What Does the Halftime Show Have to Do with Cancer Screening?

I am not a fan of football. There, I said it. This is a constant embarrassment for my wife, who is and tries gamely to feed me tidbits of information so I can participate in conversations over the course of the season. And patiently tries to explain what making a “down” means.

But earlier this month, I was very excited to watch the Superbowl because of the halftime show, which featured a remarkable lineup of hip-hop icons. Did you watch it? If so, you were among 103.4 million other folks who tuned in, way up from previous years. Maybe it wasn’t your cup of tea. But maybe, like me, you were on your feet, on fire with energy and good will and nostalgia for nights out dancing. A high point for me was Mary J. Blige singing a bit of her anthem, “Family Affair” (We got ya’ll open, now ya floatin’/So you gots to dance for me/Don’t need no hateration/Holleration in this dancery). Acknowledging that 57.5% of the players in the NFL are Black, and the centrality of hip-hop to Black culture, the halftime felt like a great thing. It was cathartic, it was real, it meant a lot to many people.

But that actually wasn’t even my favorite part of the game. That came in the form of a brief, tender commercial that features Ms. Blige. The spot, for Hologic, highlights her dressed up for a video, in a recording booth, and working out with a trainer. Interspersed with those shots, however, are images of Ms. Blige sitting on an exam table in a robe, looking anxious. And a bit later, dressed in street clothes and her signature boots, face opening up, relieved to hear her doctor say that everything looks clear on her mammogram. A doctor who, like Ms. Blige, is Black. The commercial ends with Ms. Blige commenting, “making your health a priority is real love,” echoing her song, which is playing in the background.

Who among us folks being screened hasn’t been there? Sitting on the exam table, maybe a little shivery from cold, waiting. The degree of our anxiety may not be the same. Those of us without family history may be a little less concerned; others with cancer history or known risk factors are likely on high alert. But waiting each year for the results brings uncertainty and concern. And I don’t know if it’s just me, but the anxiety almost feels a bit more intense now that the scans are more typically read right away.

The Centers for Disease Control and Prevention identifies breast cancer as the second most common cancer among women in the United States. Please note that I am continuing to use the terms “woman” and “women” in this piece because that remains the convention for the United States Preventative Services Task Force (USPSTF), while acknowledging that people of other gender identities require screening and that the USPSTF has pledged to review and act on use of gender inclusive language.

About 30% of US women do not meet the USPSTF guidelines for breast, cervical, and colorectal cancer screening annually. It may surprise you to learn that screening rates for non-Hispanic Black women are 6 to 10 percentage points higher than for non-Hispanic white women. That said, non-Hispanic Black women have much higher death rates than do non-Hispanic white women for these cancers (breast cancer 27.1 v. 19.4 per 100,000 people; cervical cancer 3.2 v. 2.1 per 100,000 people), which can be highly treatable if caught early.

The “why” of this is not well enough understood, but includes factors such as low income, lack of health insurance, out-of-pocket costs, lower rate of screening at younger ages, and both type of tumor and late stage of cancer when diagnosed. Another issue of concern is that Black women are less likely than are white women to elect surgery as an intervention. Finally, and not least important, racism in medicine, including the appalling history of involuntary experimentation on women who were enslaved, in the early stages of developing obstetric and gynecologic care in this country, has left a legacy of mistrust that has carried forward viscerally over time. This is not a historical artifact, but a present reality.

I may wish that the commercial had been a public service announcement and not a proprietary ad, but even that deserves some examination. Hologic undoubtedly benefits from promoting use of screenings. But isn’t it arguable that this high-production, professional commercial translates more effectively than the typical plain vanilla, talking head public service announcement? And that Ms. Blige and other artists – how about Cardi B? – are in a position of social influence that can move people from seeing the commercial to promoting it on platforms such as TikTok to getting screened?

In light of the tough reality of all of the barriers Black people in particular experience in accessing and using health care, it’s truly meaningful to see a hip-hop star exposing her own vulnerability, reinforcing that she isn’t only a celebrity but a patient and everyperson. A person with resources who has a good chance of having the timely, empathic, culturally competent screening experience that is depicted in the commercial. But also representative of Black people overall, who are arguably much less likely to have a provider who sees and listens to them and treats their report of lived experience with respect and concern.

Back to the halftime show. A large group of people tuned in to a culturally relevant event and saw that commercial, which looks and feels like them. But that moment of identification, while something to celebrate, isn’t all that’s needed. Let’s keep focusing relentlessly on making it easy and comfortable for people, especially those who are Black, to take the next steps: both getting screened and also accessing the appropriate, person-centered, high-quality, and affordable treatment that will help to save their lives. And in seeking their direct report of experience at every stage of the process.

No matter where you are situated — as a state leader, clinician, or even just a person who is interested in equitable health care — if you are looking for more detail on how we can make progress, here are some resources with which to get started:

• For contextual data on screening, see this report: Disparities in Meeting USPSTF Breast, Cervical, and Colorectal Cancer Screening Guidelines Among Women in the United States

Many women still do not meet current USPSTF guidelines for breast, cervical, and colorectal cancer screening. Screening disparities are persistent among socioeconomically disadvantaged groups, especially women with low incomes and without health insurance. To increase the prevalence of cancer screening and reduce disparities, interventions must focus on reducing economic barriers and improving access to care.

• For a detailed examination of the factors that influence disparities, see this article: ”Health and Racial Disparities in Breast Cancer”

The high mortality and low survival rates in breast cancer among Black women compared to ethnic groups can be attributed to late stage of breast cancer at diagnosis, barriers to health care access, biologic and genetic differences in tumors, and prevalence of risk factors. Other possible reasons for low survival rate among Black women include barriers to early detection and screening, lack of medical coverage, and unequal access to improvements in cancer treatment. The continued growth of the Black-White breast cancer mortality gap suggests that the current approaches to preventing or eliminating racial/ethnic disparities in breast cancer are not sufficient.

• For detailed recommendations on one important lever – a navigator approach – see this resource: A Plan-Do-Study-Act Approach to the Development, Implementation and Evaluation of a Patient Navigation Program to Reduce Breast Cancer Screening Disparities in Un- and Under-Insured, Racially and Ethnically Diverse Urban Women

We applied the Plan-Do-Study-Act (PDSA) quality improvement framework to the development, implementation, and evaluation of a breast cancer screening navigation program for un- and under-insured women.

Six critical steps emerged: (1) obtain program funding; (2) navigator training; (3) establish a referral base network of community partners that serve the un- and under-insured women; (4) implement a process to address the barriers to accessing mammography; (5) develop a language- and culturally-tailored messaging and media campaign; and (6) develop measures and process evaluation to optimize and expand the program’s reach.