Black women most likely to face diagnostic delays after abnormal mammography results
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Black women had an increased risk for not undergoing biopsy within 90 days after abnormal screening mammography results compared with women of other racial and ethnic groups, according to study results published in JAMA Oncology.
Rationale and methods
“We know that there are racial and ethnic disparities in important breast cancer outcomes, such as stage at diagnosis and mortality, but less is known about disparities in the diagnostic pathway leading up to a breast cancer diagnosis and how those may contribute to downstream disparities,” Marissa B. Lawson, MD, researcher in the department of radiology at University of Washington School of Medicine, told Healio.
For this reason, Lawson and colleagues sought to assess individual-, neighborhood- and health care-level factors associated with differences in time from abnormal mammography to biopsy among 45,186 women (median age at screening, 56 years) who underwent a total of 46,185 mammograms with abnormal results across 109 imaging facilities in the U.S. from 2009 to 2019.
Unadjusted and adjusted relative risk for no biopsy within 30, 60 and 90 days served as the primary outcome, with unadjusted and adjusted median time to biopsy as the secondary outcome.
Key findings
Overall, 34.6% of abnormal screening results recommended for biopsy had not been resolved within 30 days, 16.2% had not been resolved within 60 days and 12.2% had not been resolved in 90 days.
Results showed an increased risk for no biopsy within 30 and 60 days among Asian (RR = 1.66; 95% CI, 1.31-2.1; RR = 1.58; 95% CI, 1.15-2.18), Black (RR = 1.52; 95% CI, 1.3-1.78; RR = 1.39; 95% CI, 1.22-1.6) and Hispanic women (RR = 1.5; 95% CI, 1.24-1.81; RR = 1.38; 95% CI, 1.11-1.71).
The unadjusted risk for no biopsy within 90 days persisted only among Black women (RR = 1.28; 95% CI, 1.11-1.47). Even after adjusting for selected individual-, neighborhood- and health care-level factors, researchers observed no change in the risk for no biopsy among Black women within 90 days (RR = 1.27; 95% CI, 1.12-1.44). However, they did observe a modest decrease in risk among Black women after adjusting for screening facility (RR = 1.2; 95% CI, 1.08-1.34).
“We were surprised to find that while screening facility was an important factor in differences in time to biopsy, controlling for academic affiliation of the screening facility and availability of onsite biopsy services did not substantially change the risk for not receiving a biopsy within 30, 60 or 90 days,” Lawson said.
Implications
The results suggest breast imaging facilities have an opportunity to reduce disparities in time to breast biopsy by improving their processes along the diagnostic imaging pathway after screening, Lawson said.
“For example, they may consider using patient navigators to help patients with scheduling appointments,” she added. “Future work will identify other structural factors, such as at the neighborhood- or health care-level, that contribute to other disparities in outcomes in the diagnostic imaging pathway. Specifically, we aim to examine which facility-level structural factors, such as patient navigation, may alleviate delays.”
The study demonstrated increased urgency after the COVID-19 lockdown to prevent worsening of racial and ethnic disparities in breast cancer care, according to an accompanying editorial by Randy C. Miles, MD, MPH, researcher in the department of radiology at Denver Health.
“Mitigation of competing demands for patients should be a strategic priority for breast imaging centers, which can be supported by increasing availability of breast imaging services outside of standard business hours and expansion of same-day care programs that consolidate breast imaging services into fewer visits,” Miles wrote.
“Access to same-day care has been shown to eliminate previously seen disparities in time to biopsy between white and non-white patients following implementation,” Miles added. “Increased allocation of resources directed toward care coordination that help to educate patients about the significance of their breast imaging findings and facilitate patients attending their follow-up examinations will also be needed. Finally, listening to and amplifying the voices of women from minoritized groups, who can provide direct feedback about their health care experiences, will provide important insight in reducing gaps in breast cancer care seen between racial groups.”
References:
Lawson MB, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2022.1990.
Miles RC. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2022.1864.
For more information:
Marissa B. Lawson, MD, can be reached at University of Washington School of Medicine, 825 Eastlake Ave. East, LG-200, Seattle, WA 98109; email: mblawson@uw.edu.
Perspective
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Renee Kendzierski, DO
Communication, scheduling, transportation and insurance all play a role in getting patients timely care, and we need to address all these factors when trying to promote the breast health of our patients. At Temple Health, we have identified many of the factors discussed in the study as real problems for patients returning for additional imaging or even biopsy. Patients have phones that have been disconnected, they have no means of transportation, they have not communicated with family members about the need for biopsy and are relocating, they speak another language, public transportation is not available due to COVID, and on and on.
To address some of these issues, Temple Health hired a mammography navigator who helps our patients return after an abnormal screening mammogram. Our navigator assists patients with scheduling a biopsy, transportation, a translator if needed, insurance details, prescription problems and scheduling appointments with our breast surgeon if necessary so they are not lost in follow up. These are frustrating for patients and can lead to noncompliance.
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