By Michelle Crouch
Kimberly Sanders thought she was doing the right thing when she stepped into a mobile mammogram van parked outside her Charlotte workplace, a primary care clinic, last October. It seemed like a simple, convenient way to get her annual breast cancer screening.
But when the scan came back abnormal, Sanders, 60, hit an unexpected barrier that threatened to delay the time-sensitive follow-up care she needed.
Her regular Atrium Health physician referred her to Charlotte Radiology — the region’s largest imaging provider and Atrium’s partner — for the follow-up diagnostic scan she needed. Then, just days before the appointment, Charlotte Radiology called to cancel, telling Sanders it does not accept images from the mobile provider, Invision Diagnostics.
Instead, Sanders said, she was told she would need to repeat the initial mammogram. Her insurance policy covers only one screening mammogram per year, so to repeat the test would have meant paying for it out of pocket.
“They couldn’t give me a reason,” Sanders said. “Then they let me get off the phone without helping me. … That defeats the whole purpose of the (mobile mammography) van.”
Mobile mammography is designed to expand access to lifesaving screenings, particularly for women in underserved areas. Without timely access to care and follow-up, women may face delayed diagnoses, thus requiring more aggressive treatment and facing a higher risk of death from breast cancer.
Mobile provider says image rejections are baffling
Mike Dyer, founder and managing partner of Invision Diagnostics, said Charlotte Radiology has been turning away women who have mammograms through his mobile service for the past few years, and he doesn’t understand why.
He said his mammography units are accredited by the FDA and the American College of Radiology and use the same equipment and software as Charlotte Radiology. The images are read by radiologists who specialize in breast imaging, including some who used to work at Charlotte Radiology, he added.
“Everyone talks about access,” he said. “By going to areas where others don’t, we offer one way for these women to get their mammograms. If the goal really is to catch cancer early, entities should collaborate and do what’s in the best interest of the patient. But we can’t get Charlotte Radiology to speak with us.”
He said he has reached out by phone, email and LinkedIn.
Two breast imaging specialists not based in Charlotte consulted by The Charlotte Ledger/NC Health News said a blanket policy of refusing to accept screening exams from an accredited provider would be highly unusual.
“If a practice has a problem with the images, they should be reaching out and communicating with whoever owns the mobile van and working with them to fix it,” said Priscilla Slanetz, a professor of radiology and breast imaging expert at Dartmouth’s Geisel School of Medicine. “Women need access to imaging, and the best way to reach some of them is with these mobile units.”
Charlotte Radiology response
Charlotte Radiology did not answer questions about whether it has a policy about screening mammograms performed by Invision Diagnostics or if it has identified any specific deficiencies with the company’s images.
Citing patient privacy obligations, the practice said in an emailed statement that it could not comment “on individual cases or discussions involving specific providers.” (The practice was informed that Sanders was willing to waive patient confidentiality to allow Charlotte Radiology to discuss her case.)
Charlotte Radiology said its approach to diagnostic follow-up is guided by “clinical judgment, national accreditation standards and a commitment to patient safety and diagnostic confidence.” It added that its radiologists review screening exams to determine whether they meet the clinical and technical standards needed to guide follow-up care.
“In some cases, regardless of where a screening exam was performed, our physicians may determine that new baseline images are needed to accurately assess findings, reduce uncertainty, and avoid unnecessary downstream imaging,” the company’s statement said.
The need to repeat imaging is “not based on a policy toward any single provider” and is uncommon for most patients, the practice wrote, noting that “the vast majority of patients requesting diagnostic evaluations proceed without the need to repeat screening exams.”
Experts: Imaging providers must meet high standards
In Sanders’ case, it’s not clear that anyone at Charlotte Radiology looked at her screening scans before rejecting them.
When The Ledger/NC Health News called a local Charlotte Radiology office to ask whether the practice could do a diagnostic exam following an abnormal screening from Invision, the woman who answered the call said the practice “does not accept scans from Invision Diagnostics.” She said she was unable to offer further guidance.
Karen S. Johnson, division chief of breast imaging at Duke University Hospital, said Duke frequently performs follow-up scans after a woman has a screening mammogram elsewhere. Quality is rarely a problem if the scans are from an accredited provider, she said, but transferring images between systems can be time-consuming and logistically difficult.
Invision’s Dyer said his company has an “electronic bridge” with Charlotte Radiology that would allow scans to be sent directly to its platform, so he does not think image transfer is the problem.
All facilities that provide breast imaging — including mobile units — must meet strict quality standards, according to Johnson and Slanetz.
If images are incomplete or unclear, the centers where Slanetz have worked typically repeat only the necessary views as part of the follow-up scan, rather than requiring and billing for a new screening, she said.
“I’ve never heard of anyone having to repeat a screening mammogram from a reputable place,” Slanetz said.
Black women more likely to die of breast cancer
Most major medical groups recommend that women at average risk begin regular mammograms by age 45, though the timing and frequency can vary based on personal risk factors. Thanks in part to mobile mammography and other outreach efforts, breast cancer screening rates among Black and white women nationally are now about the same.
Yet disparities remain. Black women are about 40 percent more likely to die from breast cancer — a disparity that experts partly attribute to a lack of access to timely follow-up care. (Early detection is a big predictor of survival.)
Even in the best of circumstances, studies show that about 1 in 5 women who receive abnormal results on a screening mammogram do not follow up right away. Slavetz, who studies breast cancer imaging disparities, said several factors contribute:
- Limited scheduling: Diagnostic exams are rarely offered on evenings and weekends, she said, so scheduling can be tough for women with hourly jobs or caregiving responsibilities.
- Out-of-pocket costs: Unlike screening mammograms, diagnostic exams are not free under the Affordable Care Act, so women may have to pay a copay or the full cost, especially if they have a high-deductible insurance plan. In one of Slanetz’s studies, 20 percent of women said they would skip follow-up imaging if they had to pay a deductible.
- Fear of a diagnosis: Some women delay follow-up because they fear a cancer diagnosis, even though only about 5 percent of abnormal screenings result in cancer, Slanetz said.
Given those barriers, any obstacle that slows the path from screening to diagnosis is concerning, Slanetz and Johnson said.
Johnson added that mobile providers have a responsibility to make sure women have access to follow-up care.
“Mobile mammography units can go out into underserved areas and access patients who don’t necessarily have ready access to imaging centers,” Johnson said. “In those situations, that’s when people like me — radiology doctors — get nervous that you will lose those patients if you don’t have a good system in place to connect them to get a diagnostic mammogram.”
‘It seems like a bullying tactic’
Women who get mammograms through Invision get their results by mail, and the reports are also sent to their primary care provider. Dyer said Invision doesn’t specifically tell patients that Charlotte Radiology doesn’t accept its scans because the Charlotte region is just a small part of its service area and there are other local options.
The company does about 50,000 mammograms a year across the Southeast, Dyer said.
“We go to underserved areas of North Carolina all the way down to Florida,” he said. “We have a problem with just one facility in the whole country — and it’s Charlotte Radiology. It seems like a bullying tactic to keep a small, mission-based company out of Charlotte.”
Charlotte Radiology serves more than 200,000 women each year in its 20 Charlotte-area locations and operates its own mobile mammography vans. In 2018, it partnered with New York-based private equity firm Welsh, Carson, Anderson & Stowe to form US Radiology Specialists, now rebranded as Lumexa Imaging. Lumexa has grown from 30 centers in 2018 to about 180 centers across 13 states.
A second appointment is canceled
As for Sanders, when Charlotte Radiology told her they wouldn’t accept her scans, she asked her Atrium primary care provider what she should do. The provider apologized for the confusion and scheduled her for a diagnostic exam at an Atrium imaging facility, she said.
But days before that appointment, Sanders got another phone call. It was someone canceling the Atrium appointment for the same reason: The facility would not accept scans from Invision Diagnostic.
In response to questions about the cancellation and its imaging policies, Atrium emailed a statement that said, “When concerns like this are raised, we take them seriously. If there is any breakdown in the standards we expect of ourselves and our partners, our priority is to reach out directly to patients, listen to their concerns and work to resolve them. Above all, our goal is that every patient — regardless of circumstance — can depend on expert and compassionate care at every encounter.”
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Sanders got her scan. She worries other women won’t.
After the Atrium appointment cancellation, Sanders reached out to Invision, which encouraged her to try Novant Health, Charlotte’s other large health care system. She said the switch required her to spend hours on phone calls and paperwork as her anxiety mounted.
“I explained the story over and over and over again,” she said. “It’s never a good feeling when you think you might have breast cancer. I wanted to get it scheduled as soon as possible.”
When days had passed and Novant still hadn’t received a referral that her Atrium doctor was supposed to have sent, Sanders was so frustrated that she drove to her doctor’s office to get the signed order and watched as staff faxed it over. She then called Novant every day until someone confirmed they had it.
On Jan. 30, three months after her initial screening, Sanders finally had her diagnostic exam.
Fortunately, it was clear, and Sanders said she is incredibly thankful for that. But she worries about how easily other patients could fall through the cracks.
“I had time to call about this every day. I did all the legwork myself,” she said. “A woman who has children trying to get to day care, to get to work and just trying to make ends meet, she’s not going to do that. At some point she will just say, ‘Forget it.’”
After The Ledger/NC Health News reached out to Atrium last week, Sanders said she got a call from the system’s vice president of patient experience, who apologized and said he would look into what happened. Sanders is hopeful the conversation will lead to change.
“I told him my goal is not to give Atrium a bad name but to make a difference,” she said. “This cannot happen to another woman.”
This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting. You can support this effort with a tax-deductible donation.
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