Breast Cancer Screening Practice Considerations for Patients with Disabilities

Image of the breast Cancer Screening practice considerations cover.

Scope and Applicability

These practice considerations apply to patients with disabilities who meet standard U.S. Preventive Services Task Force (USPSTF) breast cancer screening criteria of biennial screening mammography for asymptomatic women aged 40 to 74. Clinical eligibility should be determined using standard USPSTF criteria regardless of disability status.

People with disabilities are significantly less likely to have had a mammogram in the past two years (71.3%) compared to people without disabilities (79.3%) (Centers for Disease Control and Prevention [CDC], 2022). Furthermore, studies suggest that people with more severe disabilities are even less likely to receive mammograms compared to people with less severe disabilities (Horner-Johnson et al., 2014). Common barriers include inaccessible mammography equipment and facilities, practitioner knowledge and attitudes, and inadequate preparation for accommodations. These barriers can lead to delayed screening, later-stage diagnosis, and worse outcomes.

This guidance addresses disability-related risk factors, barriers to screening, and accommodation needs for patients with physical or mobility disabilities, sensory disabilities (i.e., vision, hearing, and deafblind), and intellectual or developmental disabilities (IDD).

Patient Assessment

Assumptions about patients with disabilities can create significant barriers to breast cancer screening. Avoid focusing solely on the disability, which can lead to missed screening opportunities. Having a disability does not reduce the risk of getting breast cancer, and, for some types of disabilities, it may actually be associated with increased risk of breast cancer (Iezzoni et al., 2021). Avoid assuming that patients cannot undergo a mammogram or that they do not have the capacity to make informed medical decisions. These assumptions can lead to inadequate care, missed screening opportunities, and health disparities. Instead:

Assess each patient individually rather than making broad assumptions based on disability type,
Assume screening is possible until proven otherwise through careful assessment,
Inquire about previous screening experiences and any concerns or accommodations needed, and
Respect the patient’s autonomy in medical decision making and evaluate capacity for informed consent based on their demonstrated understanding, not disability status.

Accommodation Planning

Accommodation Planning for Office Staff During scheduling and intake, office staff should proactively inquire about accommodation needs and document them clearly for the clinical team. Staff should be prepared to discuss different screening options available and schedule additional time when accommodations are needed. Ask patients:

"What supports would make a mammogram accessible to you?”
"Have you had a mammogram before? What accommodations worked well?"
"Do you have any physical or mobility disabilities that might affect positioning for the mammogram?"
“How do you prefer to communicate?”

Pre-visit Planning

In preparation of the patient’s visit, practitioners should do the following:

Review the patient's medical record for documented disabilities and accommodations.
Have basic awareness of the patient’s disabilities.
Contact the patient before the appointment to discuss needed accommodations to safely and effectively complete the screening.
Ensure accessible equipment availability.

Implementing Accommodations During the Visit

During the visit, practitioners should:

Summarize what they learned from their patient’s chart and confirm that they understand their patient’s needs.
Discuss any accommodations that the patient has said worked well in the past and confirm how they can assist them.
Ask patients, “What would make the screening accessible and more comfortable for you?”

Clinical Considerations by Disability Type

Physical/Mobility Disabilities

Clinical Considerations

Patients with physical or mobility disabilities face significant barriers to breast cancer screenings that can result in missed or delayed screenings. These barriers are concerning given that people with physical disabilities may face additional risk factors for breast cancer yet often receive less screenings than those without disabilities.

The barriers are predominantly structural and procedural in nature. Standard mammography equipment is often not designed to accommodate wheelchairs or patients with limited mobility, creating access challenges (Iezzoni et al., 2010). Positioning requirements present another obstacle, as patients who cannot sit upright, have difficulty with arm positioning, experience spasticity, have limited range of motion, or live with chronic pain may find standard mammography positioning difficult or impossible to achieve. The physical demands of the procedure extend beyond positioning, as patients may need accessible dressing rooms and assistance with undressing and dressing.

Communication barriers may also arise when health care professionals are unfamiliar with disability-related needs or fail to ask patients about their accommodation requirements. Additionally, the clinic environment itself may present challenges, from inaccessible parking and entrances to examination rooms that cannot accommodate mobility aids.

Accommodation Options

Accessible facilities: Be aware of imaging centers that specialize in mammography and have experience working with people with disabilities. Consider accessible parking, entrances, restrooms, accessible equipment, and changing rooms with adequate space for mobility aids.
Accessible mammography equipment: Use machines with a minimum of 28 inches in knee and toe clearance to allow patients to get close enough to the machine, and the breast platforms with adjustable height ranges of 26–42 inches above the ground (Agaronnik et al., 2022).
Positioning assistance: Provide trained staff to assist with positioning and stabilization using aids, such as pillows, wedges, or support bars. Velcro straps can be used to help with positioning (Iezzoni et al., 2010). Consider alternative positioning techniques when standard positioning is not possible.
Assistance with undressing: Provide trained staff to assist patients who need help undressing with careful attention to dignity, privacy, and the patient's preferences for assistance.
Extended appointment times: Allow extra time for positioning and accommodations.
Breast magnetic resonance imaging (MRI): When standard mammography is not feasible despite accommodations and attempts, consider a breast MRI with tables that can lower to 17–19 inches high with transfer supports available (Agaronnik et al., 2022).
Breast ultrasound: When mammography and MRI are not feasible despite accommodations, consider breast ultrasound.
Clinical breast exam: When breast imaging (mammography, MRI, and ultrasound) are not feasible despite accommodations, consider clinical breast exam as a last resort.

Clinical Decision Points

If the patient uses a wheelchair, cannot stand for the mammogram, or would find a standard mammogram challenging for another reason: Refer to imaging centers with accessible mammography equipment and experience working with people with disabilities.

If the patient cannot achieve standard positioning: Work with the patient to find modified positioning that maintain image quality, use positioning aids (pillows, wedges, straps), and consult with a radiologist about alternative views, if needed. This may require extra time.

If the patient needs assistance with undressing: Ensure trained staff are available, respect the patient's dignity and privacy preferences, and allow extra time for assistance.

If a mammogram is not possible despite accommodations, consider:

A breast MRI.
Breast ultrasound.
Clinical breast exam.

Sensory Disabilities (Vision, Hearing, Deafblind)

Clinical Considerations

Patients with sensory disabilities face communication and information-access barriers that can interfere with bone density screening and potentially lead to inadequate care, missed screenings, or traumatic experiences. These barriers are particularly concerning because effective communication is essential for informed consent, proper positioning, and patient safety.

These barriers can vary by disability type but interconnect with their individual impact on care quality. For patients who are blind or have low vision, they may have difficulty accessing written materials, spatial orientation to exam environment, and procedure positioning. For patients who are deaf or hard of hearing, communication barriers can lead to missed or misunderstood explanations and instructions, resulting in errors in care, inadequate informed consent, or discomfort during scanning. The lack of qualified interpreters may lead to overreliance on writing or lipreading, which may be inadequate for some patients, and may be particularly problematic for patients who use American Sign Language (ASL) as a first language.

For patients who are deafblind, the challenges are compounded, as they require specialized tactile or adaptive communication support that practitioners may be unfamiliar with. Staff lacking experience with disability-specific communication needs can create additional barriers, leading to frustration, miscommunication, and potentially unsafe care situations.

Accommodation Options

Auxiliary aids and communication support:

Ask the patient what communication method they prefer, and, if unable to provide that method, work with them to choose an alternative that results in effective communication.
Always speak directly to the patient instead of their support person or interpreter.
Do not begin any explanation or procedure until the auxiliary aid is present.
Allow additional time for communication exchange and processing.

For Patients with Hearing Disabilities

Provide qualified sign language interpreters: In person or through video remote interpreting (VRI) services, real-time computer-aided transcription services (CART), assistive listening devices and systems, and written materials.
Clear visual communication: Maintain eye contact with the patient, not the interpreter. Position interpreters or visual aids where patients can easily see them whenever possible, and practitioners should be advised to refrain from verbal communication until the interpreter is in the line of sight of the patient. Ensure the interpreter has adequate lighting and positioning. Repeat and spell medical or unfamiliar terms.
Alternative breathing cue system: Develop visual or tactile signaling systems, such as dimming lights, gentle touch, or visual cards, to indicate when to hold their breath during imaging.

For Blind or Low-vision Patients

Braille or large print materials: Provide these upon request in a timely manner. A similar statement may also be included in all print materials: “If you need this information in large print, Braille or in audio, please contact xxx-xxx-xxxx” (Isaacson Kailes, 2021).
Comprehensive verbal descriptions: Provide detailed verbal descriptions of the procedure, equipment, room layout, and positioning requirements before and during the examination.
Tactile guidance and orientation: Use appropriate touch (with permission) to guide positioning and provide tactile orientation to equipment and room features.
Audio materials: Offer audio versions of educational materials and instructions.
Describe sensations: Before and during the screening, practitioners should describe sensations patients may experience and provide warning before touching or repositioning to help patients prepare for what they will feel.

For Deafblind Patients

Arrange for specialized deafblind interpreters who can provide tactile sign language interpretation.
Tactile communication systems: Use agreed-upon tactile signals for positioning guidance and procedural updates.
Support person integration: Work collaboratively with the patient’s preferred communication method, interpreter, and support person, while ensuring the patient remains the primary decision maker.

Clinical Decision Points

If the patient requests auxiliary aids: Arrange for auxiliary aid and wait to begin the procedure. Do not proceed without effective communication in place.

If the patient’s preferred auxiliary aid is unavailable: Work with the patient to find another method that results in effective communication. Document the alternative method used and if it worked well for the patient for future reference.

If the interpreter cannot be seen by the patient: Reposition the interpreter to ensure a clear line of sight or consider alternative communication methods if repositioning is not possible.

If the patient cannot hear or see breathing cues: Implement alternative signaling system (visual cues or tactile signals) established before procedure begins.

If the patient who is blind or has low vision is disoriented: Provide verbal orientation to room layout and equipment and offer tactile guidance with permission.

Intellectual/Developmental Disabilities

Clinical Considerations

Patients with IDD face barriers to breast cancer screenings that can lead to missed or delayed screenings or contribute to trauma. These barriers are particularly concerning given that research shows that people with IDD have similar rates of breast cancer compared to people without disabilities, but are more likely to be diagnosed later and have worse outcomes (Mahar et al., 2024). In fact, one study found that people with IDD are almost three times as likely to die of breast cancer than those without IDD (Hansford et al., 2024).

The barriers to effective screening are multifaceted and interconnected. Practitioners may incorrectly assume individuals with IDD don’t need screening, creating a barrier to accessing care. Communication presents another significant challenge, as abstract concepts and medical terminology can lead to anxiety, lack of understanding about the screening’s purpose, poor preparation, and negative perceptions of breast cancer screenings (Wilkinson et al., 2011). This underscores the critical importance of practitioners using communication techniques appropriate for their patients; research demonstrates that preparation and communication from health care professionals serve as a key facilitator for breast cancer screenings among people with IDD (Arana-Chicas et al., 2020).

Consent capacity adds another layer of complexity, particularly when caregivers are involved in decision making. Caregivers may avoid screening to protect the patient from discomfort or the potential of a cancer diagnosis (Greenwood et al., 2014), highlighting the importance of comprehensive patient and caregiver health education. Finally, the screening process itself can present sensory challenges, as patients with autism, or other developmental disabilities, may find the physical sensations, positioning requirements, or environmental stimuli of mammography overwhelming without proper preparation and accommodation.

Accommodation Options

Plain language explanations: Avoid medical jargon and acronyms. Use short sentences under 10 words; say, "You will get pictures taken of your breasts," instead of "Mammography will be used to detect breast cancer." Use teach-back techniques to ensure understanding of where the test occurs, how long it takes, what to expect, and the purpose.
Visual supports and social stories: Photos, diagrams, and videos showing the room, equipment, and step-by-step process can reduce anxiety and support understanding.
Sensory accommodations: Ask patients about environmental modifications that would support their sensory needs, such as dimmed lighting, reduced noise, allowing comfort items, or minimizing other sensory stimuli. If stickers or other markers need to be used on nipples, scars, moles, etc., alert the patient before doing so and be mindful of sensory overstimulation.
Preparatory visits: Offering pre-visit tours or practice sessions to familiarize patients with the environment, equipment, and staff can increase the success of the screening and the likelihood of completing future screenings (Wilkinson et al., 2011).
Extended appointment times: Patients with IDD benefit from extra time for explaining the screening's purpose, learning what to expect, and processing the information (Wilkinson et al., 2011).
Supported decision making: Collaborate with caregivers while ensuring the patient's preferences and autonomy are respected. Use communication aids or support people as needed but obtain consent from the patient directly whenever possible.
Staff training and awareness: Ensure all staff understand that people with IDD need and benefit from regular screenings and are trained in disability-competent care approaches.

Clinical Decision Points

If the patient appears anxious about the procedure: Offer a preparatory visit or additional time for explanation and accommodation planning.

If the patient cannot tolerate standard scanning environment: Consider environmental modifications (lighting, noise reduction) or alternative scanning options.

If the patient demonstrates difficulty understanding procedure despite plain language explanation: Use visual aids and teach-back methods to assess comprehension before proceeding.

If the patient needs more time to process information: Allow for extended appointment time, break information into smaller segments, use multiple communication methods, and confirm understanding at each step.

If the patient's caregiver is reluctant about screening: Provide education about breast cancer risk in people with IDD, discuss the importance of screening, address caregiver concerns, and emphasize patient autonomy in decision making, if appropriate.

Alternative Screening Options

This section discusses three alternative screening options: breast MRI, breast ultrasound, and clinical breast exam. Given considerations in these sections, practitioners should conduct a thorough assessment of each patient’s specific needs and have a conversation with the patient about their ability to tolerate mammography. When mammography is not feasible, discuss alternative screening strategies with the patient, including the risk, benefits, purpose, and basic elements of consent. Additionally, consider referring to a practitioner who is experienced in caring for patients with disabilities.

When offering self-collection, ensure that instructions are provided in accessible formats. Standard written instructions may not be sufficient for patients with visual impairments, reading difficulties, or cognitive disabilities. Consider providing instructions in multiple formats, including large print, audio recordings, videos, visual guides, or plain language versions. Allow extra time for reviewing instructions and confirm the patient’s understanding before proceeding with collection.

Breast MRI

Mammography is the most common modality (National Cancer Institute, 2025) and is considered the gold standard for breast cancer screening; however, in situations where mammograms are not possible despite accommodations, a breast MRI may be an appropriate alternative. A breast MRI is not as reliable at detecting cancer as mammograms (Lord et al., 2007), so practitioners should make every effort to achieve a successful mammogram and consider a breast MRI as a last resort.

Consider offering breast MRI if:

Despite attempting different positioning and stabilization techniques, the patient cannot achieve any positioning that allows for adequate breast compression or visualization.
Despite positioning modifications, a mammogram causes significant physical pain or distress that prevents screening.
Accessible mammography equipment is not available to the patient (no nearby facility with accessible equipment, transportation barriers, etc.).
Patient has repeatedly unsuccessful mammography attempts.

While a breast MRI may be a viable alternative when mammography is not feasible, practitioners must carefully assess whether patients can tolerate the MRI procedure itself and meet eligibility criteria.

Several clinical factors should be evaluated before recommending breast MRI as an alternative screening modality.

Physical tolerance considerations include the patient's ability to lie prone and remain still for 30–45 minutes, which may be challenging or contraindicated for patients with severe mobility disabilities, chronic pain, respiratory compromise, or positioning restrictions.

Environmental factors, such as the enclosed MRI environment and loud acoustic noise, should be assessed, particularly for patients with claustrophobia, anxiety disorders, or sensory processing sensitivities.

Equipment accessibility requires MRI tables capable of lowering to 17–19 inches high with appropriate transfer supports (Agaronnik et al., 2022). Verify the facility or referring facility's MRI capabilities before ordering the MRI.

Contrast administration necessitates IV access, which may present challenges for patients with difficult venous access or needle phobia. Contrast administration may also be contraindicated for some patients. The contrast itself can have side effects, such as cold sensation in the arm, headache, and nausea, which can be a challenging sensory experience.

Breast Ultrasound

When both mammography and breast MRI are not feasible despite accommodations, breast ultrasound may serve as an alternative screening modality. Breast ultrasound can be used as a supplemental screening tool for women with dense breast tissue and has demonstrated effectiveness in detecting cancer (Sood et al., 2019); however, ultrasound alone can lead to more false positives compared to mammography (Berg et al., 2016), so practitioners should exhaust all possibilities for mammography before considering ultrasound as a primary screening method.

Consider offering breast ultrasound if:

The patient cannot tolerate mammography despite accommodations and attempts.
Breast MRI is contraindicated or not feasible despite accommodations.

Physical tolerance considerations for breast ultrasound are generally more accommodating than other modalities. Patients can typically be positioned supine or in a semi recumbent position, making it more accessible for individuals with physical disabilities or challenges with positioning. The procedure requires minimal patient movement and can be adapted to various body positions.

Equipment accessibility can be less of a barrier for breast ultrasounds compared to mammography and breast MRI. The portable nature of the ultrasound equipment also allows for greater flexibility.

Procedural considerations include the need for direct skin contact with the ultrasound probe and conductive gel, which may be challenging for patients with tactile sensitivities or skin conditions. For patients with sensory sensitivities or sensory disabilities, explain what they will feel and where before beginning.

While breast ultrasound can be more accessible for patients with disabilities, mammography is the gold standard and should be used when possible. Practitioners should discuss the limitations of breast ultrasound, including reduced sensitivity for detecting early-stage cancers. Regular clinical breast exams should be emphasized as a supplementary screening strategy when ultrasound is the primary imaging modality.

Clinical Breast Exam

When imaging modalities are not feasible, clinical breast examinations performed by practitioners are essential. While a clinical breast exam alone is not as effective as mammography for early cancer detection, it can identify palpable masses and serve as an important screening tool when other options are exhausted.

Consider clinical breast exam when:

All imaging modalities (mammography, MRI, ultrasound) are not feasible or accessible despite accommodations and attempts.

Communication and consent are important for all screening modalities, including clinical breast exams. Practitioners should clearly explain the exam process, obtain consent, and maintain ongoing communication throughout the exam. For patients with IDD, additional time may be needed to ensure understanding and comfort. For patients with sensory disabilities, give them a verbal or visual cue before touching them.

Frequency of clinical breast exams may need to increase when they serve as the primary screening modality, and practitioners should maintain a low threshold for further evaluation of any concerning findings.

Self-exams

Regardless of alternative screening modality, practitioners should educate patients about breast self-exam techniques and the importance of being familiar with the look and feel of their breasts. While there is mixed evidence on the effectiveness of self-breast exams, this can be an important strategy especially for patients who are unable to have a mammogram.

Follow-up and Continuity Considerations

Results Communication

Provide results in accessible formats appropriate to the patient's communication needs. Use plain language summaries for patients with intellectual disabilities, ensure interpreter services for deaf patients, and provide large print or Braille formats for patients with vision disabilities. Explain what results mean for the patient and any recommended follow-up actions.

Documentation of Accommodations

Clearly document all accommodations used and their effectiveness in the patient's medical record. Include specific details about positioning aids, communication methods, and environmental modifications that worked well to facilitate future appointments.

Future Screenings

Explain to patients when they should expect their next screening. Ensure that accommodation information is transferred when referring to specialists or other facilities.

Coordination with Specialists

If referring patients for screening with a specialist, or for diagnosis or treatment, clearly communicate accommodation needs and successful strategies to the receiving practitioner’s office to ensure continuity of accessible care.

Download Resource (PDF)