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Racial Disparities in Digital Breast Tomosynthesis Screening.

A lthough breast cancer mortality has declined by more than 40% in the United States since the introduction of screening mammography in the late 1980s, significant disparities in breast cancer outcomes exist. Black women in particular have a 40% higher breast cancer mortality rate than White women and are also more likely to be diagnosed with advanced disease. Alsheik et al hypothesized that these racial disparities are likely to be exacerbated by the manner in which new screening technology is disseminated. Since gaining U.S. Food and Drug Administration approval in 2011, DBT has been more rapidly adopted in areas with higher proportions of White residents of higher socioeconomic status. The authors aimed to determine whether such trends have led to unequal DBT access and an adverse effect on screening outcomes. Their retrospective study assessed data from 804 304 screening mammograms from 63 U.S. imaging facilities from 2015 to 2019. Asian (63.1%) and White women (60.5%) had higher rates of DBT usage compared to Black women (44.4%). Hispanic women were not included due to insufficient data. Asian women had the highest rate of dense breasts (68.3%) compared to White (49.2%) and Black women (40.1%). It is uncertain to what extent women with dense breasts were triaged to receive DBT, which would have impacted the racial distribution of DBT uptake. However, the large difference in DBT uptake between White and Black women cannot be explained by breast density alone. For all racial subgroups, DBT screening resulted in decreased recall rates, increased positive predictive value, and increased cancer detection rate when compared to digital mammography (DM). Therefore, DBT improves screening performance for women of all races, and differential access to DBT can be predicted to yield racial disparities in screening outcomes. Independent of DBT, having undergone prior mammography, which can be used for comparison, has been well documented to reduce the recall rate with similar results seen in the present study. The authors found that Black women were significantly less likely to have two or more screening examinations during the study period than White women. Nevertheless, even after adjusting for the availability of prior comparisons, Black and Asian women still had higher rates of recall rate reduction with DBT compared to DM than White women. Although women of all races benefit from DBT, unequal access to this technology likely amplifies disparities in breast cancer outcomes. The authors conclude that a multifaceted approach to addressing structural barriers to health care access at the provider, institutional, and societal levels is needed. —Melanie Fung, Kimberly Ray