Optimizing Breast Imaging: Needs and Opportunities for Refugee Women in Italy and Low-Income Countries

Graziella Di Grezia; Teresa Iannnaccone; Gianluca Gatta

doi:10.4274/ejbh.2025.2025-3-1

Dear Editor,

Mammographic screening is a key tool for early detection and improved survival in breast cancer. However, access to such screening remains inconsistent and far from a universal right. Refugee women, asylum seekers, and undocumented migrants are often excluded from national programs due to legal, bureaucratic, and cultural barriers. This exclusion leads to a higher risk of late-stage diagnosis and consequently increased morbidity and mortality (1, 2).

1. Refugee Populations: Clinical Invisibility and Systemic Barriers

Screening rates among refugee women in Europe, including Italy, are significantly low. The lack of formal documentation, limited health literacy, and widespread mistrust toward institutional healthcare systems are major obstacles. While the reported incidence of breast cancer in these populations appears low, this is often an artifact of underdiagnosis. In reality, cancer is frequently detected at an advanced stage, and mortality rates are higher due to the absence of structured and continuous care pathways.

2. Low-Income Countries: Symptomatic

Focus and Accessible Technologies

In low-income settings, breast cancer incidence is traditionally lower (ranging between 40 and 80 cases per 100,000 women), yet mortality is disproportionately high, again due to late diagnosis and insufficient diagnostic infrastructure. In this context, systematic screening programs are rarely feasible and a more pragmatic approach centers on evaluating symptomatic cases. In this regard, mobile ultrasound systems combined with artificial intelligence and teleradiology offer a viable strategy to provide preliminary breast assessments in areas without radiologists on-site (3, 4).

3. High-Income Countries: Higher Incidence, Better Outcomes

In high-income nations, breast cancer incidence is higher (130–150 cases per 100,000 women) than in low-income countries, but survival has improved significantly thanks largely to early detection and timely treatment. This contrast highlights the critical role of access to prevention, diagnosis and treatment and the urgent need to adapt and simplify protocols to include women in marginalized conditions.

Toward an Integrated and Culturally Sensitive Vision

It is essential to recognize that access to breast diagnostics is not only a matter of technology or public health policy but also of social vulnerability. Refugee and displaced women often experience chronic trauma and gender-based violence, which can affect their willingness or psychological readiness to undergo breast examinations. A culturally aware approach that integrates education, symptom-based screening, mental health support, and accessible imaging technologies may help reduce inequities and promote more inclusive breast health care (5).

Authorship Contributions

Surgical and Medical Practices: G.D.G., T.I., G.G.; Concept: G.D.G., T.I., G.G.; Design: G.D.G., T.I., G.G.; Data Collection or Processing: G.D.G., T.I., G.G.; Analysis or Interpretation: G.D.G., T.I., G.G.; Literature Search: G.D.G., T.I., G.G.; Writing: G.D.G., T.I., G.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declare that they received no financial support for this study.

References

World Health Organization. Global Breast Cancer Initiative Framework. Geneva: WHO; 2021.

Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast cancer screening in women at higher-than-average risk: recommendations from the ACR. J Am Coll Radiol. 2018; 15: 408-414. (PMID: 29371086)

Rodriguez-Ruiz A, Lång K, Gubern-Merida A, Broeders M, Gennaro G, Clauser P, et al. Stand-alone artificial intelligence for breast cancer detection in mammography: comparison with 101 radiologists. J Natl Cancer Inst. 2019; 111: 916-922. (PMID: 30834436)

Gatta G, Somma F, Sardu C, De Chiara M, Massafra R, Fanizzi A, et al. Automated 3D ultrasound as an adjunct to screening mammography programs in dense breast: literature review and metanalysis. J Pers Med. 2023; 13: 1683. (PMID: 38138910)

Sardu C, Gatta G, Pieretti G, Viola L, Sacra C, Di Grezia G, et al. Pre-menopausal breast fat density might predict MACE during 10 years of follow-up: the BRECARD study. JACC Cardiovasc Imaging. 2021; 14: 426-438. (PMID: 33129736)