Driven by pandemic, doctors try to facilitate breast cancer screening

But to her surprise, Morrison immediately discovered she needed more testing, and what she heard next surprised her even more: “We can do it today.” She went from screening to further testing to a biopsy in four to five hours. Diagnosed with cancer at a very early stage, she has since completed her treatment with surgery and radiotherapy.

“It’s a godsend, not having to wait, not having to agonize for weeks,” Morrison said.

Prompt diagnosis has also been an unexpected benefit of the pandemic. Seeking to make up for missed mammograms during the lockdown, doctors looked for ways to bring patients back for treatment.

Like a storm blowing shingles off a neglected roof, the pandemic has exposed the weaknesses of the healthcare system. Most strikingly, he highlighted the inequalities that have long worsened the health of blacks like Morrison, as well as Hispanics and those of lower socioeconomic status.

The pandemic has also turned hidden practices upside down, sparking changes that many patients might consider to be longer overdue, such as the adoption of the convenience of telehealth. And reduce the agony of waiting times for mammograms.

“We try to listen to our patients and ask ourselves, ‘What do our patients need? And think outside the box, reject those beliefs – “This is not how we do things,” said Dr Constance D. Lehman, Director of Breast Imaging and Co-Director of Comprehensive Breast Assessment of the AVON Foundation at Massachusetts General Hospital

Cancer screenings of all kinds have dropped dramatically during the pandemic, including tests for breast, colon, cervical and lung cancer. Screening tests ceased completely for about three months when all elective procedures were halted.

But since mammography centers reopened this summer, they still haven’t made up for all the missed exams. Many women have not reprogrammed; others remain reluctant to go to a health facility for fear of infection.

Epic Health Research Network, a journal that analyzes data from electronic health records, find that after a sharp drop in spring 2020, cancer screening has rebounded, but the numbers have not fully caught up. Looking at screenings from March 2020 to March 2021, the journal reported that breast cancer screenings were 13% lower than historical averages, colon cancer screenings 25% lower, and cervical cancer screenings 21% lower. .

And a separate study published on June 30 found that resuming screening had occurred unevenly across a large hospital system. the study, which only looked at the experience of the Mass General Brigham Hospital Group, found that fewer black and Hispanic women had mammograms in the last quarter of 2020 compared to three months before the pandemic. During the same period, the number of white women having mammograms increased.

Lehman saw the evidence in her own practice: more women attended imaging centers that tend to serve non-Hispanic white women, while fewer were screened in centers that traditionally serve Hispanics and people. colored.

She also identified another disparity in her own practice – unintentional favoritism.

Typically, when a woman has a mammogram, the x-rays are grouped with others taken during the day. The radiologist reads them the next day. If anything looks suspicious, as is the case with less than one in 10 mammograms, the woman receives a phone call or letter within a few days, asking her to come back for another mammogram.

But Lehman found that about 15 percent of patients had their mammograms read instantly, often because they were strong self-advocates who insisted, or their doctors asked the radiologists a favor. And by studying the data, she realized that these were mostly white women with higher incomes.

“It was shocking to see. We unwittingly developed this system that supported inequalities, ”Lehman said.

Women who are less likely to get “immediate reading” may face other barriers, such as rigid work schedules or problems with transportation and childcare, making their return more difficult. This could cause delays in diagnosis. And studies have long shown that black women, despite similar rates of breast cancer, are more likely to die from it than white women.

Lehman and his colleagues wanted to find a better way. As soon as its imaging centers reopen in June 2020, Mass. General began to consistently deliver results to patients. The number of patients receiving immediate readings increased from 15% to 60%. (Lehman is studying what happened with the remaining 40%; maybe some patients preferred to come back, or maybe the staff took too long to provide the results.)

But most importantly, racial and ethnic disparities were gone: immediate results were offered to everyone equally.

The hospital has also started a “pink card” program for women who visit its Boston clinics for any reason. If they have to have a mammogram, they are given a pink card to take to the nearest imaging center for an exam that day.

The Now Reading program is based on an improvement other than Mass. General has been offering two imaging centers since 2017: same-day biopsies, or biopsies performed as soon as a follow-up test shows the need to examine a tissue sample for cancer cells.

These advances allowed 52-year-old Charlestown resident Amy Federico to complete in one morning a process that might otherwise have been a week-long ordeal.

After her annual mammogram in June 2020, she immediately learned that something was worrying to her. Doctors performed a follow-up mammogram and, still concerned, informed Federico that they would like to have an ultrasound. And then a biopsy.

A few days later, she received a phone call: the little nodule that appeared in the pictures was benign.

“It all happened so quickly, but looking back, I was happy it happened so quickly,” said Federico, 52, an oncology nurse practitioner at Boston Children’s Hospital.

In redesigning screening procedures, the hospital learned lessons from other sectors facing unpredictable customer demand, such as restaurants and hotels. Seeking to emulate the customer-centric practices of these companies, Lehman and his team sought to eliminate delays and waste, standardize procedures, and streamline workflow.

“You would have 12 different doctors who all wanted the room to be set up in 12 different ways,” she said. But things would be better if every doctor followed the same steps.

To prevent distracted radiologists from reading scans in busy clinics, all mammograms from the six imaging centers are sent electronically to a central location, where a radiologist in a dark, quiet room reads them as they go. ‘they enter.

The Dana-Farber / Brigham and Women’s Cancer Center is also promising same-day results, but to avoid cluttering waiting rooms, patients don’t have to wait, said Dr Sona Chikarmane, division chief of breast imaging. Women receive phone calls before 3 p.m. if their mammograms were taken before that time, and appointments remain open for reminders so patients don’t have to wait long.

As healthcare providers struggle to make up for missed tests, the effects of the pandemic raise big questions.

Will there be a spike in advanced stage cancers or cancer deaths? Or will failure to test make no difference, asserting the critics’ point of view that all these tests are not worth it?

For the record, doctors report an increase in more advanced cancers. Some may result from patients who showed symptoms but were afraid to seek help during the pandemic. It’s different from skipping a screening test, which by definition is for people without symptoms, most of whom don’t have cancer. Since most cancers grow slowly, it will take many years to assess the effects of ignored or delayed tests.

Three months is unlikely to make a difference in breast cancer, said Dr Ann H. Partridge, breast cancer specialist at Dana-Farber. Still, doctors are worried about cancers that might have been discovered during those missed mammograms. Will they be taken on time?

“What concerns us is that people will wait a year, two or three,” she said. “We are concerned about people not coming back to resume the screening regimen. “

But Dr H. Gilbert Welch, a well-known critic of unnecessary screening, says he doubts the backlog of screening has any effect on breast cancer death rates because treatment has improved so much that even more advanced breast cancer can be managed. Welch, who works at the Brigham and Women’s Center for Surgery and Public Health, questioned the wisdom of investing so much in disease research among wellness, “when we haven’t considered determinants of more powerful health ”.

But Lehman, of Mass. General, sticks to the dominant view: “Screening mammography has proven time and time again to be the best tool we have in reducing breast cancer mortality.

And she says she’s committed to making mammograms easier, for all women.

“We are not going to go back to what it was before,” she said. “We have learned so much. We will continue this. “

Felice J. Freyer can be contacted at [email protected]. Follow her on Twitter @felicejfreyer.