In the Journals Plus

Guidelines may lead to underscreening for breast cancer among minority women

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March 7, 2018

A larger proportion of nonwhite women than white women received breast cancer diagnoses prior to age 50 years, according to a research letter published in JAMA Surgery.

The findings suggest age-based breast cancer screening guidelines — which are based largely on data from white populations — may result in underscreening and delayed diagnosis among nonwhite women.

“[Although] a lot of attention has been focused on improving the ‘cultural competency’ of clinical care — caring for patients in ways that accommodate their cultural and language differences — we are concerned that we haven’t paid as much attention to the scientific research process,” David C. Chang, PhD, MBA, MPH, associate professor of surgery at Harvard Medical School, said in a press release. “If the science upon which clinical guidelines are based was not done in a way that respects racial differences, there is little that can be done at the point of delivery to improve patient care.”

The researchers used the SEER database to review data from 747,763 women diagnosed with breast cancer from Jan. 1, 1973, to Dec. 31, 2010. Stage and age at diagnosis across racial groups served as the main endpoint.

The majority (77%) of the women included in the study were white, whereas 9.3% were black, 7% were Hispanic and 6.2% were Asian.

Overall, diagnoses occurred at a median age of 58 years.

Median age at diagnosis was 59 years (interquartile range [IQR], 51-67) for white women, 56 years (IQR, 49-65) for black women, 56 years (IR, 48-64) for Asian women and 55 years (IQR, 48-64) for Hispanic women.

Among those diagnosed with breast cancer, a larger proportion of nonwhite women than white women received their diagnosis prior to age 50 years (34.9% for Hispanic, 32.8% for Asian, 31% for black and 23.6% for white; P < .001 for all).

The researchers noted that, to reach a similar capture rate among nonwhite women as guidelines produce among white women at age 50 years, it would be necessary to lower screening ages to 47 years for black and Asian patients and 46 years for Hispanic patients.

Further, a larger proportion of Hispanic (42.9%) and black (46.6%) patients presented with advanced disease than white (37.1%) or Asian patients (35.6%, respectively; P < .001 for all).

“The situation with breast cancer is one of the best examples of how science done without regard to racial differences can produce guidelines that would ultimately be harmful to minority patients,” Chang said. “There have been similar efforts in recent years to combat gender biases in sciences, as we now appreciate that studies conducted only on males — even basic research in rats or other animals — may not apply to, or [may] even harm female patients. … Flawed science can harm more people than flawed clinical care, which is why it is so important to detect and eventually eliminate these sorts of hidden biases in the scientific literature.” – by Andy Polhamus

Disclosures: Chang reports no relevant financial disclosures. One author reports support from the Massachusetts General Hospital Department of Surgery Earnest A. Codman Research Fellowship and the Massachusetts General Hospital Physicians Organization Torchiana Fellowship in Health Policy and Management.