Breast Cancer Screening Recommendations May Drive Inequities

Summary

New USPSTF breast cancer screening recommendations may not address the disparities experienced by Black women.

On April 30, the United States Preventive Services Task Force (USPSTF) updated its breast cancer screening recommendations (see Table 1). It lowered the age that women were recommended to start biennial breast cancer screening from 50 to 40. Previously, USPSTF recommended biennial screening for all women aged 50 to 74 (Grade B recommendation) and deferred the decision to start screening mammography for those 40–49 to providers’ professional judgement and patients’ preferences (Grade C).

Table 1: Summary of USPSTF Recommendations for Breast Cancer Screening

Population	Recommendation	Grade
Women aged 40 to 74 years	Biennial screening mammography for women aged 40 to 74 years.	B
Women 75 years or older	USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in this population.	I
Women with dense breasts	USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or magnetic resonance imaging (MRI) in women in this population on an otherwise negative screening mammogram.	I

While the updated recommendation is more closely aligned with other guidelines in terms of age of screening initiation and individual risk, the USPSTF recommendation continues to differ from other recommendations regarding the recommended screening interval (see Table 2).

Table 2: Overview of Recommendations Guideline Developers

Organization	Recommendation
American Cancer Society	Recommends annual screening mammography for women aged 45–54 at average risk and biennial screening starting at age 55. It also recommends that women 40–44 have the option to start screening with a mammogram every year, and those at high risk get a breast MRI in addition to a mammogram starting at age 30.
The American College of Obstetricians and Gynecologists	Recommends screening mammography starting at age 40 and that screening be performed every annually or biennial, based on shared decision-making.
The American College of Radiology	Recommends that all women undergo risk assessment for breast cancer at age 25, and that screening mammography be initiated for women at average risk annually starting at age 40.
American College of Family Physicians	Recommends biennial screening mammography for women of average risk women from the ages of 50 to 74.

Notably, several guideline developers recommend annual mammograms in recognition of evidence that regular mammograms can identify breast cancer at an earlier stage, when interventions are more likely to be successful. The biennial screening interval that the USPSTF currently recommends may delay the initial breast cancer diagnosis, leading to later-stage diagnoses with detrimental consequences for treatment outcomes. This is particularly true for women of color, especially Black women, who, despite having a 4% lower overall risk of developing breast cancer when compared to White women, are more prone to developing aggressive, advanced-stage breast cancer at a younger age.

Breast Cancer Disparities

While Black women have similar or higher rates of mammography screening, they are disproportionately diagnosed with breast cancer beyond stage 1 (when intervention may be more complex) as compared to other racial and ethnic groups. Additionally, the breast cancer mortality rate for Black women is 40% higher than that of White women. Rates of one aggressive form of breast cancer, triple-negative breast cancer (TNBC), which accounts for 15–20% of all cases of breast cancer, are higher in Black women (33.8 cases per 100,000) women compared to White (17.5) and Hispanic (14.7) women. The significantly higher age-adjusted incidence of TNBC in Black women as compared to White women was limited to younger women aged 20–44.

Racial disparities in breast cancer outcomes stem from a complex interplay of social and non-biological factors. While the current screening recommendations are informed by existing evidence, there is a concern that they may exacerbate these health disparities among Black women who are at a heightened risk of developing aggressive forms of breast cancer, including more aggressive cancers like TNBC.

Application of the Health Equity Framework

In acknowledgement of racial disparities in breast cancer, the USPSTF applied its health equity framework to formulate the recent breast cancer recommendation. Published in 2023, the framework and its accompanying checklist were designed to ensure that the Task Force incorporates the health equity perspective throughout the recommendation process—from topic nomination to dissemination—through equity-focused prioritization criteria, engagement with diverse stakeholders, and incorporation of equity-relevant research questions (i.e., looking beyond effectiveness and harms), among other factors.

To that end, the Task Force incorporated several key and contextual questions focused on disparities in breast cancer incidence, outcomes, and access when developing the breast cancer recommendation. Specifically, the Task Force commissioned modeling studies specific to Black women and featured contextual questions aimed at understanding the drivers of and methods to address disparate health outcomes. Additionally, the USPSTF considered the importance of equitable access to appropriate follow-up care and testing, including biopsies.

Despite using the framework, the published recommendations may not adequately address health disparities, suggesting that further research is needed to ensure future recommendations are appropriate for all women. In fact, the Task Force highlighted the need for additional research to better understand and address high breast cancer mortality in Black women, including how variations in care may lead to increased risk of breast cancer morbidity and mortality, as well as strategies for addressing this disparity.

Furthermore, the Task Force called for research to examine whether the balance of benefits and harms related to annual breast cancer screening is different for Black women than it is for all women. Though the Task Force largely focused on Black women because it is the group that experiences the poorest health outcomes from breast cancer, it also emphasized that all studies should prioritize inclusion of all racial and ethnic groups so we can understand whether the effectiveness of screening, diagnosis, and treatment varies by population.

Areas for Additional Research

USPSTF prioritizes “high quality” evidence, such as that from randomized controlled trials, when making or changing its recommendations. However, historically, Black women have been underrepresented in these studies, which may lead to standards of care that do not adequately address the specific needs of Black women and potentially overlook differences that could impact screening effectiveness and subsequent outcomes. For instance, more than 10% of Black women with breast cancer are diagnosed before age 40, which suggests the recent shift in USPSTF recommendations may still miss many Black women, despite reflecting progress.

Although USPSTF acknowledges that reducing the age of screening is not going to improve inequities in Black women they are urgently calling for more evidence to understand specific risks in Black women, until then USPSTF has acknowledge that inequities in breast cancer outcomes will continue. To address these disparities and improve the effectiveness of breast cancer screening, researchers should consider opportunities to include a diverse range of participants, including Black women under 40, in research studies and randomized control trials to inform screening guidelines to advance understanding and improve outcomes in breast cancer treatment and prevention.

Dive Deeper

Avalere is uniquely positioned to assist stakeholders in understanding USPSTF’s recommendations and can leverage a bench of experts in regulatory strategy, evidence strategy, and patient access to focus on clinical trial design, new innovations, and access considerations in this space. To learn more about how Avalere can assist you, connect with us.