Racial and Socioeconomic Disparities in Breast Cancer Diagnostic Work Up and Outcomes

While breast cancer mortality has decreased in the U.S. over the last two decades, reductions have not been experienced equally by all women. Black women as well as women with lower income, less insurance and rural residence, experience lower survival rates, more advanced breast cancers at diagnosis, and less access to high quality care after screening. Less is known about disparities during the diagnostic work-up period.  Women must navigate multiple steps after an abnormal screening mammogram, such as additional imaging and biopsies before receiving a definitive diagnosis. More than 12 million women in the U.S. must undergo additional diagnostic tests annually. Failure to receive timely, quality diagnostic work-up may result in delayed diagnosis, more invasive procedures, delayed treatment, and fewer treatment options. Women of minority race/ethnicity, lower education, lower income, rural residence, and the underinsured - may encounter more diagnostic obstacles than non-vulnerable women, such as difficulty accessing standard of-care imaging (e.g., ultrasound, image-guided biopsy) at their usual place of service. These diagnostic disparities are associated with longer delays to surgery and treatment, and worse overall outcomes. Providing equitable, timely access to quality diagnostic work-up can reduce these breast cancer disparities.

The goal of this study, led by Christoph Lee at the University of Washington, in collaboration with the VBCSS and the Breast Cancer Surveillance Consortium (BCSC) is to identify the woman-, residential-, exam-, provider-, and practice-level factors that affect diagnostic outcomes and that may serve as targets for interventions aimed at mitigating disparities. We hypothesize that vulnerable women have less access to diagnostic imaging technologies, experience more diagnostic failures and management delays, and that practice-level determinants play a significant role in diagnostic disparities.

This study has three aims - Racial and Socioeconomic Disparities

  1. Identify vulnerable women who have less access to and use of diagnostic technologies. We will identify specific groups of vulnerable women with less access to and use of standard-of-care and advanced diagnostic imaging technologies and determine the multi-level factors that contribute to these disparities.
  2. Determine woman-, exam-, provider-, and practice-level factors that affect diagnostic outcomes of vulnerable vs. non-vulnerable women. We will characterize differences in clinically significant diagnostic outcomes and use multi-level modeling to identify health determinants that mediate these disparities.
  3. Determine woman-, exam-, provider-, and practice-level factors that affect timeliness of diagnostic evaluation among vulnerable vs. non-vulnerable women. Informed by Aims 1 and 2, we will identify points of delay along the diagnostic evaluation continuum that can serve as quality-of-care indicators of disparities between vulnerable vs. non-vulnerable women and targets for future interventions.

These aims will be carried out using existing data from the Breast Cancer Surveillance Consortium (BCSC) which consists of national experts in breast cancer epidemiology, biostatistics, data science, medicine and radiology. The BCSC represents the largest longitudinal U.S. breast cancer imaging data resource that is representative of the general U.S. population by race/ethnicity. With data already collected for over 13 million exams, 5.5 million of which were performed among vulnerable women, we are well-positioned to address disparities in breast cancer diagnosis and management.

Please click here to access publications associated with this study

This project is funded by grant R01 CA266377 from the National Cancer Institute (NCI).