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3D Mammogram Disparities: Black and Low-Income Women Often Denied Access

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While the gap has narrowed, over the last 10 years, women of color and women with less education and lower incomes have had less access to 3D screening mammograms compared to white women and women who are more educated and financially well-off, according to a study.

The research was published in the Feb. 2021 issue of JAMA Network Open. Read “Comparative Access to and Use of Digital Breast Tomosynthesis Screening by Women’s Race/Ethnicity and Socioeconomic Status.”

What is 3D mammography?
About the study
What this means for you

What is 3D mammography?

Three-dimensional (3D) mammography (also called digital breast tomosynthesis, digital tomosynthesis, or just tomosynthesis) creates a 3D picture of the breast using X-rays. Several images from different angles around the breast are used to create the 3D picture.

A conventional mammogram creates a two-dimensional image of the breast from two X-ray images of each breast.

3D mammography was approved by the U.S. Food and Drug Administration (FDA) in 2011 and is a standard of care for breast cancer screening. Still, 3D mammography may not be available at all hospitals and mammogram facilities.

To start offering 3D mammograms, facilities must purchase new mammography machines or add to their existing machines to make them 3D capable. So not all facilities have been able to make the switch to 3D mammography because of large up-front costs for equipment. In other cases, facilities had rental agreements for 2D mammography equipment and had to wait until those leases ended to upgrade.

According to the FDA, more than two-thirds of U.S. screening facilities now offer 3D mammograms on at least one of their mammography units, but fewer than half of all certified units are actually 3D-capable.

Also, not all insurance plans cover 3D mammograms. So some women must either pay out-of-pocket for a 3D mammogram or have a 2D mammogram.

A number of studies have found that 3D mammograms find more cancers than traditional 2D mammograms and also reduce the number of false positives.

A false positive is when a mammogram shows an abnormal area that looks like a cancer but turns out to be normal. Ultimately, the news is good: no breast cancer. But the suspicious area usually requires follow-up with more than one doctor, extra tests, and extra procedures, including a possible biopsy. There are psychological, physical, and economic costs that come with a false positive.

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About the study

To do the study, the researchers looked at 2.3 million screening mammogram records from 2011 to 2017 done at 92 imaging facilities across the United States. All the facilities were part of the Breast Cancer Surveillance Consortium, a database of breast cancer screening records that is funded by the National Cancer Institute.

During the span of the study, 3D mammogram use increased from 3.3% in 2011 to 82.6% in 2017.

The women who had the mammograms were ages 40 to 89:

  • 63.1% were white
  • 13.1% were Black
  • 6.5% were Hispanic
  • 11.6% were Asian
  • 5.7% were "other"
  • 8.7% did not have a high school diploma
  • 19.4% had a high school diploma
  • 22.4% had some college education
  • 49.5% had a college degree
  • 25.0% were in the lowest income bracket
  • 24.2% were in the second to lowest income bracket
  • 25.6% were in the middle income bracket
  • 25.2% were in the highest income bracket
  • 85.4% lived in an urban area
  • 6.3% lived in a large rural area
  • 3.8% lived in a small rural area
  • 4.5% lived in an isolated rural area

During the time of the study, 41 of the 92 imaging facilities offered both 3D and 2D mammograms.

The researchers looked at the women’s access to a facility offering 3D mammograms and how often 3D screening mammograms were used in different groups of women.

Overall, white women were more likely to have a mammogram at a facility that offered 3D mammograms compared to women of other racial/ethnic groups:

  • 37.2% of mammograms for white women were done at a facility offering 3D mammograms
  • 34.4% of mammograms for Black women were done at a facility offering 3D mammograms
  • 30.6% of mammograms for Hispanic women were done at a facility offering 3D mammograms
  • 16.5% of mammograms for Asian women were done at a facility offering 3D mammograms

Similarly:

  • Mammograms for women with a college education were more likely to be done at facilities offering 3D mammograms compared to mammograms for women without a college education.
  • Mammograms for women who lived in urban areas were more likely to be done at facilities offering 3D mammograms compared to mammograms for women who lived in small rural areas.

Compared to white women, the researchers found that Black, Hispanic, and Asian women were less likely to have a 3D mammogram than a 2D mammogram when both types of mammograms were available at the facility at which they were screened.

Women with lower education levels and living in zip codes with lower average household income were also less likely to have a 3D mammogram when both types of mammograms were available.

Up to 4 years after a facility had adopted 3D mammograms, Black women were still less likely than white women to have a 3D mammogram.

“This study was about whether adoption of this technology is equitable. We're showing that it has not been, even though it has been FDA-approved for a decade now,” lead author Christoph Lee, M.D., professor of radiology at the University of Washington School of Medicine, said in a statement. “Black and Hispanic women, and less-educated and lower-income women, have not been able to obtain 3D mammography as easily as white, well-educated, and higher-income women.

“We're going in the wrong direction,” he added. “You have a lot more women in certain subpopulations benefiting from new technologies and other subpopulations not. Existing disparities in breast cancer screening outcomes could widen unless these factors are addressed.”

The researchers did point out that they didn’t know the women’s insurance status, which likely affected a woman’s access to 3D mammograms. The researchers also pointed out that Medicare didn’t cover 3D mammograms until 2015, which also likely affected the results of the study.

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What this means for you

The results of this study are very upsetting and highlight some of the racial disparities in the healthcare system.

Your race, ethnicity, education level, or income level should not affect the quality of care you receive. Every woman should have access to the best care possible, including 3D mammograms, which are the standard of care.

If you aren’t sure your facility offers 3D mammograms, call and check before you make your appointment. If the facility doesn’t offer 3D mammograms, ask your doctor to recommend a facility that does.

If you aren’t sure if your insurance plan covers 3D mammograms, call and ask. Both Medicare and Medicaid now cover 3D mammograms.

In some states, such as Washington, there are laws that require facilities not to charge more for 3D mammograms. So even if your insurance doesn’t cover it, you can still get a 3D mammogram for the cost of a 2D mammogram, which in almost all states is free. In other states, such as New Jersey and Pennsylvania, there are laws that require insurers to cover 3D mammograms at no cost to women.

If you’re unsure about how much, if anything, you will have to pay for a 3D mammogram, call the facility and ask.

To learn more about 3D mammography, including how it’s done and how it’s different from 2D mammography, visit the Breastcancer.org Digital Tomosynthesis page.

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Written by: Jamie DePolo, senior editor

Reviewed by: Brian Wojciechowski, M.D., medical adviser


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