Breast Cancer Diagnoses Delayed by Housing, Food Insecurities

The risk of having undiagnosed breast cancer is higher for women who are experiencing food and housing insecurities because they are more likely to miss their follow-up appointments.

Nationwide, according to 2018 U.S. Department of Agriculture (USDA) statistics, 11.1 percent of American households reported food insecurity. This problem is an even greater danger for single mothers and single women, affecting 30.3 percent and 14.7 percent, respectively. In addition, a 2020 Center for Economic and Policy Research report revealed one in three renters and one in six homeowners experienced housing insecurity during the first half of the year.

These issues present significant challenges for detecting breast cancer in women.

“Diagnosing breast cancer at an early stage is very important for survival,” said Aaron Afran, a third-year medical student at Boston University School of Medicine (BUSM). “Concerning mammography findings lead to the need for additional imaging, such as diagnostic mammography and ultrasound, and there can be a lapse in time between imaging appointments.”

Afran’s team will present their findings during this year’s Radiological Society of North America annual meeting. The goal, he said, was to better understand how social needs impact how long it takes for a woman to attend a follow-up appointment after her screening.

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To examine how these social determinants of health (SDHs) actually affect a woman’s healthcare, the team retrospectively reviewed medical records from two groups of women who both received breast imaging at Boston Medical Center (BMC) and completed the institution's THRIVE questionnaire to identify and address a patient’s unmet SDHs. THRIVE examines eight variables, including housing, employment, transportation to medical appointments, difficulties with caretaking responsibilities, and whether the patient can afford food, medicine, and utilities.

Women in the study were divided into two groups – those who underwent mammography and those who had suspicious diagnostic imaging results. Of the 4,959 women who had a mammogram, 1,510 had complete SDH data and were included in the multivariate analysis. The average age of the group was 59.1 years, and they varied by ethnicity – 56.2 percent African American, 18.2 percent white, 16.5 percent Hispanic, and 25.6 percent of unknown race.

The second group included 3,028 women, 812 (26.9 percent) of whom had complete SDH data and were included in the analysis. Their average age was similar at 60.9 years, as was their racial breakdown – 57.5 percent African American, 22 percent white, 13.6 percent Hispanic, and 20.5 percent of unknown race.

Based on the team’s statistical analysis, food and housing insecurities were, in fact, associated with longer time intervals between imaging and breast biopsy when compared to time lapses for women who do not have these unmet SDHs. These findings confirm those unmet needs do impact patient care, said senior author Michael D. Fishman, M.D., assistant professor of radiology at BUSM and breast imaging section chief at BMC.

“To best serve our patient population at a safety-net hospital, we must think creatively about the social factors that are preventing our patients from receiving the best care,” he said. “Our findings indicate longer lapses between diagnostic imaging and biopsy for patients with unmet social needs, which begs the question: are unmet social needs associated with some amount of breast cancer mortality that could have been prevented?”

Those investigations will be the focus of future work, he said.