Diminishing Racial Disparities in Screening

April 27, 2021
Jennifer Meade, Division President of Breast & Skeletal Health, Hologic

The imaging industry has a role to play in bringing about change in screening.

There have long been racial disparities in healthcare in the United States, but it has become an increasingly recognized topic due to disparities revealed during the COVID-19 pandemic. Data from the Center for Disease Control & Prevention’s COVID-NET showed that, from March 2020 through July 2020, age-adjusted hospitalization rates due to COVID-19 for Black, Hispanic, and American Indian and Alaska Native people were about five times higher than that of white people. This heightened awareness of disparities in healthcare has ushered in a renewed focus and long overdue effort to reverse these inequalities.

Recent research has shed light on disparities directly related to breast cancer screening, reinforcing what many of us within the industry already suspected to be true.

Considering screening access, utilization and outcomes based on race

In February, the Journal of the American College of Radiology (JACR) published Outcomes by Race in Breast Cancer Screening with Digital Breast Tomosynthesis versus Digital Mammography. The study reported breast cancer screening access, utilization, and outcomes by race for 385,504 Asian, Black and white women who underwent a total of 804,304 screening exams at 63 breast imaging facilities in the United States from January 2015 through January 2019.

The study revealed Black women were less likely to receive screening via digital breast tomosynthesis (DBT) and less likely to be screened multiple times during the five-year period than white women, despite the fact that DBT is widely considered the standard of care for annual breast cancer screening. It also found that screening via DBT improved both recall rates and cancer detection for women of all races.

Related Content: Fewer African American Women Screened with Digital Breast Tomosynthesis

Simply put, Black women are receiving inferior breast cancer screening compared to white women.

This is particularly concerning given that previous research has shown, despite having a similar breast cancer incidence rate, Black women are almost 40 percent more likely to die from breast cancer than non-Hispanic white women.[i] This is an urgent issue that will require a concerted effort to reduce inequalities in DBT utilization to improve the effectiveness of breast cancer screening for Black women.

Reconsidering existing guidelines and technology through a racial lens

It's important to recognize that while systemic change won't happen overnight, there are steps those of us within the breast health industry can do to spur a more balanced and equitable future for Black women and those who have historically been underserved. It is imperative that we commit to act urgently, as an industry, to evaluate current policies, technologies and guidelines to determine the best path forward to accelerate change.

A sensible place to start is by acknowledging that in many instances, the research that informed today's screening guidelines and technology lacked diverse representation to ensure inclusivity and consideration of a variety of races. This resulted in guidance and technology that claim to be "one-size-fits-all" yet neglects to take into account the inherent biological factors associated with different races.

For instance, we know that while the screening rates for Black and white women are comparable, Black women are more likely to be diagnosed at a younger age and later stage than women of other races. They are also more likely to have triple-negative breast cancer. The current U.S. Preventive Services Task Force screening guidelines fail to take that fact into account, likely because much of the research the organization utilized to develop the screening recommendations fails to appropriately represent Black women in the data sets. It is critical that we, as an industry, commit to supporting more diverse research and studies that will reverse this trend and result in Black women being screened earlier and more consistently than they currently are.

Beyond impacting guidance, diversifying clinical research can improve our ability to ensure the effectiveness and efficiency of breast care, from screening to diagnosis and treatment.

Identifying investments into research and partnerships to impact change

As the global leader in breast health, we are committed to using our resources and standing to increase women’s health literacy, conduct clinical research among Black, Indigenous, and Women of Color (BIWOC) populations and create pathways to diagnostic care that serve diverse communities.

To that end, in 2019, we launched a comprehensive research project designed to analyze mammograms, screening intervals and interpretation performance across multiple health systems throughout the United States. At the time, we prioritized research into racial breast health disparities as a critical aspect of the project, given the general understanding that Black women are more likely to receive conventional digital mammography screening and also experience longer intervals between detection, diagnosis and treatment. That prioritization resulted in the aforementioned JACR study.

Additionally, in October 2020, we launched a multi-year commitment to decreasing breast cancer screening disparities for Black women in partnership with Black Women’s Health Imperative (BWHI), the only national non-profit organization created by Black women solely dedicated to help protect and advance the health and wellness of Black women and girls through awareness and education, and RAD-AID, a non-profit dedicated to ensuring equal access to radiology health services for medically underserved communities.

The multi-pronged initiative includes BWHI’s P.O.W.E.R. of Sure campaign, which examines common barriers to early screening and encourages Black women to schedule and attend their annual mammograms. Hologic will also fund innovative care, radiology, public education and nurse navigation at multi-regional sites selected by RAD-AID as clinical partners to provide critical screening and diagnostic breast imaging, and to provide access to treatment for women who may otherwise go without.

Driving manufacturer and customer collaboration

Across the board, making equitable and inclusive decisions often begins with leadership. A newly released study found that female health providers tend to drive better and faster outcomes and resolutions for female patients, which reinforces that a diverse industry that is more reflective of the patient population served may have the greatest impact on health outcomes. Additionally, a study published in JAMA Network Open found that patients who shared the same racial or ethnic backgrounds as their physicians were more likely to give them the maximum patient rating score, suggesting racial and ethnic similarities can affect patient-physician interactions.ii

While diversity in leadership is important, so is education from the C-suite to the sales force to increase awareness and understanding of systemic disparities. It would be wise to begin by addressing the longstanding history behind these inequalities to ensure they are top of mind at every level and interaction, internally and externally. It is our responsibility to create a forum to share information so we can then work towards impacting care.

On a global level, understanding the myriad of barriers to screening, and healthcare in general, are key to enacting effective change. For example, we recently announced the Hologic Global Health Women’s Index, a proprietary first-of-its-kind global survey that tracks critical markers for women’s health and safety by country and over time. The goal of the index is to improve the quality of life and life expectancy of the 3.9 billion women worldwide.

Committing to a lengthy yet worthwhile endeavor

Initiatives such as those referenced earlier allow us to establish a foundation for enabling change through research and actions aimed at increasing knowledge, awareness, and access. However, none of this is an instant solution for all the challenges before us. Rather, these are starting points to compel change.

The authors of the JACR study agree the data indicates a need for improved access and educational strategies to emphasize the importance of regular screening.[ii]i Additionally, governmental and local policies and guidelines must be improved to decrease barriers to screening, particularly with DBT for breast cancer screening.

It is up to us, as an industry, to do all within our considerable power to receive this message loud and clear, and work together to ensure life-saving screening, treatment and education is accessible to as many women as possible, regardless of race.

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[i] CDC, 2019. Health United States, 2018. Table 33
[ii] Takeshita J, Wang S, Loren AW, et al. Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Netw Open. 2020;3(11):e2024583. doi:10.1001/jamanetworkopen.2020. 24583
iii Rauscher GH, Allgood KL, Whitman S, Conant E. Disparities in screening mammography services by race/ethnicity and health insurance. J Womens Health (Larchmt). Feb 2012;21(2):154-160.