NEW YORK (Reuters Health) – Age-based breast cancer screening guidelines that do not account for race may harm nonwhite populations, so lowering the screening age for these individuals should be considered, researchers in Boston say.
The U.S. Preventive Services Task Force recommends initiating breast cancer screening at age 50, but the guideline may not be sensitive to racial differences, according to Dr. David Chang and colleagues at Massachusetts General Hospital.
To investigate, the team analyzed SEER data from 1973 through 2010 on women ages 40 to 75 with malignant breast neoplasms. A total of 747,763 women were included: 77% white, 9.3% black, 7% Hispanic, and 6.2% Asian.
As reported online March 7 in JAMA Surgery, the median age at diagnosis was 59 for whites, 56 for blacks, 55 for Hispanics and 56 for Asians. A higher proportion of breast cancer patients were diagnosed under age 50 among blacks (31%), Hispanics (34.9%) and Asians (32.8%) than among whites (23.6%).
A higher proportion of black and Hispanic patients presented with advanced disease (46.6% and 42.9%, respectively) than did whites (37.1%) or Asians (35.6%).
To achieve similar capture rates as current guidelines do for whites at age 50, screening ages would need to be lowered to 47 for blacks, 46 for Hispanics and 47 for Asians, the authors contend.
Dr. Marleen Meyers, director of the Perlmutter Cancer Center Survivorship Program at NYU Langone Health in New York City, commented, “I have always felt the screening age should be lower than 50. Breast cancer is a highly complex and diverse disease.”
“There is no consensus with respect to age at first mammogram,” she said in an email to Reuters Health. “The American Cancer Society recommends starting at age 45 but one may start at age 40. The (American College of Obstetricians and Gynecologists) recommends beginning at age 40.”
“I am in favor of starting at age 40 in the average-risk person of any race,” she said. “We need more data to definitively tie race to screening age.”
“This study reports age at diagnosis, not age at first screening,” she added. “Screening at age 45 would encompass the capture rates for black, Hispanic and Asian patients.”
“In addition, the primary endpoint was age and stage at diagnosis,” she continued. “A more useful assessment would be to evaluate survival, not stage, based on age of first screening and frequency of screening,” she suggested, “and look at types of cancers within each group, as more aggressive cancers such as triple negative can have a poorer prognosis even if stage I.”
“It is likely that residents of urban areas already start screening at a younger age,” she noted. “The two factors important in improving screening are education for health care professionals and patients and funding/accessibility.”
Dr. Chang told Reuters Health by email that “the message of this study is simple – the screening guideline developed based on the majority population may not be applicable to minority women. But there is a larger message, i.e., that flawed science may contribute to healthcare disparities more so than flawed care.”
“We as a society have focused a lot of attention on improving cultural competency at the care delivery point,” he said. “But I am concerned (that) we haven’t paid as much attention to the scientific research process. If the science was not done in a way that respects racial differences, then there is little you can do at the care delivery point to improve care.”
“The breast cancer problem is one of the best examples, although we have many others,” he said. “Since the scientific basis was flawed – it was done without regards to racial differences – we produced a guideline that is ultimately harmful for minority patients. And it has nothing to do with the care delivery. It has to do with our guidelines being flawed.”
Similar disparities are seen with regard to gender differences, he added, because researchers mainly have focused their attention on males, “even all the way back to basic science, where scientists prefer male to female rats.”
Dr. Chang concluded, “We will be starting a course at Harvard Medical School entitled, ‘Culturally Sensitive Science: Preventing medicine’s contribution to social bias and disparity,’ to begin to equip future physicians and physician scientists to detect these sorts of hidden biases in our current scientific literature.”
SOURCE: http://bit.ly/2p8Mk8x
JAMA Surg 2018.
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