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Study: Disparities in research impact breast screening guidelines

Summary

For women at average risk of breast cancer, the United States Preventive Services Task Force (USPSTF) currently recommends beginning annual breast cancer screening at age 50. However, because these guidelines are largely based on data from white women, they may not be sensitive to racial differences.  A new study assesses the age distribution of breast cancer cases across race/ethnicity in the U.S. (6/21/18)

Disparities in research impact breast screening guidelines

Relevance

This article is most relevant for Women at average risk for breast cancer

Relevance Rating Details

Relevance: High

Strength of Science: High

Research Timeline: Post Approval

Media Ratings

Did you see the media coverage of this article?

See all media ratings.

How we rated the media

Who covered this study?

Tonic

Should doctors screen women of color for breast cancer even earlier
This article rates 4.5 out of 5 stars

Modern Health Care

'Flawed science' may play a role in health disparities
This article rates 3.5 out of 5 stars

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Contents

At a glance                  Questions for your doctor
Findings               In-depth                
Clinical trials Limitations
Guidelines Resources


STUDY AT A GLANCE

This study is about:

the age distribution of breast cancer diagnoses across race/ethnicity in the United States.

Why is this study important?

Breast cancer screening recommendations are based on data that is predominantly from white women.  Because of this, the authors of this study hypothesize that current screening guidelines may not be sensitive to racial differences. This could result in underscreening of nonwhite women.

Study findings: 

The data in this study was obtained from U.S. cancer registries for female patients who were diagnosed with breast cancers from January 1, 1973 through December 31, 2010.  Data included race, age at diagnosis and .

For the 747,763 female patients included in this study:

  • Overall, median age at diagnosis was 58 years, but varied among racial groups:
    • White women: 59 years
    • Hispanic American women: 55 years
    • African American women: 56 years
    • Asian American women: 56 years
  • A higher proportion of nonwhite patients were diagnosed with breast cancer before age 50. The percentage of patients diagnosed before age 50 varied between races:
    • African Americans: 31%
    • Hispanic Americans: 35%
    • Asian Americans: 32.8%
    • White Americans: 23.6%  
  • A higher proportion of African American and Hispanic women had more advanced breast cancer at the time of diagnosis than white and Asian American women.

What does this mean for me?

Current USPTF guidelines are based primarily on data for white women and are designed to detect breast cancer early. 

The findings of the study do not question current screening recommendations. The findings of this study show that the age of breast cancer occurrence is different for different ethnicities with the youngest occurrence in African American women. Because of these findings the current ethnicity blind recommendations may need to be re-evaluated.

Women of color were diagnosed with breast cancer at a younger age than white women.  Because breast cancer diagnosis in white patients peaks at age 60, the screening recommendation is to begin annual screening at age 50.  If the same screening initiation/early detection window (10 years prior to peak of breast cancer diagnosis) is applied to these new data, African American and Asian women should begin screening at age 47 and Hispanic women at 46.

Under the Patient Protection Affordable Care Act, Guidelines can impact insurance coverage for preventive services. However, in the case of breast screening, legislation known as the PALS Act supercedes the Guidelines by requiring health insurance companies to cover annual for women starting at age 40. 

Posted 6/21/18

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References

Stapleton SM, Oseni TO, MD; Bababekov YJ and Hung Y-C. Race/Ethnicity and Age Distribution of Breast Cancer Diagnosis in the United States. JAMA Surg. 2018. 153 (6):594-595.

Monticciolo DL, Newell MS, Moy L, Niell B, Monsees B, Sickles EA. Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR.  J Am Coll Radiol. 2018. 15(3 Pt A):408-414.

U.S. Preventative Services Task Force: Breast Cancer Screening.  Release Date January 2016.
 

Disclosure

FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.

This article is relevant for:

Women at average risk for breast cancer

This article is also relevant for:

healthy people with average cancer risk

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IN-DEPTH REVIEW OF RESEARCH

Study background:

Professional and governmental organizations differ in their recommendations for when women of average risk should begin annual breast cancer screening. While the USPTSF recommends screening beginning at age 50, the American Cancer Society recommends beginning at age 45, and the American College of Obstetricians and Gynecologists and the American College of Radiology recommends annual screening beginning at age 40. 

Currently, legislation known as the PALS Act requires health insurance companies to cover annual mammograms for women beginning at age 40 with no out-of-pocket costs. Recently the act was extended until January 31, 2019. 

Researchers of this study wanted to know:

whether current breast cancer screening recommendations reflect age-specific patterns based on race.

Study findings:  

The authors report 2 distinct distributions of patterns at age of diagnosis.  White patients’ diagnoses peak in their 60s, while nonwhite patients peak in their 40s.  Compared to white patients, a higher proportion of nonwhite patients present with more advanced disease.

For the 747,763 female patients included in this study:

  • Overall, median age at diagnosis was 58 years, but varied among racial groups:
    • White women: 59 years
    • Hispanic American women: 55
    • African American women: 56 years
    • Asian American women: 56 years
  • A higher proportion of patients with breast cancer were diagnosed before age 50 among nonwhite patients compared to white patients:
    • African Americans: 31%
    • Hispanic Americans: 35%
    • Asian Americans: 32.8%  
    • White Americans: 23.6%
  • A higher proportion of African and Hispanic American patients presented with advanced (regional or distant) disease (46.6 % and 43% respectively, than white or Asian American patients (37.1% and 35.6% respectively).

Study design:

In a letter published on March 7th, 2018 in the Journal of the American Medical Association, Stapleton and colleagues analyzed data in the Surveillance, Epidemiology and End Results () Program database collected between January 1, 1973 and December 31, 2010.  Female patients aged 40 to 75 years with malignant breast cancers were included.  Primary endpoints were age and at breast cancer diagnosis across all racial groups.

Limitations:

The main limitation to this study is that despite being the largest cancer database in the U.S., does not capture all of the U.S. population.

Conclusions:

Though women of color were diagnosed with breast cancer at a younger age than white women, the age at which the  recommends regular screenings is based on research done on white women. This is one example of a larger bias in scientific research-most research is done in predominantly white populations. This bias affects science, medicine, and ultimately may affect a women’s health.

The findings of this new study challenge established screening recommendations, currently based on predominantly white women, and provide evidence that race-based breast cancer screening recommendations should be considered.  The study authors suggest that age-based screening guidelines that do not account for race and may adversely affect nonwhite women in the U.S.  It is important to note that the authors recommend selective increases in breast cancer screening among nonwhite women, but they do not suggest increased screening across the entire U.S. population.

Of particular note, this April, the American College of Radiology (ACR) and Society of Breast Imaging (SBI) breast cancer screening guidelines were the first to recognize that African-American women are at high risk for the disease and should be screened accordingly. The ACR and SBI guidelines now recommend a risk assessment at age 30 for all women to see if screening earlier than age 40 is needed. Both groups now also recommend that women who were previously diagnosed with breast cancer be screened with magnetic resonance imaging ().  The ACR and SBI continue to recommend that women at average breast cancer risk begin screening at age 40. Extension of the PALS Act assures that women will have access to annual mammograms beginning at age 40.  

Share your thoughts on this XRAYS article by taking our brief survey.

Posted 6/21/18

Expert Guidelines
Expert Guidelines

There are different breast screening guidelines. 

  • The American Cancer Society recommends the following breast cancer screening guidelines for average risk women.
    • Women between 40 and 44 have the option to start screening with a every year.
    • Women 45 to 54 should get mammograms every year.
    • Women 55 and older can switch to a every other year, or they can choose to continue yearly mammograms.
    • Screening should continue as long as a woman is in good health and is expected to live at least 10 more years.
  • National Comprehensive Cancer Network (NCCN) screening guidelines for average risk women include the following recommendations for women ages 40 and older. 
    • Women should be told about the benefits, risks and limitations of breast screening. Shared decision-making is encouraged based on a woman's preferences and values. 
    • Annual clinical exam.
    • Annual .
    • Consider .

Expert Guidelines
Expert Guidelines

The National Comprehensive Cancer Network breast screening guidelines recommend the following for women at average risk for breast cancer: 

  • ages 25-39: 
    • practice breast awareness
    • clinical breast exam every 1-3 years
    • risk assessment, including questions about family and personal medical history should be done during clinical exam to find high risk women who may need additional screening
  • ages 40 and older:
    • practice breast awareness
    • yearly clinical breast exam
    • risk assessment, including questions about family and personal medical history should be done during clinical exam to find high risk women who may need additional screening
    • yearly  - consider if available. 
  • NCCN has a different set of guidelines for individuals who are determined to be at increased risk for breast cancer.

Many other professional societies and organizations have breast cancer screening guidelines that differ slightly. They don't all agree on the age screening should start and how frequently they should be done. 

It is important to note, that all the groups support the opportunity for women ages 40 to 49 to decide it screening is right for them.

Updated: 02/05/2022

Questions To Ask Your Doctor
Questions To Ask Your Doctor

  • When should I begin routine breast cancer screening?
  • Which risk factors are considered in your breast screening recommendation?
  • Are there other risk factors I should be aware of?

Open Clinical Trials
Open Clinical Trials

The following clinical research studies focus on addressing in cancer. 

Updated: 11/03/2022

Related Resources
Related Resources

The following organizations have resources related to cancer disparities. 

Updated: 03/18/2023

Related Resources
Related Resources

The following organizations have breast cancer screening resources. 

Updated: 05/26/2023

Who covered this study?

Tonic

Should doctors screen women of color for breast cancer even earlier This article rates 4.5 out of 5 stars

Modern Health Care

'Flawed science' may play a role in health disparities This article rates 3.5 out of 5 stars

The Harvard Gazette

Race bias seen in breast-cancer screening This article rates 3.5 out of 5 stars

Well+Good

Women of color might want to start breast cancer screenings earlier-here’s why This article rates 3.5 out of 5 stars

How we rated the media

Back to XRAY Home

Article Rating Details

Tonic: Should doctors screen women of color for breast cancer even earlier?
Rating: 4.5 Stars

  • The title and lede match what the article claims.
  • This is an excellent, well sourced article which presents a conflicting view point on data analysis and interpretation.
  • It is easy to read and well written. 
  • It clearly lays out the issue of racial bias in science.
  • The image of a women of color getting a mammogram that accompanies this article emphasizes the the focus of the research is.
  • The article states what is covered by the ACA and how that coverage conflicts with the USPSTF recommendation.
  • Like the article from the Harvard Gazette, this article incorrectly states that the average age at diagnosis for Asian women is 46.  It should read 56.  

Modern Health Care: 'Flawed science' may play a role in health disparities
Rating: 3.5 Stars 

  • The title is somewhat misleading.  The science is not flawed.  What is flawed is the populations historically analyzed with conclusions applied across all races.
  • The article is clear and well written and correctly reports results.
  • The article is not particularly well balanced. The only outside source referenced other than the CDC is a report by Modern Health in 2017 that looked at how age guidelines for screening breast cancer might be contributing to racial disparities.

Well+Good: Women of color might want to start breast cancer screenings earlier-here’s why
Rating: 3.5 Stars

  • The headline matches what the article claims
  • The article only includes comment from one of the original study authors.
  • The article is clear and easy to read.
  • The articles clearly portrays  the novelty of the research emphasizing that race bias is prevalent in most scientific fields.
  • While the article is factually correct it does not mention 2 important findings: 
  1. A higher proportion of nonwhite patients were diagnosed with breast cancer before age 50 and
  2. A higher proportion of African American and Hispanic women had more advanced breast cancer at the time of diagnosis than white and Asian American women.

The Harvard Gazette: Race bias seen in breast-cancer screening
Rating: 3.5 Stars

  • The title and lead are accurate and match what the article claims.
  • The article only includes comment from one of the original study authors.
  • The article is clear and easy to read.
  • The articles clearly portrays the novelty of the research emphasizing that race bias is prevalent in most scientific fields.
  • Like the article from Tonic, this article also misstates results stating that the researchers found that the average age at diagnosis was 46 for Asian women.  This should be 56 years for Asian American women.

Study Rating Details

Relevance: High

  • This study is directly about screening age for breast cancer prevention in women. 
  • This study is particularly relevant for women of color but examines rates in women of many ethnicities. The results support re-evaluation of current ethnically blind screening recommendations. 

Strength of Science: High

  • This a simple but well-designed analysis of publically available data with an emphasis on race/ethnicity and age distribution of breast cancer diagnosis in the U.S. 
  • This is a retrospective analysis of data from U.S. cancer registries from January 1973-December 2010. While likely, it is not yet known yet known whether analysis of data from 2010 to the present would arrive at the same conclusions.
  • It is possible that a more robust analysis of the data would be to use age-adjusted incidence rates, not proportions.
  • This study is particularly relevant for women of color. The results support re-evaluation of current ethnically blind screening recommendations.

Research Timeline: Post-Approval