Bringing Breast Cancer Screening to the Neighborhood With Martha Welman, MD, and Jasmin Hundal, MD, MS, MPH

Addressing Post‑COVID Shifts in Breast Cancer Presentation

The initiative arose from a concerning clinical signal in the aftermath of the COVID‑19 pandemic. “We were seeing more younger women with more advanced breast cancer diagnoses, maybe from lack of screening,” Dr. Welman explained. At Neighborhood Health—an FQHC caring for 42,000 mostly underserved, many uninsured patients—late‑stage breast cancer was often the first presentation.

To address this disparity, Neighborhood Health partnered with the Gilead Sciences FOCUS Program and hired two dedicated patient navigators. The goal of the pilot project was to reduce “cycle time”— the time from order placement to screening mammogram, diagnostic workup, biopsy when indicated, and referral to treatment. System-level changes complemented navigation, including implementation of standing orders, strengthened partnerships with imaging centers, and a mobile mammography van, as mammography is not performed on-site at the FQHC.

Study Design and Impact on Time to Diagnosis

Baseline data from 2023 included approximately 2,300 referred screening mammograms. The team then tracked time from order to study completion across each step: screening, callbacks, diagnostic mammography, and biopsy.

“When you have a breast lump or an abnormal mammogram, every day is a year while you’re waiting to get your answers,” Dr. Welman said. “And at each stage, we showed very significant reductions in time.” When all intervals were combined—from screening to callback, diagnostic exam, and biopsy—the average time fell from 118 days to 81 days. Individual components saw similar gains: time from screening order to study completion decreased from 79 to 41 days (a 48% reduction); time for diagnostic mammograms dropped from 62 to 33 days (a 47% reduction); and time to biopsy decreased from 40 to 21 days (a 48% reduction).

Early Signals of Stage Migration

Importantly, the intervention was associated with a marked shift in stage at diagnosis. “In the first baseline year, we had 23% late‑stage cancer diagnoses. In the second year of the intervention, it was only 7%,” Dr. Welman noted. While the numbers are small and did not reach statistical significance, “the trend was very positive,” and the team is planning continued monitoring. These findings align with the core premise familiar to oncologists: “the earlier we catch it, the better,” Dr. Hundal summarized.

Why Patient Navigation Was Central

Although the program involved multiple interventions, Dr. Welman was clear about the primary driver of impact: “The patient navigators. I think all the other things just made it easier for them to do what they do.”

Neighborhood Health’s patients frequently face low literacy, limited English proficiency, and lack of digital access. “Everything’s now ‘use our web‑based tool, get a two‑factor authentication.’ Our patients often struggle with that. They might not have computers or Wi-Fi,” she explained. Scheduling a single mammogram could take up to 30 minutes of phone calls and holds; for asymptomatic patients, motivation for screening alone is often insufficient.

Navigators bridge these gaps by providing education, logistical support, and continuity. “When you have a navigator who’s explaining to you the importance of breast cancer prevention and really working with you to find a time and a place where your test will get done, I think that there’s no substitute for that human touch.”

Remaining Barriers Across the Diagnostic Pathway

Despite improvements, significant barriers persist. Access to radiology appointments is a major constraint. Transportation remains another challenge, even with rideshare funding. Emotional barriers are equally important. Many patients equate a positive result with death. Dr. Welman underscored the need for reframing and emphasizing the positive outcomes often seen with early disease. Normalizing prognosis for early-stage disease is critical to overcoming avoidance.

Policy and Structural Changes Needed

For broader adoption, sustainable financing and structural supports are essential. “Navigation has real value, and there’s a cost to it,” Dr. Welman said. She endorsed moves to reimburse navigation services but noted that current FQHC reimbursement structures make this challenging.

Payer quality incentives tied to mammography rates can help, but they must be calibrated to the realities of high‑risk populations. “Sometimes you can’t meet those metrics even if you’re having a lot of impact,” she cautioned, advocating for adjustment of benchmarks based on social risk and literacy.

She also highlighted the value of mobile mammography, coined Mammo Vans. On-site vans at familiar clinics yield “a very high show rate and a very high completion rate.” Patients do not need to navigate unfamiliar systems or language barriers: “you can come to the place you’ve always come to, and a friendly face will be there to help you.”

Strengthening Oncology/Primary Care Communication

From an oncologist’s perspective, Dr. Welman emphasized that communication with primary care is foundational: “I think that is the foundation of good medical care now.” Electronic medical record (EMR) systems and workload often limit seamless information flow, but the impact on patient safety and experience is substantial.

“Often we’re the ones telling the patient about their diagnosis the first time,” she explained. Ensuring that primary care clinicians are “armed with all the information” enables more accurate counseling and consistent messaging. As patients move through treatment, they frequently return to their “primary care medical home,” and gaps in oncology‑to‑primary‑care communication can leave both patients and PCPs uncertain about current plans.

“Open communication takes time. It’s part of the job, it’s work too, but it’s well worth it,” Dr. Welman said. “I think our patients really benefit and their care is much safer when we communicate well.”

A Team Sport Against Breast Cancer

Dr. Welman closed with a call for a truly multidisciplinary, team-based approach: “The more we can all align and think of it as a team sport, as they say, the more impact we will have.”

For oncology clinicians, her experience underscores the importance of:

• Investing in and advocating for navigation as a core component of cancer screening and diagnosis, as well as care.
• Partnering with FQHCs and community clinics to reduce time to diagnostic resolution.
• Supporting mobile and on‑site mammography models.
• Proactively closing the loop with primary care to ensure safe, coordinated care.

Key Takeaways

• Navigation is pivotal: Dedicated patient navigators in an FQHC reduced total time from screening order to biopsy from 118 to 81 days and halved time to key diagnostic steps.
• Stage migration is achievable: Late‑stage breast cancer diagnoses declined from 23% to 7% in the year following implementation, suggesting meaningful impact on disease stage at presentation.
• Structural barriers are multifactorial: Limited radiology capacity, transportation challenges, digital exclusion, language barriers, and fear of diagnosis all contribute to delays.
• Policy and payment matter: Sustainable reimbursement for navigation and risk‑adjusted quality metrics are critical to scaling this model in safety‑net settings.
• Communication is a safety strategy: Timely, bidirectional communication between oncology and primary care—especially in FQHCs—is essential for accurate patient counseling and safe longitudinal care.

About the Speakers

Martha Welman, MD, is a Primary Care Physician and the Chief Medical Officer of Neighborhood Health, a Federally Qualified Health Center serving more than 42,00 patients in Northern Virginia. She joined the organization in 2000 as its first physician, and as Chief Medical Officer, she has helped oversee significant growth in the number of patients served. Throughout her career, Dr. Welman has initiated and managed numerous community health projects.

Jasmin Hundal, MD, MS, MPH, is a third-year Hematology/Oncology Fellow at the Cleveland Clinic in Cleveland, Ohio. Previously, she completed her Internal Medicine Residency at the University of Connecticut. Dr. Hundal’s main area of interest is the overlap between cardiometabolic health and cancer, particularly for breast cancer patients and survivors. Outside of work, she enjoys traveling, cooking, and hiking.

Gilead Sciences’ Breast Cancer Pilot is a public health initiative that seeks to enable routine screening and linkage to care for breast cancer in accordance with public health guidelines to advance timely diagnosis.  FOCUS Breast Cancer Pilot Program awards do not fund activities beyond linkage to pre-treatment care.