Breast Cancer Screening: How to Guide Black, White, and Asian Patients

Désirée Lie, MD, MSEd

Disclosures

March 09, 2010

Background

In 2009, the US Preventive Services Task Force (USPSTF)[1,2] revised its 2002[3] recommendations for breast cancer screening as follows:

  • Regular biennial mammography should be performed from ages 50 to 74 years;

  • Routine mammography screening at ages 40-49 is not recommended, and the decision should be based on individual risk;

  • Current evidence is insufficient to recommend mammography beyond 75 years;

  • Evidence is insufficient to recommend clinical breast examination in women 40 years and older; and

  • The evidence does not support teaching women breast self-examination as a screening tool.

The main rationale for the use of mammography for breast cancer screening is mortality reduction from early detection.[2,3] The argument for downgrading the recommendation for routine screening in the 40-year to 49-year group in the 2009 guidelines rested on the lower cost-effectiveness of screening: The number needed to screen to extend one woman's life is 1904 for women aged 40 40-49 years vs 1339 for women aged 50-59 years, and the additional benefits of starting screening at 40 years were deemed to be small.[4] Individual risk assessment for breast cancer is often based on family history; genetic risk, as expressed by the BRCA1 and BRCA2 genes; parity; and lifestyle factors, such as obesity.[5,6,7]

Few recommendations systematically examine the weighting for other risk factors, such as race and ethnicity,[8,9] which affect outcomes of screening and treatment. Some of the early data on risk assessment were based primarily on research in white women.[10] In the meantime, breast cancer screening and treatment have become a global model of disparity reduction[11,12,13] with clearly documented disparate survival outcomes that range from 32% in sub-Saharan Africa to 81% in the United States,[14] driving research to improve outcomes. Although social factors, access to mammography, and expensive treatments lead the causes of disparities in developing countries, in the United States different forces operate to maintain racial disparities.

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