Study: Systemic racism may delay breast biopsy for Black and Asian people

Relevance: Medium-High

Strength of Science: Medium-High

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What is this study about?

This study is about who experiences delays in getting a breast biopsy and why. It looks at the number of days between an abnormal screening mammogram and biopsy by race and ethnicity and the factors that might cause delays.

Why is this study important?

Mammograms screen for breast cancer. For about 1 in 10 women, additional imaging may be needed after a screening mammogram. If additional images are abnormal, a biopsy may be recommended. During a biopsy, a sample of tissue is removed and sent to a lab to test for cancer. Experts recommend that biopsies be done as soon as possible to reduce the person’s anxiety and allow them to get treatment quickly if cancer is found. Yet this doesn’t always happen. In the United States, people from racial and ethnic minority groups are more likely than white people to have a delay between the time of their breast imaging and a biopsy.

The impact of a long delay can be serious. People with breast cancer who have a biopsy within 90 days of having an abnormal mammogram have better health outcomes than those who do not. Delays of more than three months are linked with:

• more late-stage cancer
• more spread to lymph nodes
• larger tumor size
• the need for more aggressive treatments and more severe treatment-related side effects

This study is the first to explore the possible causes of biopsy delays in a large, diverse sample of U.S. residents from different parts of the country. It takes into account individual, neighborhood and healthcare system factors that may affect the timing of a biopsy. The findings provide new information about the disparities in cancer care and highlight areas for further study and advocacy.

Who was studied

The researchers looked at data from 2009 to 2019 provided by more than 100 imaging centers in six states. The sample set included about 45,000 people between the ages of 40 and 79 who were recommended for a biopsy after an abnormal mammogram. The sample did not include anyone with a history of breast cancer or symptoms of breast cancer at the time of screening.

The study included diagnostic mammograms with abnormal results that were assigned a Breast Imaging Reporting and Data System or BI-RADS score of 4 or 5 (a scoring system that describes mammogram results). A breast biopsy is often recommended for people with a BI-RADS score of 4 or 5.

The study researchers used a framework developed by the National Institute of Minority Health and Health Disparities (NIMHHD) to study factors that might affect the time from mammogram to biopsy. NIMHHD is a government agency whose role is to study and work to overcome health disparities in the United States. The NIMHHD framework looks at personal, neighborhood and healthcare factors:

• personal factors were age, race, ethnicity, family history of breast cancer, breast density and time since the last mammogram.
• neighborhood factors were the likelihood of high school or college education, household income, and living in an urban, large rural, small rural, or isolated rural area.
• healthcare factors were the type of mammogram used and whether the facility is affiliated with a university and has the ability to do an onside biopsy.

Study findings

Some key findings are:

• Among all people who had an abnormal screening mammogram:
  • 35% did not have a biopsy within 30 days.
  • 12% had yet to have a biopsy within 90 days.
• Time to biopsy varied by race:
  • Black, Asian and Hispanic people were less likely to have a biopsy within 30 or 60 days.
  • Black people were at significantly higher risk than any other group of not having a biopsy within 90 days.
• Besides race, the only other factor linked to delays in biopsy was the facility where the mammograms were done.
  • Black and Asian people were less likely to have a biopsy within 90 days than white people who had mammograms at the same facility.

The authors concluded that because the factors they studied did not entirely account for differences in time to a breast biopsy, unmeasured factors must therefore account for delayed biopsies. They suggest that systemic racism is a primary delaying factor. Racism could show up in the way a hospital or screening clinic communicates with patients, the ease of scheduling a biopsy or the availability of translators. Systemic racism can also affect insurance coverage, reimbursement or how a hospital uses resources.

What does this mean for me?

This study is a reminder that not everyone receives the same level of care at every hospital or clinic. Some factors that influence your healthcare experiences, such as systemic racism, may be hidden.

If you or someone you care about has had an abnormal mammogram, try to schedule a biopsy as soon as possible. Having a biopsy 90 days or later is associated with worse outcomes. If a biopsy finds cancer, it is better to know sooner rather than later, and to plan for treatment. If your biopsy does not show cancer, you will be relieved of your anxiety sooner.

If you have trouble getting an appointment or feel that the wait time for an appointment is too long, look for another doctor who may be able to see you sooner. The National Cancer Institute’s list of approved cancer centers is a good resource for high-quality cancer centers. You can also ask for recommendations from your doctor or a trusted friend.

Reference

Lawson MB, Bissell MCS, Miglioretti DL, et al., Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity. Journal of the American Medical Association Oncology; 2022; 8(8):1115-1126. Published online June 23, 2022

Miles RC, Addressing racial and ethnic differences in diagnostic resolution of abnormal mammographic findings. Journal of the American Medical Association Oncology; 2022; 8(8):1126-1127. Published online June 23, 2022

Disclosure: FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.

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posted 3/8/23

Strengths and limitations

Strengths

• This study had a large sample size that reflects the diversity of the U.S. population. It includes 10 years of data from 109 screening facilities.
• Data for this study came from established cancer registries that collect information on demographics, risk factors, screening history, mammography results and lab results from breast lesions.
• This is the largest study of racial and ethnic differences in biopsy delays.
• This study lays the groundwork for further efforts to reduce racial and ethnic disparities.

Limitations

• This study excluded people for whom data was incomplete. Facilities with low biopsy rates were also excluded.
• The research team could not analyze or account for structural racism because it was not measured in the data.

Context

This study highlights one way in which structural racism within the healthcare system can affect patient outcomes. Structural racism is racism that is built into systems in ways we don’t always notice. It is hard to study because it is not one factor that can be measured.

These findings are consistent with earlier study findings that confirm that people from racial and ethnic minority groups are more likely to face a delay in getting a breast cancer diagnosis or starting treatment. One related study found that delayed biopsies occur less often at breast imaging centers that offer mammograms and biopsies in the same clinic. People from racial and ethnic minority groups are less likely to go to these centers.

There have been a number of other key findings related to disparities in breast cancer. Notably, even though more white people develop breast cancer, Black people are more likely to die of breast cancer. Black and Hispanic people are not well represented in clinical trials. Gaps are also seen in genetic testing, with Black people being less likely to be referred for testing.

Conclusions

Black, Asian, and Hispanic people are more likely to have a delayed biopsy after an abnormal mammogram. Asian and Black people are more likely to have to wait longer than 90 days. This disparity does not appear to be caused by the many other factors, other than screening facilities, that researchers looked at in this study. The researchers concluded that the disparity is probably caused by something that is difficult to measure, likely systemic racism. A commentary that went with the article recommends that healthcare centers carefully review their own data to assess whether they are providing equal care for all patients.