Racial Disparities In Breast Cancer Screening

After skin cancer, breast cancer is the second most common type of cancer among women in the United States, with one in eight being diagnosed in their lifetime.¹ ²

Regular screening can reduce your risk of dying from breast cancer in the 10 and 20 years following diagnosis by 60% and 47% respectively when compared to women who are not regularly screened.³ However, racial disparities in breast cancer screening have negatively impacted health outcomes for racial and ethnic minority communities.

Breast cancer screening

In breast cancer screening, your breast tissue is checked for cancer before any apparent signs or symptoms appear. Screening doesn’t prevent the disease, but early detection leads to more favorable treatment outcomes.

Here are some of the screening methods used to detect breast cancer:⁴ ⁵

Mammography

Mammography breast tissue imaging is currently the standard and most common tool for breast cancer screening.

Women aged 40 and above are advised to undergo screening every other year. Your doctor might recommend yearly screening or starting screening from the age of 30 if they believe you have a high risk. You may be considered high risk if you have a family history of breast cancer, test positive for certain gene mutations, or have previously been exposed to radiation therapy.

These regular tests are important, but they do have some limitations. You might find getting a mammogram a little uncomfortable, but this feeling should only last for a few moments. Additionally, mammograms are not the most sensitive test. Sensitivity refers to how accurately a mammogram detects cancer cells.

Mammogram sensitivity may depend on some individual factors. You’ll have more chance of receiving false-positive or false-negative results if, for example, you have high-density breast tissue.

Ultrasound

A breast ultrasound is not as common as a mammogram but is cost-effective and widely available. This technique is best if you have a high risk of breast cancer or dense breast tissue.

Sound waves reflect off tissue and create an image. Since they can better identify cysts and solid masses, ultrasounds are often used to complement mammograms, improving overall mammogram sensitivity.

Magnetic resonance imaging (MRI)

Usually implemented in conjunction with mammography, MRIs use magnetic fields and radio waves to generate an image.

MRI is only recommended for high-risk groups — not for the average population. It is time-consuming, expensive, requires highly experienced radiologists, and may cause high false-positive rates. However, the screening technique is superior at detecting small tumors in people with a high breast cancer risk.

Biopsy

A biopsy is an invasive technique where fluid or tissue is removed from the affected area for further testing. It’s the main method for diagnostically confirming cancer.

If the area is cancerous, biopsies help provide a fuller picture of the tests and treatment you need based on the type of cancer identified.

There are a few types of biopsies:

Fine-needle biopsy

During a fine-needle biopsy, whether you have a solid or cystic lesion, a very thin needle is inserted to obtain fluid and cell samples from the affected area.

Core-needle biopsy

This is the most common biopsy procedure used to take breast tissue samples. You would typically undergo this procedure under local anesthesia.

The doctor makes a small incision and uses the needle to remove an intact tissue sample. This is made possible by the type of hollow needle used. The doctor can glean more information about the cancer cells and the surrounding area when the sample is intact.

Wire-guided excision biopsy

You may undergo a wire-guided excision biopsy if your scan shows abnormal areas but your doctor can’t feel a lump. It may also be useful if a needle biopsy is difficult to perform.

Under local anesthesia and guided by the scan, a doctor will insert a thin wire into the breast mass. They will mark the area for surgery, which will be performed afterward to remove the tumor.

Surgical biopsy

During a surgical biopsy, or lumpectomy, a doctor removes some or all of the abnormal tissue for examination. They carry out the procedure when you are under general anesthesia, intravenous sedation, or local anesthesia.

Microwave imaging (MI)

Tumor cells retain more water than normal cells. Microwave signals can highlight the difference in water content between healthy and malignant breast tissue.

This method is an emerging technology and has not been widely adopted. However, it is non-invasive and harmless to humans. Scientists believe this may become a safe and cost-efficient alternative to routine mammography.

Overview of racial groups affected by breast cancer screening disparities

Breast cancer research and treatments have come a long way, but not everyone has benefited equally from these advancements.

In the US, Black and other women of color are more likely to be diagnosed during the later stages of breast cancer. They also have significantly higher mortality rates compared to White women.⁶

Being able to access screening more easily improves health outcomes across all communities. Consider the states that expanded Medicaid after the 2010 Patient Protection and Affordable Care Act (ACA). They showed higher mammography screening rates and reduced incidences of advanced breast cancer in Black women.⁷ ⁸

So, why, despite a lower incidence of breast cancer, is the mortality rate for Black women 40% higher than that of White women?⁹

Black women aren’t the only racial group experiencing these disparities. Studies have shown that, compared to non-Hispanic White women, Hispanic women are less likely to receive a mammogram.¹⁰ Additionally, in cases where results are abnormal, Hispanic and Black women experience longer wait times before receiving a definitive diagnosis.⁹

American Indians and Alaskan Natives are also diagnosed at a later stage than White women, and they experience the largest outcome disparities for breast and stomach cancers.¹¹

Better access to screening is just one piece of the puzzle. Routine early detection tools, like mammography, can be more accurate at detecting hormone-receptor (HR)-positive cancers at an earlier stage. HR-positive breast cancers are the most common type in White and Black women.

However, you can also develop HR-negative cancers. One of these is triple-negative breast cancer (TNBC), a particularly aggressive subtype. HR-negative cancers are 65% more common among Black women than White women. This diminishes some of the benefits of mammography within this population but highlights why acknowledging and working to rectify these disparities is so important.¹²

Risk factors for breast cancer that can be managed

You can’t control some breast cancer risk factors, such as your age, race, ethnicity, or family history, but addressing some modifiable factors may lower your risk. Here are some of the steps you can take:¹³

• Being physically active

• Maintaining a healthy weight (not being overweight or obese)

• Being mindful of oral contraceptives and hormone therapies, especially during menopause

• Limiting or avoiding alcohol

• Reducing exposure to chemicals or toxins

• Carefully reviewing and routinely discussing your medications with your doctor

• Avoiding highly processed foods or those high in saturated and trans fat

• Stopping smoking

Unmodifiable risk factors for breast cancer

Factors outside of your control can be frustrating, but being aware of those that apply to you can be useful. Your risk of breast cancer can increase with the following:¹⁴

• Age — the overall risk of breast cancer increases with age, but some aggressive types like TNBC are more common among younger women

• Genetic mutations like BRCA1 and BRCA2

• Dense breast tissue

• A previous history of breast cancer or non-cancerous breast diseases

• A family history of breast or ovarian cancer

• Starting menstruation before the age of 12

• Starting menopause after the age of 55

• Having radiation therapy (especially before the age of 30)

Factors contributing to racial disparities in breast cancer screening

Let’s dig deeper into why these disparities might exist.

Income 

Income is a key social determinant of health. There’s an obvious connection between your income and your ability to access good food, housing, and medications. It also affects your ability to receive a comprehensive education, health literacy, and access to better-resourced neighborhoods.¹⁵

Studies show that women with lower incomes have lower rates of screening, later diagnoses, and higher mortality rates for breast cancer. While this is true across all races, a larger proportion of women of color from minority ethnic and racial backgrounds live in poverty compared to White women.¹⁶

Access to high-quality and timely healthcare

Better-resourced neighborhoods also tend to have more robust healthcare and public transport infrastructures. This means more healthcare providers, better healthcare equipment, and easier access to hospitals and clinics for screening and preventative care appointments.¹⁷

Even when Black and Hispanic women can access more screening appointments, data shows they are not kept as up to date on screening recommendations. They are also less likely to receive timely follow-ups compared to White women.

For example, Asian, Hispanic, and Black women were less likely to receive a biopsy within 30 days of abnormal mammography. Black women experienced the worst diagnostic delay time at 90 days or longer.¹⁸ This gap lessens the benefit of early screening and contributes to cancer diagnoses at more advanced stages, leading to worse outcomes.

Access to health insurance is another factor. Among Black, Indigenous, and Hispanic women, not having health insurance is associated with delayed breast cancer diagnoses and fewer breast cancer screenings. Black women are twice as likely to be uninsured or underinsured compared to White women.¹⁹

Lack of awareness

You would think that just expanding access and affordability in these communities would reduce racial disparities. However, some studies show that despite interventions like mobile mammography vans, Black women in some areas still face lower screening rates.²⁰

This can be partially explained by two key factors: mistrust of the medical system and cultural barriers.²¹

Mistrust of the medical system

Researchers in a 2021 study interviewed 39 Black women about their experiences with breast cancer screening.²²

Multiple participants mentioned not fully understanding what mammography might involve. They had previous negative experiences within the healthcare system and with healthcare providers. They were also skeptical and mistrustful of the system. Some interviewees explained how they felt stereotyped and dismissed. Some also mentioned how they felt they were treated differently or given poor treatment due to their race.

Cultural barriers

Some women interviewed were so wary of the discomfort felt during mammograms that it deterred them from attending screening. Others feared the intimacy of the procedure, which requires exposing the breast. For communities of color, already suspicious of the healthcare system, that may act as an additional deterrent.

On the other hand, some felt that receiving a cancer diagnosis was outside of their control. They didn’t believe that getting the mammography itself would change that.

Many studies have shown that Black women value being part of the decision-making process when it comes to their health and would greatly benefit from forming trusting relationships with their doctors.²³

Ways to improve the accessibility of breast cancer screening

Federal and state programs play a key role in improving affordability. This has been seen through the decreased incidence of advanced-stage breast cancer diagnoses in the Black community in states that expanded their Medicaid programs to include screening.

Even if screening is made more affordable, it’s not impactful unless you can easily access a healthcare facility. Community education, support, and outreach like patient navigators or setting up mobile mammography, telehealth, or access to radiologists can all help reduce structural barriers for racial or ethnic minority women, particularly those in rural communities.²⁴ ²⁵

Having a doctor recommend mammography and referring people for screening offers the best chance of increasing uptake by women of all races. Therefore, it’s important that women of color feel able to trust their healthcare providers and receive adequate information about breast cancer screening.

Diversifying the medical workforce and creating public policies and medical guidelines with the specific needs of minority communities in mind can help with this.²³ These changes have been shown to help bridge cultural gaps and improve patient outcomes.

The lowdown

The reasons for racial and ethnic disparities in breast cancer screening are multi-faceted and include barriers in affordability, access to high-quality healthcare, availability of appropriate healthcare providers and technology, and factors surrounding spirituality and cultural beliefs.

With recent research providing greater insight into why these disparities exist, there has been a renewed focus on updating public health priorities to address these inequities, promoting diversity in healthcare, and expanding strategic community partnerships.

Frequently asked questions

Can breast cancer screening cause cancer?

Mammograms use small doses of radiation, but the amount is not life-threatening. There has been no recorded instance of radiation from a mammogram causing a case of breast cancer.²⁶

How effective is breast cancer screening?

Mammography is the standard practice for breast cancer screening. However, it can cause false-negative or false-positive results depending on factors like your age, breast tissue density, cancer type, and family history. It’s important to stay vigilant about any breast cancer symptoms and speak to your doctor.

When in doubt, other available screening methods could improve the accuracy of mammograms, such as ultrasound or MRI. Biopsies offer the most definitive results if your doctor suspects you have breast cancer.²⁷

What’s a good age for screening if I have a family history of breast cancer?

The average age to start annual screening is 30 years if you have a family history and/or a known genetic mutation. Screening may include both MRI and mammogram.

Your doctor should conduct a risk assessment and evaluation. Based on your results, they can recommend the best type of screening and frequency for you.²⁸

Where can I go to get a breast exam?

The National Breast and Cervical Cancer Early Detection Program provides breast cancer screening and diagnostic services for women with low incomes or those who are underinsured or uninsured. You can find information for your state here.²⁹