Addressing care gap in underserved women not easy

In an effort to fill a significant gap in the breast care of underserved women, physicians and nurses at Mayo Clinic's campus in Jacksonville, Fla., developed a program, still ongoing, to help overcome barriers that prevent women from receiving timely care after an abnormal mammogram.

From 2001 through 2006, Mayo Clinic's Multidisciplinary Breast Clinic offered free diagnosis services to 447 women who had been screened for breast cancer by their county health departments in Northeast Florida. The goal was to substantially reduce what can be a long delay between an abnormal screening mammogram and diagnosis — which they succeeded in doing — and thus improve outcomes for the 38 women found to have cancer and reduce distress in many others.

Arriving at a correct diagnosis was relatively easy; overcoming the barriers to health care that many women have was not, says the lead author and researcher presenting an analysis of the program at the annual San Antonio Breast Cancer Symposium meeting.

For example, many women participating in the program had no address, or just a temporary one, such as a battered women's shelter, says Frances M. Palmieri, M.S.N., clinical manager of the Multidisciplinary Breast Clinic. Few had telephones, public transportation to the clinic was nonexistent, and some women were reluctant to come in any case, Palmieri says. Others could not take time away from child care or work to come to the clinic for evaluation.

“This is a snapshot of what happens nationally to financially disadvantaged, medically uninsured women,” she says. “We all need to understand and try to overcome the challenges and barriers to patient care that exist for many.”

Among other things, the Breast Clinic worked with local charities to provide clothing to those who needed it, and worked with the city of Jacksonville to have the public bus service stop at the clinic. They assigned a research nurse, Judith Smith, to help find and bring women into the clinic, which quickly emerged into a full-time pursuit.

“It is important that women undergo appropriate diagnostic studies as soon as they receive an abnormal breast cancer screening, but it takes much more coordination than we ever expected,” Palmieri says.

Several programs exist nationally to provide free breast cancer screening mammograms to underserved women, but there is no unified system for providing diagnostic services when abnormalities on the mammograms are detected. As a result, in late 2000, Mayo Clinic in Jacksonville and Betty Anne Mincey, M.D., who was at Mayo at the time, instituted a program to address this gap in care. The Breast Clinic worked with health departments in four counties surrounding the institution (Nassau, Duval, St. Johns and Clay), so that women with abnormal mammograms would be referred to Mayo Clinic for a diagnosis. A team of radiologists, led by Elizabeth DePeri, M.D., current principal investigator of the study, worked to provide flexible procedure times and overcome system barriers to offer a timely review of screening films and a rapid diagnosis.

Of the 447 women enrolled through 2006, 65 percent were white, 21 percent were black, and 11 percent were Hispanic. The mean age was 49.7 years. Physicians performed 893 procedures (mostly diagnostic mammograms and ultrasound tests) and found that 90 percent of the abnormalities detected on initial mammograms were benign. They also diagnosed 38 cancers, of which 76 percent were invasive carcinoma that needed immediate treatment. In most cases, county health departments provided that treatment, but some patients were cared for at Mayo Clinic. No data is available yet on outcomes.

The clinic succeeded in reducing what had been a typical delay of several months down to an average of 36 days, well below the 60-day benchmark established by the U.S. Centers for Disease Control and Prevention (CDC), Palmieri says.

“This has been a real education for all of us, but our study demonstrates that timely diagnostic resolution of abnormal mammograms in low socioeconomic status women is achievable with a coordinated, collaborative program between an academic medical center and public health departments,” she says.