Comparative Access to and Use of Digital Breast Tomosynthesis Screening by Women’s Race/Ethnicity and Socioeconomic Status

Christoph I Lee,Diana L Miglioretti,Ellen S O’Meara,Tracy Onega,Roberta Diflorio-Alexander,Jennifer S Haas,Anna N A Tosteson,Louise M Henderson,Celia Kaplan,Garth H Rauscher,Karla Kerlikowske,Brian L Sprague,Weiwei Zhu

doi:10.1001/jamanetworkopen.2020.37546

Abstract

Digital breast tomosynthesis (DBT) has reduced recall and increased cancer detection compared with digital mammography (DM), depending on women's age and breast density. Whether DBT screening access and use are equitable across groups of women based on race/ethnicity and socioeconomic characteristics is uncertain. To determine women's access to and use of DBT screening based on race/ethnicity, educational attainment, and income. This cross-sectional study included 92 geographically diverse imaging facilities across 5 US states, at which a total of 2 313 118 screening examinations were performed among women aged 40 to 89 years from January 1, 2011, to December 31, 2017. Data were analyzed from June 13, 2019, to August 18, 2020. Women's race/ethnicity, educational level, and community-level household income. Access to DBT (on-site access) at time of screening by examination year and actual use of DBT vs DM screening by years since facility-level DBT adoption (≤5 years). Among the 2 313 118 screening examinations included in the analysis, the proportion of women who had DBT access at the time of their screening appointment increased from 11 558 of 354 107 (3.3%) in 2011 to 194 842 of 235 972 (82.6%) in 2017. In 2012, compared with White women, Black (relative risk [RR], 0.05; 95% CI, 0.03-0.11), Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly less DBT access, and women with less than a high school education had lower DBT access compared with college graduates (RR, 0.18; 95% CI, 0.10-0.32). Among women attending facilities with both DM and DBT available at the time of screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] to 0.98 [95% CI, 0.97-0.99]); women with lower educational level experienced lower DBT use (RRs, 0.79 [95% CI, 0.74-0.84] to 0.88 [95% CI, 0.85-0.91] for non-high school graduates and 0.90 [95% CI, 0.89-0.92] to 0.96 [95% CI, 0.93-0.99] for high school graduates vs college graduates); and women within the lowest income quartile experienced lower DBT use vs women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]) regardless of the number of years after facility-level DBT adoption. In this cross-sectional study, women of minority race/ethnicity and lower socioeconomic status experienced lower DBT access during the early adoption period and persistently lower DBT use when available over time. Future efforts should address racial/ethnic, educational, and financial barriers to DBT screening.

Highlights

Routine breast cancer screening with digital breast tomosynthesis (DBT, or 3-dimensional mammography) may improve screening outcomes over traditional digital mammography (DM, or 2-dimensional mammography).[1,2,3] Multiple prospective trials and observational studies[4,5,6,7,8,9] demonstrate that Digital breast tomosynthesis (DBT) can improve the cancer detection rate while decreasing the recall rate from screening compared with DM screening at the population level depending on women’s age, breast density, and screening interval
In 2012, compared with White women, Black, Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly less DBT access, and women with less than a high school education had lower DBT access compared with college graduates (RR, 0.18; 95% CI, 0.10-0.32)
Among women attending facilities with both DM and DBT available at the time of screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] to 0.98 [95% CI, 0.97-0.99]); women with lower educational level experienced lower DBT use (RRs, 0.79 [95% CI, 0.74-0.84] to 0.88 [95% CI, 0.85-0.91] for non–high school graduates and 0.90 [95% CI, 0.89-0.92] to 0.96 [95% CI, 0.93-0.99] for high school graduates vs college graduates); and women within the lowest income quartile experienced lower DBT use vs women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]) regardless of the number of years after facility-level DBT adoption

Summary

Introduction

Routine breast cancer screening with digital breast tomosynthesis (DBT, or 3-dimensional mammography) may improve screening outcomes over traditional digital mammography (DM, or 2-dimensional mammography).[1,2,3] Multiple prospective trials and observational studies[4,5,6,7,8,9] demonstrate that DBT can improve the cancer detection rate while decreasing the recall rate from screening compared with DM screening at the population level depending on women’s age, breast density, and screening interval. Since its approval by the US Food and Drug Administration in 2011, DBT has become available in more than two-thirds of all US mammography screening facilities.[10]. Diffusion of DBT screening in the US has been relatively rapid, it is unknown whether adoption has occurred across different populations.[11] Populations with traditional disparities—Black race, Hispanic ethnicity, lower educational level, or lower income level—have historically experienced greater breast cancer morbidity and mortality than their less disadvantaged counterparts.[12,13,14] These populations have historically been the last to benefit from newer medical technologies.[15,16]

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Conclusion