The 9,600 Missed Diagnoses: How Geography Still Shapes Breast Cancer Outcomes

Despite improvements over the past few decades in breast cancer detection and care, an important new report says that 9,600 early-stage detections are being missed annually in the U.S.

Ten years ago, the results of this new Milken Institute report would have been unsurprising. But after a decade of attention, resources, and federal funding and policy focused on that breast cancer, there are still barriers to adoption. And it’s not what you might think.

The report - which is well worth a read over the weekend - emphasizes that population density, and ultimately, your zip code, are still determinants of healthcare access and outcomes. The study used the location of mammography machines in the U.S. to help predict areas that could use greater focus to ensure greater early detection of breast cancer.

First, some context:

Breast cancer is one of the leading causes of death in the U.S., expected to impact 42,000 women per year. In the past few decades, significant work has been done to ensure earlier detection. The Affordable Care Act helped by making it a covered preventative care service for women over the age of 40 – requiring private insurers and Medicare to cover the costs.

The study at a glance:

• The locations of mammography machines was based on data collected by the FDA
• Population data for each county were based on U.S. Census data
• The goal of the study was to find which areas of the country are still missing mammography machines and suggest other solutions to access barriers

What I found jarring:

1. There are 890 counties in the U.S. that have zero mammography machines. 

That number should be zero. With the amount of technology today with portable diagnostic tools in developing countries, what is the excuse here? How can community-based public health efforts succeed when the basics – tools for diagnosis – are not available? The report doesn’t explain why these counties have no machines, but my hunch is the string of hospital closures that the U.S. has seen in recent years is playing a significant role. The idea that a low-volume region doesn’t support the expense of having and maintaining a machine is how detections fall through the cracks and lead to more expensive care down the line.

2. It’s not just about the machines. Problems that plague the rest of the health system – access to transportation, ability to take time off, cost burden for follow-ups – matter a lot. Even in an advanced country like the U.S., basic health needs remain unmet. And companies like Uber and Lyft have had programs in the past to try and help patients get to appointments and remain adherent, but those efforts are less effective in low-population zones inclusive of rural areas. 

3. There is no pattern. I thought I would find a clear color zone with Middle America more likely to have no mammography machine counties than the rest of the country. The zero-county zones stretched all over the map from coast-to-coast and north to south. Totally scattered. 

Why it matters:

The ACA was supposed to help erase the gaps in healthcare by covering preventative care. It has helped women gain greater access to mammograms, preventative medication for those at higher risk, and genetic testing and tools for those who have it in their family to determine their risk. The federal government, notably the National Institutes of Health, have also invested heavily in searching for better treatments and any cures.

But this year saw numerous efforts undo that work. Between legal challenges to the ACA, as well as the reduction in research funding, there’s less support than ever to bridge these gaps. Meanwhile, the insurance industry is increasing the cost-sharing burden for patients, creating additional barriers. A 2018 study in the New England Journal of Medicine (NEJM) showed that elimination of cost sharing significantly increased the number of women getting mammograms.

With that context, more than ever before, it seems crucial to find the gaps and plug them with access to preventative care.

One might argue that mammograms are covered for a lot of people with insurance - but studies are also finding that heavy amounts of cost-sharing make patients more hesitant to go to the doctor for any reason. Patients equate healthcare with the experience of getting a bill in the mail weeks later that seems exorbitantly high, and they can’t afford.

What needs to be done:

1. Employers need to ensure that these diagnostic tools and care visits are covered, and that their members are aware.

2. State coalitions that have been forming to fight DC policy should ensure their public health dollars are going towards finding those who are falling through the cracks.

3. Medical device makers should target these dead zones and find ways through public-private partnerships to ensure access to tools. 

Final thought:

The study makes it feel like we’re somewhat back at square one, after more than a decade of progress in preventative care. Just another day to say in another way that the American health system is broken.