This Letter to the Editor of the Journal of the American College of Radiology was rejected for publication in the Spring of 2020, shortly after Dr. Monticcillo’s article appeared on line, and is offered on this blog. The author has not renewed his membership in the American College of Radiology in 2021.

I am grateful for Dr. Monticciolo’s recent work entitled “Current Guidelines and Gaps in Breast Cancer Screening”, and especially for discussing the challenges among low socioeconomic (SES) and black populations. Dr. Monticillo’s point that the elimination of cost sharing “helped mainly those already insured” is a critical economic issue.^[1]  

Scandinavian studies lend evidence to the value of image based breast cancer screening, particularly given their frugality. Some use single-view screening, while more recent data uses two-view exams.^[2] The lower cost of their techniques creates great value for those populations, and raises the possibility access to any form of imaging has the greatest benefit while technical factors may be less significant.  

I disagree that cost and access “need[s] to be addressed at the primary care level”.  Low SES communities, by definition, do not have the resources to increase access.  This is an issue that radiologists must own or risk forfeiting our leadership position. Without ownership, and actively working to break down barriers to care, radiologists cannot criticize the American Cancer Society or the United States Preventive Services Task Force.   

Furthermore, ACR advocacy for increased coverage of tomosynthesis will only help the insured,^[3] not the most vulnerable populations described by Dr. Monticciolo. Half of the uninsured in our country are people of color.^[4]Furthermore, in 2018, 11.5% of black and 19.0% of Hispanic populations were uninsured vs. 7.5% of whites.^[5]  

While industry may believe that it needs tomosynthesis to increase accuracy (or perhaps to drive sales), the increased technical costs only widen the gaps between insured and low SES and/or black populations. The ACR must refrain from advocating for policies which may have the unintended effect of reinforcing structural racism.  

Leaders in breast cancer screening, the ACR, and our journal must address economic barriers and structural racism, or we will be displaced. As an industry we need to be mindful of the disparate impact which insurance and new technology have on our most at risk populations.

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^[1] Monticciolo D. Current guidelines and gaps in breast cancer screening. J AM Coll Radio. 2020 Oct;17(10):1269-1275..

^[2] Tabár, L., Vitak, B., Chen, T.H.-H. et al. Swedish two-county trial: impact of mammographic screening on breast cancer mortality during 3 decades. Radiology. 2011; 260: 658–663

^[3] Grosskreutz S. How we achieved universal 3D mammography coverage in Hawaii – and how you can, too. ACRpublicrelations November 6, 2019. https://voiceofradiologyblog.org/2019/11/06/how-we-achieved-universal-3d-mammography-coverage-in-hawaii-and-how-you-can-too/ accessed 7/13/20.

^[4] Young CL. There are clear, race-based inequalities in health insurance and health outcomes. Brookings. February 19, 2020. https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2020/02/19/there-are-clear-race-based-inequalities-in-health-insurance-and-health-outcomes/ accessed 7/13/20.

^[5] Artiga S, Orgera K, Damico A. Changes in health coverage by race and ethnicity since the ACA, 2010-2018. Kaiser Family Foundation. March 5, 2020. https://www.kff.org/disparities-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/ accessed 7/13/20.