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Investigators suggested that guidelines which recommend initiating screening mammography at age 50 may be putting Black women at a disadvantage, and screening should thus begin by age 40.
An article published in the Journal of Breast Imaging indicated that breast cancer occurs at a younger age in Black women and is more likely present as the triple-negative (TN) and HER2-positive subtypes.1
Moreover, the paper also revealed that though the incidence rate of breast cancer in Black women is slightly lower than in white women, the mortality rate is much higher. Altogether, these findings suggest that guidelines, which recommend initiating screening mammography at age 50, may be putting Black women at a disadvantage.
“If African American women’s lives are to be saved, these aggressive breast cancers must be diagnosed and treated early,” co-author of the paper Murray Rebner, MD, a diagnostic radiologist at Beaumont Health who specializes in breast imaging, said in a press release.2
In order to review why this discrepancy is occurring, researchers examined the biology of breast cancer among Black and white populations, the barriers to screening for some of these groups, the imaging features of highly aggressive breast cancers, and how some screening guidelines may be having an adverse effect on this segment of the Black population.
Ultimately, the investigators discovered that breast cancer diagnosed before age 50 represents 23% of all breast cancers in African American women, and only 16% of all breast cancers in white women. White women were instead found to have a higher incidence of breast cancer over the age of 60.
Moreover, tumor subtypes also varied among racial and ethnic groups. The TN subtype, which typically has a poorer outcome and occurs at a younger age, represents 21% of invasive breast cancers in Black women and only 10% of invasive breast cancers in white women. However, the HR-positive subtype, which is more common in older women and often has the best outcome, has a higher incidence in white women (70%) than in Black women (61%). The BRCA2 mutation was also revealed to be more common in Black women than in non-Ashkenazi Jewish white women.
Further, researchers indicated there are also many barriers to screening for Black women, including the lack of contact with a primary health care provider, pain, embarrassment, low income, and a lack of health insurance.
“Certainly, the higher risk of breast cancer death in Black women is multifactorial,” the authors explained. “There are opportunities to improve education about breast cancer risk and utilization of screening mammography as well as screening MRI in those who are at a high risk for breast cancer. There are opportunities to improve access to primary care providers and ensure that they are aware of the younger age at diagnosis for Black women, particularly for those less than 50 years of age.”
“Risk assessment and genetic counseling may be important to implement more widely given the higher incidence of BRCA mutations in Black women,” added the authors.
However, health care providers who follow national organization recommendations for screening mammography may be unintentionally putting Black women at a disadvantage. The US Preventive Services Task Force, the American Academy of Family Practice, and the American College of Physicians all advise for mammography screening to begin at age 50, with the option to initiate screening between the ages of 40 and 49 years based on individual risk factors and personal choice. Additionally, the American Society of Clinical Oncology and the American College of Surgeons now recommend starting screening mammography at age 45, with the option to begin at age 40.
“Since Black women are more likely than white women to be diagnosed with breast cancer at a young age, initiation of screening mammography should be strongly encouraged by age 40,” the authors wrote. “Likewise, because Black women have a higher likelihood to be diagnosed with the TN subtype, which has a faster tumor doubling time, screening should take place annually.”
Of note, organizations which currently support annual screening from age 40 to 49 years include the Society of Breast Imaging, the American College of Radiology, the American Society of Breast Surgeons, the American College of Obstetrics and Gynecology, and the National Comprehensive Cancer Network.
“Fact one is earlier onset. Fact two is a more aggressive cancer type,” said Rebner.
“Be aware of your own risks and feel empowered to discuss your risk of breast cancer and when and how often to get screened with your doctor.”
1. Rebner M, Pai VR. Breast Cancer Screening Recommendations: African American Women Are at a Disadvantage. Journal of Breast Imaging. doi: 10.1093/jbi/wbaa067
2. Breast cancer screening by age 40 or younger for Black women advise Beaumont researchers [news release]. Beaumont Health. Published October 26, 2020. Accessed November 5, 2020. https://www.newswise.com/articles/breast-cancer-screening-by-age-40-or-younger-for-black-women-advise-beaumont-researchers?sc=sphr&xy=10021790