Reviews and CommentaryFree Access

Addressing Racial Inequities in Access to State-of-the-Art Breast Imaging

Published Online:https://doi.org/10.1148/radiol.222405

See also the article by Christensen et al in this issue.

Dr Christoph Lee is a professor of radiology in the Department of                     Radiology at the University of Washington School of Medicine and a breast imager                     at Fred Hutchinson Cancer Center. He directs the Northwest Screening and Cancer                     Outcomes Research Enterprise and is principal investigator of multiple NIH R01                     grants focused on breast cancer screening technology assessment and health                     disparities

Dr Christoph Lee is a professor of radiology in the Department of Radiology at the University of Washington School of Medicine and a breast imager at Fred Hutchinson Cancer Center. He directs the Northwest Screening and Cancer Outcomes Research Enterprise and is principal investigator of multiple NIH R01 grants focused on breast cancer screening technology assessment and health disparities.

Dr Marissa Lawson is an acting instructor in the Department of Radiology                     at the University of Washington School of Medicine and a breast imager at Fred                     Hutchinson Cancer Center. She is a T32-funded Data Driven Cancer Research                     Scholar at the University of Washington.

Dr Marissa Lawson is an acting instructor in the Department of Radiology at the University of Washington School of Medicine and a breast imager at Fred Hutchinson Cancer Center. She is a T32-funded Data Driven Cancer Research Scholar at the University of Washington.

Although advances in screening, early detection, and treatment for breast cancer have led to improved overall survival over the past 2 decades, these improvements have not been experienced equally across different racial groups (1). Black women continue to experience higher mortality rates than White women, likely due to a combination of higher prevalence of biologically more aggressive disease and socioeconomic barriers including higher rates of poverty, underinsurance, and poor access to care (2). This includes access to high-quality services throughout the cancer care continuum, starting with screening and early detection.

Imaging remains at the center of efforts in earlier breast cancer screening and detection. Mammography is the only screening test shown to decrease breast cancer mortality in multiple randomized trials (3). However, mammography itself has been subject to significant technological changes over the past 2 decades, with relatively rapid transitions from screen-film to digital mammography in the 2000s and then to digital breast tomosynthesis (DBT, or three-dimensional mammography) in the 2010s. Digital mammography improved accuracy for younger, premenopausal women and women with dense breasts compared with screen-film mammography (4), while DBT has been shown to lower recall rates and improve cancer detection compared with digital mammography (5).

Approved by the U.S. Food and Drug Administration in 2011 and reimbursed by Medicare beginning in 2015, DBT is now offered in the vast majority of mammography facilities in the United States. However, not every mammography unit is DBT-capable at this time, as high capital costs are associated with replacing existing units. The current state of mammography screening in the United States is thus a hybrid environment, where not every patient has access to the same imaging technologies at their place of usual service. Those facilities that have the resources to replace or upgrade expensive mammography units are the most likely to offer the newer technologies to their patient populations. A similar hybrid environment existed for screen-film and digital mammography in the 2000s.

In this issue of Radiology, Christensen et al (6) examine a 5% sample of Medicare insurance claims data from 2005 to 2020 to determine the use of newer mammography technologies according to women’s race over time. The study team looked within institutions as well as across comparable institutions to determine differences in mammography technology use according to patient race. In multivariable regression models, they adjusted for multiple patient-level factors that could impact use, including age and Charlson comorbidity score. With a total sample of more than 4 million mammography claims during the study period, they found that Black women were 20% less likely than White women (odds ratio, 0.80; 95% CI: 0.70, 0.91) to receive digital mammography in 2005 and 16% less likely than White women (odds ratio, 0.84; 95% CI: 0.81, 0.87) to receive DBT in 2015–2020. Difference in DBT use according to race persisted at the end of 2020, suggesting ongoing disparities in use by race.

This study by Christensen et al adds to the literature that demonstrates that minority patients are often the last to benefit from newer medical technologies when looking across racial groups. Similar to a previous study by the Breast Cancer Surveillance Consortium (7), they demonstrated that DBT access was the lowest among Black women compared with White women in the early adoption period followed by an incremental closing in the access gap over time. Christensen et al further demonstrated similar historical adoption trends for digital mammography in the 2000s.

Of note, Christensen and colleagues limited their analysis to patients with Medicare insurance coverage. This distinction allowed the authors to examine racial differences in mammography technology use without the confounder of insurance status. They also attempted to account for other potential confounders in their multivariable analysis, including zip code–level per capita income levels and urbanicity. This effort further provides credence for the observed racial disparities in use of newer mammography screening technologies. Based on their findings, the authors argue for enhanced reimbursement policies as a tool to mitigate differential access to new imaging technologies. Such policy changes could help institutions that serve disadvantaged populations—which often include a disproportionate number of racial and ethnic minority groups—to purchase and offer newer screening technologies quicker.

However, there are limitations to this study and its broader applications. First, this study’s publicly available data set is inherently limited to patients who qualify for Medicare fee-for-service insurance, with a mean patient age of 72 years. More difficult patient decisions on use of newer screening technologies are likely among younger women of working age with competing work-life priorities and associated potential out-of-pocket costs. Second, zip-code level per capita income and urbanicity are rough estimates of neighborhood-level factors that may impact patients’ decisions on the use of medical technologies. More robust, publicly available measures of neighborhood-level social determinants of health, such as the National Institutes of Health–funded PhenX toolkit (8), are available for use for future studies. Finally, although this study examines use of newer technologies based on race, differences in use should be tied to differences in outcomes to truly demonstrate health inequities.

Nevertheless, Christensen et al did highlight multiple areas for future investigation. Racial disparities in breast cancer screening and early diagnosis are likely multifactorial, and teasing out drivers and eventual interventions will require a truly multilevel framework (9). Effective, tailored availability and use of newer and advanced imaging technologies are just one aspect that may improve outcomes and close existing racial disparities. Identifying intervenable patient- and neighborhood-level social determinants of health that drive persistent disparities is equally as important, if not more important, but remains challenging. Robust population-based registries that capture patient-, neighborhood-, and care-related data throughout the cancer care continuum (including the diagnostic imaging and treatment periods) linked to long-term outcomes can be used for multilevel analyses as promoted by the National Institute of Minority Health and Health Disparities (10).

Given the central nature of imaging throughout the breast cancer care continuum, radiologists are in a unique position to improve access to, use of, and outcomes from state-of-the-art imaging technologies. Radiologists must demonstrate how timely access to and use of newer and advanced imaging technologies not only for screening but also during the diagnostic period, treatment decision-making period, and surveillance period can improve patient outcomes for all populations with a health equity lens. As radiologists identify intervenable factors (eg, patient navigation services, financial assistance programs) that impact access to and use of newer imaging technologies as well as those associated with breast cancer outcomes, imaging facilities and health systems can better prioritize health equity and commit resources to address these factors. This intentional approach to addressing health equity is required to close the health disparities gap in the face of increasing economic constraints.

In conclusion, the 2000s and 2010s saw a rapid transition from screen-film mammography to digital mammography, and then to DBT, after studies demonstrated improved performance metrics of the newer technologies. However, Christensen et al found that, compared with White women, Black women were less likely to have access to newer technologies, especially in the earlier years of adoption, both within and across comparable institutions. In the future, radiologists and imaging facilities have the opportunity to identify other multilevel factors that impact differential use of and outcomes associated with newer breast imaging technologies across women not only of different race but also other socioeconomic factors. Future investigations should also address state-of-the-art breast imaging technology use and associated outcomes throughout the screening and diagnostic episode of care.

Disclosures of conflicts of interest: C.I.L. Grants to institution from the National Cancer Institute; participation on a data safety monitoring board at GRAIL; personal fees for editorial board work from the American College of Radiology. M.B.L. No relevant relationships.

C.I.L. supported in part by the National Cancer Institute (grants P01CA154292 and R01CA266377). M.B.L. supported in part by the National Cancer Institute (grant T32CA009168).

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Article History

Received: Sept 20 2022
Revision requested: Sept 20 2022
Revision received: Sept 20 2022
Accepted: Sept 21 2022
Published online: Oct 11 2022