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Discussing personal, practical and technological challenges that may thwart breast cancer screening, this author says increased sensitivity, advances in mammography imaging and creative awareness-raising alliances can make a difference in communities big and small.
One in eight women will have breast cancer.1 However, starting yearly mammography at age 40 has helped cut breast cancer deaths by over 40 percent.2 While most women’s health professionals already know these statistics, not all women do. That’s why it is critically important that the health-care field continues to raise awareness about breast cancer and boost efforts to increase yearly mammography screenings.
Consider for example, Wyoming, the state where I practice radiology. According to 2018 National Institutes of Health data, only 62 percent of women aged 40 and older in Wyoming reported having a mammogram in the last two years. That puts Wyoming near the bottom of the list—48th out of 50 states—when it comes to annual mammography screening rates.
While there are many reasons why Wyoming’s screening rate is so low, the fact is every provider in every state has encountered an array of challenges when it comes to screening compliance.
Accordingly, this article offers a closer look at some of the common obstacles and some of the unique barriers to screening that we have noted at two very different facilities: St. John’s Health based in Jackson, Wyoming and South Lincoln Medical Center located in Kemmerer, Wyoming. My goal is to offer insights and share solutions that can ultimately help any breast imaging provider, in any corner of the country, improve his or her screening program and increase patient compliance.
Sister Facilities with Distinct Patient Populations
Just as siblings can often have very different personalities, our two facilities have separate and distinct patient populations. Located in a county with a population of 23,331, St. John’s Health is a public hospital that serves the Jackson area, which is very health-oriented. We have a combination of small town rural women, active outdoors types, working women, and the retired - including a substantial contingent of wealthy patients. In this area, you will see a combination of pickup trucks, Subarus, Chevrolet Suburbans, and Range Rovers.
St. John’s Health is an American College of Radiology (ACR)-accredited facility that earned the distinction of breast imaging center of excellence in 2019. We have an incredibly strong and active foundation that has been very successful in supporting breast imaging.
While St. John’s Health draws a somewhat wealthier patient population, our sister facility draws what one might describe as the “true” Wyoming-ite. A critical care hospital, South Lincoln Medical Center is in the heart of rural coal and natural gas country. It is a 16-bed hospital with an attached 24-bed long-term care unit. The hospital is located in Kemmerer, a town of 2,700 on the high desert of southwest Wyoming.
This blue-collar community has thrived and survived on ranching and mining. Fiercely independent, the town’s hard-working community stands firmly with its Wyoming roots. Pickup trucks rule in this region.
In regard to screening volumes, we performed 3,113 mammography exams at St. John’s Health in 2021 in comparison to 2,294 in 2020. At South Lincoln Medical Center, we did 280 mammography exams in 2021, up from 224 in 2020.
Given the differences in the patient populations, we also experience some unique challenges at each facility when it comes to screening compliance. That said, there are also several issues surrounding screening that have an impact on both patient populations.
Identifying and Addressing Screening Challenges
Here are some of the obstacles to screening that we’ve encountered along with ways to address the barriers and boost screening rates.
Confusion and misinformation. Inconsistency and variations in screening recommendations from the government and professional medical societies have led to confusion about who should get an annual mammogram and when. Differences in these guidelines are also confusing to providers who may not have the time and resources to make an informed decision to pass on to their patients. For example, the American Cancer Society, American College of Radiology, American College of Obstetricians and Gynecologists, and the United States Preventive Services Task Force all have different recommendations for breast cancer screening. The resulting confusion from a lack of consensus guidelines as well as the increased use of social media, where information is anecdotal at best, may leave patients wavering on mammography screening. I believe this state of indecision may lead to many women moving on to other challenges in life and foregoing screening. Then screening may be out of mind until their next health visit.
Fears and embarrassment. Fear of pain or pain with a prior mammogram is one of the most common problems our mammographers encounter. Having personable, caring technologists who are willing and able to spend a few minutes reassuring patients and addressing their concerns is key for the current exam and to ensure women return for future screenings. A painful examination from an impersonal or hurried technologist is a big risk for lack of compliance. Patients have been known to skip several years of screenings due to a single painful examination.
The right technology can help as well. At the South Lincoln Medical Center in Kemmerer, our ASPIRE Cristalle mammography system with Digital Breast Tomosynthesis (DBT) (Fujifilm) features patented comfort paddles designed to more comfortably adapt to individual breast shape and minimize pinch points. Our mammographers say patients have commented on the improvement in comfort in comparison to previous mammograms they have had with other equipment.
In my opinion, as radiologists, we need to let our mammographers know that if a woman is particularly tender, as some women are at baseline, “adequate compression” may not be entirely attainable. In these cases, our technologists let patient feedback and comfort be the guide and make a comment on the paperwork to alert the radiologist. That way, if there appears to be suboptimal tissue spread on an examination, the interpreting radiologist can comment about the cause in the report.
The goal is compliance in getting the patient through the mammography exam. As a radiologist, I will take a suboptimal compression mammogram to ensure patient comfort over future non-compliance every day of the week.
I have also had patients with a palpable lump or an abnormal thermography who initially refuse mammography. These women often want to go straight to MRI for an abnormal finding or physical examination. In these cases, I talk with the referring provider about the importance of the standard workup: mammography, ultrasound and then magnetic resonance imaging (MRI) if necessary. In my experience, I have often found that additional discussion can overcome the fears of these women and allow us to proceed with appropriate management.
However, if MRI or ultrasound is absolutely the only thing acceptable to a patient, we will do that. Losing apossible cancer diagnosis to insisting on a mammogram does not make sense to me. I only recall one patient in my limited population who fell into this group at scheduling. Once we were able to talk directly to this patientand address her concerns, we wereable to do a full workup including mammography.
Finally, our mammography techs say they’ve had a few women who are embarrassed the first time they have a mammogram. That can be a barrier to future compliance as well unless your technologists handle the situation with compassion and kindness. Radiologists, especially male radiologists, need to demonstrate sensitivity and understanding in these cases. For example, when I perform subsequent ultrasound examinations, I ask a female sonographer to help limit exposure to just the area required during scanning.
Scheduling and accessibility. In 2020, we had difficulty keeping pace with volume in St. John’s Health in Jackson and that was due in part to the fact that we only have a single mammography unit. Often, our screening schedule was six weeks out. Such a long lead time to appointment has a negative impact on compliance, especially for working women. When an exam date is over a couple of weeks away, women may just put it off for later, which can end up being much later.
Our initial solution was to open the schedule for Saturday screenings, which helped greatly. We then made a concerted effortto purchase a second mammography unit, which we successfully obtained thanks to a grant from St. John's Health Foundation. It is scheduled to be installed this spring. Our hope is to see a dramatic decrease in lead time and increased screening rates this fall.
Technology. When it comes to screening compliance, technology can be a true asset or a real hindrance. Women want their exams to go as quickly and smoothly as possible. If the tech must repeat images, it can be a painstaking process for the patient. We had positioning seminars last year in both facilities to help our technologists get the best views on the first try. We had noticed a trend of increased technologist-driven repeats in screeners and were able to dramatically reduce those additional images. Each vendor’s units have their own geometriesand differenttechniques canhelp in acquiring consistentresults. Utilize your vendor’s application specialists to help your technologists.
Last summer, we upgraded an older digital 2D system at the South Lincoln Medical Center to the aforementioned ASPIRE Cristalle system. There was a huge jump in quality. The new tomography unit has dramatically increased resolution, even showing fine calcifications on individual tomographic reconstructions. This has already noticeably decreased callbacks. Most importantly, we are catching more cancers. It only took three months of screening in our low volume of womento findourfirst breast cancer—a 3 mm lesion—that was detectable on tomosynthesis only.
Capturing the “first-timers.”One of the larger challenges is thefact that many younger women just turning 40 are not getting that first baseline mammogram. Yet research shows that women are getting breast cancers earlier. Moreover, one in six breast cancers occur in women aged 40 to 49, and those cancers are often higher grade and more advanced.3 It’s hard to pinpoint exactly why it’s difficult to convince some women to get that first mammogram. Our mammographers theorize that some women are simply unaware when they should begin screenings. Another theory is that the 40-ish generation simply is not practicing preventive care in general.
Social media is one way to target and communicate with younger women. St. Johns Health has been steadily increasing its social media presence over the last several years. As radiologists, we need to engage and educate providers to stress the importance of early detection so women will start getting screened at 40 and continue doing so yearly.
Different Ways to Build Awareness and Increase Screenings
Building awareness about the importance of breast cancer screening and detection truly takes the entire community. Our organization uses multiple communications channels like social media to distribute promotional information. We also place advertisements in the local paper to publicize screening events, emphasizing that women aged 40 and over can obtain free screenings.
Over the years, we have tried many different marketing tactics and special offers. To increase accessibility of screenings at our facilities for busy women, we have extended hours and offered some weekend screenings. We’ve hosted open houses and luncheons as well to engage the community and show the simple and non-threatening nature of mammography screenings.
Women in our area are also getting the screening message from other resources such as the Wyoming Cancer Coalition and the Wyoming Cancer Program though the state Department of Health. These and other local programs help uninsured and underinsured women obtain screening and diagnostic imaging.
Community events hosted by various local organizations and businesses aid in keeping the screening message top of mind with both women and referring providers. For example, in Jackson, we have a “light the town pink” event the first week of October. Here, the famous elk antler arches at town square are lit in bright pinkand remain so for the entire month. During this event, we provide screening information, short talks, and patient testimonials.
Other yearly breast cancer events in Jackson include a women’s fly fishing outing and “Bras for a Cause,” an auction of artist-designed bras. In both cases, proceeds go to the Women’s Health Fund, which provides support for women in need of preventiveservices or for those who are in active treatment. There is also a yearly golf tournament called “Tee it up for Oncology.” During October, we also arrange with local restaurant groups to present a breast cancer postcard with the check.
In Kemmerer, there have been other events and fundraisers, including “Paint the Town Pink” in October when businesses dress up their front windows,stay open later in the evening and provide local discounts.This year, the technologists put together a mammography float for homecoming.
This year we launched a partnership with our local town ski hill Snow King. They were upgrading an old chair lift to an eight-person gondola thatruns year round, offering a much faster ride to the top in winter for skiers and stunning views of the Tetons year-round for everyone. I contacted them and suggested that we wrap a cabin in pink. Management was on board and we were successful in getting a cabin wrapped by opening day of the ski season. It is visible from the entire town and really grabs people’s attention.
There is a QR code inside the gondola that links to an introductory page on cancer screening recommendations for breast cancer as well as cervical, skin, lung, and other cancers. On that screening page, there are deeper links, specifically for breast and colon cancer, that connect directly to the St. John’s Health website, describe available services (including mammography screenings) and how to schedule.
Increasing efforts for breast cancer screening programs is never an easy feat nor is there a universal panacea, especially in western Wyoming. Various barriers to screening exist and can be quite different for different locales.
In Jackson, our main roadblock has been scheduling limits. There are different challenges in the even more rural Kemmerer. Wyoming is second only to Alaska in low population density with less than 6 people per square mile. Access to screening is contingent on a patient’s and provider’s geographic locale. Physical distance and location of mammography units are big challenges that are further complicated with severewinter weather.
We know mammography saves lives. If you are at a loss about how to boost screenings and patient compliance, just try something, no matter how small or non-traditional. If it works for a few patients, that’s better than none, and you may indeed find that early cancer.
In addition, hire compassionate, professional mammographers who screen women in the most caring, unhurried and pain-free manner as possible. Support your mammographers with training and constructive feedback, add mammography units as necessary, and court the community and foundations to support initiatives that educate and raiseawareness.
Finally, make sure the patients who do come for their mammograms are welcomed and heard. It can go a long way in keeping them compliant with regular screenings and finding cancer at earlier stages.
Dr. Haling is affiliated with Jackson Hole Medical Imaging in Jackson, Wyoming.
1. American Cancer Society. Key statistics for breast cancer. Available at: https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html . Updated January 12, 2022. Accessed March 24, 2022.
2. Hendrick RE, Helvie MA. United States Preventive Services Task Force screening mammography recommendations: science ignored. AJR Am J Roentgenol. 2011;196(2):W112-W116.
3. Ray KM, Joe BN, Freimanis RI, Sickles EA, Hendrick RE. Screening mammography in women 40-49 years old: current evidence. AJR Am J Roentgenol. 2018;210(2):264-270.