Best practices in breast cancer screening versus resource constraints: A concordance statement

I would like to thank Dr Gordon for her well-intentioned article,[1] which advocates for improved screening of breast cancer, the most common cancer in Canadian women. I read the data she presented with interest and concern.

My clinical experience has been that breast cancer screening, and its response times, is one of the hardest-hit areas in our health care system as we emerge from the COVID-19 pandemic. I have patients anxiously waiting 12 months for their 6-month follow-up imaging after abnormal initial screens. I recently saw a woman with a high-risk family history present with a palpable breast nodule whose initial appointment for diagnostic mammogram was scheduled 3 months after the requisition was sent. The same patient was subsequently told her biopsy wait time would be 3 to 4 months.

Successful efforts to expedite my own patients’ appointments have no doubt left another woman with similar risks, but without the confidence to self-advocate, or without the benefit of a primary care provider to advocate on her behalf, one appointment further down the wait list for her assessments.

The benefit of enhanced screening practices is dependent on a health care system with the resources to facilitate these tests and to respond in a timely manner to positive screens. Dr Gordon has already sounded the alarm to the burgeoning response times between abnormal screens and subsequent scans and biopsies.[2] This lag is distressing to patients and will result in higher morbidity and mortality rates from detected cancers.

The proposed increase in screening of women ages 40 to 49, and annual instead of biannual mammography, would more than double the volume of scans in the Breast Screening Program. Screening ultrasound for women with dense breasts has long wait lists at limited imaging sites where this service can be accessed. Breast MRI, in my practice experience, is a resource so scarce that it is realistically available in this province only to women who are already attached to a cancer centre.

On the treatment end, we all recognize that capacity is strained. Recently in the news we learned that some British Columbian breast cancer patients will be treated at centres in Washington.[3]

While I am strongly in favor of an evidence-based approach to screening optimization, this cannot be pragmatically applied without considering access in our resource-strained system. Dr Gordon’s well-referenced article[1] admirably sets out an idealized end goal for our provincial breast cancer screening practices, but until such time as our current program wait times have been addressed, “how to make it even better” requires prioritizing resources to improve the current system before expanding its use.
—Colette Davis, MD
Vancouver

This letter was submitted in response to “Breast cancer screening in BC: What we should be proud of and how to make it even better.”

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References

1.    Gordon PB. Breast cancer screening in BC: What we should be proud of and how to make it even better. BCMJ 2023;65:133-138.

2.    Azpiri J. Waits for cancer testing in BC continue to grow amid staff shortages, radiologists say. CBC News. 8 November 2022. Accessed 21 May 2023. www.cbc.ca/news/canada/british-columbia/wait-times-for-medical-and-have-gotten-progressively-worse-1.6643844.

3.    Harnett CE. BC cancer patients waiting for radiation treatment to be sent to US. Vancouver Sun. 15 May 2023. Accessed 21 May 2023. https://vancouversun.com/news/local-news/b-c-cancer-patients-waiting-for-radiation-treatment-to-be-sent-to-u-s.