The following story was submitted by DAV, an organization that aims to empower veterans by fighting for their interests on Capitol Hill, educating the public about the sacrifices and needs of veterans as they transition back to civilian life, and ensuring that they can access all benefits available to them. You can read more about them here.

Relief.

That was the overwhelming sensation Air Force veteran Krista Jakub felt when she found out the lump in her breast was benign.

Jakub, a DAV chapter service officer and volunteer coordinator in Nebraska, has a family history of breast cancer and has received annual mammograms through the Department of Veterans Affairs since her early 40s.

During a self-exam in February, she felt a lump. Jakub immediately talked to her provider, who ordered a mammogram. When the mammogram didn’t find anything, her provider requested an ultrasound for that same day.

“They did find a lump, and then the following week is when I went in to get a biopsy,” Jakub said.

It’s a scare many women veterans know well. Between 2018 and 2022, there was an annual average of 942 cases of breast cancer among female patients and 89 cases among male patients within the VA. Research into the overall rate of breast cancer among veterans — both men and women — is limited.

While she waited for the biopsy results, Jakub was referred to an oncologist to get ahead of any potential bad news. At her first appointment with the oncologist, Jakub learned the lump was benign.

“I was overjoyed,” she said.

The kind of timely and thorough care Jakub said she received through the VA is the goal for advocates and VA leaders. That’s because early and accurate detection of breast cancer has been shown to save and improve lives. And as more women serve in uniform and turn to the VA for their post-military health care, access to high-quality mammograms is more important than ever.

Two DAV-championed laws are getting the VA closer to that ideal, but progress isn’t as fast as some would like. As with much of women’s health care, resources, outreach and trust remain challenges.

Expanding access

Enacted into law in June 2022, the Making Advances in Mammography and Medical Options for Veterans (MAMMO) Act called for a three-year pilot program providing tele-screening services. Tele-screenings are meant to improve access to veterans in rural areas or near VA facilities that don’t provide in-house mammograms.

As of June 2024, 78 out of 157 VA facilities — or less than half — offer in-house mammograms. Dr. Patrick Malloy, the executive director for the VA’s National Radiology Program, said that radiology licensing requirements set by the American College of Radiology require mammogram technicians and radiologists to perform a certain number of cases per year to maintain proficiency. To meet those standards, there have to be enough patients — in this case veterans —eligible for those services. Malloy said the National Radiology Program has determined that a facility needs about 3,500 eligible veterans to maintain in-house mammograms.

“It’s not the only criteria that we look at,” Malloy said. “We do look at the trends in the growth of women veterans at a facility and we do make projections into the future and... also look at ... if there’s any access issues that a facility is having to make a decision on when to activate a new site.”

When a VA facility doesn’t provide in-house screenings, veterans are referred to community care. The VA estimates that around 40% of mammography screenings are done in the community.

Dr. Sally Haskell, acting chief officer of the VA’s Office of Women’s Health, said that for many patients, community care is more convenient. That’s been the case for Jakub, who said the community care in her area is “top notch.”

The downside, Haskell said, is that referring screenings to community care requires more resources.

“It really requires additional staffing for us to make sure that we can appropriately help those patients navigate through the process, get them scheduled, get them to their appointments, get the results back and notify the patients of their results and then ensure that they get the appropriate follow-up care,” she said.

All VA sites have a part- or full-time mammography coordinator, Haskell said, but that coordination is sometimes a collateral duty for a single staff member.

With tele-screening services, the mammogram is performed at one site and the results are sent to reading center hubs, aggregating the volume needed to meet licensing requirements. If additional imaging is needed, it would be referred to community care, requiring a higher level of coordination.

As of June 2024, the VA had five tele-screening sites across the country performing more than a combined 400 mammograms a month. Malloy said the VA is looking to add more tele-screening sites in 2025.

The MAMMO Act also expanded access to 3D mammograms, which have been shown to result in better breast cancer detection and decrease the need for additional imaging. Malloy said all of the VA’s in-house mammography programs and the five tele-screening sites use 3D mammograms.

Expanding eligibility

The same day the MAMMO Act became law, so too did the Supporting Expanded Review for Veterans In Combat Environments (SERVICE) Act. The law expands eligibility for mammograms to veterans who served in certain areas with known toxic exposures, such as burn pits, even if the veteran is younger than 45, the recommended age for beginning annual mammograms.

Before toxic-exposed veterans are referred for mammograms, they undergo a templated risk assessment that looks at things like patient history, family history and incidents of toxic exposure. Based on the answers, providers will receive guidance on whether they should order a mammogram or a more detailed assessment.

“It’s not completely straightforward, to be honest,” Haskell said. “We really try to counsel the patients on the risks and benefits, and then the patient and provider together would make a decision.”

Haskell said the VA has estimated around 51,000 veterans are eligible for a breast cancer risk assessment under the SERVICE Act. As of June 2024, providers had reached out to roughly 25,000 of those veterans and offered the risk assessment to around 10,000. About 8,500 of those veterans actually received a risk assessment.

“It’s a little slower than we’d like, but we’re continuing to push,” Haskell said.“ I think we’ll gradually get there.”

Meanwhile, Haskell said the link between toxic exposure and breast cancer among veterans remains unclear, but that research is ongoing.

Breast cancer, including male breast cancer, is now considered a presumed service-connected disability for eligible toxic exposures.

Continued vigilance

Jakub said she never misses an annual mammogram and is grateful for the VA.

“I would not go to any other place for my medical care. I’ve tried [privately purchased] care in the community and it just — I love the VA here,” she said.

While many women veterans share that sentiment, others have a hard time trusting a health care system in which they haven’t always felt welcomed or safe.

In response to a social media post about the VA’s mammography services, Tiffany Koehler, an Army veteran and commander of DAV Chapter 19 in Milwaukee, said she “cannot fathom utilizing the VA for an intimate examination.”

“For me, the anxiety comes directly from being in service,” Koehler said. “Many of us women, you know, sometimes we were just one of the very few women in our units or a battalion, and just sometimes even walking in the chow hall filled with men and all eyes turn to you and it’s just kind of like, you relive those experiences when you walk into a VA.”

Koehler added that she experienced military sexual trauma (MST), which can include assault and harassment during service. Of women who use VA health care, 1 in 3 reported having experienced MST. A 2022 report from the VA further showed that 25% of women veterans who regularly used VA primary care experienced inappropriate or unwanted comments or behaviors by male veterans on VA grounds.

“Of course, we are very concerned about wanting to make sure that women veterans always feel safe, feel respected, feel like they belong at the VA,” Haskell said.

Haskell said the VA works hard on its environment of care to ensure safety and privacy. Providers also practice trauma-informed care that considers that many veterans have complex trauma histories.

“And that’s really ensuring that ... all of our employees recognize that patients’ trauma can impact how they sort of experience the health care system. And we want to make sure that they always feel that they’re in control,” Haskell said.

Every VA facility has an MST coordinator to help survivors access care, as well as a women veterans program manager dedicated to advising and advocating for female patients. Additionally, veterans can contact the VA’s Women Veterans Call Center at 855-829-6636 for help navigating services.

DAV National Legislative Director Joy Ilem applauded the significant progress the VA has made in recent years to better serve women veterans and provide quality, comprehensive and gender-specific care.

“DAV celebrates the recent expansions in breast health care and will continue to work alongside [the] VA to ensure women can access timely and potentially lifesaving mammograms,” Ilem said. “We will also continue to monitor the implementation of these laws and listen to veterans’ experiences to inform our advocacy efforts.”

Learn more about what DAV does for women veterans at davwomenveterans.org.

This story was shared by DAV, an organization working to empower veterans and ensure they lead a high-quality life with respect and dignity. Read more about them here!