For Black Women, Breast Cancer Screening Should Begin Almost a Decade Earlier than Current Universal Recommendations

Among Black women the increased risk of mortality from early-onset breast cancer could potentially be reduced by initiating screening up to 8 years earlier than the current recommended starting age of 50 years, according to a new US population-based study.

The research found that compared with other racial and ethnic groups, breast-cancer mortality at age 40 to 49 years is higher among Black women and, specifically, 2 times higher than among White women. In contrast, according to the study data, women of other racial and ethnic groups reach the current 10-year cumulative risk threshold for universal screening at ages older than 50 years, some up to a decade older.

“The current one-size-fits-all policy to screen the entire female population from a certain age may be neither fair and equitable nor optimal,” wrote Tianhui Chen, MD, PhD, from the department of cancer prevention at Zhejiang Cancer Hospital and the Institute of Basic Medicine and Cancer at the Chinese Academy of Sciences in Hangzhou, China, and colleagues.

“The current one-size-fits-all policy to screen the entire female population from a certain age may be neither fair and equitable nor optimal...It is an example of what happens when race and ethnicity are not considered in guidelines.”

The assumption of an equal playing field when it comes to risk, they add, “is an example of what happens when race and ethnicity are not considered in guidelines. This may pose a significant risk for greater harm to a group already at increased risk.” Chen and colleagues state that the benefits of screening can be optimized by recommendations that are based on “risk-adapted starting ages” and that those must be “based on known and readily available risk factors, such as race and ethnicity.” In the absence of sufficient data to make such recommendations, Chen and team designed the current study to provide evidence for the rationale to support such a practice.

The nationwide population-based cross-sectional study tapped the US National Center for Health Statistics for data on mortality rates from invasive breast cancer with any histology among women from 2011 to 2020. To infer race and ethnicity adapted screening ages, researchers compared 10-year cumulative risk in each racial/ethnic group with overall US population risk, a method that allowed them to provide the age at which women of a specific race or ethnicity reached a similar level of risk for breast cancer-related death as an individual aged 50 years in the general population.

FINDINGS

Breast-cancer specific deaths were recorded for 415 277 women of whom 0.5% were American Indian/Alaskan Native (AI/AN); 2.9% were non-Hispanic Asian or Pacific Islander; 15.1% Black, 6.9% Hispanic; and 74.6% White. Just over one-quarter (27.7%) of women died before age 60 years.

Chen et al reported significant variation in breast cancer mortality by race and ethnicity before the age of 50 years. Per 100 000 person-years for ages 40 to 49 years, mortality was 27 deaths among Black women, 15 deaths among White women, 11 deaths each in the groups of AI/AN, Hispanic, and Asian or Pacific Islander women.

The investigators note that the United States Preventive Services Task Force currently recommends screening for breast cancer begin universally at age 50 years, guidance based on a 10-year cumulative risk of death from breast cancer of 0.329%. The study analysis found that Black women reached this risk threshold level 8 years earlier, at age 42 years, whereas White women reached it at age 51 years and AI/AN and Hispanic women reached the threshold at age 57 years. Asian or Pacific Islander women females did not reach the threshold until 11 years later, at age 61 years.

Risk for Black women persists

When investigators evaluated breast cancer screening beginning at age 45 years for all women with a mean 10-year cumulative risk of 0.235%, they found that Black women would reach the threshold 7 years earlier than all other racial/ethnic groups considered. Further, if screening commenced for all women at age 40 years with a cumulative 10-year risk of 0.154%, Black women would arrive at the threshold 6 years earlier than all other groups.

“We believe that when fairness and optimization of resource allocation to reduce [breast cancer] BC mortality is the aim of BC screening, health policy makers should pursue equity not just equality,” explained investigators in the study conclusion.

“Equality in the context of BC screening means that everyone is screened from the same age regardless of risk level. On the other hand, equity or risk-adapted screening means that everyone is provided screening according to their individual risk level. We believe that a fair and risk-adapted screening program may also be associated with optimized resource allocation.”

Reference: Chen T, Kharazmi E, Fallah M. Race and ethnicity-adjusted age recommendation for initiating breast cancer screening. JAMA Netw Open. 2023;6(4):e238893. doi:10.1001/jamanetworkopen.2023.8893