Women of Minority Race/Ethnicity, Lower Socioeconomic Status Experience Lower Digital Breast Tomosynthesis Access

A cross-sectional study of digital breast tomosynthesis (DBT) screening published in JAMA Network Open indicated that women of minority race/ethnicity and lower socioeconomic status experienced lower DBT access during the early adoption period and consistently lower use when available over time.¹

Given these findings, the investigators suggested that future efforts should address racial/ethnic, educational, financial, and geographic barriers to receiving DBT screening at the facility level.

“This study was about whether adoption of this technology is equitable. We’re showing that it has not been, even though it has been FDA-approved for a decade now,” lead author Christoph Lee, MD, MS, MBA, professor of radiology at the University of Washington School of Medicine, said in a press release.² “Black and Hispanic women, and less-educated and lower-income women have not been able to obtain 3D mammography as easily as white, well-educated, and higher-income women.”

In this study, 92 geographically diverse imaging facilities were evaluated across 5 states in the United States. Investigators assessed whether the facilities offered DBT onsite at the time of a screening exam and compared the use of DBT and digital mammography across patient populations at those facilities.

Overall, 2,313,118 screening examinations had been performed among women aged 40 to 89 years from January 1, 2011 to December 31, 2017. Of the total screening examinations, the proportion of women who had access to DBT at the time of their screening appointment increased from 11,558 of 354,107 (3.3%) in 2011 to 194,842 of 235,972 (82.6%) in 2017.

In 2012, it was revealed that Black (relative risk [RR], 0.05; 95% CI, 0.03-0.11), Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly lowered access to DBT compared with White women. Moreover, when compared with college graduates, women with less than a high school education had lower DBT access (RR, 0.18; 95% CI, 0.10-0.32).

“These subpopulations of women with poorer access to 3D [imaging] are already traditionally underserved and more at risk for greater morbidity and mortality from breast cancer,” added Lee.

Among women attending facilities with both digital mammography (DM) and DBT available at the time of their screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] and 0.98 [95% CI, 0.97-0.99], respectively). Women with lower educational level, such as those with and without a high school diploma, also experienced lower DBT use than those with a college degree (RRs, 0.79 [95% CI, 0.74-0.84] and 0.88 [95% CI, 0.85-0.91], respectively). Regardless of the number of years after facility-level DBT adoption, women within the lowest income quartile experienced lower DBT use as compared to women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]).

“Given the large research sample and our longitudinal data collection, we were able to evaluate use by minority and traditionally underserved populations,” senior author Diana Miglioretti, PhD, professor and division chief of biostatistics at the University of California Davis, said in the release. “Unfortunately, we were not surprised to find that these traditionally underserved populations were less likely to attend facilities that offered 3D mammography, and even when they did, they were less likely to receive a 3D mammogram.”

Importantly, the current study did not evaluate whether structural racism in health care environments or out-of-pocket costs could have contributed to the lower access and use of new technologies among women of minority race/ethnicity. However, given that these may be real barriers, investigators recommended radiology practices and policy makers be cognizant of these screening access issues and consider disparities going forward.

References:

1. Lee CI, Zhu W, Onega T, et al. Comparative access to and use of digital breast tomosynthesis screening by women’s race/ethnicity and socioeconomic status. JAMA Netw Open. 2021;4(2)e2037546. doi: 10.1001/jamanetworkopen.2020.37546

2. Race, income, education affect access to 3D mammography. News release. University of Washington School of Medicine. Published February 19, 2021. Accessed February 22, 2021. https://www.eurekalert.org/pub_releases/2021-02/uowh-rie021721.php