To the Editor:

Michelle Lee and Benjamin Williams argue that the decision to screen should be based on the patient’s values and beliefs and not limited by financial barriers.

We thank Bartholomew and colleagues (Bartholomew et al., 2022) for their thoughtful discussion on the ethics of providing financial incentives for breast cancer screening. We applaud the authors’ focus on the patient-physician relationship and their emphasis on providing individualized information on the harms and benefits of screening to allow patients to make the most informed decisions for themselves. We agree that education is key and that there needs to be a continued focus on bridging any knowledge gaps that providers or patients may have. Offering financial incentives, particularly to vulnerable populations, remove obstacles to access and allows patients to make decisions based on risks and benefits without consideration of costs.

The value of education and healthcare engagement cannot be understated, and as with other screening measures and outcomes, low-income and minority populations participate less in early detection programs with disproportionately higher breast cancer mortality rates (Hardy et al., 2000). We believe that health care policies and incentives addressing these discrepancies for both patients and physicians are beneficial. Despite improvement in access to screening mammography over the last decade through the removal of significant barriers such as the cost of a mammogram and access to a primary care provider through the implementation of the Affordable Care Act (ACA), disparities between race and socioeconomic status continue to exist (Cooper et al., 2017). In a study by Ahmed, even after addressing the above barriers, mammography use rate among women in the lowest income bracket was 23.5%, substantially lower than that of the general population (Ahmed et al., 2010). While equality was created to provide patients a primary care physician and access to free screening mammography, additional barriers for low-socioeconomic patients were not addressed. Until these additional barriers are addressed, we will not have equality in access to screening mammography and will continue to see these disparities.

Bartholomew and colleagues’ main concerns about providing incentives are that they may lead patients to make choices that they would not ordinarily make, which can potentially undermine the validity of consent. We believe that providing the financial means to address these barriers should not be viewed as an incentive but rather an opportunity to address known obstacles. Frequent economic barriers to screening include lack of childcare, transportation costs, and lost wages (Faguy, 2020; Kiefe et al., 1994). Financial support evens the playing field and allows patients in low-socioeconomic positions to make the most informed decision for themselves without the concern of financial hardship.

In conclusion, we believe that all women should have equal access to screening mammograms without fear of financial burden regardless of socioeconomic status. In order to create this equal opportunity for patients of low socioeconomic status, financial incentives are needed to remove proven barriers. Removing these barriers allows women to make the most informed decisions based on their values and beliefs. Access to screening should not be limited due to financial hardship.


Ahmed, Nasar U., et al. “Randomized Controlled Trial of Mammography Intervention in Insured Very Low-Income Women.” Cancer Epidemiology Biomarkers & Prevention, vol. 19, no. 7, 29 June 2010, pp. 1790-1798.,

Bartholomew, Theodore, et al. “Financial Incentives for Breast Cancer Screening Undermine Informed Choice.” BMJ, 10 Jan. 2022,

Cooper, Gregory S., et al. “Cancer Preventive Services, Socioeconomic Status, and the Affordable Care Act.” Cancer, vol. 123, no. 9, 9 Jan. 2017, pp. 1585-1589.,

Faguy, K., 2020. Challenges of the underserved and underscreened in mammography. Radiol, Technol. 91, 267m-81m.

Hardy, Robert E., et al. “Difficulty in Reaching Low-Income Women for Screening Mammography.” Journal of Health Care for the Poor and Underserved, vol. 11, no. 1, 11 Feb. 2000, pp. 45-57.,

Kiefe, C. I. “Is Cost a Barrier to Screening Mammography for Low-Income Women Receiving Medicare Benefits? A Randomized Trial.” Archives of Internal Medicine, vol. 154, no. 11, 13 June 1994, pp. 1217-1224.,