Adequacy of and Barriers to Breast Cancer Screening in Women With Disabilities

Abstract

This cohort study evaluates the adequacy of and barriers to breast cancer screening for women with disabilities treated at a specialty clinic dedicated to gynecological care.

Women with disabilities face substantial disparities in breast cancer screening, detection, and treatment, resulting in poorer outcomes.¹ Many of these disparities stem from structural barriers within health care systems that fail to provide reasonable accommodations.² Physicians across specialties often lack the comfort and knowledge to properly provide care for women with disabilities, contributing to inaccessibility and substandard care.³

To address these barriers on an institutional level, some health care organizations develop specialty clinics with experienced practitioners to provide comprehensive, accessible care for women with disabilities. However, the effectiveness of these clinics, particularly for breast cancer screening, remains underexplored. We evaluated screening mammography (SM) rates at a clinic dedicated to gynecological care for women with disabilities, assessing both adequacy and opportunities for improvement in the breast cancer screening process.

Methods

The NYU Langone Health (NYULH) Institutional Review Board exempted this retrospective cohort study from review due to low risk to human participants. Informed consent was waived. The study followed the STROBE guideline.

We reviewed consecutive electronic health records (EHRs) for 2023 to 2024 from the NYULH Initiative for Women With Disabilities specialty clinic. The primary outcome was SM rate as defined by American Society of Breast Surgeons (ASBrS) guidelines, which recommend annual screening for women starting at age 40 years (or earlier for those with a family history).⁴ Data on race and ethnicity were collected to determine whether these were intersectional factors with disability in screening disparities. Participants self-identified as Asian, Black, Hispanic, White, or other or unknown race or ethnicity (no further information in the EHR at the time of data collection was available for other). Statistical analyses were conducted with JMP, version 18.0.1 (JMP Statistical Discovery), and Excel, version 16.98 (Microsoft).

Results

We reviewed 189 EHRs and included 138 patients (mean [SD] age, 51.2 [15.8] years) who met breast cancer screening criteria. Three patients (2.2%) were Asian, 47 (34.1%) were Black, 13 (9.4%) were Hispanic, 44 (31.9%) were White, 3 (2.2%) were of other race or ethnicity, and 28 (20.3%) had unknown race or ethnicity. Most patients (115 [83.3%]) required mobility accommodations. All patients but 1 (0.7%) were insured: 71 (51.4%) had Medicare, 44 (31.9%) had Medicaid, and 22 (15.9%) had private insurance.

Fifty-nine patients (42.8%) received screening in accordance with ASBrS guidelines, 58 (42.0%) received no breast cancer screening, and 21 (15.2%) received inadequate screening, meaning either ultrasonography instead of SM (8 patients [5.8%]) or SM with suboptimal views (13 patients [9.4%]) (Figure). Of the 72 women (52.2%) who received SM, 13 (18.1%) had images with limited views for reasons such as wheelchair use or patient immobility. Reasons for ultrasonography without SM were patient refusal or inability to tolerate the procedure.

Figure. Breast Cancer Screening Flowchart of Women in the Initiative for Women With Disabilities Cohort.

ASBrS indicates American Society of Breast Surgeons.

^aReasons included limitations owing to wheelchair use or patient immobility.

Overall, 80 women (58.0%) presented for breast cancer screening, 21 (26.3%) of whom received inadequate screening. Five women (6.2%) were recommended to undergo biopsy, 1 of which yielded breast cancer.

Discussion

In this study, 42.8% of women with disabilities received ASBrS-recommended mammography, which was substantially lower than the 65.0% uptake rate observed in the general population and within our institution.⁵ In addition, 26.3% of women received suboptimal care (ultrasonography without SM or SM with incomplete views), possibly due to physical accessibility barriers that created challenges in positioning patients.

Notably, most EHRs do not support documenting accommodations (eg, mobility devices), which can lead to challenges in providing care even when these transfer devices are available. Most patients in our study (83.3%) required mobility accommodations, but our own EHRs lack demographic information on disability type, which is a study limitation. Lack of documentation perpetuates barriers that reduce adherence to screening guidelines and recommendations.⁶

The findings of this cohort study were drawn from an urban clinic providing comprehensive women’s health care tailored to the needs of women with disabilities, suggesting that suboptimal rates of breast cancer screening and barriers to screening in the general population may be considerably higher. Enhancing imaging accessibility and educating health care professionals about the needs of people with disabilities are essential steps toward improving screening uptake and reducing long-standing disparities.

Supplement.

Data Sharing Statement