Even with Growing Adoption of Advanced Breast Cancer Screening Disparities in Care Remain

Watching a mammogram-the result of x-ray examination of the mammary glands for the prevention of breast cancer. Courtesy: Fotolia/Evgeniy Kalinovskiy
Watching a mammogram-the result of x-ray examination of the mammary glands for the prevention of breast cancer. Courtesy: Fotolia/Evgeniy Kalinovskiy

While more women than ever in the United States are receiving advanced, 3-D mammography, disparities remain.

This is the conclusion reached by Yale researchers in a new study published in the journal JAMA Internal Medicine. The study, funded in part by the National Institutes of Health/National Center for Advancing Translational Sciences and by the American Cancer Society, shows that, according to the researchers, the adoption of the screening technology technology varies widely, reflecting emerging disparities in care.

Digital breast tomosynthesis

Three-D mammography, also known digital breast tomosynthesis, or DBT combines low-dose X-rays with software that creates a 3-D image of the breast. Compared to 2-D mammography, DBT may make it easier for radiologists to detect an abnormality. However, DBT has not been widely endorsed for routine breast cancer screening. Organizations like the U.S. Preventive Services Task Force and the American Cancer Society, which provide guidance to clinicians about cancer screening, have not made recommendations for or against the routine use of DBT.

Use of DBT

To assess the extent of DBT use nationwide, the Yale team examined deidentified claims data from private health insurance plans, received through Yale University?s participation in the Blue Cross Blue Shield Alliance for Health Research (BCBS Alliance), which engages leading U.S. healthcare researchers in collaborative efforts to improve the health of Americans.

Their investigation included more than 9 million screening exams performed over three years. They also compared DBT use with privately insured versus Medicare-insured patients.

Substantial Growth

The researchers found that DBT use rose substantially, from 12.9% to 43.2% of screening exams between 2015 and 2017. The increase was consistent among women who were privately insured and women with Medicare.

Ilana Richman, MD, Assistant Professor, Yale
Ilana Richman, MD, Assistant Professor, is a general internist and health services researcher. Her research interests explore how health policy and preventive services intersect and how we can use specific policies to promote both better health and value in healthcare.

?DBT has become very popular overall, although uptake has been uneven. In some areas of the country, it is rarely used while in others, it is the predominant mode of screening,? noted corresponding author Ilana Richman, MD, assistant professor in the Section of General Internal Medicine at the Yale School of Medicine.

Richman and her co-authors also observed that adoption of DBT varied greatly by region and demographics. Use of the technology grew more quickly in the Northeast and Northwest but more slowly in the Southeast. DBT was more rapidly adopted in areas with higher incomes, greater education, and larger white populations, they said.

While there is evidence that DBT may boost cancer detection rates and reduce false-positive results, more research is needed to determine the true impact of the technology on breast cancer mortality, the researchers said.

Cary Gross, MD, is a Professor of Medicine, and Director of the National Clinician Scholars Program at Yale. Gross completed his residency in Internal Medicine at New York Hospital-Cornell Medical Center and served as chief medical resident at Memorial Sloan-Kettering Cancer Center the following year.His research addresses comparative effectiveness, quality, and population health, with a focus on cancer prevention and treatment. He is a founding Director of Yale?s Cancer Outcomes Public Policy and Effectiveness Research Center (COPPER). His research has been supported by the National Cancer Institute, the Agency for Healthcare Research and Quality, and the American Cancer Society, among others. As a former Robert Wood Johnson Foundation Clinical Scholar, Gross has advanced training in biostatistics, epidemiology, research ethics, and outcomes research.

?Although there is a lot of interest in this new technology, we don?t know much about how it will affect the long-term health of women,? Richman noted. ?There are ongoing studies designed to answer these questions, and we hope to have clearer answers in the next few years.?

The authors predict that, given these findings, DBT will replace 2-D mammography as the standard of care.

?[Our] findings highlight how quickly changes in medical practice ? the rate that doctors adopt these new tests ? can eclipse our ability to evaluate whether they are helping patients to live longer and healthier lives,? concluded senior author and professor of medicine Cary Gross, MD.