Breast and Lung Cancer Screening: The Push for Patient Engagement

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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