October is Breast Cancer Awareness month. While social media awash in pink, we should also raise awareness to the barriers women, mostly of marginalized groups, have to overcome on their way to screening mammography.
October is Breast Cancer Awareness month. Social media, commercials and billboards awash in pink, encouraging women to get screened for breast cancer. It happens for a good reason: According to the World Health Organization, breast cancer is the most common non-skin cancer diagnosed in women worldwide, and the second most fatal (after lung cancer). One woman out of 8 will develop invasive breast cancer over the course of her lifetime, as risk increases with age. Other risk factors are family history of breast cancer (especially in first degree relatives), reproductive history and prolonged exposure to estrogen, smoking, excessive alcohol consumption, poor diet, physical inactivity and ethnicity.
Screening healthy adult women to breast cancer has made a real change: Earlier diagnosis allows earlier, often more successful, treatment. The decreasing breast cancer death rate is attributed mainly to these screening efforts, mammogram being the most common, and the only proven effective method so far.
But in order to benefit from screening tests, women first need to be screened. This might sound simple and intuitive, but it really isn’t, not for some women. Many barriers can keep a woman from testing, some of them ironically affect women at higher cancer risk. Screening mammography utilization is still lower among underprivileged groups, like ethnic minorities, immigrants, low-income women and LBTQ+ people.
Breast cancer awareness month should not be over without mentioning the barriers women need – but don’t always manage – to overcome.
Low health literacy
Health literacy is the degree one can obtain, process and understand information regarding health, in order to make appropriate health decisions. Studies have shown that health literacy had a very strong relationship with mammography adherence. Not surprisingly, it’s a central factor in women’s awareness of screening existence and importance.
Health literacy depends on the person’s level of education and ability to communicate: to express oneself, to ask questions, to absorb and to understand communicated information, and to do so in a way that is linguistically and culturally appropriate. Gaps in spoken and written language, and cultural discrepancies, can pose a significant barrier to many women, and especially to immigrants.
eHealth literacy, the ability to obtain medical information from digital sources, also requires the technical skills and access to digital devices. This might be another obstacle in the way of women of lower socioeconomic status, or of older age.
Some racial disparities in breast cancer screening are attributed to perceived discrimination. Although this hypothesis is difficult to investigate and quantify, it is reasonable to believe it influences women’s health behaviors, including screening habits. Perceived discrimination on the basis of age, gender and religion is also suspected to contribute to women’s non-adherence to screening mammography.
Research identified cost as a main barrier to mammography in under-served women. The study, that reached individuals of one of the poorest counties in the US, found that women of all ethnic groups mentioned cost as a barrier. Overestimation of the true cost, and out-of-pocket cost of mammography was prevalent, and influenced the women’s perception and utilization of screening mammography.
Transportation is one of the components of accessibility. Transit marginalized women, who depend on public transit, and whose travel time to a mammography facility is long – face a physical barrier in their way to screening. A study that examined 6 major urban areas in the US, found that most of the transit marginalized women lived outside of the central cities, and had over-representation of women of ethnic minorities.
Mammogram isn’t a simple test for many women, but it is especially complex for women with disabilities. According to the Center of Disease Control and Prevention, the percentage of mammography screening within the recommended time frame is lower in women with disabilities, even though their risk is similar to that of the general population.
Barriers like limited transportation and parking, physical inaccessibility to the examination room, unsuitable medical equipment, need of assistance with undressing and positioning, and uncomfortable interactions with the medical personnel – all limit mammography use for women with disabilities. Cost and insurance are other factors, as disability unfortunately correlates with lower socioeconomic status.
The barriers mentioned above are only the tip of the iceberg. The disparities in screening mammography utilization are no coincidence, nor faith. Acknowledging it is an important step in our journey to close these tragic gaps, and to bring equal healthcare to women and people of all groups.