Radiologists know screening is important. There is strong evidence that screening for cancers —lung, colorectal, and breast, among others— catches these diseases early, making them easier to defeat. Yet the numbers of patients who come in for these procedures, even when eligible, remains low. In 2016, less than 2 percent of those eligible for lung cancer screening underwent the procedure, and screening rates for diseases such as breast, cervical, and colorectal cancers also remain below federal target rates.
There are many reasons why patients don’t get screened, including a lack of awareness. Additionally, patients may face financial burden, fear of what happens next if the test is positive, or anxiety about potential discomfort. But many are simply misinformed. And the wealth of misinformation about screening can dissuade patients from life-saving procedures.
The Realities of Misinformation
Misinformation and lack of knowledge abound when it comes to screening. “Lung cancer screening in particular is at a disadvantage because it’s such a new technology,” says Ella A. Kazerooni, MD, MS, FACR, interim chair of the department of radiology at the University of Michigan and chair of ACR’s Lung Cancer Screening Registry Committee and Lung-RADS™ Committee. In addition to lagging awareness about lung cancer screening, false information about the procedure itself is common. “Patients may be concerned about the radiation dose in these screenings,” Kazerooni adds. “However the radiation exposure in these tests is low, and older patients who are eligible for these screenings have little lifetime risk associated with the exposure, compared with the risk of having lung cancer. Without appropriate context for this radiation concern, some patients may opt to avoid screening.”
Judy Yee, MD, FACR, chair of the ACR Colon Cancer Committee and chair of the department of radiology at Montefiore Health System and Albert Einstein College of Medicine in New York, adds, “A lot of patients avoid colonoscopy for colorectal cancer screening because they’re concerned about the invasiveness and the associated requirements, such as having to have another person accompany them. Although you do need to have dietary restrictions before you undergo CT colonography (virtual colonoscopy), patients can drive themselves after, eliminating some of the logistical hurdles patients might worry about.”
Referring physicians, while they might not have false information, are also looking to be educated about screenings, from whom to screen and whom not to screen, and how to3d manage abnormal screens, says Kazerooni. “Primary care physicians are very concerned about incidental findings. Often, the low-dose CT will find additional issues, and referring physicians don’t always know what to do with that information,” Kazerooni says.
Concerns and misinformation about radiation exist in breast imaging as well, says Dana H. Smetherman, MD, MPH, MBA, FACR, chair of the ACR Commission on Breast Imaging and chair of the department of radiology and section head of breast imaging at Ochsner Medical Center in New Orleans. “A lot of patients and referring physicians are also concerned about the anxiety that multiple procedures or additional images related to a recall from screening mammography might cause, as well as the pain associated with the procedure,” says Smetherman.
The First Steps
One way to combat misinformation about screening is to spread factual information about the term. To do that, you have to create relationships with stakeholders: referring physicians, patients, and patient advocacy groups, says Cheryl R. Herman, MD, FACR, breast imager and assistant professor of radiology at Washington University School of Medicine in St. Louis.
Smetherman notes that one way to establish a good relationship with referring physicians is to help make the communication process seamless for them. “Understand that these physicians are extremely busy too. Reach out to them and see how they want to be contacted,” she says.
Yee suggests being an open resource for referring physicians, no matter your environment. “Actively approach your referring providers and offer to provide the latest literature and educational lectures. Participate in multidisciplinary conferences. These approaches can help other physicians understand how imaging tests can be used for cancer screening,” she says.
“Have open communication with your referring physicians, such as calling or emailing them with answers to questions they might have,” adds Herman. Herman also requests to visit internal medicine meetings at her institution, where she initiates quick discussions on screenings and any updated screening information that referring physicians might need. Another way that Herman reaches referring physicians is through her reports. If she sees a diagnostic patient who should be considered for additional screening, such as breast MRI, she adds that recommendation at the bottom of the report.
Radiologists can also help provide information to referring physicians at their clinics and in their hospital administrations by passing along some of the resources the ACR has to share. For example, when she was approached about referring physician concerns with incidental findings, Kazerooni shared the recently published ACR Incidental Findings Committee’s white paper on thoracic CT. Yee also addresses concerns about colorectal screening by sharing a patient brochure (available in English and Spanish) developed by the ACR Colon Cancer Committee.
Patient and Community Outreach
According to Kazerooni, another way to dispel misinformation and fear is to reach out to patients directly. This is especially important for patients eligible for lung cancer screening, who often feel stigmatized, says Kazerooni. “Patients who have lung cancer often feel or are approached as if they gave the disease to themselves by smoking — that it’s their fault. Even if patients are not smokers, they have been treated as if they’re lying about smoking.” Kazerooni adds, “A lung cancer patients is just like any patient who has cancer. They are afraid, anxious, worried about their families, and do not deserve the stigma they face. It’s important to educate our communities so that everyone can understand that.”
Herman suggests radiologists go out into their communities and spread the word about the importance of screening at workplaces, churches, and local health fairs. “News and radio stations are usually looking for physicians to come talk about screenings, especially during awareness months,” says Herman. “If your institution or practice has a public relations department, consider partnering with them. They’ll know who to start with and how to contact places that might be suitable. They’ll also be able to give you tips on how to speak and what to do during interviews.” The more outreach you do, the more doors will open, so say yes when you can, advises Herman.
You can also look to your institution to see what groups are already connected, suggests Smetherman. Often cancer survivors or community outreach groups are already involved and may be open to you speaking at their meetings. These groups might have other outreach connections you can pursue. Finally, reach out to those you communicate with every day. “People in your personal life are just as important to reach out to and may be even more open to learning,” says Smetherman. Kazerooni adds, “A lot of patient education and outreach is done at the grassroots level. All you have to do is start sowing the seeds, no matter how small.”
According to Kazerooni, partnering with patient advocacy groups is another way to dispel misinformation and alleviate concerns. Patient advocacy groups often have a lot of resources to share and have already done groundwork in making connections within the larger community. Physicians and advocacy groups are natural partners. “We both have the same goal: saving lives,” says Kazerooni.
To connect with patient advocacy groups, check with your institution, suggests Smetherman. Visiting various community events may also introduce you to advocacy groups. “I’ve found that our patients often end up becoming advocates,” Herman says. “You can also speak to them to see if they may know of opportunities.”
The Bottom Line
Patients learn about screening from a variety of sources — from the media, from referring physicians, and, most importantly, from radiologists. Radiologists perform these procedures, and they’re the ones with the most knowledge, so it makes sense that they do outreach, says Smetherman. Doing so not only helps patients realize that screening saves lives, but that those doing it are important partners in the care team. Herman says, “Screening needs to have a face, and radiologists need to be it. We need to show we’re physicians who care for our patients and more than just an extra charge on the bill.”