Every woman dreads the moment, after a screening mammogram, when she learns the X-ray has detected a “spot” or a “shadow” requiring a closer look. Janet Humdy Morrison of Milton faced one such moment at the imaging center at Massachusetts General Hospital when she went for her annual mammogram in July 2020.
Morrison, a 72-year-old semiretired executive coach, knew that repeating a mammogram is commonplace. She had friends who had gone through it: the anxiety-spiking call asking them to come back for a second mammogram, then sometimes weeks or months of waiting for various follow-up exams to yield results, usually showing that nothing is wrong.
But to her surprise Morrison found out immediately that she needed additional testing, and what she heard next surprised her even more: “We can do it today.” She went from screening to further tests to biopsy in a matter of four to five hours. Diagnosed with very early-stage cancer, she has since completed treatment with surgery and radiation.
“This is a godsend, not having to wait, not having to agonize over weeks,” Morrison said.
The speedy diagnosis was also an unexpected benefit of the pandemic. Seeking to make up for mammograms missed during the lockdown, doctors have looked for ways to draw patients back in for care.
Like a storm that blows shingles off a neglected roof, the pandemic exposed the weaknesses in the health care system. Most strikingly, it highlighted the inequities that have long worsened health for Black people like Morrison, as well for Hispanic people and those of lower socioeconomic status.
The pandemic also shook up hidebound practices, prompting changes that many patients might consider longer overdue — such as adopting the convenience of telehealth. And reducing the agony of the mammography wait times.
“We’re trying hard to listen to our patients and ask ourselves, ‘What do our patients need?’ And thinking outside the box, rejecting those beliefs — ‘That’s not how we do things,’” said Dr. Constance D. Lehman, director of breast imaging and co-director of the AVON Foundation Comprehensive Breast Evaluation at Massachusetts General Hospital.
Cancer screenings of all kinds dropped dramatically during the pandemic, including tests for breast, colon, cervical and lung cancer. Screening tests stopped altogether for about three months when all elective procedures were halted.
But since mammography centers reopened in the summer, they still haven’t made up for all the missed exams. Many women haven’t rescheduled; others remain reluctant to come to a health care setting for fear of infection.
The Epic Health Research Network, a journal that analyzes electronic health record data, found that after a sharp drop-off in the spring of 2020, cancer screening has rebounded, but the numbers haven’t fully caught up. Looking at screenings for March 2020 through March 2021, the journal reported that breast cancer screenings were 13 percent below historical averages, colon cancer screenings 25 percent below, and cervical cancer screenings 21 percent below.
And a separate study published June 30 found that the resumption of screening happened unequally at one large hospital system. The study, which looked just at the experience of the Mass General Brigham hospital group, found that fewer Black and Hispanic women underwent mammograms during the last quarter of 2020 as compared with the three months before the pandemic. During the same period, the number of white women getting mammograms increased.
Lehman saw the evidence in her own practice: More women have been coming to the imaging centers that tend to serve white non-Hispanic women, while fewer have been screened at centers that traditionally serve Hispanic people and people of color.
She also identified another disparity in her own practice — an unintentional favoritism.
Typically, when a woman gets a mammogram, the X-rays are grouped with others performed over the course of the day. The radiologist reads them the next day. If anything looks suspicious, as happens with fewer than 1 in 10 mammograms, the woman receives a phone call or a letter within a few days, asking her to come back for another mammogram.
But Lehman found that some 15 percent of patients got their mammograms read instantly, often because they were strong self-advocates who insisted, or their doctors asked the radiologists for a favor. And studying the data, she realized those were mostly white women with higher incomes.
“That was shocking to see. We had unintentionally developed this system that supported inequities,” Lehman said.
The women least likely to get the “immediate read” may encounter other obstacles, such as inflexible job schedules or challenges with transportation and child care, making it harder to come back. This could lead to delays in diagnosis. And studies have long shown that Black women, despite similar rates of breast cancer, are more likely to die of it than white women.
Lehman and her colleagues wanted to find a better way. As soon as itsimaging centers reopened in June 2020, Mass. General began routinely offering patients results right away. The number of patients receiving immediate reads increased from 15 percent to 60 percent. (Lehman is studying what happened with the other 40 percent; perhaps some patients preferred to come back, or maybe it took the staff too long to provide the results.)
But most important, the racial and ethnic disparities vanished: Immediate results were offered to everyone equally.
The hospital also started a “pink card” program for women who visit its Boston clinics for any reason. If they are due for a mammogram, they get a pink card to take to the nearby imaging center for an exam that day.
The immediate-read program builds on another improvement Mass. General has offered since 2017 at two imaging centers: same-day biopsies, or biopsies performed as soon as a follow-up test shows the need to examine a tissue sample for cancerous cells.
Those advances enabled Amy Federico, a 52-year-old Charlestown resident, to complete in one morning a process that might otherwise have been a weeks-long ordeal.
After her annual mammogram in June 2020, she learned right away that something looked worrisome. Doctors performed a follow-up mammogram, and, still concerned, advised Federico that they’d like to do an ultrasound. And then a biopsy.
A few days later, she got a phone call: the small nodule that showed up in images was benign.
“It all happened so quickly, but in hindsight I was happy it played out that quickly,” said Federico, 52, an oncology nurse practitioner at Boston Children’s Hospital.
In overhauling screening procedures, the hospital drew from lessons in other industries that deal with unpredictable customer demand, such as restaurants and hotels. Seeking to emulate these companies’ customer-first practices, Lehman and her team looked to eliminate delays and waste, standardize procedures, and streamline workflow.
“You’d have 12 different doctors who all wanted the room set up in 12 different ways,” she said. But things would go smoother if every doctor followed the same steps.
To avoid having scans read by distracted radiologists in busy clinics, all the 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 come in.
The Dana-Farber/Brigham and Women’s Cancer Center also promises same-day results, but to avoid crowding the waiting rooms, patients do not have to wait around, said Dr. Sona Chikarmane, division chief of breast imaging. Women get phone calls by 3 p.m. if their mammograms were taken before that time, and appointments are kept open for callbacks so patients won’t have to wait long.
As health care providers struggle to make up for the missed screenings, the pandemic’s effects raise some big questions.
Will there be a spike in late-stage cancers or cancer deaths? Or will the failure to screen make no difference, affirming the critics’ view that all this testing isn’t worth it?
Anecdotally, doctors are reporting increases in more advanced cancers. Some may result from patients who had symptoms but feared seeking help during the pandemic. That’s different from skipping a screening test, which by definition is for people without symptoms, most of whom don’t have cancer. Because most cancers grow slowly, it will take many years to assess the effects of skipped or delayed screenings.
A three-month delay probably won’t make a difference in breast cancer, said Dr. Ann H. Partridge, a Dana-Farber breast cancer specialist. Still, doctors worry about cancers that might have been discovered in those missed mammograms. Will they be caught in time?
“What we’re concerned about is that people will wait a year or two or three,” she said. “We’re concerned about the people that aren’t coming back in to get back on the screening regimen.”
But Dr. H. Gilbert Welch, a well-known critic of unnecessary screening, says he doubts the screening backlog will have any effect on breast cancer death rates, because treatment has improved so much that even later-stage breast cancers can be managed. Welch, who is with the Brigham and Women’s Center for Surgery and Public Health, questioned the wisdom of investing so much in searching for illness among the well, “while we’ve not attended to more powerful determinants of health.”
But Lehman, of Mass. General, holds to the mainstream view: ”Screening mammography has proven again and again to be the best tool we have to reduce breast cancer mortality.”
And she says she’s committed to making mammography easier, for all women.
“We’re not going to go back to the way it used to be,” she said. “We learned so much. We’re going to carry that forward.”