ACR Bulletin

Covering topics relevant to the practice of radiology

Advocating for Breast Imaging

Radiologists in Arizona worked with the state medical association to educate lawmakers about breast health and push for the breast screening statute to be updated. Together, they scored a win.
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Dr Christina Ferraro
Christina R. Ferraro, MD
August 29, 2023

A new law in Arizona helps remove the financial barriers to imaging that can rule out breast cancer or confirm the need for a biopsy. According to the Susan G. Komen organization, which supported the law, more than 6,240 people in Arizona alone will be diagnosed with breast cancer this year and more than 920 will die. On May 8, Gov. Katie Hobbs signed SB1601 into law that requires insurers to cover diagnostic and supplemental breast imaging when medically necessary. The ACR Bulletin interviewed Christina R. Ferraro, MD, a breast imager in Phoenix, Ariz., about the importance of this new legislation. Ferraro was the lead advocate for SB1601. 

Advocacy sometimes refers to the three C’s — communicate, collaborate and compromise. Please share a little bit about your experience in Arizona.

Working on this issue has been a labor of love, and I was very new to this process. A couple of years ago, I spoke with Amy K. Patel, MD, medical director for The Breast Care Center at Liberty Hospital in Liberty, Mo., and current Chair of the Radiology Advocacy Network (RAN), about her experience with being an advocate for a breast health bill in Missouri. Working on the Arizona bill was my first time doing this type of advocacy, and I had to learn along the way. 

My intent was straightforward: to update an outdated statute. The statute was updated to include a definition of tomosynthesis as well as a mandate for coverage of diagnostic imaging (in addition to preventive mammography screening) performed on dedicated equipment for diagnostic purposes on referral by a patient’s physician. The final language isn’t exactly the same as what was proposed, but it’s a win for Arizona’s women.

What was the most surprising element of being an advocate for this bill?

A lot of work went into keeping the original intent of the bill. As more and more players became involved, the language and therefore scope of the bill started changing. When we started the process, we were working closely with the Arizona Medical Association (ARMA), but as more stakeholders joined the discussion, some parties argued for U.S. Preventive Services Task Force (USPSTF) standards. We then had to argue for changing the language back to the original proposed guidelines that were based on what is used in clinical practice. We had to stay vigilant with every redraft to steer the changes back to the original language. We’ve had to stick to our guns and support what is evidence-based and used in clinical practice. 

What would you recommend someone do or not do if they are planning to advocate for a bill?

The original intent of what I wanted to do is, at the bare minimum, change the law to reflect the standard of care and to secure universal tomosynthesis coverage. Of course, as we began the process, we included all evidence-based points. As things evolved, the language morphed a bit, but it is a vast improvement over the outdated statute we had in place before. You have to expect a certain level of compromise, but you also cannot accept changes that leave too much room for interpretation. In our example, initial language was drafted to be very succinct: what women at what age qualify for what screening procedure. The compromise included a reference to National Comprehensive Cancer Network (NCCN) guidelines.

We had to stay vigilant with every redraft to steer the changes back to the original language. We've had to stick to our guns and support what is evidence-based and used in clinical practice.

—Christina Ferraro, MD

If there was an opportunity for a re-do, is there anything you would change? 

Going through this process was an eye-opening experience for me. I have to say that working with ARMA staff was extremely helpful. I relied on the state medical society to choose sponsors and co-sponsors because, as physicians, we are not at the Capitol and don’t know the legislators as well. Finding a good sponsor to champion your bill is key. I also saw the importance of strategic allies — ARMA for on-the-ground work of securing the meetings and shepherding the bill along the whole process, and the ACR and my colleagues on the Government Relations Committee under the Commission on Breast Imaging. Committee Chair Bethany Niell, MD, PhD, and others gave valuable feedback, not only on the verbiage but on strategy and direction in mapping out the advocacy process for this issue. Reaching out and accepting help from others is paramount to your success. And physically, it takes someone on the ground. 

Is there anything unique about your state when it comes to advocacy? 

Arizona has a Democratic governor in a historically red state, so overall there is a lack of working across the political aisles. As a result, issues that perhaps shouldn’t be partisan may be perceived as such. The political environment kept the opposing parties occupied with other bills in the hopper, and their having bigger fish to fry may have contributed to the fact that our bill did not face too much opposition. There were issues here and there with suggested changes — such as tying screening guidelines to USPSTF or CMS — but overall, the bill had continued progressing. Arizona’s statute went back to 1971 and had some slight changes in 1998, so it was extremely outdated as far as breast cancer screening guidelines go. 

The Arizona Health Care Advocacy Coalition, led by ARMA, is a coalition of multiple societies, and the Arizona Radiological Society is a member. Although the focus of their efforts is not radiology-specific, the committee of members meets regularly and there are opportunities to secure sign-on letters of support from multiple medical stakeholders. Although we did not have to secure their support on this bill, it is something that could be helpful. As the bill starts moving, this may be an opportunity to get a letter-writing campaign from several physician specialties in a centralized effort. 

Do you have any other advice for peers who are advocates in other states? 

It’s really important to reach out for help ahead of time and to rely on guidance from experts. As physicians, we bring the breast imaging expertise, but don’t hold back from reaching out to other colleagues, staff, state medical society staff, local chapters and the ACR. Taking it on by yourself, you may fail. And keep in mind that getting something over nothing will be more beneficial for the patients. You might have to compromise over the final result, but that should still be seen as a win. 

Author Eugenia Brandt  ACR senior government relations director