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Structural Racism and Health-Care System Barriers May Contribute to Breast Biopsy Delays


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Black and Asian women are more likely than White women to experience significant delays in getting breast biopsies after a mammogram identifies an abnormality. Moreover, those delays appear to be influenced by screening site–specific factors that may stem from structural racism, according to research published by Lawson et al in JAMA Oncology.

“Even after adjusting for multiple factors thought to contribute to delayed diagnosis, we still see persistent disparities among minority women, particularly Black women. To me, this suggests that other underlying factors are contributing to these differences in time to biopsy,” said first study author Marissa B. Lawson, MD, acting instructor of radiology at the University of Washington School of Medicine in Seattle.

Findings on Delays

The study reviewed the cases of 45,186 women whose screening mammograms had shown a tissue abnormality that called for a biopsy to ascertain whether it was cancerous. Across the study population, 34.6% of women were not biopsied within 30 days, 16% were not biopsied at 60 days, and 12% were not biopsied within 90 days. The delays are concerning because previous studies have indicated that the benefit of screening diminishes with time, and these lags are associated with later-stage disease at time of diagnosis.

Using the time-to-biopsy of White patients as the benchmark, the researchers found that at 30 days out, Asian women had a 66% higher risk of not undergoing a biopsy; Black women, 52% higher; and Hispanic women, 50% higher. At 90 days out, Black women had a 28% higher risk of not undergoing a biopsy; among Asian women and Hispanic women, the risk was 21% higher and 12% higher, respectively.

KEY POINTS

  • Using the time-to-biopsy of White patients as the benchmark, the researchers found that at 30 days out, Asian women had a 66% higher risk of not undergoing a biopsy; Black women, 52% higher; and Hispanic women, 50% higher.
  • At 90 days out, Black women had a 28% higher risk of not undergoing a biopsy; among Asian women and Hispanic women, the risk was 21% higher and 12% higher, respectively.

With that unadjusted model, the researchers then examined whether specific factors of individual patients, their neighborhoods, and their screening facilities influenced the time to biopsy among women of different races and ethnicities. 

“Controlling for individual- and neighborhood-level factors, we saw that risk was not very different from the unadjusted model,” Dr. Lawson explained. “But when we controlled for the screening facility attended, delays in time to biopsy were reduced.”

Digging deeper, the investigators examined the influence of predesignated site-level factors—academic affiliation, screening exam modality, and the availability of onsite biopsy—and were surprised to find that none of those factors explained the overt difference.

“The findings indicate that there are some differences among the screening facilities associated with the time to biopsy. We just don't know what the specific differences are,” Dr. Lawson said.

The authors wrote, “Structural racism, within and beyond health care, may contribute to these differences.”

The screening sites are all associated with the Breast Cancer Surveillance Consortium, a U.S. network of breast imaging registries that is representative of the country’s population in terms of age, race, and ethnicity.

“Our findings highlight an opportunity for radiology departments to consider where they can commit resources to improve wait times for biopsy. This could include implementing changes in that diagnostic pathway, such as using navigators to help guide patients through the process of scheduling exams and procedures,” said Christoph I. Lee, MD, MS, Professor of Radiology at the University of Washington School of Medicine and the paper’s senior author.

Disclosure: The research was supported by the National Cancer Institute, the Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, the Lake Champlain Cancer Research Organization, the Breast Cancer Surveillance Consortium, the University of Vermont, the University of California Davis, and the Placer County Breast Cancer Foundation. For full disclosures of the study authors, visit jamanetwork.com.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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