Breast cancer is the second-most-common cancer among women and the second leading cause of cancer death in the United States. Even though it's slightly less prevalent among Black than white women in the U.S., Black women are more likely to die from the disease.
The U.S. Preventive Services Task Force (USPSTF) — a group of independent medical experts who make recommendations about clinical preventive services, such as screening tests — recommends that women begin breast cancer screening at age 50. However, the group notes that women have the choice to begin getting mammograms earlier, starting at 40.
Now researchers involved in a large new study are proposing that health policymakers and clinicians consider screening Black women for breast cancer earlier than other racial and ethnic groups, starting at age 42. This strategy, the researchers said, could reduce the breast cancer mortality gap that exists between Black and white women.
“The current one-size-fits-all policy to screen the entire female population from a certain age may be neither fair and equitable nor optimal,” the researchers wrote in the study, published in the journal JAMA Network Open last week.
Although Black women are diagnosed with breast cancer at similar rates as other ethnicities, they have dramatically higher mortality rates. Compared with white women, Black women have a 4% lower incidence rate of breast cancer but a 40% higher risk of dying from the disease.
The significant breast cancer mortality disparity between the two groups has remained stable since 2011 after widening over the past three decades, according to the researchers.
The study looked at a total of 415,277 female breast cancer deaths in the U.S. from 2011 to 2020. The dataset included age, race and ethnicity categories.
The researchers then estimated the 10-year cumulative risk of dying from breast cancer in the general population after reaching age 50 — the time the USPSTF recommends that women begin biennial mammograms. Based on the data, the study authors concluded that Black women reach this risk level at 42, roughly eight years before white women, and they propose that it would make sense to screen them earlier.
“The take-home message for U.S. clinicians and health policymakers is simple. Clinicians and radiologists should consider race and ethnicity when determining the age at which breast cancer screening should begin,” Dr. Mahdi Fallah, one of the authors of the study and leader of the Risk-Adapted Cancer Prevention Group at the German Cancer Research Center in Heidelberg, Germany, told CNN.
Robert A. Smith, senior vice president of cancer screening at the American Cancer Society, said the study was “nicely done” and he expects it “to generate considerable discussion about enduring disparities in the risk of breast cancer death between Black and white women.”
“This study suggests that our current recommendations for mammographic screening in the U.S. (and the age at which women start this screening) should not be uniform and should instead be based on one’s risk of breast cancer,” Dr. Rachel Freedman, a breast medical oncologist at Dana-Farber Cancer Institute, told Yahoo News in an email.
She noted that current guidelines for breast cancer screening already recommend that the time a woman initiates routine mammograms be based on her risk of developing cancer. However, race and ethnicity have not been traditional factors that are considered in these decisions, and perhaps they should be.
Smith said that, as the authors of the study noted, cancer screening guidelines have historically been based on risk in the general population, even though certain groups may have different levels of risk.
“More and more, there are calls to tailor recommendations not only to group differences but individual differences, since individuals in groups can have similar variance in the risks we see between groups,” Smith said in an email.
But both Smith and Freedman noted that many medical groups’ breast cancer screening recommendations already differ somewhat from the USPSTF guidelines referenced in the study.
“The American Cancer Society recommends that all women begin screening at age 45,” Smith said, adding that women should also have the opportunity to begin screening earlier. Most women, he explained, do not wait until they are 50 to get their first mammogram and instead begin screening in their early 40s.
Smith also said his organization is in the process of updating its breast cancer screening guidelines.
“We are examining the scientific literature for how screening guidelines could differ for women in different racial and ethnic groups, and by other risk factors, in a way that would reduce disparities based on risk and disparities in outcome,” he said.
Although earlier screening may be beneficial for women of all ethnicities, some experts have doubts that earlier screening for Black Americans will make a dramatic impact on the current disparities in mortality rates because these disparities, they say, are more strongly correlated to things such as socioeconomic differences and differences in access to health care, which earlier screening recommendations cannot address.
Biological factors also contribute to the disparity in the breast cancer mortality rate between Black and white women, experts say. According to the Breast Cancer Research Foundation, “Black women are disproportionately affected by more aggressive subtypes, such as triple-negative breast cancer (TNBC) and inflammatory breast cancer.” They are also more likely to get diagnosed at an earlier age and when the disease has progressed to advanced stages.
Freedman said that early screening may have some impact in reducing the breast cancer mortality gap because it may find cancers earlier, but there are multiple factors that go into the long-term outcome of a woman with the disease. Some of these include “tumor features, tumor biology, treatments received, barriers to care, lack of access to high-quality care, and disproportionate degrees of poverty in Black women compared with white women,” she said.
“Screening is an important piece but certainly not the only piece,” Freedman explained. “In some places where screening rates are high across race and ethnicities, you will still see mortality differences.”
Even though Freedman thinks the study's findings are intriguing and should be followed up with further studies, these are are not sufficient to change current screening practices, she told Yahoo News.
The researchers who conducted the study acknowledged that multiple factors, including those highlighted by Freedman, contribute to the disparity in the breast cancer mortality rate between Black women and women of other ethnicities. But even though these issues are complex, the authors propose this early testing strategy as an easy step that could potentially make a difference.
“Making everything too complex may lead to doing nothing,” the researchers said. “One can try to start from a first scientific step (like race- and ethnicity-adapted screening) and evaluate and build more complex steps along the way and reevaluate. Otherwise, the racial and ethnic disparity of early-onset BC [breast cancer] mortality may continue or even widen again.”