Hello, everyone. Thank you so much for joining us this evening in a very busy month of October for many of us. As we present to you today, breast imaging and health equity, bridging gaps and improving outcomes. I'm the course director today and also a presenter, and I am so honored to have just two very amazing esteemed colleagues and friends who are here with us today. I'm so honored to have just two very amazing colleagues and friends who will also be joining us this evening and sharing their expertise. I'm a breast radiologist and medical director at the Breast Care Center at Liberty Hospital in the Kansas City, Missouri area. I'm an associate professor of radiology at the University of Missouri-Kansas City School of Medicine. I'd like to take a few moments to go over a few items before we begin. So the webinar is being recorded, and you will be available, you will have an on-demand aspect available in the RS&A Online Learning Center next week. You will also have access to a really awesome supplemental resource guide that includes recommended readings on health equity specific to breast imaging. It's a very comprehensive guide, and we hope that you benefit from that. There will be time for the audience to ask questions during the Q&A portion at the end. So if anything comes to mind during this webinar when any of us are speaking, please jot your questions down in the chat, and we will try to address these questions to the best of our ability at the conclusion of this webinar. The following slides include some important CME information that I also need to go through before we proceed, and I would just ask if you could just quickly read through each slide yourself. Also, to claim your CME credits after the webinar, please visit the RS&A Online Learning Center's My Learning tab, which will be where you go to complete the survey and obtain your CME certificate. Please review the RS&A disclaimer as well here. And with that, I'll dive in, particularly with our learning objectives for today. So today, we're going to cover quite a bit of information as much as we can in the hour. We'll identify key disparities in breast cancer screening and diagnosis across different demographic groups. We will describe how social determinants of health impact access to breast imaging services. We will evaluate the potential of new breast imaging technologies to reduce health inequities. We will outline strategies for improving cultural competence in breast imaging practices. And we will discuss policy initiatives aimed at increasing equitable access to breast cancer screening and treatment. Also, the Radiological Society of North America would like to gratefully acknowledge Hologic, Inc., for their contribution in the form of an educational grant for this webinar. So thank you to Hologic. So today, Drs. Omofoye, Dr. Miles, and I, we will be discussing breast imaging and health equity, addressing disparities in breast cancer screening, diagnosis, treatment, not just in the United States, but also globally. And then again, we will conclude with the Q&A panel. And with that, we'll start our presentation with Dr. Randy Miles. Thank you so much, Dr. Patel. Really excited to talk to you all today about health equity and breast imaging. As Dr. Patel mentioned, we'll discuss this topic from our different vantage points and our different practice settings. I'm Dr. Randy Miles. I'm the Chief of Breast Imaging at Denver Health. And I'll be giving my perspective from the urban safety net setting from my hospital here in Denver, Colorado. So first thing is very important that we define the term health equity. Defined by Healthy People 2030, it is defined as the attainment of the highest level of health for all people. It requires valuing everyone equally while focusing efforts to address inequalities, historical and contemporary injustices, and the elimination of health care disparities. It's really important to separate out these terms health equity and health equality. Whereas health equality is providing everyone the same care, health equity really takes into account the differences of the populations that we treat. So Dr. Omopoye and Dr. Patel and myself, we all are different with dealing with different patient populations. And taking into account their different population characteristics really helps us to make sure that we can optimize the care that we are providing for our patients. Center around health equity are these social determinants of health. We know that health care is more than just that care that we provide when patients are in our clinic. So things such as safe and supportive neighborhoods, high quality education and employment, accessible, affordable, and culturally relevant health care really do impact how patients perceive and uptake care, particularly in breast imaging. And we've shown that, and here are a few studies that I've been a part of where we've really shown that there are many determinants that are outside of the care that people provide that actually influence whether or not they seek care. So this was a study where we looked at the impact of health care associated cost concerns on mammography utilization. And we showed that subjective cost concerns, so whether a patient, whether or not this was true or not, whether or not they perceived that they could afford dental care, whether they could afford eyeglass, and many other cost concerns that were health related. If they had these concerns, they were less likely to receive or to pursue mammography screening. So ultimately, we showed that cost concern measures were associated with decreased screening mammography use. In this study here in JACR, we looked at the association between food security and mammography screening use. And we showed that patients that had food insecurity were also less likely to pursue mammography screening, again, showing that if patients have Again, showing that if patients have other concerns or if some of these social determinants of health are not optimized, they may not pursue care, even if that care is available. Here is a chart or a figure from the American Hospital Association that really just shows the importance of social determinants of health in patient care. And only about 20% of a patient's health is associated with the actual care that we provide. Some of these other things, such as health behaviors, physical environment, and socioeconomic factors really impact their overall health. So it's very important that we not only focus on this 20%, but look at some of these other factors to really optimize care for our patients. In the US, we do see disparities in care that are largely influenced by these social determinants. When we look at breast cancer stage by race and ethnic subgroup, we do see disparities in Black women at stage of diagnosis and also Hispanic patients. If you look at this slide here, we can see that patients who are non-Hispanic white, patients who are non-Hispanic white, about 65% are diagnosed at an early stage. And we see, comparing that to Hispanic white, non-Hispanic Black, and Hispanic Black patients, those patients who are non-Hispanic white are more likely to be diagnosed at a later stage, which decreases treatment options and also is associated with the poor prognosis. And this is a disparity that many of us in the US know about, but this is evidenced by this mortality disparity that we see in Black women, who, although they have decreased incidence compared to non-Hispanic white women, they are more likely to die from breast cancer, a little bit above 40% more likely to die from breast cancer. So many of these patients who come from these minoritized groups are being treated at safety net hospitals. And these safety net hospitals are mandated to provide care, regardless of insurance coverage, ability to pay, or immigration status. Safety net hospitals have a high dependence on public funding and are often operating on a thin profit margin. Similar to my hospital, I have a patient similar to my hospital in downtown Denver, often located in major cities and serve historically low income patients, but also minority and immigrant communities. So how are we doing at these safety net hospitals? If we look at this meta-analysis, each of these bars represents a different institution, a different safety net hospital. And you can see patients presenting with breast cancer at these institutions are overwhelmingly more likely to be diagnosed at stage 2 disease versus earlier stages. When we look at the days from diagnosis to breast surgery at safety net hospitals, we also see a disparity in the time from breast cancer diagnosis to the time that patient has surgery. If you look at the blue bar there, that represents the time to surgery after a diagnosis at the safety net in the safety net setting. And when we look at all groups, we see this disparity, including white women who usually have a wait time of 52 days in the safety net setting compared to 34 days in the non-safety net setting. We see that in African-American women, where they have a wait time of 64 days compared to, on average, 43 days in the non-safety net setting. We see up to a 30% delay in women being seen in the safety net setting compared to the non-safety net setting. And that's irregardless of background. So kind of what I've shown you in these first few slides that we see these disparities that are impacted by social determinants of health that may impact whether patients actually come and see us. And then once they do enter into some of these centers, these safety net hospitals, we see continuous barriers all along the breast cancer continuum of care. And these are all things that we, as breast imagers, looking to optimize care must address. So really briefly about our clinic, just so you can kind of see the diversity in our patient population. About 35% of our patients are non-white. Nearly 50% of our patients are Hispanic ethnicity. Only 20% of our patients, only around 20% of our patients have commercial insurance. And about 30% of our patients, their primary language is Spanish. So to really address these social determinants of health and to improve care for our patients, we really focused on the six IOM domains of health care quality and really tried to make these tangible items that we can actually measure to ensure that we are providing optimal care for our patients. So those six Institute of Medicine domains include safety, effectiveness, patient-centered care, timeliness, efficiency, and health equity. So first, in terms of patient safety, one of the things that we've really focusing on is ensuring that we have our routine tumor boards each week, ensuring that each patient's case is discussed between all breast sub-specialists. And then also that we have quality improvement conferences where we review challenging cases that may not have such a straightforward outcome or straightforward pathway from diagnosis to final treatment. Focusing in on effectiveness, we really looked at the MQSA parameters. So these are parameters such as the sensitivity, specificity, our callback rate, and cancer detection rate of us reading our screening mammograms, also our diagnostic mammograms, and ensuring that the breast imagers in our service have access to these metrics every few months just to monitor to see how they're doing and to make necessary improvements based off of education programs that we have in-house. Patient-centered care focused on flexible scheduling, including same-day biopsy. Timely care, focusing on a third next available appointment for our screening exams, our diagnostic exams, really monitoring that weekly to ensure that those wait times for patients getting in do not extend out too long. Focus on efficiency, we have a patient navigator who works with our patients to make sure that they can transition to the next step and have the necessary support. Focus on exam time in terms of how we're utilizing those slots, are we utilizing them efficiently, making sure that we can get as many patients in during the day and make sure that that patient, while we're being efficient, feels like they are the primary focus while they're in our clinic. But in terms of equity, really focusing on making sure that when patients come in, they are going to want to return the next year. Make sure we have diverse staff that they can relate to, make sure our staff have cultural competency training, and make sure that we have feedback mechanisms so that patients can tell us what we did right, but also what we did wrong so we can improve on those items. And this is an example of some of the metrics that we look at. One of the big things that we look to improve was our third next available appointment for screening. If you are dealing with barriers to care in your patient population, and then once you do get a woman who is willing to get screened, if you tell her they have to wait 60 days or above 70 days where we were at a certain point, that provides another challenge where another barrier could pop up when she is ready that next day to come in for screening. So that was something we really wanted to decrease to less than one week so that we can make sure we can get patients in in a timely manner. And we worked with, as a team, our big strategy was to take one clinic day to turn it into an all-day screening day to ensure that we can maximize those slots and move the radiologist availability to another day to increase our diagnostic capabilities on that non-screening day. The other thing we looked at is exam to report final, how we were getting back patients' results in a timely manner. We were at two days, which we felt was not great for our patients. So we created rotations that were very strict in terms of everyone had a responsibility and still do have a responsibility when they come in to either cover screens, diagnostics, procedures. And with everyone understanding what their responsibility is, we make sure that we clear the list each day to ensure that our patients now, instead of waiting two days, now we're getting their results sometimes before they even leave our clinic, on average, 1.5 hours. The other big thing in the safety net setting is just ensuring that patients have access to the latest technology. In our hospital setting, we did not provide access to our patients to 3D tomosynthesis, which we know can help with decrease in callback rate, can also help with cancer detection, particularly in those women with those heterogeneously dense breasts. This was something that we really had to come together as a team, figure out how we could put all the necessary, put the necessary foundation in place, with getting, consulting other experts like Dr. Patel and some other experts, really figuring out how we can make this work in our air safety net setting. And we went from 0% tomosynthesis to now today, we have 95%, by really focusing in on making sure our patients have access to technology and also just kind of making sure that we have these things in the forefront, in a dashboard that we're monitoring them. And even if we're not at that point yet, focusing in on getting there and make sure our patients have the access to the highest level of care. So I think the biggest thing in terms of health equity, no matter what you're setting is understanding your patient's needs, right? That component of health equity is you have to provide the right type of care for your patients and only you, the one that's treating your patients, who is encountering your patients each day and who's getting that feedback, you're gonna be in the best possible position to understand their needs and to focus in on those healthcare, those healthcare determinants that need to be addressed to optimize care. There's so many studies that have shown evidence-based strategies that have worked in clinic. This is one that I was a part of that looked at the effect of rideshare programs on missed appointments and timeliness for MRI appointments. We offered our patients Ubers to come in if they need it for their appointment. And we showed a statistically significant improvement in timeliness to appointment by providing access to these rideshares. And this is something that can be utilized for screening exams, diagnostic exams, if this is a big problem for your patients. So our rideshare patients were more likely to be on time for their appointments. Another thing is the impact of same-day care. We know women are busy, they're working, they have family obligations, and there's a lot to balance. So we wanna make sure when patients come in, we don't provide additional challenges in terms of them receiving the care that they need. So by consolidating care, you help to remove some of these challenges with competing interests. So this was a study that was performed at MGH where we looked at the impact of same-day breast biopsy programs in disparities in time to biopsy. And what we showed with this project, or with this study, is that there was a disparity in between non-white and white women prior to the implementation of the same-day biopsy program. And there was a disparity between Medicare versus private or self-paid patients. When this program was implemented where we started offering patients same-day biopsy, this disparity was no longer present. So just by offering access to same-day biopsy, we were able to show that this was a mechanism that you really can reduce disparities in care, particularly time to biopsy, which potentially could end up leading to a woman getting her surgery earlier, that this is a mechanism that can really support that. So how do you implement this in the safety net setting, right? At MGH, there's a lot of resources. There's a lot of radiologists around to support this. And in these limited resource settings, sometimes you may have to be a little bit creative. One of the things that we did is we added a medical assistant to our staff to help us with our ultrasound biopsies. So that would take some of the burden off of our technologists. So our medical assistant handled all aspects of getting the consent forms together for the doctor, getting the ultrasound room set up, everything set up so that the patient, if they were willing and wanting to stay for that same-day biopsy, we could get them going, set the room up, and get started without taking away from other patients that are scheduled during the day. And we studied this and, you know, just analyzed our data, and we took our time to biopsy from 17 days until now, where our average time to biopsy is less than five days. And these same-day biopsy programs not only help the patients who take advantage of the same-day biopsy, the ability to have a same-day biopsy, but for those patients that do want to go home and think about, you know, whether or not they want a biopsy, for those other patients who are taking those same-day slots, your scheduled slots, you know, now are more readily available. You decrease the time for also for those patients who want to come back another day. So it benefits everyone in your system. I think this is the last study that I have here. We also looked at patients such as demographic characters associated with Saturday breast imaging clinic utilization. So offering more flexibility for patients to get in, you know, even outside of the weekdays where, you know, a lot of patients, like I said, are either working, may have issues with gathering or obtaining childcare, offering those Saturday slots, we found that racially ethnically minoritized women, those who speak English as a second language, were more likely to obtain screening on Saturdays than their respective counterparts. So providing another avenue to reduce those barriers to care. So in summary, when we're looking at, you know, health equity, a lot of it's about figuring out what barriers your patient population is experiencing. Is it involving patient engagement? And if it is involving patient engagement, how can you look at those barriers and understand the facilitators to improve those barriers to care? Is it access and uptake of services? You know, some things that doctors sometimes don't like to talk about include costs, but like I showed on some of those studies that we did earlier, costs often is a big topic on patients' minds. And it doesn't have to be the doctor that discusses it, but do you have a navigator that can help assure patients that, you know, that they can receive this study or receive their imaging procedure and not be strapped with a big bill and help them understand what are the ramifications for them receiving their breast imaging services? And then lastly, you know, is it delivery of follow-up services? How can you ensure that that patient's going to come back and focusing on that? So, you know, there's a lot of things that you can address, but, you know, similar to, you know, just reinforcing the statement on one of those prior slides of understanding your patients, you really want to kind of hone in on those big things that your patients are – those big challenges that your patients are facing so you can create those facilitators to make sure that you can improve care for them. So, in summary, social determinants of health represent important targets for improving breast care in vulnerable groups. You know, the targets are likely going to be different for the different populations that all three of the doctors presenting today are going to be targeting, but it's something that, you know, we have that expertise just by seeing these patients every day and understanding our patient populations. Multidimensional interventions targeting social determinants of health and in the clinic are needed to maximize care among these vulnerable groups. I did add on this next slide, I did want to underline this part, but interventions focusing resource towards health equity, we know that they're right, but they're also cost-effective. You know, we are – if we're able to catch cancer earlier, we're really able to not only help provide the optimal care for that particular patient, but limit – we're able to increase the amount of resource that we're able to focus in on other patients, so thank you so much. I'm going to pass this along to – back to Dr. Patel. Well, thank you, Dr. Miles, for that just incredible information and incredible – yes, I can do that, and just incredible to see what you have accomplished, particularly at your institution. It's very, very commendable. Okay, all right. So I'm going to dive in now into my portion of the presentation, which is a little bit different. It will focus a little bit on our institution as well as some of the aspects on the policy side that can really help bridge the gap to improving particularly breast health equity outcomes. These are my disclosures. So we all know that health equity matters. Achieving health equity can address disparities in all arenas of medicine, and especially when it comes to access to breast cancer screening and then beyond that in the continuum of breast cancer care. So true or false? Racial disparities in cancer mortality have improved when comparing black to white patients over the past decade. That is false. Black U.S. residents have higher rates of mortality for most of the 15 leading causes of death in the United States, including cancer, which is the second highest cause of death. That is true. Black patients have higher rates of developing and dying from invasive cancers compared with white patients, increased exposure to risk factors that place them under a disproportionate burden of disease, greater likelihood of having the cancer diagnosed at a later stage and treated by physicians at lower volume hospitals. And that is unfortunately true. So according to the United States Centers for Disease Control and Prevention, and Dr. Miles alluded to this as well in his slides, black women are less likely to develop breast cancer but 40% more likely to die from it compared to white women. And in my neck of the woods in the United States, the same is true in the state of Kansas, which is right next to where I practice in Missouri, but the lines are very blurred between Missouri and Kansas as many know who live around the region. Unfortunately in Missouri, it's 50% more likely. So we most certainly have a lot of work to do when it comes to this population. So although some molecular factors that lead to more aggressive breast cancer are known, we really need to garner a fuller understanding of the exact mechanisms that might lead to more tailored interventions and could possibly help decrease mortality disparities. So population-based approaches are truly imperative. Having an increased knowledge of family history of cancer, empowering your patients to know that, encouraging them to increase their physical activity. We know that obesity is a strong risk factor in the development of breast cancer. Promoting that healthy diet to maintain a healthy body weight. Improving screening access for breast cancer and targeted treatment interventions. So as breast radiologists, yes, we are reading the imaging, performing the biopsies to diagnose cancer, but we also can play a very unique role where we can bridge the gap to comprehensive breast care for our patients working with our multidisciplinary teams. So when we're addressing disparities and access for screening for breast cancer and beyond, collaborating with health care stakeholders including hospital systems and advocacy groups is really important. As the old saying goes, it truly takes a village. An organized grassroots approach to engaging community members based on demographics, also very important. And health care reform is also very important. So this is showing you the United States breast cancer mortality hotspots. And particularly I wanted to point out where I practice in Missouri is where you see in our catchment area in that sort of northeast-northwest corridor, you can see that there's a lot of hotspots, meaning increased breast cancer death rates, particularly for black and Hispanic women. And then fortunately, you will see here at the state of Missouri, the most superior county that's in red, that's Livingston County, and that's where I grew up. So for me, it's truly a calling, a life's calling to help these patients, particularly in this part of the country that need it, and has really spurred why I do what I do and what we do as a team here to try to improve these outcomes for patients in the region. So what are we doing to address this, and what can you do? Because you might be sitting here listening to this presentation thinking, well, I can't do this at my institution. There's so many barriers. But I think that hopefully you can find that there's something that you can do to hopefully help implement in your practice that could apply to any really practice type. So as Dr. Miles talked about too, he was an advocate for digital breast tomosynthesis. So I joined our practice in July of 2018, and soon I assumed a lot of responsibility and became lead interpreting physician of eight hospitals. And at the time, only two out of eight of these hospitals had digital breast tomosynthesis. So the hospital spanned from where I'm the medical director at Liberty Hospital, which is a nonprofit hospital, particularly in the city, to overseeing critical access care hospitals, breast imaging programs, to a federally qualified health center. So quite the spectrum. But unfortunately, only two of these eight had digital breast tomosynthesis. Then, however, we got to work quickly. And as of October 2021, all of the sites have digital breast tomosynthesis from critical access care hospitals to the FQHC facility. And so how is this done? So the approach has to vary per institution, per center, and you've got to really know the lay of the land. You've got to know the players. You've got to know the culture. So for us, I took a very deep dive. Whether I knew that at the FQHC facility, through federally qualified health centers, they oftentimes can qualify for lots of robust grants, so helping them in spearheading writing a grant and getting grant funding for that DBT unit, we went that approach there. I knew at one of our critical access care hospitals in that city, they had just a pot of money that was sitting there that they were deciding what to do with it in the community. So I started, you know, I wrote a letter to the city council asking them for these funds and how they would be so critical in the fight against breast cancer. I met with all of these hospitals, administrators, CEOs, talking at med exec meetings about the importance of DBT in terms of the reduction in callback rate, increasing cancer detection rate, what the literature is showing, and just getting that physician buy-in, the providers that are at these facilities. So really just understanding that culture and how to approach at each facility and seeing potentially what resources and access are out there in order to make this a reality. Really, you know, once you do that deeper dive in that study, you really can do this, and it can really benefit your patients. So it really comes down to strategy, strategy, strategy. Partnerships. I can't stress this enough. Whether you are at a, you know, very large academic institution versus you're at, you know, you're helping or you're providing services at a federally qualified health center or you're working at sort of a mid-sized, at a mid-sized institution, partnerships are very, very important because, like I said earlier, you just can't do this alone. It takes a village. So we partner with Gildas Club of Kansas City, which provides great resources for our breast cancer patients, Gateway to Hope, which is based out of actually St. Louis, Missouri, on the other side of the state, where they provide great navigation services, support for patients who are at the 200% poverty level who might need transportation access, who might need, you know, somebody to come clean their house. They might need something for, you know, some sort of funding for groceries. I mean, just things like that where we can work together. And then additionally, we're a part of the Kansas City Breast Health Equity Task Force, which is a task force that was formed a number of years ago, and the goal of it is to reduce breast cancer mortality, particularly in black and Hispanic women, and that's comprised of stakeholders all over the city, whether it's navigators, whether it's physicians, community advocates, different health systems, different advocacy groups, and then we have an even broader one called the Missouri Breast Cancer Consortium Work Group that does similar, has similar objectives, but across the entire state. So then we include institutions like Washington University and St. Louis. So getting involved in the community is really important to raise awareness, to make sure patients know the importance of screening, that if they don't have access to screening, where they can go to get help. So we have been really fortunate to work with different groups such as Susan G. Komen. I myself raised funds for them a few years ago. I got to do some cool things like Meet Boys to Men, who are very supportive of breast cancer equity and research, which is really awesome. And as a result of our partnership, we were able to receive a Susan G. Komen grant a few years ago, and we used those funds through the Liberty Hospital Foundation to help those patients at the 200% poverty level, those patients who needed access to imaging services, to a biopsy. Maybe they needed funding for transportation to get to their cancer appointment. So that was really wonderful to have these funds available for our patients. We also have really strong ties with the American Cancer Society. And, you know, full disclosure, I am chair of the American Cancer Society Kansas City Board currently, so it's very near and dear to my heart. But just having that relationship with ACS, we've been able to help a lot of patients, whether it's support services, they also, this is now the second year, have awarded us a very generous transportation grant for patients so we can get them to their cancer appointments, to their imaging appointments. We see, although we are in the Kansas City metro area, we do see a large swath of rural patients from northwest Missouri, southern Iowa. So being able to provide these services so that they can get to their appointments has really been an incredible game changer, and we're really supportive, really appreciative of the support of American Cancer Society. When I came on as medical director at Liberty in 2018, I met with the foundation. That was the first thing, because I was seeing that there were so many patients here that were being turned away. And I just did not want these patients to be turned away under my watch. So I met with the foundation, and we were able to form the Women's Health Fund through their patient assistance program. And this is for patients who meet the 200% poverty level criteria for household income. And the fund covers the cost of anywhere from any kind of breast imaging exam, biopsies, gas cards, even arrangement for transportation, even if they need payment, you know, help them with their groceries or any sort of bills that they have to pay for their home. This is all in there. And the only way this came together was just having this strong relationship between our breast imaging department, the foundation, our finance department, customer relations department, and patient advocate department. So really bringing together all the stakeholders and saying, we need to make this reality. How do we figure this out? And then bring the key people to the table really was imperative. And we were able to get this toward the finish line and past the finish line for these patients. So educational outreach, I think, is really important for closing the gap for inequities. We still know there's a significant percentage of women not getting screened, particularly in my catchment area. There's still approximately around 40% not getting screened, which is very commensurate to a lot of different parts of the country. So anywhere from speaking at churches on Sunday morning, which I have done, to congregations to talk about screening and access. Or if you're feeling a lump, please go get it checked out. And if you can't afford it, please contact us. Or here are some other resources I think are really important. And just trying to dispel that taboo. In certain cultures, you know, it's taboo to talk about if you feel a lump or if you're worried, you know, you have breast cancer or if you're diagnosed with breast cancer, you don't really talk about it. But having these conversations is really important. And we can be at the forefront to helping facilitate that. Radio, still a thing, especially in the Midwest. And you can reach a lot of patients that way. And so I still am a firm believer of speaking on the radio. I do it quite a bit. And just speaking in so many different parts of Missouri this month, going to, you know, rural places, two, two and a half hours away. And a lot of patients actually show up. Why? Because they have a thirst for this information. And then if they need help, they will seek the help. So that's been really amazing to see over the years that I've been practicing in this part of the country. Partnering with the underserved. So we have a partnership with a federally qualified health center, Samuel Rogers. And that was a facility as well where we helped them obtain a DBT through a grant. And, you know, partnering with FQHC facilities can be an excellent way because a lot of times at these FQHC facilities, they may just provide the basic imaging services like mammography, ultrasound, plain film, but then any advanced testing, like the patient needs a biopsy, et cetera. They oftentimes don't provide those onsite services. So that's why it's important to have that relationship with them. So then if the patient does need a biopsy, you can triage them to your center appropriately or figure out a way that works for both parties so that patients can be seen in a timely fashion. The Show Me Healthy Women program is also a program in Missouri that started in 1992 that provides free breast and cervical cancer screenings throughout Missouri for women ages 30 to 64 who have an income at or below the 200% poverty level. And then once somebody qualifies for Show Me Healthy Women and they are diagnosed with breast cancer, they qualify for BCCT Medicaid and they're covered for the rest of their services which is really great. So we have a commensurate program in Kansas called Early Detection Works. So these are programs that unfortunately there is funding in these states for these programs and they're not being utilized to the maximum degree. So it's important for us to be cognizant of these state programs, making sure that patients are aware of these programs, facilities that offer, that are Show Me Healthy Women providers, that are Early Detection Works providers. So that if they do need these services and there's a potential malignancy that they can be taken care of throughout the continuum of cancer care. So transitioning now to access to breast imaging care. So we talk a lot about the patients, particularly at the 200% poverty level, but what about patients who have insurance, they're just underinsured. So we know in this country we have had issues with patients not having adequate insurance coverage, whether it was DBT, whether it was diagnostic breast imaging, whether it's imaging for above average risk patients, it's been an issue. So particularly in Missouri, I've been really fortunate to be involved in three pieces of critical legislation that's passed in 2018, 3D mammography legislation or DBT coverage for women annually at 40, which has been amazing because prior to that, only women starting at 50 every other year with 2D mammography or a full-filled DM, that was all that was covered in Missouri. So it was a huge game changer in 2018 when we were able to pass this. And then in 2020, I teamed up with Senator Lauren Arthur that you'll see here on this slide, and we were able to work on coverage for women who are above average risk, which was incredible. And now in 2023, we were able to also pass diagnostic breast imaging legislation without copay or deductible. So these aspects of this aspect of legislation and just getting this passed can really help so many patients and access to care for this demographic. So what about the other states that don't have this legislation? So we're working very reciprocally at the federal level to make sure that no patient is left behind. And so right now there is, and particularly the PALS Act, the Protecting Access to Life-Saving Screenings Act, is a piece of legislation that we've been able to keep going or extending the moratorium, rather, for many years so patients have mammography coverage beginning at age 40 throughout the country. And that has been really amazing. But we need to take it a little further. And so currently in Congress, there is the Find It Early Act that's been introduced on the House side and now as of October of this month on the Senate side. And this is a very robust legislation at the federal level that would provide coverage with no cost sharing for additional screening and diagnostic breast imaging exams for the detection of breast cancer, both FFDM and DBT, breast ultrasounds, MRI, and other technologies. Those who need supplemental screening with dense breasts and those who are at increased risk for breast cancer. So it's a big bill, but it is something that we need to continue to push for. We need to continue to push for it at the state level, of course, but ultimately at the federal level so no patient is left behind. There's also a similar piece of legislation called the Access to Breast Cancer Diagnosis Act, which is very similar to Find It Early, but it has a bit of a narrower scope of insurance coverage to that. So our members of Congress are cognizant of the issues to access for our patients throughout the country, and there are many that are working across the aisle to eventually get this type of legislation passed. So again, no woman is left behind. So as I said before, it takes a village. It truly takes multidimensional strategies. And really, you know, part of that solution entails community-based participatory approaches that really leverage the experience and influence of community stakeholders to promote policy, environmental and systems advocacy, approaches for comprehensive integrated systems of care, improving that community health leadership in terms of their competencies and skills, really working together and honing resources and see what everyone has available, and public health strategies, including education, increasing awareness, and creating a workforce to focus on underserved communities, like we're doing here in the city with the Kansas City Breast Health Equity Task Force, truly has been amazing to see. And we hope to see that we have positive outcomes in the years to come. And with that, I thank you for your time and attention. And I will now hand it off to Dr. Omofoy. Hello. I'm Dr. Toma Omofoy. I'm the Associate Professor of Breast Imaging at MD Anderson Cancer Center and Director of Breast Imaging, the Global Oncology Program. In that role, I do have the opportunity to work in global breast imaging in Africa, Asia, the Americas and the Caribbean, and collaborate with the International Atomic Energy Agency, the World Health Organization, Pan American Health Organization, and our partner ministries of health through the MD Anderson partnerships. Thank you for the opportunity to speak with you all today. And I'll be speaking about breast imaging gaps and outcomes in global health. LMICs have less than 5% of the global resources, but bear 80% of the global cancer burden. Global breast cancer mortality disproportionately affects low income and low to middle income countries. If you look at this chart of the breast cancer burden across income group world areas, it's easy to see that the incidence of breast cancer is highest in high income countries, while the mortality is highest in the low income countries. This means that the mortality to incidence ratio is really high for the low to middle income and low income countries. Unfortunately, data is lacking from some of the most affected regions, like sub-Saharan Africa. If we look at the African Breast Cancer Disparities and Outcomes, ABCDO study of breast cancer in sub-Saharan Africa, this study, a prospective cohort hospital study, was performed in five countries, looking at 2000 plus women who were newly diagnosed with breast cancer and following them for three years. The key findings of this study included that the mean age of diagnosis is 45 to 59 years, so lower than we see in high income countries, but also about 61% of patients total were diagnosed at late stages. In fact, that number was up to 95% in Nigeria. The three year survival for patients in the study overall was around 50%, so much, much lower number than what we see in high income countries. This study revealed significant survival disparities. So there are disparities by race, for example, the survival of white women versus black women in Namibia was 90 versus 56% respectively. We see that there are survival disparities by country, where the survival in Nigeria was the lowest at 36%. It identified that there were significant social determinants of health that contributed to the survival disparities. The socioeconomic status of a woman, the education level had a two times effect on patient survival. Breast cancer awareness was a significant factor in patient survival. Women who didn't know that breast cancer could be cured had much lower survival rates. A woman's geographic location, whether rural or urban, had significant impact on her survival. Interestingly, some of what was found to be minor is the fact that a lot of women were young at age of diagnosis or even women who are HIV positive. Those factors did not contribute significantly to survival. What does this say? That our targets to improve survival really should be around focusing on earlier diagnosis and improved treatment. And if we're able to combine these two factors, 20 to 40% of women would be able to survive. Or 20 to 40% more women would be able to survive. Stage of diagnosis is a quality indicator. We see more and more data identifying that there is a relationship between the human development index of a country and the proportion of patients who are diagnosed at stage one with breast cancer. So, the patients who live in higher income countries are more likely to be diagnosed at stage one. The survival estimates of Black women in the ABCDL cohort was about equal to what we saw in the women in the USA in about 1935 to 1950s before screening mammography and modern therapy was introduced. We do know that in our context, since the introduction of mammography, breast cancer mortality has decreased by 40%. However, population-based screening is really not feasible in weaker health systems. So this brings us to the WHO Global Breast Cancer Initiative, which really targets downstaging as a major goal. I know this is a lot in this chart, but we'll focus right here. The three pillars of this initiative are health promotion and early diagnosis. So patients being diagnosed at greater than 60% of patients being diagnosed at stages one or two, having timely breast diagnostics. So the diagnostic workup, including pathology, should be completed in less than or equal to 60 days. And then, of course, comprehensive management of care. The two of these three pillars of the GBCI need radiologists. Now what are the challenges to downstaging in LMICs? There are multiple, and this is a disclaimer I have to give, is that it would be impossible to address all of this in the time that we have for this webinar. But I do love that RSNA and the organizers are even going to introduce this conversation. So we know that workforce and training is a huge need. For example, in Tanzania, with a population of 60 million people, there are approximately 60 radiologists and about 600 radiographers. The equipment is a huge challenge in LMICs. On average, you have one to two mammography machines per million people in a population in LMICs. Processes are also really difficult. We know that about 80% of medical equipment in LMICs is donated, and up to 40% of that is non-functioning. This is related often to limited ability for servicing, obtaining spare parts, limited QA processes. All of those factors can implicate the care. Patient and community factors are also significant. For example, 75% of Ugandan women in one study had symptoms greater than six months before presentation. And also, we know that health system challenges are very significant. Two-thirds of the world has no access to basic radiology services. And often, when countries do have those services available, they tend to be centralized in the urban areas that may be more difficult for patients to access. And I'll show you some examples of a few cases in which these issues have arisen. This is a case of a 53-year-old woman who underwent opportunistic screening mammography. And this exam was performed on a computer radiography cassette, because the technologist really was trained much more for extremity X-ray, and so didn't really know the principles of mammography and just used the X-ray setup that they would typically use for a knee X-ray to do the mammogram. This is a case in which a 50-year-old woman underwent evaluation of a palpable lump. And a community health worker using actually a probe that's not optimized for breast estimated the disease to be around 1.5 centimeters. However, when that patient underwent repeat evaluation with a trained radiologist and appropriate equipment, there's an additional 10 centimeters of disease. So I'm going to talk really quickly about some of the strategies for improving breast imaging access. I would like to highlight that it's important to address workforce scarcity, but we want to address it in a sustainable way. The RSNA Global Learning Centers are capacity-building programs where we create multi-year agreements with multiple stakeholders, ministries of health, ministries of education, training programs to train local radiology subspecialists building onto existing radiology residencies. And as part of this, there's accreditation for these individuals who can then go on to lead imaging in their country. It's important that we steward limited resources. So we know that resource stratified guidelines are available. These evidence-based guidelines can be translated into clinical and training programs in a way that's resource sensitive. And so in the setting where screening cannot be prioritized because we don't want all of the early stage breast cancer to compete with the management of the later stage breast cancer, we have to be able to use our resource adapted guidelines and prioritize the available technology like ultrasound to focus more on early detection rather than screening. It is important in the setting to also leverage available human and imaging resources. We have to scale up technology, which according to the Lancet Oncology Commission, scaling up technology returns $180 for every dollar invested. So it is worthwhile. But of course, this has to be done in a way that also leverages the available training and resources so that the technology is sustainable. We've seen studies where low cost biopsy is introduced into village health care centers and the successful implementation also utilized regionally supplied and created breast biopsy kits so that the intervention and the implementation are sustained long term. We've seen training in ultrasound and simplified bi-rads be very successful when applied to community health care workers in just creating a condensed bi-rads to increase their ability to identify normal versus more abnormal breast imaging findings and help to reduce some of the unnecessary biopsies and steward limited resources. It's always exciting to think about what technological innovations can do for LMICs. One interesting study by Berg looked at AI in ultrasound use to examine women with palpable breast lumps in a low resource setting. Here we compared standard of care ultrasound with low cost portable ultrasound with AI and found that AI did identify all malignancies in the low cost portable setting, but the specificity was reduced from advances. And interesting, AI performance is reduced when the low cost portable ultrasound was used by an untrained observer. So training remains important even with AI. It is important to consider improving access through mobile mammography for the more mature health care systems in which screening is taking place. In Brazil, a government organized mammography program, including mobile and fixed units, the amount of women who were eligible for mammography who participated and detected 76 more cancers. 87 of those were early stage. Radiologists can also participate in patient-centered practices, like organizing multidisciplinary patient outreach, where a combination of different health care professionals can provide education, you know, history and physical for patients, clinical breast exam, and then offer same day ultrasound and ultrasound guided biopsy for positive cases. There are numerous policies to address systemic barriers, but it's important to think about as we address these policies, do we include everyone of the stakeholders at the table? Universal health care with breast diagnostics being included in health care plan is really, really important. We know that scaling up the workforce and imaging infrastructure is cost effective, and that's something we have to communicate to our policymakers and governments. Service delivery targets, addressing processes, quality is very, very important. Patient navigations, policies to reduce wait times for patients, increasing opportunities to participate in research are all very important. Multidisciplinary teams and meetings have been found to be high yield value-based care, and it's a way to really provide patient-centered care for our populations. And of course, we want to make sure that we're integrating with the available community services. So in conclusion, radiologists are key players in promoting early detection of breast cancer, and we can use innovative approaches to really address these global breast cancer disparities, and hopefully avert one third of unnecessary breast cancer deaths. Thank you. Thank you so much, Dr. Almafoye, for that amazing presentation. We are so apologetic that we do not have time for the Q&A, but we thank you so much for being in attendance today. Please be sure to click on the link in the resources panel to complete the survey to gain CME credit for your participation. You will receive a notification email from the RSNA next week when the recording and supplemental resource guide are available in the RSNA Online Learning Center. And be sure to check the RSNA website for upcoming educational events and webinars. And with that, thank you so much for your time and attention this evening.

breast imaging

health equity

breast cancer disparities

social determinants of health

safety net hospitals

insurance coverage

global health challenges

community partnerships

radiologists role