In a study involving over 68,000 women in Pennsylvania who had mammography exams, researchers found that Black women were significantly less likely than White women to be eligible for coverage of supplemental breast cancer screening due to a lower prevalence of high lifetime breast cancer risk and extremely dense breasts.
For the cross-sectional study, recently published in JAMA Network Open, researchers reviewed data from 68,478 women who had mammography exams between January 2015 and December 2021. The cohort included 38,397 Black women (median age of 57) and 30,081 White women (median age of 58), according to the study.
As per the passage of Act 1 of 2023 in Pennsylvania, eligibility for coverage of supplemental breast care screening includes extremely dense breast tissue as well as heterogeneously dense breast tissue with one additional factor including a greater than 20 percent lifetime risk of breast cancer.
The researchers found that Black women were less likely to have extremely dense breasts in comparison to White women (2.1 percent vs. 5.8 percent). The study authors also noted that Black women in the cohort were over five percent less likely to have greater than a 20 percent lifetime risk of breast cancer (0.7 percent vs. 6.4 percent) as assessed by the National Cancer Institute’s Breast Cancer Risk Assessment Tool (BCRAT).
Accordingly, after researchers adjusted for factors such as age and BI-RADS breast density assessments, they found that Black women were 11 times less likely than White women to receive insurance coverage for supplemental breast cancer screening.
“ … If the eligibility criteria for supplemental screening based on breast density and BCRAT risk were applied, none of the Black women who had a false-negative mammogram would have been eligible for supplemental screening, compared with 29 percent of White women with a false-negative mammogram,” wrote lead study author Mattia A. Mahmoud, M.Phil, who is affiliated with the Department of Biostatistics, Epidemiology and Informatics at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues.
While pointing out that expanding supplemental screening coverage to include women with heterogeneously dense breasts would likely facilitate improved detection of false negative cases, the study authors said this would come at an unsustainable cost of significantly increased breast magnetic resonance imaging (MRI) and ultrasound exams.
“This expansion would lead to high costs and limited, delayed access for those who need it most, making this approach currently unfeasible due to capacity constraints,” maintained Mahmoud and colleagues.
Three Key Takeaways
- Disparities in screening eligibility. Black women were significantly less likely than White women in Pennsylvania to qualify for insurance-covered supplemental breast cancer screening, primarily due to lower rates of extremely dense breasts and lower calculated lifetime breast cancer risk.
- Potential gaps in risk models. The current eligibility criteria, based on BI-RADS density and BCRAT risk scores, may not adequately identify Black women at risk. The researchers noted that none of the Black women with false-negative mammograms met this criteria for supplemental screening, highlighting possible underestimation of risk.
- Need for improved risk assessment. Researchers suggested that quantitative measures of breast density (like dense volume) may better capture the risk of false negatives than current BI-RADS categories, which could help address racial disparities in screening outcomes.
The study authors also acknowledged that their findings of higher false-negative mammograms among White women differs with other study findings revealing that Black women have the highest rates of false negative mammography results.
“One possible explanation is that newer BI-RADS density classifications — which emphasize how dense tissue can obscure cancers — may not fully capture the risk of false negatives. Quantitative measures, such as dense volume, may offer more accurate insight,” posited Mahmoud and colleagues.
(Editor’s note: For related content, see “A Closer Look at the Impact of Expanded Mammography Coverage in Missouri: An Interview with Amy Patel, MD,” “The Reading Room Podcast: Current and Emerging Insights on Abbreviated Breast MRI, Part 1” and “New Study Examines Key Factors with False Negatives on AI Mammography Analysis.”)
In regard to study limitations, the authors acknowledged that BI-RADS breast density assessment and the BCRAT for evaluating lifetime risk were the only factors they evaluated for supplemental screening eligibility. A higher rate of missing information for factors such as genetic predisposition and personal/family history of breast cancer prevented their inclusion in the study, according to the researchers. They also conceded the analysis was limited to one mammogram per patient.
