Biopsies confirm breast cancer diagnosis after abnormal mammogram – but structural racism can lead to long delays

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By Marissa Lawson, University of Washington and Christoph Lee, University of Washington

Although mammograms are often the first step in detecting breast cancer, patients need additional tests after an abnormal screening result. Further imaging can determine whether a finding is truly suspicious for cancer, and sometimes a biopsy is needed to confirm a diagnosis. But biopsy delays reduce the benefit of early detection, putting patients at a higher risk of treatment failure and lowering their chances of survival.

Breast biopsies involve removing a small sample of tissue from a suspicious area and examining the sample under a microscope. Once doctors can confirm the presence of tumor cells and what type they are, they can create a treatment plan.

Much previous research has looked at differences in breast cancer care, including possible factors underlying diagnostic and treatment delays. On average, black patients are more likely to be diagnosed with late-stage breast cancer, have a higher mortality rate, and are less likely to receive guidelines-recommended treatment than white patients. Hispanic and South Asian patients are also more likely to be diagnosed with late-stage breast cancer compared to non-Hispanic white patients.

But previous studies have not looked at how multiple factors, including at the neighborhood and institution level, can influence breast cancer care for different groups in different geographic locations. And not many studies have evaluated the differences that can occur within the time-sensitive period between routine screening and an official diagnosis.

As radiologists studying health disparities and population health, we wanted to fill this research gap. Our recently published study found that patients from racial and ethnic minority groups are more likely to experience significant delays in obtaining a diagnosis-confirming breast biopsy after a mammogram compared to Caucasian patients.

Racial and Ethnic Differences in Biopsy Delays

We wanted to explore possible reasons why some patients experienced a delay between getting an abnormal mammogram result and having a diagnostic biopsy. That’s why we used data from the Breast Cancer Surveillance Consortium, a network of image registries investigating ways to improve breast cancer detection. We collected the demographic information of 45,186 patients in six US states and analyzed their risk of not having a biopsy within 30, 60, or 90 days of receiving an abnormal mammogram.

We found that all racial and ethnic minority groups had a higher risk of a biopsy delay greater than 30 days compared to white patients. Asian patients had the highest increased risk; they were 66% more likely to have a biopsy more than 30 days after their mammograms. However, when we looked at biopsy delays of 90 days or more, we found that only black patients had a significantly increased risk – they were almost 30% more likely to have prolonged delays compared to white patients.

Factors Behind Biopsy Differences

To find out the possible reasons for these differences, we statistically accounted for other factors that may contribute to racial and ethnic differences in biopsy delays. These include factors on an individual level, such as age and family history of breast cancer; neighborhood-level factors, such as the region’s median income and education; and screening facilities, such as academic affiliation and availability of on-site biopsy services.

We found that which screening facility a patient went to had the greatest effect on biopsy delays. This suggests that there are differences in health care that may contribute to longer waiting times for non-white patients. These differences in healthcare can include a number of factors, including whether there is a robust patient navigation system to provide guidance during the healthcare process or the availability of same-day biopsies.

Our analysis suggests that non-white patients still had a higher risk of breast biopsy delay even when we compared white and non-white patients with similar individual, neighborhood and screening facility characteristics.

Structural racism plays an important role in the long-standing public health inequalities in the US

This persistent difference in risks suggests that unmeasured factors, such as structural racism, or persistent policies and practices that lead to an unequal distribution of resources for racial and ethnic minorities, may also explain these differences. This could be inequality in health care coverage with higher out-of-pocket costs, or policies that limit access to higher quality care.

Structural racism may also have contributed to the facility-level differences we saw. For example, facilities where more white people went may have allocated additional resources to patient navigators and same-day services that would have allowed for more timely biopsies.

Narrowing the Diagnostic Gap

Long diagnostic delays after an abnormal screening mammogram can reduce the benefit of early cancer detection. Consequently, racial and ethnic differences in timely biopsy scheduling may exacerbate existing differences in breast cancer diagnosis, treatment, and survival, especially for black patients.

While we could not identify more specific drivers behind these differences, we found that screening facilities contribute to differences in biopsy delays between racial and ethnic groups. Our future work will focus on identifying facility-specific factors that may influence timely diagnosis after abnormal screening results. Our goal is to ultimately address these factors with interventions that reduce racial and ethnic disparities in breast cancer outcomes.The conversation

Marissa Lawson, Medical Fellow in Radiology, School of Medicine, University of Washington and Christoph Lee, Professor of Radiology, School of Medicine, University of Washington

This article is republished from The Conversation under a Creative Commons license. Read the original article.