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In a one-on-one conversation, Murray Rebner, M.D., past president of the Society of Breast Imaging, discusses how current screening guidelines overlook these women and what that means for radiologists.
Recent research from the Journal of Breast Imaging revealed current breast cancer screening guidelines do not work well for African American women, leaving many to be diagnosed at a younger age with more aggressive cancers at later stages.
Currently, the accepted recommendation is to begin breast cancer screening between ages 45 and 50, but existing research shows African American women are more likely to develop aggressive cancers earlier than that. This reality has many radiologists in women’s imaging worried that they are missing significant numbers of treatable cancers.
Diagnostic Imaging spoke with lead study author Murray Rebner, M.D., professor of diagnostic radiology and molecular imaging at Oakland University William Beaumont School of Medicine and director of the division of breast imaging at Beaumont Health System, about the complex reasons why these screening guidelines are not optimal for this patient population and what that means for radiologists.
Diagnostic Imaging: When we consider the intent and implementation of breast cancer screening guidelines, what do we need to keep in mind about how the disease impacts African American women differently from white women?
Rebner: There are several things we need to keep in mind. First of all, even though white women are slightly more likely to get breast cancer over their lifetime than African American women, African American women have a 40-percent higher mortality rate than white women, which is quite significant. When you look back to 1990, the breast cancer mortality rates have dropped significantly. They’ve come down 40 percent for white women, but they’ve only come down 26 percent for African American women. So, the benefit is there, but it’s certainly not as good as we’d like to see in African American women.
The other thing we need to realize is that certain types of breast cancer – most notably the very aggressive, what we call, triple-negative cancers – occur twice as often in African American women than white women. And, they’re also more likely to be diagnosed at a young point in their lives. Therefore, those cancers tend to be more aggressive, and the effect on someone who has more life years ahead of them is more significant than a woman who is older. Also, from a genetic standpoint, African American women are twice as likely to have the BRAC gene than white women.
Because of all of these things, we recommend that all organizations recommend African American women start screening with mammography at age 40 and that they do it annually because we don’t want to miss some of these aggressive cancers by waiting too long.
Diagnostic Imaging: Given that background, what is the likelihood that they are following the existing guidelines?
Rebner: Unfortunately, the compliance rate is much lower in the African American population. Depending upon what study you read, they’re 70 percent to 80 percent less likely to get screened than white women. And, there are a lot of reasons for that. The primary one, according to our study, is that they’re not hooked up with a primary care doctor. Not just for breast cancer, but for other illnesses that are more common in their population, such as diabetes, hypertension, cardiovascular disease, they need to be plugged into the appropriate screening guidelines and therapies in order to benefit from these programs.
Another thing is that there might be some pain or embarrassment in getting a mammogram. And, there are socioeconomic factors. Even though there are laws that mandate that women have free screening mammograms, what happens if you have a positive one? Those laws don’t cover diagnostic mammograms. Surgery or treatment becomes very, very expensive – far more than the mammogram itself. So, a lot of women don’t want to go that route because they just can’t afford to do it. All of these things factor into why we think African American women are not partaking as much in screening as we would like them to.
Diagnostic Imaging: What recommendations or suggestions can be made to potentially make screening more available to this patient population or, at least, alert them that they should have more access to the providers and imaging services they need?
Rebner: The most important thing is education. Women, themselves, need to understand, No. 1, that they may be at increased risk overall. It’s difficult to pinpoint risk for a particular woman, but as a group, they are at increased risk. They have the 40-percent higher mortality rate. They’re at risk for being diagnosed later, and the risk is higher that they’re going to have the BRAC gene.
Studies have shown that African American women tend to perceive their own risk as much lower than white women. That’s one of the reasons why they don’t often ask for supplemental screenings like MRI if they’re BRAC-positive. It’s not so much denial – it’s probably more a function of education. They just don’t know or aren’t thinking they could be affected by breast cancer. Consequently, we recommend they have a risk assessment done by no later than age 30 to benefit from supplemental screening if they’re candidates for it. If they have the BRAC gene, they may need to speak to a genetic counselor to understand how this all affects not just them, but potentially their sisters, their daughters, and other members of their family.
We also think it’s important that other organizations strongly consider changing some of their guidelines to recommend annual screening starting at age 40. There are organizations like the National Comprehensive Cancer Network, the American College of Radiology, and the American College of Obstetricians & Gynecologists – they do that, and we think it’s terrific. But, some groups, like the family practitioners, the internists, the U.S. Preventive Service Task Force – they just say to start at age 50 and leave it up to the individual to consider age 40.
When you look at the data, if you were to consider an African American woman under age 50, with all we know about highly aggressive cancers occurring twice as likely in that population, we’re going to be missing a lot of breast cancer and, perhaps, having a lot of women die unnecessarily because these guidelines weren’t more tied in. All of these organizations admit that starting screening annually at age 40 saves the most lives, it’s in their own written reports. But, because they think the so-called harms of screening outweigh the benefits, they don’t start age 40.
To me, that’s mind-boggling. What’s the harm? Anxiety? Women can tolerate the anxiety of getting a bad diagnosis. They give birth, they can certainly tolerate that. The other issue is the callback. The callback rate is only about 10 percent, and most often, it involves a couple extra pictures, either being told you’re normal or to come back and see the radiologist in six weeks because there’s something of very low suspicion he or she wants to follow. The third thing is over-diagnosis. I can categorically say that that number is exceedingly low – way under 10 percent.
The benefits of doing all the things we talked about – finding cancer early; being able to treat patients morbidity, not just impact their mortality; paving the way for less extensive therapies – all these things far outweigh the theoretical risk of a few cases of cancer being diagnosed that wouldn’t affect the woman.
Getting organizations to sign on to these things that will recommend annual screening starting at age 40 is also very important. Cancer screening for breast cancer saves lives. We know that it doesn’t work in a lot of other areas – pancreatic cancer has dismal results, and it’s starting to work with lung cancer. But, breast cancer is the poster child that if you find the tumor early, you can help benefit mortality.
Diagnostic Imaging: How can providers use these findings? What do they need to keep in mind about getting these breast cancer screening services to African American women?
Rebner: Radiologists need to be aware of the data that supports screening younger African American women annually. Many, I’m sure, don’t realize that these higher aggressive tumors occur in the young African American population twice as often as in the Caucasian population.
They need to know that, in our reports, we do recommend getting a risk assessment by age 30. Not to tie their hands, but we suggest the possibility that these women, if they are potentially going to benefit from supplemental screening, consider it. We need to educate them about what the ramifications of not doing it are – higher mortality, higher morbidity, more women likely to be diagnosed at late stages who will not benefit from less extensive therapies. All of these things have a negative impact on their patient population.
If they were to take heed and plug themselves into some of these recommendations for their African American patients, they would be doing them a great service. It’s about communication and education. Radiologists, people used to think, hid in the dark – that we never saw the light of day. But, nowadays, the focus is on being out there to talk to patients. In breast imaging, we see patients who have abnormal screening studies come in with lumps. We’re interfacing with them all the time, and I take that opportunity to try to, in the small amount of time I have with the patient, to educate them. Educating the patient, the referring physician, the clinical, the nurse practitioner – it’s all going to make a difference.
The patient needs to take ownership of her own healthcare and to be an advocate for herself. If she’s not raising these issues with her primary care doctor, she needs to start raising them, pointing out her increased risk and asking what the office can do. And, if her primary care doctor isn’t going to do anything, she needs to find someone who will.