Study: Disparities in research impact breast screening guidelines


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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)

Contents

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


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 stage.

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 USPSTF screening recommendation is to begin annual screening at age 50.  If the same USPSTF 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, USPSTF Guidelines can impact insurance coverage for preventive services. However, in the case of breast screening, legislation known as the PALS Act supercedes the USPSTF Guidelines by requiring health insurance companies to cover annual screening mammograms for women starting at age 40. 

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 mammogram every year.
    • Women 45 to 54 should get mammograms every year.
    • Women 55 and older can switch to a mammogram 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 mammogram.
    • Consider 3D mammogram.

Questions To Ask Your Health Care Provider

  • 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

The following breast cancer screening clinical trials are currently enrolling participants:

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 USPSTF 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 (SEER) 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 stage 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., SEER 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 USPSTF recommends regular mammogram 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 (MRI).  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.  

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Posted 6/21/18

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