System-level barriers to breast cancer screening completion in community-based navigation: Lessons from a quality improvement initiative

BACKGROUND: Black and Latina women experience persistent breast cancer screening disparities. Patient navigation has demonstrated effectiveness in clinic-based populations, but evidence regarding navigation for women engaged through community outreach remains limited. 

LOCAL PROBLEM: In Northern New Jersey, late-stage breast cancer diagnosis rates among black women range from 38% to 44% compared with 27% among all women. Our institution lacked a systematic community-based outreach-to-screening navigation pathway. 

METHODS: This quality improvement initiative, conducted from December 2023 through December 2025 within a large integrated health system, leveraged existing Community Outreach and Engagement infrastructure across 230 community events, tracking a navigation process cascade from engagement through screening completion. Eligibility: women aged 40+ years without a mammogram in the past 12 months (United States Preventive Services Task Force/American Cancer Society). 

INTERVENTIONS: The programme included community outreach, eligibility screening, navigation enrolment, navigator follow-up (4-6 contact attempts over 4-6 weeks), scheduling support and social needs screening. 

RESULTS: The programme engaged 1318 women; among 277 with demographic data, 80.9% identified as black or Latina and 78.8% were uninsured. Of 564 screened for eligibility, 333 (59.0%) enrolled in navigation. Contact success was 73% (210/288 with documented contact attempts in 2024). A critical gap emerged at scheduling: only 5 women (1.5% of enrolled) had mammography scheduled. Post-hoc analysis revealed navigators lacked operational authority to schedule appointments directly. Among 400 women completing social needs screening, 96.0% reported food insecurity. 

CONCLUSIONS: This initiative identified an immediately actionable infrastructure gap: navigators lacked direct scheduling authority, appearing to be a critical barrier to translating engagement into completed care. The 96% food insecurity prevalence characterises a population facing compounding structural barriers, suggesting self-scheduling may be a structurally inequitable expectation. We propose that direct scheduling authority is a potentially necessary condition for effective community-based navigation-a hypothesis warranting prospective testing.