Improving breast cancer screening rates in Filipina, Native Hawaiian, and Pacific Islander populations in West O‘ahu

Abstract

Introduction: Breast cancer (BC) is the most common cancer in women. Screening mammograms (SM) enable earlier detection of BC and thus reduce mortality. However, Filipina, Native Hawaiian, and Pacific Islander (NHPI) women experience increased prevalence and mortality from BC compared to non-minority populations, possibly due to lower SM rates.

Objective: This Quality Improvement (QI) project aimed to identify the primary systemic and patient-level barriers contributing to low BC screening among Filipina and NHPI women and to test targeted outreach interventions in an underserved West O‘ahu community.

Methods: A retrospective electronic medical record (EMR) review of 318 female patients covered by HMSA insurance was conducted at a well-established primary care practice in West O’ahu and matched against insurance claims data from May-July 2025. Filipina and NHPI constitute a large portion of this practice. Patients included in this study were 50-74 years of age and due for biennial SMs based on HMSA guidelines. Patients who met exclusion criteria per HMSA’s 2025 Provider Resource Guide, including those under hospice care, were excluded from this project. Our team observed the primary care team workflow and contacted local imaging centers and associated nonprofit organizations to identify possible factors contributing to low SM rates. Four iterative Plan-Do-Study-Act (PDSA) cycles were conducted over two months to target the most common root causes: Cycle 1) Text message (TM) outreach to patients due for SM with an active SM order, but no scheduled appointment, was initiated using a HIPAA-compliant text messaging app; Cycle 2) A second round of TMs were sent to patients who had not responded after 1 week; Cycle 3) TMs were sent to the patients due for SM who had not been seen in the past 12 months; Cycle 4) Patients unresponsive in the previous 3 cycles were called. Clinic staff identified fear of receiving bad news and pain associated with the SM procedure as potential cultural barriers which were addressed in phone calls during cycle 4. Education on the importance of SMs and assistance scheduling SMs were offered during all cycles.

Results: Baseline SM rate for eligible individuals covered by HMSA was 59%. The SM rate increased to 66% after reconciling discrepancies between SM rates reflected by insurance claims and those reflected in EMR and excluding one patient who met exclusion criteria. Text messaging outreach alone was not as effective as text with subsequent phone call outreach. Following the four PDSA outreach cycles, SM adherence rates increased by 6%, reaching 72% by December 31, 2025. Further analysis identified limited SM appointment availability and resource constraints in West O‘ahu to be the root causes, coupled with patient-specific scheduling challenges despite having an active order from a physician.

Discussion: This QI initiative successfully used data-driven outreach to increase breast cancer screening in high-risk Filipina and NHPI populations. This project identified the main barriers affecting SM rates as difficulty with appointment scheduling and limited local resource capacity. Focusing future QI efforts on building streamlined scheduling workflows and advocating for increased imaging resource allocation shows promise to reduce health disparities in these minority populations in addition to benefitting all women seeking to receive SMs.

Target Audience: Those interested in Quality Improvement; healthcare providers and administrators; public health officials; West O’ahu community.