Eliminating health disparities that exist in breast care is an urgent priority on both global and local fronts. On a global scale, the number of breast cancer cases in high-income countries has traditionally been higher, but women have a much greater risk of dying from this disease in low- and middle-income countries [1] (LMICs) due to late diagnosis and limited access to treatment and care. In the US, black women are over 40 percent more likely to die of breast cancer than white women.[2]
According to health advocates, changing these statistics is not only possible, but critical. Pursuing health equity in breast care is a commitment to strive for the highest possible standard of health for all people, giving special attention to the needs of those at greatest risk. Whether it’s improving access to care, removing social determinants, sharing scientific information across the globe, or rethinking patient communications, by removing the barriers that exist in women’s health, clinicians believe that patient outcomes can be improved. Disparities in breast health show alarming differences among populations and demographics such as incidence, survival and mortality rates between social and ethnic groups.
To discuss what can be done by the radiology community, a panel of leading medical experts participated in a recent webinar hosted by GE Healthcare. Moderated by Agnes Berzsenyi, President and CEO of Women’s Health and X-ray at GE Healthcare, the speakers shared how their organizations are working together to improve awareness within their organizations, their communities, and across the industry. Sonali Johnson, PhD, Head of Knowledge, Advocacy and Policy at the Union for International Cancer Control (UICC), Randy C. Miles, MD, MPH, Clinical Service Chief for Breast Imaging at Massachusetts General Hospital (MGH) in Boston, and Kim Johnson, MD, Senior Director of African American Health Equity at the Susan G. Komen organization discussed trending research and shared the work they’re doing to promote equity in women’s health.
Reducing health inequalities—A global perspective
Dr. Sonali Johnson said, that for the members of the Union of International Cancer Control, which number more than a thousand organizations and span more than 170 countries, improving health equity continues to be a priority.
“Cancer is a disease characterized by inequality and there are huge disparities around the world in the ability of people not only to access cancer information and prevention services, but also early diagnosis and care. Today, we’re talking about breast cancer, which has a survival rate of over 90 percent in high-income countries, but falls to 66 percent in countries like India, and even lower in others.”
Dr. Sonali Johnson explained that although there are many factors that influence these outcomes, some of the main reasons for lower survival rates in breast cancer in LMICs is that awareness of cancer and treatment is very low and that screening programs are limited. The inequalities in cancer, can be seen in large variations in incidence, survival, and mortality rates between social groups, as well as knowledge and attitudes about cancer. The impact of a cancer diagnosis also leads to social stigma and contributes to reluctance to seek cancer care particularly where cancer deaths are high and cancer is seen as "incurable." Though these differences are unfair and entrenched, they can also be changed.
According to the Global Cancer Observatory published by the International Agency of Research on Cancer, the global cancer burden is growing. Dr. Johnson and her team at the UICC are working on understanding the drivers behind that growth, and how it can be addressed effectively through cancer policy and programs.
The largest growth, she said, can be seen in LMICs, where existing health systems are not set up to work on preventing, diagnosing, and treating non-communicable diseases including cancer. The UICC is part of the International Cancer Control Partnership (ICCP) that monitors national cancer control plans, where countries set out their national cancer control strategies and the actions they want to take. As part of these efforts, the partnership is looking at ways to to identify the gaps in cancer prevention and care due to health inequalities.
Identifying gaps in access to technology for screening, follow-up, and treatment
The ability of all patients to access innovative technology to improve care and outcomes also differs by geographic location, even within higher-income countries, according to data Dr. Sonali Johnson reported from the IAEA (International Atomic Energy Agency). Dr. Johnson also referred to a Lancet Oncology Commission on surgery which reported that though surgery may be available in 95 percent of high-income countries, it is only available in 25 percent of low-income countries.
“While 50-60 percent of all cancer patients will need radiotherapy, the availability of radiotherapy is mainly concentrated in high income countries, with a huge unmet need in LMICs,” she explains. “For example, 90 percent of people in low-income countries have no access to radiotherapy.”
Similarly, she explained, the mean number of people served by one computed tomography (CT) scanner in high income countries was 25,000. In lower income countries, as many as 1,694,000 people are served by one scanner. The World Health Organization (WHO) is trying to address this issue and have countries set benchmarks on the availability of equipment. The lack of availability means that clinicians are unable to properly stage patients, which can have an impact on the adequate or inappropriate use of medications, surgery or radiotherapy.
One of the major ways this information can be aggregated to address continuing issues is for LMICs to begin to develop population-based cancer registries, which connect incidence data, mortality survival and stage of diagnosis, as well as the demographic information so that departments of health can identify the underserved and understand what the outcomes are in these populations.
Continuing to address women’s health inequality in the US
Despite the status of the US as a high-income country, as well as the progress that has been made by Black women in terms of social, economic, and political power, that progress has not translated into gains in healthcare and health outcomes for Black women. In fact, Black women in the US are more than 40 percent more likely to die of breast cancer than white women.[3]
“In some of the communities we’re working with,” Dr. Kim Johnson explained, “the disparity is as high as 74 percent, meaning Black women with breast cancer living in those cities are 74 percent more likely to die of than white women."
In Dr. Johnson’s work at Susan G. Komen, in an initiative called, Stand for H.E.R.- a Health Equity Revolution, she and her team are working across sectors to mount a rigorous and effective response and strategies for dismantling the drivers of disparities in breast cancer in the Black community.
The Susan G. Komen organization recently published a report entitled, “Closing the Breast Cancer Gap, A Roadmap to Save the Lives of Black Women in America.” The report findings indicate that Black women experience higher rates of death from breast cancer due to a combination of factors, including barriers to early diagnosis, the aggressive nature of certain breast cancers that are more prevalent in Black women (TNBC, for example), genetics (mutations in BRCA1/BRCA2 genes), lack of quality care, discrimination, and systemic racism. According to Dr. Kim Johnson, although data show that many Black women are being screened, the qualitative data from the focus groups pointed to confusion about the varying, current screening recommendations.
“Some of these are issues we can really do something about,” explained Dr. Kim Johnson. “We know that these types of services are so valuable for family members to really understand their family health history with cancers and to determine if they have genetic mutations. Many women in the black community were not aware of these services being offered or not knowledgeable as to whether or not they were high risk and should receive genetic counseling testing services.”
Additionally, Dr. Kim Johnson added that Black women in the US have reported that they did not feel as if the communication between themselves and their clinical providers was fruitful, or that communication flowed freely, specifically with respect to answering questions around their treatment, or providing more detailed information for them. "In our study, many Black women reported that they feel they are treated differently in the healthcare setting because of their race and perceptions their provider may have." Black women exercising decision-making and/or practicing self-advocacy within the health care setting reported often feeling ignored or met with disapproval.
Communication is key in removing some barriers to care
“Especially for radiologists,” explained Dr. Miles, “communication is key when we are interacting with patients in the breast imaging suite. Communication is truly the vehicle in which we can use to educate patients, so they are able to advocate for their own health needs. The old model of ‘I talk, you listen’ is clearly not effective, as illustrated by the data presented by Dr. Kim Johnson.”
Dr. Miles teaches a new model of communication to the trainees, residents, and fellows at MGH using the acronym PEER, which encompasses Prioritizing the patient, Explaining medical topics thoroughly, Empathizing with the patient, and building a Rapport during these interactions
“It’s important that we take that acronym, PEER, and look at it with deeper meaning, that the patient is actually our peer, with the shared goal of ensuring their best possible health outcome. These interactions are important because if you’re able to talk them through each element of care, they’re more likely to understand. They’re more likely to listen and follow your recommendations, and lastly, it’s our duty as physicians to ensure patient comprehension."
Additionally, Dr. Miles explained the importance of understanding communication is not only verbal, and that many patients are using other resources, including online patient education resources, to learn about screening and other health conditions.
“We need to make sure that health information is consumable and ensure comprehension by a broad audience,” he continued. “The National Center for Education Statistics has reported that 22 and 14 percent of US adults have a basic and/or below basic health literacy, respectively. We know that limited health literacy has been associated with higher mortality and poor overall health status; Related to breast cancer care, this often results from decreased mammography utilization.”
The clinical team at MGH is making a difference and removing some of those barriers, according to Dr. Miles, especially by ensuring that when women do come in for screening exams, they are given the option to remain for diagnostic screening if necessary, and even biopsy on the same day.
“We’ve really streamlined our process so that every screening exam is interpreted on the same day before the woman leaves our center. This allows the woman to receive her breast imaging care, which is both convenient, and also lessens a lot of the anxiety associated with the time waiting for the next iterative step, the screening to the biopsy pathway.”
MGH is focusing on programs like this that directly attack issues of access and the implementation of these programs has shown that the disparities in care that were previously seen between white and ethnic minority groups with the MGH patient population have actually resolved.
Working together to eliminate disparities in breast care
As the panelists shared their experiences, knowledge and plans to reduce and ultimately eliminate disparities in breast care, one thing was clear: things CAN change. Advocating for health equity in breast care enables people across the industry to come together, identify the drivers behind disparities in care, and change the ideas and practices that are prevalent in the medical community to those that will promote health equity for all. There are many unique opportunities where clinicians, patient advocates and public health administrators can find natural synergies where they can collaborate to improve screening, care, and outcomes in breast cancer.
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[1] https://gco.iarc.fr/today/data/factsheets/cancers/20-Breast-fact-sheet.pdf
[2] https://blog.komen.org/blog/black-women-in-us-most-likely-to-die-from-breast-cancer/#:~:text=In%20fact%2C%20black%20women%20are,American%20women%20in%20the%20US.
[3] https://blog.komen.org/blog/black-women-in-us-most-likely-to-die-from-breast-cancer/#:~:text=In%20fact%2C%20black%20women%20are,American%20women%20in%20the%20US.
