that media coverage of the issue only exacerbates matters because “no one reads beyond the headlines.”
Fear of the unknown and a desire to avoid unnecessary stress from recalls comprises yet another impediment to breast cancer screening utilization.
“Many women rationalize that there is no need to ‘endure’ all of this worry at 40, so they choose the recommendation that says it is fine to start at 45 or 50,” Monticciolo says.
In addition, a recent study published in Cancer Epidemiology, Biomarkers & Prevention showed that women who experience a false-positive mammogram are more likely to delay their next mammogram or even skip it altogether (Cancer Epidemiol Biomarkers Prev. 2017 Mar;26(3):397-403.) The study revealed that women who had a true negative mammogram result were 36 percent more likely to return for another mammogram within three years than those who had a false-positive mammogram.
Morris points to the financial constraints of patients, a lack of insurance and high co-pays as three significant factors that contribute to poor breast cancer screening utilization rates. In addition, she says, these same factors add to the disparity between breast cancer screening utilization by Caucasian women and breast cancer screening utilization by African American and Hispanic women.
The disparity, Morris adds, also stems from the fact that screening guidelines seem to have been developed primarily with Caucasian women in mind.
“Younger black women have a higher tendency than white women to develop triple-negative breast tumors, so scanning should absolutely be early in this population,” Morris says. “Yet as we know, the guidelines do not account for it.”
But specialists are quick to highlight the fact that not all obstacles to higher incidences of mammography procedures originate with patients; practitioners are also to blame. Some referring physicians, Morris notes, are as confused as their patients about breast cancer screening guidelines. She says many general practitioners do not read professional journals or other materials that may increase their understanding of screening parameters. Additionally, she has encountered radiologists who are “uncomfortable with discussing the screening literature” and advising patients about screening.
Lags in Lung Screening
Recent years also have seen little improvement in lung cancer screening utilization rates, according to a recent study published in JAMA Oncology (JAMA Oncol. 2017 Feb 2). The study found that the proportion of eligible current and former smokers who reported having had a low-dose CT study based on United USPSTF recommendations (individuals ages 55 to 80, with a 30 pack-year smoking history calculated by multiplying the number of packs of cigarettes smoked daily by the number of years the person has smoked) remained consistently low between 2010 and 2015, rising from only 3.3 percent to 3.9 percent. With these figures in mind, the authors of the study estimated that a mere 262,700 of the 6.8 million current and former smokers who were eligible for lung cancer screening in 2015 actually received it.
According to Ella A. Kazerooni, MD, professor of radiology, associate chair of clinical affairs, service chief for adult radiology, director of cardiothoracic radiology and chair of the Radiology Service Excellence Program at the University of Michigan in Ann Arbor, there are several culprits at work here.
“Unlike breast cancer screening, lung cancer screening is new, and it will take several years, if not more, for us to have enough data connecting lung cancer screening with decreases in lung cancer mortality to make a convincing argument” for increased patient acceptance, she says.
Kazerooni, who also chairs the ACR Lung Cancer Screening Committee, the ACR Thoracic Imaging Panel and the American Cancer Society Lung Cancer Screening Panel, adds that many patients who should be screened for lung cancer “do not understand the benefits of the test” and would likely be “hard-pressed to take the time from work to undergo it, particularly if they are of limited means.” At the same time, she adds, lung cancer screening service is yet to be up-and-running at every hospital and large imaging practice.
Jamie L. Studts, PhD, assistant professor of medicine at the University of Louisville School of Medicine and director of the Behavioral Oncology Program at the James Graham Brown Cancer Center in Louisville, Ky., observes that some patients shy away from lung cancer for another reason: embarrassment.
“One thing we have seen is that in the smoking population, there is shame that they could have brought cancer upon themselves, and they are reluctant to even acknowledge it through screening,” he says.
Driving Engagement Through Education
Studts and others agree that while patient engagement is not the sole antidote to sluggish screening utilization rates for breast and lung cancer, it is a powerful one—and it starts with giving physicians the base of knowledge needed to build a stronger case with patients for undergoing appropriate tests at the appropriate time.
Stamatia Destounis, MD, a faculty member at Elizabeth Wende Breast Care in Rochester, N.Y., regularly confers with referring physicians by telephone to discuss mammographic screening and how it will benefit individual patients. The practice also holds “lunch-and-learn” events for local physicians to discuss this and other topics. Similarly, Monticciolo frequently educates referring physicians about breast cancer screening guidelines and related subjects in addresses to medical groups and hospitals.
Morris says SBI has adopted a “multi-pronged” approach to physician education. A mentorship program allows radiologists to get up to speed on the latest data pertaining to screening, so that they, in turn, can convey information to referring obstetricians, gynecologists, and general practitioners as well as members of the media during interviews. Webinars, slide decks and tutorials are also all offered to the radiology community.
“The objective is for radiologists to become more active not only in helping other physicians to do a better, highly informed job of discussing screening with their patients, but also in doing a more effective job of persuading patients who come to them for breast cancer screening to continue to do so,” Morris says.
In other patient education initiatives designed with an eye toward heightened engagement, both the ACR and the SBI leverage information online to clarify breast cancer screening guidelines and present patients with a concrete rationale for undergoing mammography beginning at age 40. The ACR also developed a series of public service announcements in English and Spanish to spread the word. Titled “Start @40,” the spots address confusion pertaining to screening guidelines, misconceptions about breast cancer screening and help viewers find accredited mammographic imaging facilities.
With an identical goal in mind, Elizabeth Wende Breast Care includes information about breast cancer screening in its patient newsletters and on its website. A section on the website geared toward first-time patients features an internally authored document entitled, “Screening 101: Key Guidelines to Know.”
“Many of these types of patient engagement initiatives would likely translate well to lung cancer screening,” Studts says. “Also helpful would be a shared decision making approach—physicians communicate both the risks and benefits of lung cancer screening to patients and a joint determination of whether to go ahead is made. Provider recommendations, not the fear of false positives and invasive follow-up, is one of two primary factors in patients’ lung cancer screening decisions. The other is cost.”
Community outreach aimed at encouraging patients to undergo screening procedures is yet another piece of the patient engagement puzzle, at least where mammography is concerned. Elizabeth Wende Breast Care leverages its Facebook and Twitter accounts to remind potential and existing patients about the importance of screening for breast cancer, as well as to inform social media account users of new laws and developments that may make it easier for them to be screened.
In addition, it has established a “speaker’s bureau” service. Community organizations can use the service to arrange for one of the practice’s clinicians to address their group about a variety of topics, including breast health and the importance of regular screenings starting at age 40 and continuing beyond the age of 74. And the practice holds periodic on-site events where uninsured and underinsured women can obtain mammography screening free of charge.
Destounis notes that while community outreach is critical to better engaging patients and improving mammography screening rates, radiology practices should go one step further to get the job done.
“We need to eliminate, or at least mitigate, elements that make the idea of going for a scan better than the idea of having breast cancer without knowing it,” she says. “Waiting around for results is one of those elements.”
Toward this end, patients of Elizabeth Wende Breast Care have the option to obtain same-day mammography results. “The ability to know right away whether or not there is a concern has made a difference in patients’ willingness to be screened for the first time,” Destounis says.
Trained technologists and patient navigators or advocates play a role as well. In Monticciolo’s practice, the clinician says technologists are “well-informed” about the controversy surrounding breast cancer screening recommendations and have been instructed to explain why yearly mammograms starting at age 40 are advisable. Often, they will cite statistics from the ACR and SBI websites, which lend credence to these explanations and help to debunk erroneous notions, such as a common belief among some women that the radiation doses used in mammography can cause cancer.
Both Destounis and Morris note that access to assistance from patient advocates would likely prove very effective in eliminating or minimizing the disparity in breast cancer screening utilization rates among the Caucasian and African American/Hispanic populations. Kazerooni believes the same is true when it comes to increasing lung cancer screening utilization efforts. But every patient engagement effort, whether to address disparity or transcend it, should incite increased breast and lung cancer screening usage in all appropriate populations.
As Monticciolo puts it: “Patient engagement is as critical as the screening itself.”