With the advent of new screening technologies, including digital breast tomosynthesis, screening ultrasound, and breast magnetic resonance imaging, there is growing concern that existing disparities among traditionally underserved populations will worsen. These newer screening modalities purport improved cancer detection over mammography alone but are not offered at all screening facilities and often require a larger co-pay or out-of-pocket expense. Thus, the potential for worsening disparities with regard to access and appropriate utilization of supplemental screening technologies exists. Currently, there is a dearth of literature on the topic of health disparities related to access and the use of supplemental breast cancer screening and their impact on outcomes. Identifying and addressing explanatory factors for persistent and potentially worsening disparities remain a central focus of efforts to improve equity in breast cancer care. Therefore, this paper provides an overview of factors that may contribute to present and future disparities in breast cancer screening and outcomes, and explores specific relevant topics requiring greater research efforts as more personalized, multimodality breast cancer screening approaches are adopted into clinical practice.
Introduction
Although breast cancer incidence in the United States has steadily increased over the past four decades, breast cancer mortality rates have declined with current 5-year relative survival rates of 99% and 84% in women diagnosed with localized and regional diseases, respectively . Decreased mortality has largely been attributed to both increased mammography screening resulting in early detection and improved therapies . However, not all women have benefitted equally from these advances that have led to improved breast cancer survival. Racial and ethnic minorities, women from low socioeconomic backgrounds, those living in rural areas, and the elderly bear a disproportionate burden of breast cancer morbidity and mortality . These vulnerable populations often contend with barriers to screening, experience delays in diagnosis, and present with a more advanced stage of disease at the time of diagnosis .
With the advent of new screening technologies, including digital breast tomosynthesis, screening ultrasound, and breast magnetic resonance imaging (MRI), there is growing concern that existing disparities will worsen because typically, vulnerable populations have been the last to benefit from new health technologies . These newer screening modalities purport improved cancer detection over mammography alone but are not offered at all screening facilities and often require a larger co-pay or out-of-pocket expense . Thus, the potential for worsening disparities with regard to access and appropriate utilization of supplemental screening technologies exists.
Currently, there is a dearth of literature on the topic of health disparities related to access and the use of supplemental breast cancer screening and their impact on outcomes. Identifying and addressing explanatory factors for persistent and potentially worsening disparities remain a central focus of efforts to improve equity in breast cancer care . Therefore, this paper provides an overview of factors that may contribute to present and future disparities in breast cancer screening and outcomes, and explores specific relevant topics requiring greater research efforts as more personalized, multimodality breast cancer screening approaches are adopted into clinical practice.
Persistent Disparities
Between 1973 and 2010, breast cancer incidence in the United States rose from 82.6 to 127.3 per 100,000 women, with white women having a higher incidence rate (127.3 per 100,000) compared to African-American, Hispanic, Asian-Pacific Islander, and American Indian-Alaskan Native women (rates of 118.4, 91.1, 84.7, and 90.3, respectively). Despite having a lower incidence rate, African-American and subgroups of Hispanic women demonstrate higher mortality rates . Although African-American women have the highest breast cancer-specific mortality of all ethnic groups, breast cancer represents the leading cause of cancer death in Hispanic women .
Differences in outcomes seen among vulnerable populations are linked to more advanced disease at diagnosis, worse biological features of disease, and more comorbid conditions . Patient-level factors, including low income, limited education, lack of health insurance, and rural residence, have all been associated with worse breast cancer outcomes, potentially because of decreased screening and delays in care . Other patient-level factors, including cultural differences, acculturation, and linguistic barriers, may also play a role . Many of these characteristics are disproportionately seen in certain ethnic minority groups, potentially exacerbating mortality disparities observed in these populations.
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Advanced Imaging Use Beyond Mammography
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Patient-level Enabling Factors
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System-level Enabling Factors
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Summary
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