FormalPara Key Points

  • Lack of access to primary care providers (PCPs) causes decreased access to screening services for First Nations women in British Columbia (BC).

  • Mobile screening mammography (SM) is a key part of breast cancer screening in rural and remote communities in BC.

  • The Virtual Doctor-of-the-Day program may help to overcome screening barriers, including issues associated with attachmentFootnote 1 to PCP that is required for access to SM.

British Columbia (BC) is the most westerly of Canada’s provinces. It has a population of more than 5.3 million people distributed over 944,735 km2 [1]. Most non-surgical cancer care services are organized provincially, with interdisciplinary care provided at six BC Cancer (BCC) regional centers. The province’s population-based breast, colorectal, cervical, and lung cancer screening programs are overseen by BCC and incorporate a partnership framework with primary care providers identifying eligible patients for screening, and regional health authorities and community (private) imaging clinics and laboratories delivering screening tests. Depending on the screening program, primary care providers (PCPs) are key to informing, referring, and/or performing screening tests and follow-up.

The breast cancer screening mammography (SM) program, known as the BCC Breast Screening Program (BSP), was established in 1988 and is publicly funded (free of charge). The BSP operates 36 fixed SM sites across BC in hospitals or clinics with trained staff and permanent technology. In addition, it operates 3 mobile units across the province, which transport mammogram machines and technicians by van to 170 rural and remote communities, including over 40 First Nations communities [2]. Women who are eligible for SM can self-refer to access the BSP; however, attachment to a PCP is required. Eligibility for BSP has varied over the years. The current criteria are shown in Table 27.1. SM in BC is only available via the BSP. Fixed SM sites provide follow-up for patients with abnormal mammograms, including recommendations for diagnostic mammograms and/or ultrasounds, biopsy, and/or in some locations, breast MRI.

Table 27.1 SM eligibility recommendations for average-risk women
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Screening Barriers

Barriers to screening for First Nations women in BC may be similar to those found for Indigenous peoples in other Canadian regions. These include jurisdictional ambiguity, suboptimal program design, geographic distance and lack of transport, low levels of health literacy often linked to lack of PCPs, and lack of cultural safety [3]. First Nations women in BC are less likely to be attached to a PCP, which is a requirement to access SM in the province [4]. PCP attachment is required to ensure that the responsible PCP receives the SM results for patient records and coordinates and supports next steps if the SM is abnormal. The PCP’s role is critical, as SM is only the first step in a continuum of care for breast cancer that spans from prevention to treatment. It is unknown whether PCP attachment is associated with differences in SM uptake, but, given that being attached to a PCP is required for booking SM, this question should be explored to increase accessibility and utilization of the BSP program among First Nations people in BC.

Mobile Services: Bringing Resources to Communities

A number of practices show promise for increasing cancer screening among BC’s First Nations communities [5]. Mobile screening services have led to an increase in screening uptake among both Indigenous and non-Indigenous communities [6]. BC’s mobile mammography service, which began in 1990, has expanded to include approximately 40 of over 200 First Nations communities per year. This suggests the need for further expansion of this service.

Many BC First Nations communities are rural, remote, and/or northern, which can make it challenging for mobile vans to access them, especially during winter months. This reality highlights the need for creative solutions to address challenges related to weather and location. Multisector collaboration is needed to address the logistical challenges in delivering BSP services to rural and remote First Nations communities, in addition to challenges to access SM services outside of First Nations communities (for both fixed sites and mobile units). The adoption of digital mammography may have been useful, given the limited number of accredited SM radiologists in much of BC. In other jurisdictions, digital SM has been shown effective, enabling accredited radiologists distant from the SM site to interpret images [7].

Mobile SM units could increase uptake and impact by (1) increasing the number of participating communities, and (2) adding additional mobile resources for communities that already have access. For example, mobile units could also provide access to fecal occult blood testing for colorectal cancer screening and access to cervical cancer screening opportunities. Culturally relevant resources can be presented or provided to improve health literacy regarding all cancer screening programs along with cancer prevention education and assistance (e.g., smoking cessation). Resource development should be specific to community-identified needs and requests from First Nations communities as these programs expand in scale and scope under their leadership (Fig. 27.1).

Fig. 27.1
A map of British Columbia. It highlights the locations of the first-nation communities and fixed sites, mostly in the south. The former are represented by circles and triangles, and the latter are represented by pinned location icons.

Map of British Columbia First Nations communities, fixed SM sites, and participating mobile SM units. (Map: N Raveinthiranathan)

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Supporting Individual Travel to the Screening Program

The First Nations Health Authority (FNHA) [11] Health Benefits Program provides transportation support to increase accessibility for “Status First Nations peoples” (i.e., those recognized as First Nations by federal government legislation) who require medically necessary services unavailable in their communities of residence. A transportation subsidy supports travel to publicly funded diagnostic tests and preventive screening services, including SM [8]. Promotional campaigns co-produced by FNHA and BCC aim to increase understanding of program benefits and partnership development with SM services to address barriers to participation [9]. The extent to which financial support impacts uptake of out-of-community SM compared to mobile SM by those living in rural and remote locations is unknown. However, it is hypothesized that in-community, “closer-to-home” services would have greater influence.

Opportunities to Increase Screening: Virtual Doctor of the Day

Cultural safety is the foundation of access to healthcare services. In the absence of cultural safety, even if resources are accessible, they will not be used and benefits will go unfulfilled. A major operational barrier is the requirement to be registered with a PCP in order to self-refer for BSP. In April 2020, the FNHA launched the Virtual Doctor-of-the-Day program for Indigenous individuals in BC to increase access to PCPs via remote virtual consultation, with five telephone lines currently in use [10]. This is a unique service for First Nations peoples in BC and their family members, even if those family members are not Indigenous. The program strives to include doctors of Indigenous ancestry and all doctors are trained to follow the principles and practices of cultural safety and humility. The program provides health services for people who require episodic and ongoing care. This resource has been discussed as an opportunity to increase access to SM by overcoming PCP attachment barriers. During the appointment, the PCP and the patient can discuss SM and the role of screening and, when indicated, enable the individual to sign up for a SM. This “Doctor of the Day” would then be the contact for mammogram results and program physicians can support the individual on the next steps.

Conclusion

The SBP aims to prevent or diagnose malignancies at an earlier stage. First Nations women in BC and in other Indigenous communities across Canada have lower rates of uptake of breast cancer screening. To address this, we must demand culturally safe services, improve understanding of the role and impact of cancer screening, increase accessibility (including, but not limited to, increasing the scope and scale of the mobile SM units that bring resources to communities), and break down barriers to SM that are embedded in BSP policies, such as issues related to the requirement for PCP attachment. There is much to be done to address the well-documented priority of screening and prevention in the BC Indigenous cancer strategy.