A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together

Abstract

A decade ago, in a commentary titled, “Eliminating Racial Disparities in Colorectal Cancer in the Real World: It Took a Village,” Grubbs et al¹ reported on the results of a successful decade-long effort led by the Delaware Cancer Consortium to target colorectal cancer (CRC) disparities statewide. By working across sectors to increase CRC screening rates overall while equalizing screening uptake across racial groups, CRC incidence decreased by 34% for Black and 26% White Delawareans, eliminating the racial disparity in CRC incidence across the state. In turn, CRC mortality decreased by 42% and 13% for Black and White Delawareans, respectively, effectively eliminating what had been a 60% higher CRC mortality rate for Black Delaware residents. These gains have been largely sustained for over a decade now (dhss.delaware.gov/dph/dpc/cancer.html), providing compelling evidence in support of “getting the village back together” to replicate this approach for other cancer types.

In this commentary, we describe our plan to reduce racial disparities in breast cancer (BC) mortality, the leading cause of cancer deaths for Black women in the United States.² While our focus is on racial disparities, we note that this plan also stands to benefit other groups who experience poor BC outcomes, including Hispanic, Ashkenazi Jewish, and transgender individuals.

Racial Disparities in BC Morality

Although Black and White women are diagnosed with BC at similar rates, Black women experience a 40% higher BC mortality rate.² This overall disparity appears to be driven by much higher BC mortality rates for Black women under age 50, who are at an 18% and 88% greater risk of being diagnosed with and dying from advanced BC relative to their White peers.³ According to the State Cancer Profiles website (https://statecancerprofiles.cancer.gov/about/), Delaware leads the United States in the incidence of late-stage BC among women under 50. The greater risk of advanced BC at a younger age observed for Black women is compounded by inequities in BC screening and other treatment-related factors.⁴ More than half of the Black–White difference in BC mortality can be attributed to triple-negative breast cancer (TNBC), an aggressive BC subtype that presents at a younger age and is twice as prevalent among Black women.⁵ Delaware leads the United States for TNBC incidence among Black women and has the largest racial disparity in TNBC incidence.⁶

As we have reported elsewhere, the more aggressive tumor biology observed among younger Black women has been linked to reproductive (eg, limited breastfeeding), metabolic (eg, diabetes, alcohol use), and environmental (eg, carcinogenic emissions) risk factors.⁷ These risk factors appear to be more prevalent among individuals who reside in segregated, predominantly Black communities where structural racism, historical disinvestment (eg, “redlining”), predatory businesses, and environmental injustices limit healthy options while exposing residents to hazardous conditions.⁷ Therefore, addressing cancer disparities will require partnering with the community, health officials, policymakers, and other stakeholders to coordinate our strategies both up- and downstream to advance the cause of health equity. Here, we propose 2 evidence-based health care strategies to mitigate the risk imposed by these “upstream” factors, acknowledging that these represent first steps rather than a complete solution to BC disparities.

Health Care Strategies to Advance Health Equity in BC Prevention

Drawing on the lessons learned from successfully addressing disparities in CRC, we prioritize both primary (ie, reducing cancer incidence) and secondary (ie, reducing cancer mortality via earlier detection) forms of prevention. It should be noted that while CRC screening can function as both primary and secondary prevention, screening mammography decreases BC mortality by 40% or more solely via secondary prevention, by detecting tumors at a more treatable stage.⁸ To complement this approach, we consider additional forms of primary prevention to target potentially modifiable BC risk factors.

Strategy #1

Advise all women statewide to initiate screening mammography at age 40, with targeted strategies developed specifically for Black women. The US Preventive Services Task Force (USPSTF) recently issued a draft recommendation that women of average risk for BC should begin screening mammography at age 40, down from age 50 in their prior recommendation (uspreventiveservicestaskforce.org). By advising women to initiate screening at age 40, the USPSTF took an important step toward aligning their guidelines with those published by other medical organizations, such as the National Comprehensive Cancer Network (nccn.org), the American Society of Breast Surgeons (breastsurgeons.org), and the American College of Radiology (acr.og). However, the USPSTF continues to advise women to complete biennial screening, whereas these other organizations recommend annual screening. The distinctions between the different guidelines are important because, by legislation, the USPSTF guidelines are used to establish which preventive services third-party payers are required to cover without patient cost-sharing.^*

The USPSTF update applies to all women but may produce a disproportionate benefit for Black women given the racial difference in age at diagnosis referenced above, and as simulation studies would support.⁹ Nevertheless, the recommendation for biennial rather than annual screening may limit the potential to detect more aggressive cancers. In light of these changes, health care systems should review the evidence and update institutional policies on screening initiation age and interval, disseminate these updates to providers, revise clinical workflows, communicate the new recommendations to patients, and increase mammography capacity if warranted.

We recommend targeted strategies developed specifically for Black women to identify and dismantle the barriers to equitable BC screening that are caused by structural forms of racism. Screening access is a multidimensional construct that comprises geographic considerations (eg, travel time to a mammography facility), available modes of transportation, hours of operation, and the quality of screening facilities. It will be important to ensure equity across all these dimensions. It will also be important to ensure equity in the time-to-diagnosis and -treatment across racial groups. As was the case in addressing CRC disparities, we fully anticipate that improving screening equity is a necessary precursor to reducing disparities in BC mortality.

Strategy #2

Conduct formal BC risk assessments for all women before age 25. Whereas the recommendation to begin screening mammography at age 40 applies to women of average risk, the American College of Radiology and the Society of Breast Imaging (sbi-online.org) advise that women should complete formal assessments at a younger age to improve the identification of women at elevated risk for BC. Such women should be considered for initiating screening before age 40 and/or undergoing supplemental screening modalities (eg, magnetic resonance imaging) and prophylactic medical and surgical interventions.

Identifying women at an elevated risk for BC can be aided by taking a comprehensive family history, referring patients to genetic counseling as indicated, and leveraging validated risk prediction models. Without a standardized approach to conducting formal BC risk assessment in women at a young enough age to proactively manage that risk, we squander the opportunity to improve prevention for the very patients who stand to benefit the most. And again, given the greater BC risk experienced by younger Black women, implementing a BC risk assessment process offers the opportunity to close racial disparities in BC mortality.

Implementing formal BC risk assessments offers 2 additional advantages. First, these assessments can be designed to include screenings for potentially modifiable BC risk factors that can then be addressed with evidence-based interventions through primary prevention. For example, dietary and other behavioral interventions can be offered to patients at risk of developing diabetes or for those who use alcohol above recommended levels. The latter is critical for Delaware where we have the highest rates of alcohol-attributable BC in the United States, with alcohol accounting for nearly 1 in 5 BC cases.¹⁰ For women who may become pregnant, educational materials and other resources can be offered to support breastfeeding.

Second, completing BC risk assessments among younger women could support the development of a registry and a more organized approach to engaging women of average risk in initiating screening at age 40. As was the case for Strategy #1, the successful and equitable implementation of a formal BC risk assessment process would need to account for multiple operational and communications considerations. This would include providing education to providers and patients on the importance of BC risk assessments, establishing and resourcing BC risk assessment workflows, developing clinical pathways to address modifiable risk factors, and creating a registry infrastructure. Any attempt to close racial disparities in BC mortality without a strategy for improving prevention among women at elevated risk is unlikely to produce the desired result.

Overcoming Barriers and Translating Strategy into Action

The CRC screening program was implemented statewide, with the support of the Governor, the Delaware State Legislature, and local health care systems. Funding was appropriated to support care coordination and navigation services across multiple clinical settings. In addition, the Delaware Cancer Treatment Program was established to cover the costs of cancer care for the uninsured, predating the passage of the Patient Protection and Affordable Care Act by 6 years.¹ In other words, addressing CRC disparities required resources beyond billable revenue. Similarly, our plan to target BC disparities statewide will require new resources to support community outreach, data infrastructure and analytic activities, and redesigning clinical programs. In the wake of social justice movements following George Floyd's murder 3 years ago, many health care organizations across the United States made strong public commitments to the values of equity and racial justice. But as Delaware's own, President Joe Biden, has been known to say, “Don't tell me what you value. Show me your budget—and I'll tell you what you value.” To put it simply, reducing racial disparities in BC mortality will require a budget.

Resources are needed to address multiple potential barriers to implementation. Primary care providers (PCPs) may have reservations about the new guidance from the USPSTF juxtaposed with multiple other sets of BC guidelines that are sometimes in conflict with 1 another. Additional concerns could include balancing the mortality and other benefits of screening with the risks of overdiagnosis and overtreatment. PCPs' concerns should be treated seriously, preferably in venues that allow for developing a consensus through a consideration of the evidence and our guiding values rather than attempts to impose compliance.¹¹

Patients may also be confused or troubled by the inconsistent messages on screening. Black women in particular may harbor distrust for health care institutions that historically have not always placed their best interests first. In addition, many women face challenges with housing and food security, caregiving, and managing their other health concerns that may interfere with their ability to receive or act on recommendation to undergo BC screening. Developing outreach strategies with trusted messengers such as community health workers and patient navigators, and culturally appropriate communications tools to address these challenges and facilitate conversations between patients and their providers will be critical.¹² This is important to consider because any attempt to improve BC prevention at a population-level without addressing barriers to prevention for at-risk subpopulations may lead to the unintended consequence of exacerbating preexisting disparities.

Finally, while available BC risk calculators can improve the identification of women at elevated risk, new research is needed to improve on the performance of these prediction models, particularly for underrepresented subgroups. Until the performance of these models is improved, the concurrent use of multiple models has been recommended.¹³ Economic concerns also represent barriers to the equitable access to BC risk management activities.¹⁴ Addressing these concerns through care coordination, financial assistance, and innovative models of care may help to overcome these barriers.

Conclusion

The work of advancing health equity requires vision, resources, deliberate action, and ongoing evaluation. This work is challenging, and progress may be slow at times. To quote from Grubbs et al commentary on eliminating CRC disparities, “That there are complexities and nuances we do not deny, but the State of Delaware has shown us that if we have the will, there is a way.”¹ May the State of Delaware once again summon the will to show us the way on ending cancer disparities.

Footnotes

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