When it comes to breast cancer screening, mammograms are a critical tool. However, the quality of mammographic services can significantly affect outcomes. Research indicates that higher quality mammography can lead to earlier detection of breast cancer, which is crucial for successful treatment. In fact, studies have shown that the sensitivity of mammography can vary widely, from 68% to 90% (1-4), depending on the quality of the equipment and the skill of the radiologist . Additionally, false-negative rates can range from 10% to 30%, (5) emphasizing the importance of high standards in mammographic services. Unfortunately, disparities in mammographic quality and outcomes persist, particularly among racial and ethnic minorities. For example, African American women are more likely to receive lower-quality mammography services, contributing to a higher mortality rate from breast cancer compared to their white counterparts. (6-8)

The Mammographic Quality Initiative (MQI) is leveraging the Community and Cancer Science Network (CCSN) transdisciplinary approach to delve into the factors influencing mammography quality. By building a shared measurement system, MQI aims to monitor and enhance mammographic quality comprehensively.

Since its inception, the leadership team has made significant progress within Southeastern Wisconsin’s healthcare systems. They have engaged mammography facility leaders and providers, patient navigators, Wisconsin Well Woman Program coordinators, and patients and community members with mammography experiences, in thoughtful, responsive collaborations, expanding the scope of who provides insights into mammographic quality and understanding what quality means from various perspectives.

One striking revelation from MQI’s work is the general lack of knowledge about screening mammograms among first-time patients. Most individuals are only aware that they need a mammogram or have heard from family members about the potential discomfort. This lack of information can be a barrier to scheduling and following through with these crucial screenings.

We’ve also learned that while access to facilities is undoubtedly important (and Wisconsin has made considerable efforts to improve this), financial support, a comfortable and safe environment during procedures, and addressing mental models and power dynamics are equally vital to ensure patients return for future screenings.

Additionally, quality standards and annual audits, mandated by the Mammography Quality Standards Act, ensure the safety and efficacy of all U.S. mammography facilities. Despite this, many quality markers remain unrecorded or are inconsistently reported due to variations in electronic medical records systems and provider documentation practices. This inconsistency complicates efforts to track follow-up timeliness from screening to biopsy or to identify patients who never completed their recommended follow-up diagnostics.

Finally, patient navigators and Wisconsin Well Woman Program (WWWP) coordinators have proven to be invaluable assets. Their dual perspectives as providers and patient advocates enhance the understanding of mammogram quality within MQI.

There are several actionable steps we recommend based on our learning and experiences to date:

1. Understand the Process Yourself. Familiarize yourself with the mammogram process if you don’t yet understand it. Numerous credible online resources explain the steps, from initial screenings to ultrasounds, MRIs, and biopsies. Examples include information from reputable organizations like the National Breast Cancer Foundation, or videos from health systems like Froedtert.
2. Promote, Educate & Discuss the details! Talk about mammograms with family and friends. Go beyond telling someone to get a mammogram, and get into the details of the screening process. Knowledge about mammograms is surprisingly limited among patients before their first screening, apart from hearing from family members that it might hurt. Sharing accurate information can demystify the process, encourage people to schedule their screenings, and empower people with knowledge to reduce fear and anxiety.
3. Support Local Programs: Advocate for programs that provide exceptional services to patients across Wisconsin. The WWWP, for instance, has been offering breast and cervical cancer screening support for thirty years to tens of thousands of patients. Despite changes like mergers and acquisitions, the program maintains partnerships in all counties and tribal nations in Wisconsin, providing timely and excellent services.
4. Encourage Transformational Change: Critically assess your work, beliefs, institutions, and norms. Question existing systems and the decisions that shaped them. MQI is bring collective impact into the health care system - collaborating with a diverse range of mammogram providers from various Southeastern Wisconsin systems to understand and enhance quality across health systems, and expanding our definition of quality beyond what has always been measured. We cannot do what has always been done, and expect real transformational change.

By actively participating in discussions, familiarizing ourselves with the mammogram process, supporting local initiatives, and advocating for systemic change, we can collectively enhance the quality of mammographic services. The Mammographic Quality Initiative exemplifies how a collaborative, transdisciplinary approach can lead to significant improvements in healthcare outcomes, ultimately ensuring better and more equitable breast cancer screening for all.

Together, we can make a difference in the fight against breast cancer, one high-quality mammogram at a time.

Sources:

1. Elmore JG, Armstrong K, Lehman CD, Fletcher SW. "Screening for breast cancer." JAMA. 2005 Mar 9;293(10):1245-56.
2. Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. "Likelihood ratios for modern screening mammography: risk of breast cancer based on age and mammographic interpretation." JAMA. 1996 May 1;275(17):1318-25.
3. Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S, Conant EF, Fajardo LL, Bassett L, D'Orsi C, Jong R, Rebner M; Digital Mammographic Imaging Screening Trial (DMIST) Investigators Group. "Diagnostic performance of digital versus film mammography for breast-cancer screening." N Engl J Med. 2005 Oct 27;353(17):1773-83.
4. Duffy SW, Tabár L, Vitak B, Chen TH, Yen MF, Chiang CF, Smith RA, Khan K, Rosen M, Stenbeck M, Holmberg L, Fagerberg G. "The Swedish Two-County Trial of mammographic screening: cluster randomisation and end point evaluation." Ann Oncol. 2003 Aug;14(8):1196-8.
5. https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/limitations-of-mammograms.html
6. https://www.bcrf.org/blog/black-women-and-breast-cancer-why-disparities-persist-and-how-end-them/
7. Fayanju, O.M., Edmonds, C.E., Reyes, S.A. et al. The Landmark Series—Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women. Ann Surg Oncol 30, 58–67 (2023). https://doi.org/10.1245/s10434-022-12535-8
8. Lee, C.S., Goldman, L., Grimm, L.J. et al. Screening mammographic performance by race and age in the National Mammography Database: 29,479,665 screening mammograms from 13,181,241 women. Breast Cancer Res Treat 203, 599–612 (2024). https://doi.org/10.1007/s10549-023-07124-6

When it comes to breast cancer screening, mammograms are a critical tool. However, the quality of mammographic services can significantly affect outcomes. Research indicates that higher quality mammography can lead to earlier detection of breast cancer, which is crucial for successful treatment. In fact, studies have shown that the sensitivity of mammography can vary widely, from 68% to 90%(1-4), depending on the quality of the equipment and the skill of the radiologist . Additionally, false-negative rates can range from 10% to 30%,(5) emphasizing the importance of high standards in mammographic services. Unfortunately, disparities in mammographic quality and outcomes persist, particularly among racial and ethnic minorities. For example, African American women are more likely to receive lower-quality mammography services, contributing to a higher mortality rate from breast cancer compared to their white counterparts.(6-8)

The Mammographic Quality Initiative (MQI) is leveraging the Community and Cancer Science Network (CCSN) transdisciplinary approach to delve into the factors influencing mammography quality. By building a shared measurement system, MQI aims to monitor and enhance mammographic quality comprehensively.

Since its inception, the leadership team has made significant progress within Southeastern Wisconsin’s healthcare systems. They have engaged mammography facility leaders and providers, patient navigators, Wisconsin Well Woman Program coordinators, and patients and community members with mammography experiences, in thoughtful, responsive collaborations, expanding the scope of who provides insights into mammographic quality and understanding what quality means from various perspectives.

One striking revelation from MQI’s work is the general lack of knowledge about screening mammograms among first-time patients. Most individuals are only aware that they need a mammogram or have heard from family members about the potential discomfort. This lack of information can be a barrier to scheduling and following through with these crucial screenings.

We’ve also learned that while access to facilities is undoubtedly important (and Wisconsin has made considerable efforts to improve this), financial support, a comfortable and safe environment during procedures, and addressing mental models and power dynamics are equally vital to ensure patients return for future screenings.

Additionally, quality standards and annual audits, mandated by the Mammography Quality Standards Act, ensure the safety and efficacy of all U.S. mammography facilities. Despite this, many quality markers remain unrecorded or are inconsistently reported due to variations in electronic medical records systems and provider documentation practices. This inconsistency complicates efforts to track follow-up timeliness from screening to biopsy or to identify patients who never completed their recommended follow-up diagnostics.

Finally, patient navigators and Wisconsin Well Woman Program (WWWP) coordinators have proven to be invaluable assets. Their dual perspectives as providers and patient advocates enhance the understanding of mammogram quality within MQI.

There are several actionable steps we recommend based on our learning and experiences to date:

1. Understand the Process Yourself. Familiarize yourself with the mammogram process if you don’t yet understand it. Numerous credible online resources explain the steps, from initial screenings to ultrasounds, MRIs, and biopsies. Examples include information from reputable organizations like the National Breast Cancer Foundation, or videos from health systems like Froedtert.
2. Promote, Educate & Discuss the details! Talk about mammograms with family and friends. Go beyond telling someone to get a mammogram, and get into the details of the screening process. Knowledge about mammograms is surprisingly limited among patients before their first screening, apart from hearing from family members that it might hurt. Sharing accurate information can demystify the process, encourage people to schedule their screenings, and empower people with knowledge to reduce fear and anxiety.
3. Support Local Programs: Advocate for programs that provide exceptional services to patients across Wisconsin. The WWWP, for instance, has been offering breast and cervical cancer screening support for thirty years to tens of thousands of patients. Despite changes like mergers and acquisitions, the program maintains partnerships in all counties and tribal nations in Wisconsin, providing timely and excellent services.
4. Encourage Transformational Change: Critically assess your work, beliefs, institutions, and norms. Question existing systems and the decisions that shaped them. MQI is bring collective impact into the health care system - collaborating with a diverse range of mammogram providers from various Southeastern Wisconsin systems to understand and enhance quality across health systems, and expanding our definition of quality beyond what has always been measured. We cannot do what has always been done, and expect real transformational change.

By actively participating in discussions, familiarizing ourselves with the mammogram process, supporting local initiatives, and advocating for systemic change, we can collectively enhance the quality of mammographic services. The Mammographic Quality Initiative exemplifies how a collaborative, transdisciplinary approach can lead to significant improvements in healthcare outcomes, ultimately ensuring better and more equitable breast cancer screening for all.

Together, we can make a difference in the fight against breast cancer, one high-quality mammogram at a time.

 Sources:

1. Elmore JG, Armstrong K, Lehman CD, Fletcher SW. "Screening for breast cancer." JAMA. 2005 Mar 9;293(10):1245-56.
2. Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. "Likelihood ratios for modern screening mammography: risk of breast cancer based on age and mammographic interpretation." JAMA. 1996 May 1;275(17):1318-25.
3. Pisano ED, Gatsonis C, Hendrick E, Yaffe M, Baum JK, Acharyya S, Conant EF, Fajardo LL, Bassett L, D'Orsi C, Jong R, Rebner M; Digital Mammographic Imaging Screening Trial (DMIST) Investigators Group. "Diagnostic performance of digital versus film mammography for breast-cancer screening." N Engl J Med. 2005 Oct 27;353(17):1773-83.
4. Duffy SW, Tabár L, Vitak B, Chen TH, Yen MF, Chiang CF, Smith RA, Khan K, Rosen M, Stenbeck M, Holmberg L, Fagerberg G. "The Swedish Two-County Trial of mammographic screening: cluster randomisation and end point evaluation." Ann Oncol. 2003 Aug;14(8):1196-8.
5. https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/limitations-of-mammograms.html
6. https://www.bcrf.org/blog/black-women-and-breast-cancer-why-disparities-persist-and-how-end-them/
7. Fayanju, O.M., Edmonds, C.E., Reyes, S.A. et al. The Landmark Series—Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women. Ann Surg Oncol 30, 58–67 (2023). https://doi.org/10.1245/s10434-022-12535-8
8. Lee, C.S., Goldman, L., Grimm, L.J. et al. Screening mammographic performance by race and age in the National Mammography Database: 29,479,665 screening mammograms from 13,181,241 women. Breast Cancer Res Treat 203, 599–612 (2024). https://doi.org/10.1007/s10549-023-07124-6

In CCSN’s first year, we were focused on providing a strong foundation for its three initial programs. Once this foundation was set, we realized we needed to focus more on our communication strategies. Mainly focusing on how we communicate with those outside of our network, and how to promote our efforts to other stakeholders working in cancer disparities. This blog explains the process of how I have learned to use visuals as communication tools to create brand recognition and convey messaging to multiple target audiences- without being an expert in communications or design.
 
The first promotional item I developed was our logo. CCSN needed its own logo because it would provide a unifying image that would remain with our network, even as we continue to grow and expand. Logos can also convey core values and provide brand recognition, having people equate the image with an initiative’s, hopefully positive, reputation at a quick glance. Since I do not have experience in logo creation, I sought out a webtool with the following features to help me create a high quality image:

1. A comprehensive library of original images to pick from
2. The ability to customize components of the image’s color and font style
3. Provide purchasing rights for our exclusive use of the logo 

I discovered the website BrandCrowd met each of these requirements, all while being an extremely user-friendly platform. Selecting and customizing the logo was a collaborative effort within our leadership team. Tobi Cawthra, the Program Manager for CCSN and one if its original founders, noticed symbolism in the logo’s shape. She found it to resemble how CCSN brings people together with different experiences and perspectives around a central unifying purpose. And after she explained this symbolism, our team completely agreed! 
 
Color choice for a logo is also an important component because color can convey its own messaging within an image. After playing around with a variety of color palates and multiple team deliberations, we decided on the logo above to represent CCSN. Greens are often associated with growth, and felt organic and neutral. Blue tones are often associated with trust and clarity, and the orange provides energy and vibrancy. And just like that, it all came together, and we had created and purchased CCSN’s logo!
 
In addition to a logo, we needed a website that could reflect the vastness of our partners, help increase our visibility, and legitimize CCSN in an ever-growing digital world. Tobi had already created a domain/web address for CCSN through a web building platform called Weelby. Weebly has a plethora of tools delivering customization of nearly every aspect of a website, which is awesome, but can also be daunting to figure out where to begin.
 
Thankfully, Collaborative Work Group’s Co-leader, David Frazer helped Tobi and I think about the website’s audiences, which content was necessary for those audiences, and consider the styles of other websites to start envisioning what CCSN’s could be. We quickly agreed that both community members and cancer researchers would use the website for information and as a way to connect with CCSN. From there, I had a lot of creative freedom with the website. I really liked the idea of having the home page show off multiple communities throughout Milwaukee, and a drone video-banner was able to accomplish that better than a still photo could. I also decided to incorporate the logo and logo colors throughout the website to reinforce brand recognition.
 
All of these visual aspects have come together nicely in combination with the written content our teams have developed over the past years. And as our initiatives progress, we can continue to reimagine and adjust using these tips I’ve learned along the way:

• Use logo colors to stay on brand and create brand recognition
  • Use the Hex/ Red, Blue, Green color numbers to be precise
• Experiment and have fun with new tools such as Canva or Weebly to enhance your skillset
• Use arrows, text bubbles, or section blocks to create a visual flow or progression
• Understand the purpose of the communication tool
  • Who is your audience and what do they need to get from the tool?
  • Is your style more casual or formal? Which style would resonate better with your audience?
• Use concise wording to prevent text overload
  •  You can always link out to a website, QR code, or email address for more information
• Be open to critiques from trusted colleagues
  • Multiple perspectives can create better products! Which is a core value of CCSN-

​“Group project”- two words that earn a groan from just about any classroom. Most kids don’t enjoy working on team projects and neither do adults. Collaboration is hard. It is especially challenging when you are bringing together people from many different fields and experiences.

So, if collaboration is so hard, why do we do it?
“Collaboration” is a bit of a buzzword; we hear it everywhere. But what does it really mean? By strict definition, when you collaborate two or more people cooperate; they work to achieve something. It’s from Latin, collaboratus, -to labor together. The theory is that in laboring together we can accomplish more than we can alone.

This is especially true when we are working with complex problems, those with numerous interconnected elements. No one person can address every facet of a problem. If one person just works on what they know, they will miss a lot of information and opportunity. An if multiple people are only working on one part of the issue, well, they probably won’t be very effective either.

The more complex or seemingly intractable a problem is, the more broad the knowledge and expertise is needed to find an answer. This requires transdisciplinary collaboration (or transdisciplinary research in academic settings). In transdisciplinary collaboration, people come together representing multiple disciplines and experiences. They work to integrate their individual knowledge to create a new knowledge or understanding .

Transdisciplinary Collaboration- the How of Collaboration
Just bringing multiple disciplines together doesn’t automatically produce good transdisciplinary collaboration. In fact, good transdisciplinary collaboration is often messier and less straightforward than simple multi-disciplinary or interdisciplinary collaboration. Our collaborative, known as the Community and Cancer Science Network (CCSN), consists of researchers, community organizations, providers of care, individuals with direct experience with cancer and disparities, funders and more. When our collective work began, we didn’t use the same language to talk about the problem we were addressing; we didn’t use the same methods to solve problems; we didn’t have exactly the same resources at our disposal and we didn’t have the same motivation for being there. 

Yet, through transdisciplinary collaboration, we have been able to build these differences into collective strengths and develop several transdisciplinary teams whose efforts center on reducing cancer disparities. The process to develop these teams has contributed to our learning on ways that transdisciplinary teams can work.

Start with a consolidated understanding of the problem
When CCSN brings partners together, we start by finding ways to help them see the wealth of knowledge and expertise each partner brings. This comes through facilitated discussion that surfaces the collective awareness of the group. In one CCSN team, we used the “5-whys” exercise to explore the collective knowledge of the root causes of disparities for specific cancers. The illustration produced from this exercise demonstrated three things. First, it showed visually the breadth and depth of knowledge and expertise on the team. Next, it pointed to linkages across disciplines. Last, and perhaps most importantly, it illustrated each person’s unique contribution to solving the problem.

This team returned to this document on several occasions to reground the team on the interconnections between team members. The team also updated the document periodically to reflect new knowledge or understanding allowing them to document their progress and learning. This simple and important exercise proved helpful whenever the team struggled with collaboration or were not advancing as quickly as they would like. It reminded them that they need all the perspectives to fully understand and address cancer disparities.

Coach and convene; don’t dictate and control
A shared understanding is not enough. CCSN also uses coaching tools. Instead of focusing facilitation on moving through an agenda, we used meetings to coach collaboration and identify barriers and promoters for collaboration. Tobi, who served as the primary facilitator, focused on developing trust among team members and identifying group communication styles and preferences, while still advancing the work. As the developmental evaluator, Laura, focused on frameworks and processes to draw out nuanced perspectives.

After each meeting, we reflected together on how the meeting went, where collaboration could be enhanced and what strategy would get us there. For example, when team members did not offer opinions or insights in a meeting, we provided opportunities to get insights and feedback between meetings via email or one-on-one conversations. We also led the team in small group activities, always assigning team members to groups to expand the interaction among team members. Through these types of activities, we were able to draw out engagement across the different sectors represented.

​In this process, we also modeled an inquisitive approach. We did not discourage any ideas or threads of inquiry. We allowed agendas to be flexible or even set aside when a topic arose that was of particular relevance. This approach welcomed others to do the same and developed an environment where everyone was free to explore questions and not be the expert.

Let the collaborators benefit from messiness
Our teams experience a great degree of learning during their time together. And this learning is not a straightforward process. All of the teams have felt stuck and confused at times. Often, team members felt that they were re-hashing decisions or rethinking steps. At times, they were, but they were approaching those decisions and steps with a new and deeper understanding of an issue.

CCSN teams are eager to advance solutions. As a result, they struggle, at times, to be patient with learning and incorporating new knowledge. This happens most frequently when a collaboration is struggling or when necessary information to solve the problem is missing. At these times, we intentionally slow down progress to either address how the team could work better together, or perhaps find ways to draw in missing information.

CCSN teams mature as collaboratives by working through this messiness and discomfort together. We have observed that the harder the challenge, the more connected the team becomes once they push past this discomfort. For example, the original CCSN team members continue to stay connected as well as bring in other partners. Initial team members have gone on to lead a transdisciplinary team or participate on one, and many report seeing how a transdisciplinary approach could benefit their other collaborations. They describe the original team as the “Dream Team” and continue to reflect upon how this collaboration changed how they do their work and how they understand the issue.

And, this is why we struggle through collaboration. Yes, it can make work go more smoothly and yes, it can streamline processes. But, why we struggle through collaboration is that it changes us. It makes us better at our vocations and our avocations.

Most programs and initiatives gather a lot of data. Having the capacity to hone in on the most important data to help improve the process is a common challenge. This is where a dashboard can be useful. A dashboard is a visual snapshot of your data. Dashboards use charts and graphs built from underlying data in a spreadsheet or database to highlight patterns in data. What elements get included in a dashboard are based on specific questions about how a strategy is expected to perform. Although it seems simple, it is a powerful way to synthesize and interpret data in a visual form. 

Why a Dashboard 
Creating a dashboard from the existing Scholars Program tracking tool addressed several challenges: (1) project leadership was primarily focused on executing program activities and had little time for record-keeping; (2) the tracking tool dataset was getting too big to focus on the most critical information; and (3) notes about required follow-up and next steps were getting lost with so much information. Providing a quick visual snapshot of the data helped direct the project team’s attention to the most important information. 

There are many dashboard tools on the market for purchase that will populate dashboards at the click of a button. We built our visual dashboard in the same Excel workbook we use to track outreach and recruitment. While we are not experts in creating dashboards, we found we could create a customized dashboard with minimal effort. The visual elements of our dashboard, once developed, allowed us to quickly answer questions about the size and strength of our recruitment pool and what immediate actions we needed to take to course correct. 

Using Dashboards to Grow Our Recruitment Strategy 
Since our tracking tool was designed to hold a lot of data, we first had to determine the most critical data points for understanding our immediate recruitment goals. We chose fields that would trigger further conversation between team members that would encourage them to think about next steps or strategy. For example, listing how many contacts were “closed” vs. “open” led to a discussion about whether follow-up communication was needed. A graph showing which sectors our contacts belonged to led to a conversation about whether we had enough scholars interested from the sectors we needed. Charts displaying the outcomes from our contacts led to conversations about what strategies they were responding to and what they were not. These discussions helped us identify critical next steps to adapt recruitment and outreach strategies to meet our recruitment goals. 

In order to identify action steps to achieve recruitment goals, we made reviewing the data dashboard a standing agenda item. The team dedicated time on each agenda to debrief on closed contacts and focus on new strategies for open contacts. The discussion further strengthened the quality of our data. As the team reflected on the visual dashboard components, it reminded them of the details of their outreach; they could focus on strategic approaches and ways in which to make the best use of their time. As a standing agenda item, it created a great opportunity to discuss the communication and recruitment process and provided a context for the team to identify areas for immediate improvement, and surfaced important questions to strengthen future cycles. 

Implementing a Dashboard in Your Own Work 
Dashboards are effective tools to help a team focus on progress toward meeting goals and identifying critical steps in a process. Dashboards focus a team’s attention where it is needed most, which is helpful when team members are engaged in different aspects of the work. Lastly, and most importantly, they are a simple tool you can use whenever you need to stay on track and make data-informed decisions. 
During the recruitment period, we learned a lot about how to get the most out of our data. Below are recommendations for teams considering a similar process. 

Be flexible and reasonable 

• Don’t be a perfectionist. You may have missing data or an incomplete picture especially when you are gathering data in real time. Focus on what the data tells you and make decisions accordingly. The point is to use your data, not make it look pretty. 
• Start with a simple dashboard that summarizes totals and focuses your attention on the most important issues. You can always add on more nuanced data and interactivity, such as pivot tables, once you have a better feel for what you want to know and how you’ll use this extra information. 

​
Actually use your data 

• Agree upon targets and measure progress against those targets. The data collected is arbitrary if you do not know what you’re aiming for. 
• Set a recurring time to review the data and engage your team in what it means. Leave with clear action steps to move forward with the project. 
• Realize that what you want to know about your program may change over time and that’s okay. Adjust your tracking tool and dashboard accordingly to serve your goals. 
• Set aside time at the end of your program cycle for a debrief or After Action Review to reflect and improve for the future.