• Black women are much more likely to die from breast cancer due to more limited access to “high-quality prevention, early detection, and treatment,” says the American Cancer Society.
• Current mammography guidelines are “one size fits all” for all women in the United States.
• A new study proposes custom screening guidelines that can significantly reduce the higher breast-cancer mortality of Black women.

Deaths from breast cancer in the U.S. are trending downward. However, the improvement is uneven across racial groups. Non-Hispanic Black women are 40% more likely to die from cancer than Non-Hispanic white women. A new study investigates addressing this disparity with new screening mammography recommendations for Black women.

The study finds that biennial mammography screening starting at age 40 could reduce the racial disparity by 57%.

The study’s conclusions derive from extensive modeling performed by the Cancer Intervention and Surveillance Modeling Network (CISNET).

The study appears in the Annals of Internal Medicine.

Understanding the problem

According to the study, “Screening mammography guidelines do not explicitly consider racial differences in breast cancer epidemiology, treatment, and survival.”

The study’s senior author, Jeanne S. Mandelblatt, MD, MPH, who works with CISNET and is a professor of oncology and medicine at Georgetown Lombardi Comprehensive Cancer Center in Washington, D.C., explains:

“Black women have higher rates of aggressive cancers at younger ages than white women, and treatments for those types of tumors are not as effective. However, even when we account for cancer subtypes, mortality is higher for Black women largely due to factors that are ultimately rooted in racism.”

Dr. Mandelblatt cites “access to medication, delays in treatment, dose reductions, and discontinuation of treatment — all factors that have been shown to be suboptimal more often in Black than white women.”

Lead author Christina Hunter Chapman, MD, MS, of the Department of Radiation Oncology at the University of Michigan, describes the concept behind the research:

“There is an increasing focus on eliminating race-based medicine. However, calls to end race-based medicine that ask for the immediate cessation of any discussion on race are not likely to eliminate racial disparities. Carefully selected solutions for health inequity may involve tailoring interventions to specific racial groups.”

Dr. Chapman told Medical News Today, “Breast cancer and other health disparities have been described for decades, but there has not been as much emphasis on solutions to reduce these disparities.”

Dr. Chapman added, “Black women were not sufficiently included in screening mammography trials, so simulation modeling represented the next best research approach to identifying equitable screening strategies.”

President and CEO of the Black Women’s Health Imperative, Linda Goler Blount, MPH, told MNT:

“I suppose a computer model is better than nothing, but it speaks volumes that after all these decades, we still don’t have a study that examines this issue that includes significant numbers of Black women.” She added, “What the model can’t do is incorporate or account for the lived experiences of Black women.”

Blount asserted that what is needed are randomized control trials, saying:

“These have been proposed many times, but NIH [National Institutes of Health] refuses to fund them. This will be the only way we understand how the lived experiences of Black women influence their risk and treatment outcomes outside the impact of racism.”

Striking a balance in screening

Some people have expressed concerns about exposure to radiation during mammograms. Modern digital mammography, says Dr. Sarah Zeb of Johns Hopkins Medical Imaging, involves a minimal amount of radiation that is within safety guidelines. “A mammogram is safe as long as the facility you go to is certified by the regulating agencies,” says Dr. Zeb.

Another often-cited potential harm is that mammograms are fallible. They may miss abnormalities obscured by tissue, resulting in false negatives. Mammograms may also deliver a false positive result, requiring follow-up tests and doctor visits.

Blount said, however, that 3D, or digital breast tomosynthesis, “is the superior technology and reduces call-backs, which helps deal with the overdiagnosis issue. Even the [U.S. Preventive Services Task Force] had to admit that false-positives were not a huge stress-inducer or deterrent for women.”

Modeling a new recommendation

The study’s authors created models for women of different races to identify those who systemic racism was most likely to affect.

The researchers projected a birth date of 1980 to simulate a cohort that would be 40 years old in 2020.

They also incorporated variations in breast density, molecule subtypes of breast cancer, age, cancer stage, subtype-specific treatment effects, as well as non-breast cancer mortality rates among Black and white women.

Around 100 million simulated life histories taken up through age 120 allowed the researchers to pinpoint the optimal balance between screening benefits — such as early detection and fewer deaths — versus harms.

Says Dr. Chapman, “For Black women, three biennial screening strategies (beginning at age 40, 45, or 50) yielded benefit-to-harm ratios that were greater than or equal to those seen in white women who started screening at age 50.”

The new recommendations

The analysis revealed, Dr. Chapman says:

“Among those three strategies, initiating mammograms at age 40 yielded the greatest mortality reduction and reduced Black-white mortality disparities by 57%. This approach is consistent with the US Preventive Services Task Force’s overarching guidance for when women may want to consider beginning biennial mammography.”

“This isn’t a surprise,” said Blount, “since about 25% of breast cancers in Black women occur under 50 and 8% occur under 40.”

“Black Americans have higher mortality than other populations for almost every cancer type and for the vast majority of other health conditions,” Dr. Chapman told MNT. Ultimately, she added, “the solution for inequity in many or even most cases is not necessarily to deliver a different treatment to the Black population, but to instead ensure that they receive the same quality of care that other populations are receiving.”

Blount told MNT:

“A way to make advancements in reducing health inequities will likely have to come through legislation rather than voluntary behavior change. If insurers considered race/ethnicity in [Healthcare Effectiveness Data and Information Set] measures, and patient outcomes as a determinant for reimbursement, we’d likely see the gaps between Black and Brown patients and white patients drop dramatically. Imagine where we’d be if they would also consider socioeconomic status?”

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