How Can Patients in Underserved Communities Access Quality Care for Breast Cancer?

In In The News by Barbara Jacoby

By: Elaine K. Howley


Just as breast cancer isn’t a single thing for all patients, neither is the quality of the treatment patients receive for it. And even accessing that care can be a varied experience for many patients depending on factors ranging from location and ethnicity to education level and socio-economic status.

Dr. Electra Paskett, associate director for population sciences and program leader of the cancer control program in the Comprehensive Cancer Center of the Ohio State University, says that for “rural folks across the country, there are huge access barriers in terms of having to travel long distances to receive care.”

Paskett says it’s easy for a doctor in a remote location to make a referral to a quality institution, but that may not be enough. Making sure patients can actually get to that other location is important, too. “For rural patients, they come here and have to stay overnight, and then there’s driving distance to consider. I think when we make a referral, we have to make sure” the patient is able to follow through.

One way some facilities are making this happen is by offering rides to patients or partnering with local hospitals and care centers to deliver care closer to the patient’s home. For patients in Big Sky Country – some of whom may have to drive more than 10 hours to reach a high quality care center – having a place to stay near the hospital has worked too, says Dr. Melissa Hulvat, medical director of the Bass Breast Center at the Kalispell Regional Medical Center in Kalispell, Montana.

“We have some housing where people can stay, and we have a concierge who will help people get hotel rooms and find them transportation,” she says. But being able to offer these sorts of services to patients starts with the doctor being cognizant of the patient’s situation, and your doctor might not realize that traveling to the hospital is a hardship for you unless you speak up. If you live far from the center where you’ll be receiving treatment, speak with your care team about coordinating appointments and finding ways to lessen the travel burden.

Many medical centers have options available for scheduling appointments on the same day, finding you accommodations during your treatment or partnering with a hospital closer to your home to deliver that care. Hulvat says her center seeks to set appointments on the same day.

But proximity to health care doesn’t necessarily mean patients have access to it or that the accessible care is good. Paskett says a recent study “looked at why African-American women on the south side of Chicago have high death rates from breast cancer.” According to data published in 2007 by the Illinois Department of Public Health Vital Statistics, between 1981 and 2007, black women in Chicago had a 62 percent greater chance of dying of breast cancer than their white counterparts. Chicago is home to some of the best medical facilities in the world, so clearly proximity isn’t the only issue at work.

“The problem was they did not have adequate capacity of mammography machines and there was a shortage of fellowship-trained radiologists” to read the mammograms, Paskett says. This was because there was an “inequitable geographic distribution of these providers. Quality of care was concentrated in high-volume academic centers, which are much less likely to serve the African-American and Hispanic population.” Therefore, “women in these areas were less likely to have their mammograms read by breast imaging specialists,” meaning that some cancers were missed, if the women had mammograms at all.

The Metropolitan Chicago Breast Cancer Task Force investigated these disparities and implemented policy changes that resulted in elevated quality of care in inner city facilities. In addition, they set aside $8.2 million in funding and lobbied to pass a bill to improve care delivery. Community navigation programs and outreach and media campaigns rounded out the group’s efforts. “As of 2010 they have decreased [the care] disparity from 62 percent to 40 percent. So some of these things are working. It will take a little time, but you can see that the place where people live really does impact their health,” Paskett say.

A similar disparity is being addressed in the District of Columbia, says Dr. Robert C. Clarke, dean of research at the Georgetown University Medical Center and co-director of the Breast Cancer Program at the Georgetown Lombardi Comprehensive Cancer Center. Beginning in 2004, GUMC launched the Capital Breast Care Center, a patient navigation program that initially aimed to help women in southeastern D.C., where some neighborhoods are impoverished and have mostly minority populations. Tesha Coleman, program director for the CBCC, says the three nurse navigators who work for the program now also serve women in parts of Maryland and Virginia close to D.C.

Although the areas the CBCC program serves are just a few miles from Georgetown, many women in these areas lack the resources or the knowledge to get the care they need. Coleman says the nurse navigators not only drive the bus to transport eight to 10 women at a time for mammograms at MedStar Washington Hospital Center, they also help navigate them through a diagnosis and subsequent treatment, which women can elect to receive at either MedStar or the Lombardi Cancer Center.

Clarke explains that the nurse navigators in the CBCC program visit “public housing facilities and gather women there to do education sessions explaining why you need to come in for a mammogram.” And by doing so, Coleman says, they can actively thwart the fears and other impediments that prevent women from getting screened and treated for breast cancer. “Fear is definitely one of the biggest things” that prevents women from seeking the care they need, Coleman says. “Fear of the results, and the myth of [mammograms] being painful.” Beyond that, many women are fearful of what might happen if their routine mammogram shows a cancer, because most of the women CBCC works with are uninsured. “I have heard women say, ‘What’s the point of finding out if I can’t do anything about it?'” But the CBCC nurse navigators can help women sign up for Medicaid if they’re eligible and find them other sources of insurance or free treatment.

In addition, having a familiar face to help these women through the process is a big part of the program’s success, Coleman says. “A large number of our patients are Spanish-speaking and immigrants or recent immigrants. There’s a huge trust factor in filling out paperwork for them, and building that trust is necessary,” Coleman says.

Coleman says the program has grown from screening about 25 patients in its first year to screening “about 1,500 women per year. We have diagnosed about 200 cases of breast cancer since the program began.” The majority of program funding currently comes from the AVON Foundation and Susan G. Komen organization.

Offering these varying approaches to reaching patients improves the chances that all patients will be able to access the care they need, Paskett says, because “the solution has to be comprehensive and multi-level.” In Chicago, she says policy changes were instituted at the top to address “social issues and institution issues,” as well as developing new ways to work with patients directly in ways that will improve their quality of care. She explains that Ohio State also has a mobile mammogram unit that travels to Appalachia to bring care to populations that might not otherwise be able to access it.

Similarly in Montana, Hulvat says the emphasis is on “treating the patient, not the disease,” and that means reaching people the way they need to be reached. We have to be a little bit creative,” she says, citing the example of the Native American population in Montana, which typically relies “on oral histories. It’s in their blood, so they have to know somebody who gives them a message. They don’t care about a billboard or a tweet, but if someone at church says you need a mammogram and the bus comes here,” then they’re much more likely to take advantage of the service. Although it can be a slower means of education, if it works, that makes it more efficient in the long run.