Should Black Women Start Breast Cancer Screening Earlier?
A study looking at the number of women who die from breast cancer in the United States suggests that screening guidelines should be updated so Black women start screening about eight years earlier than white women.
The research was published online on April 19, 2023, by the journal JAMA Network Open. Read “Race and Ethnicity-Adjusted Age Recommendation for Initiating Breast Cancer Screening.”
Breast cancer in Black women
Black women are less likely than white women to be diagnosed with breast cancer. Still, for the last four decades, we’ve known that Black women are about 40% more likely to die from breast cancer than white women. Studies have suggested that a number of factors contribute to this disparity, including structural racism in the healthcare system and the biology of the cancer tumor.
Confusion around breast cancer screening recommendations
From 2000 to 2015, a number of large studies ignited debate over when people should begin having screening mammograms.
Public health experts agree that breast imaging saves lives, but question the value of screening mammograms. These experts say that for each breast cancer death screening mammograms prevent, three to four women are overdiagnosed.
Overdiagnosis means that a screening mammogram finds:
a suspicious area that would have been eventually diagnosed as cancer by other means without affecting the prognosis
a suspicious area that never would have been diagnosed as cancer if it had been found or treated
False-positive results from screening mammograms also have helped fuel the debate about the value of breast cancer screening and when it should start. When a mammogram shows an abnormal area that looks like cancer but turns out to be normal, it’s called a false positive. 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.
Because of the continued debate, a number of organizations revised their breast cancer screening recommendations for women at average risk of breast cancer. Some organizations recommend starting screening mammograms at age 50, and others recommend starting at age 40. At the same time, some organizations recommend having a mammogram each year, and others recommend having a mammogram every other year. As a result, there is confusion about when you should start having screening mammograms, as well as how often you should have them.
Aiming to clarify when people should start getting mammograms, the National Comprehensive Cancer Network (NCCN) released guidelines for breast cancer screening and diagnosis in 2022 that everyone who has breasts age 40 and older at average risk of breast cancer should have an annual mammogram.
About the study
Given that Black women are more likely to die from breast cancer than white women, in this study, the researchers questioned the one-size-fits-all screening recommendations put out by the U.S. Preventive Services Task Force and other organizations. The researchers looked at breast cancer death statistics to offer evidence that race and ethnicity should be considered when deciding the recommended age to start breast cancer screening.
The researchers looked at the number of women who died from breast cancer in the United States between 2011 and 2020 in the SEER database. The SEER database is a large registry of cancer cases from sources throughout the United States maintained by the National Institutes of Health. The researchers said that more than 99% of deaths in the United States are in the database.
Overall, 415,277 women died from breast cancer during the study period:
309,869 white women
62,695 Black women
28,747 Hispanic women
12,086 Asian or Pacific Islander women
1,880 American Indian or Alaska Native women
Black women were nearly twice as likely to die from breast cancer before age 50 than white women. The rate of breast cancer deaths among women ages 40 to 49 was:
27 deaths per 100,000 person-years for Black women
15 deaths per 100,000 person-years for white women
11 deaths per 100,000 person-years for Hispanic, Asian or Pacific Islander, and American Indian or Alaska Native women
This means 27 out of every 100,000 Black women ages 40 to 49 in the United States die from breast cancer during one year of follow-up, or that 0.027% of Black women ages 40 to 49 die from breast cancer each year.
For all women in the United States, the average risk of dying from breast cancer from ages 50 to 59 is 0.329%.
The researchers found that women from different racial and ethnic groups reach this average risk level at different ages:
Black women reached it at age 42
white women reached it at age 51
Hispanic and American Indian or Alaska Native women reached it at age 57
Asian or Pacific Islander women reached it at age 61
The researchers wrote that if guidelines say breast cancer screening should start at age 50, then women of different racial and ethnic groups should start screening at the age they reach the average risk level. For example, if guidelines say to start screening at age 50, Black women should start at age 42.
If guidelines say breast cancer screening should start at age 45 (with an average risk of dying from breast cancer from ages 45 to 55 of 0.235%), then:
Black women should start screening at age 38
white women should start screening at age 46
Hispanic women should start screening at age 49
Asian and Pacific Islander women should start screening at age 50
American Indian and Alaska Native women should start screening at age 51
If guidelines say breast cancer screening should start at age 40 (with an average risk of dying from breast cancer from ages 40 to 50 of 0.154%), then:
Black women should start screening at age 34
white women should start screening at age 41
Hispanic, American Indian or Alaska Native, and Asian or Pacific Islander women should start screening at age 43
The researchers pointed out that breast cancer mortality depends on many factors, including:
quality of screening tests
breast size and density
treatment access and quality
tumor grade and stage at diagnosis
barriers to healthcare access
biological and genetic differences in tumors
But they also noted: “However, making everything too complex may lead to doing nothing. One can try to start from a first scientific step (like race and ethnicity-adapted screening) and evaluate and build more complex steps along the way and reevaluate.
“This study provides evidence-based race-adapted starting ages for breast cancer screening,” the researchers concluded. “These findings suggest that health policymakers may consider a risk-adapted approach to breast cancer screening in which individuals who are at high risk are screened earlier to address mortality due to early-onset breast cancer before the recommended age of mass screening.”
What this means for you
At Breastcancer.org, we believe your best chance for early detection requires coordination of the current screening tools:
high-quality mammography
clinical breast exam
breast self-exam
If you’re not using all three tools starting at age 40, it’s a missed opportunity for early detection.
The reality is that everyone with breasts is at risk for breast cancer, and this risk tends to increase over time. It’s important to understand your health information related to breast cancer risk and to keep your doctor updated throughout your life. Here are some points to discuss with your doctor:
family history of breast or other related cancers (ovarian, melanoma)
any test results for gene mutations linked to a high breast cancer risk
results of past breast biopsies, even if they were benign
personal history of radiation treatment to the face, chest, or both before age 30
breast density
weight
level of physical activity
any use of post-menopausal combined hormone replacement therapy (HRT)
alcohol consumption, if you regularly drink more than three alcoholic beverages a week
the amount of processed food and trans fats you eat
your smoking history
whether or not you have carried a pregnancy to term or have breastfed
If you have a higher-than-average risk of developing breast cancer, you should talk to your doctor about starting annual mammograms at a younger age and consider other screening tools (such as MRI or ultrasound) to increase your chances of early detection.
Learn more about breast cancer screening.
Updated on June 5, 2023