Mammography Compliance: Fear Factors and Mental Health Matters

After an approximate four-month hiatus due to the coronavirus outbreak, hundreds of women’s imaging facilities in the Northeast are gearing up to reopen as states relax countermeasures designed to battle the pandemic. Breast imaging professionals are working diligently to start serving patients under new, stricter guidelines. 

For example, the Centers for Medicare and Medicaid Services (CMS) has offered guidance on how community healthcare facilities can begin providing services once again. The American College of Radiology (ACR) has issued direction on how imaging facilities can resume non-urgent care. And, in early May, the Society of Breast Imaging (SBI) released reopening recommendations for breast imaging facilities impacted by COVID-19 closures.

In all cases, the recommendations aim to ensure a safe and socially distant environment for patients and staff. But, while breast imaging facilities are ready and eager to welcome women back through their doors, not all women are ready to cross that threshold.

Just like in ordinary times, in the age of COVID-19, mammography screening compliance remains an ongoing concern. Only about 67 percent of women receive their annual screening mammograms on schedule, according to the American Cancer Society. Yet, approximately 42,170 women in the United States are expected to die in 2020 from breast cancer.

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Providers know that indigent women and female patients living in remote areas are among those that tend to most often skip screenings. However, there are two other key factors that appear to have a negative impact on mammography compliance for many other women—fear and mental health issues.

As imaging centers begin to reopen, it seems an opportune time for providers to jumpstart outreach efforts to women who may avoid annual screenings due to common fears or challenging mental illnesses.

Fear Factors

There is ample evidence that suggests many women forgo screenings due to a host of fears. A study published in 2014 investigated perceived barriers to mammography among 9,000 underserved women. Some 40 percent said that fears of cost held them back from getting a screening, while another 13 percent cited mammogram-related pain as a barrier. In addition, 13 percent feared receiving bad news.

A 2019 survey conducted by HealthyWomen explored the subject of mammograms with nearly 1,200 women over age 40. Almost one-in-six women reported that discomfort has deterred them from getting a mammogram as recommended. In fact, 12 percent said they postponed a mammogram due to discomfort, and 3 percent said they would not get them anymore because of it.

Radiation was also a worry. Of the 169 women who had not had a mammogram, nearly 16 percent reported worries about radiation as the reason.

As if there were not already enough concerns, the coronavirus has now likely added a new reason and level of fear to procrastinate having these exams. In a Gallup poll conducted this April, 64 percent of women said they were worried about contracting COVID-19 as compared with just 50 percent of men.

Recent news reports across the country indicate that this kind of worry is leading people to skip appointments with their doctors. Skipping an exam or procrastinating can be a dangerous gamble. As we all have come to know, catching breast cancer early is the key to best chances of cure.

For example, in early May, Alabama-based WKRG news reported that patients are cancelling doctor appointments—and annual screenings— due to fears of COVID-19. The report featured an oncologist with USA Health Mitchell Cancer Institute who said she is concerned that 6-to-12 months from now we’re going to see a whole lot of new cancers that were diagnosed quite late.

Nationally, breast screening appointments dropped 94 percent in March 2020 compared to the average number of appointments before January 20, 2020, according to an analysis by Epic Health Research Network. While the bulk of the dip was due to pandemic-related restrictions on routine screenings, it remains to be seen if women’s fears of COVID-19 will lift along with the restrictions. Or, will fears of contracting the virus become yet another compliance issue for breast imagers to address.

Mental Health Matters

The other patient population that poses unique challenges – and an equally significant compliance concern – is women with mental illness.

Two recent studies point to woefully low screening compliance rates for women with mental illnesses, including depression, mood disorders, anxiety, eating disorders, bipolar disease, schizophrenia, and more.

According to a global analysis published in The Lancet-Psychiatry in 2019, adults with mental health issues were 24 percent less likely overall to get screened for any type of cancer as compared with the general population. However, the disparities among women with mental health issues were staggering.

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Specifically, the study found that women with schizophrenia were 48 percent less likely than those in the general population to be screened for breast cancer. What’s more, women with any kind of mental illness, including depression and mood disorders, were 35 percent less likely than those in the general population to be screened for breast cancer.

The analysis included 501,559 adults with mental illness and 4.2 million in the general population of the Americas, Asia, Australia and Europe.

A second study in 2020, specific to the United States, points to a similar disturbing trend. Researchers explored the association between depression, specifically, and mammography screening by reviewing data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative phone survey of women ages 50-to-74.

Nearly 140,000 U.S. women participated in the survey, and 23 percent reported they had been told they have a depressive disorder, including depression, major depression, dysthymia, or minor depression. The findings showed that women with some form of depression had a 15-percent lower chance of undergoing a mammogram in the past two years than women without depression.

Clearly, women with mental illnesses are at risk for skipping screenings—and therefore, upping their odds of breast cancer going undetected until a later stage.

It is important to note that the authors of both studies conclude that more than one issue could be at play when it comes to inhibiting women with mental illness from seeking out annual screenings. Some of the other key barriers they cite include lack of access to mammography screenings, especially in remote or rural communities, lack of transportation to imaging facilities, cost, and lack of insurance.

Finally, there is the barrier of mental illness itself. Women with depression—and especially those with more severe mental health issues—may have trouble just coping every day, let alone taking the time to schedule a mammogram.

How Imaging Providers Can Help

Empowering fearful and vulnerable women to take charge of their breast health is no easy feat. However, there are several steps imaging facilities can take to help encourage compliance among these populations.

Breast imaging facilities have ample ways to quell common fears. Communicate with patients through your website and educational materials. Let patients know the facts. Those who skip screenings because they are fearful of receiving bad news might be reassured to know that only two-to-four screening mammograms in 1,000 lead to a diagnosis of breast cancer.

As for women concerned about pain, make sure to distribute literature about the comfort features built into your mammography system.

Finally, to calm fears about contracting the coronavirus, consider the ACR’s list of strategies for managing fear. These include providing frequent, fact-based information, advertising institutional infection control processes, acknowledging that fear is normal during a pandemic, and noting that COVID-19 risk is low with the right safeguards and highest for aerosolizing procedures or prolonged contact. Every site will have their own protocols for protecting patients in how they schedule appointments and how they prep, clean, and disinfect for each exam. Conveying these safety measures upfront can go a long way to ease fears.

Fearful women are one concern. But, when it comes to increasing compliance among women with mental illness, referring physicians can be your best ally.

Primary care doctors and OB/GYNs are on the front lines of women’s healthcare. Many likely know and treat patients suffering from mental illness. However, they may not be aware of the lack of mammography compliance among this population. This gives imaging facilities an important opportunity. It’s a chance to reach out to referring physicians—with a simple email, flyer, or a link to one of the studies mentioned previously—and alert them that screening reminders are especially important for women with a history of mental illness. 

Here, again, patient education is equally important. Imaging providers can use their website or create simple waiting room materials to inform women about the link between mental illness and lack of compliance. For example, one key statistic can help alert women that if they—or a friend or a relative—suffers from mental health issues, she is more at risk for skipping annual screenings, meaning she is at greater risk for detecting cancer at a later, more dangerous stage.

Finally, research shows that lack of access may be a contributing factor to why women with mental health issues forgo their screenings.

Imaging facilities across the nation can help provide access to screening mammography by partnering with FUJIFILM Medical Systems, U.S.A. Fujifilm’s Aspire to be Fearless mobile coach provides free screenings in underserved areas. Our 18-month, 48-state campaign is a collaborative effort between Fujifilm and trusted local women’s imaging clinicians. With the help of medical experts, the goal is to provide screenings to every woman that attends along with invaluable information about the importance of early detection.

To learn how your imaging facility can participate in the Aspire to be Fearless mobile coach program, visit our website.