Breast Cancer Screening Guidelines May Lead to Delayed Diagnosis in Nonwhite Women

Current guidelines for mammographic breast cancer screenings, based on data from primarily white populations, may lead to underscreening and delayed diagnosis of breast cancer in nonwhite women, according to a research letter published last week in the Journal of the American Medical Association Surgery.

Lead authors Sahael Stapleton, MD, and Tawakalitu Oseni, MD, both of Massachusetts General Hospital, hypothesized that the United States Preventative Services Task Force recommendations—which hold that breast cancer screenings should begin at age 50 for patients with average risk—may not be sensitive to racial differences, and may be inappropriately extrapolating data from white populations to use in diverse populations.

Stapleton and Oseni’s research team analyzed the Surveillance, Epidemiology and End Results (SEER) Program database from 1973 through 2010 to obtain data on female patients, aged 40 to 75 years, who were diagnosed with malignant breast neoplasms. Their analysis included 747,763 patients who had a median age at diagnosis of 58 years (interquartile range (IQR], 50-67 years). The racial and ethnic makeup of the cohort was 77% white, 9.3% black, 7% Hispanic, and 6.2% Asian.

The median age at diagnosis was as follows:

• 59 years for white patients (IQR, 51-67 years)
• 56 years for black patients (IQR, 49-65 years)
• 55 years for Hispanic patients (IQR, 48-64 years)
• 56 years for Asian patients (IQR, 48-64 years)

A higher proportion of those patients who were diagnosed with breast cancer at an age younger than 50 were nonwhite; among black patients, 31% were diagnosed when they were below 50, as were 34.9% of Hispanic patients and 32.8% of Asian patients. Furthermore, a higher proportion of black (46.6%) and Hispanic (42.9%) patients present with advanced disease than do white (37.1%) or Asian (35.6%) patients.

The authors say that, to achieve a similar capture rate for nonwhite patients as for white patients at age 50, screening ages would need to be reduced to 47 years for black and Asian women, and 46 years for Hispanic women.

While it has been argued that lowering screening age may lead to overdiagnosis and overtreatment, better diagnostic modalities and improved technology should help to alleviate both potential problems, say the authors. Additionally, non-US and non-European countries should exercise caution when they consider adopting practice guidelines based on US and European data, and clinical research should incorporate analytical techniques to determine whether findings are generalizable to a diverse population.

“While a lot of attention has been focused on improving the ‘cultural competency’ of clinical care—caring for patients in ways that accommodate their cultural and language differences—we are concerned that we haven’t paid as much attention to the scientific research process,” said author David Chang, PhD, MBA, MPH, associate professor of Surgery at Harvard Medical School. “If the science upon which clinical guidelines are based was not done in a way that respects racial differences, there is little that can be done at the point of delivery to improve patient care.”

Reference

Stapleton SM, Oseni TO, Bababekov YJ, Hung YC, Chang DC. Race/ethnicity and age distribution
of breast cancer diagnosis in the United States. JAMA Surg. [Published online March 7, 2018]. [Accessed March 14, 2018]. doi:10.1001/jamasurg.2018.0035.