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Comparative Study
. 2021 Feb 1;4(2):e2037546.
doi: 10.1001/jamanetworkopen.2020.37546.

Comparative Access to and Use of Digital Breast Tomosynthesis Screening by Women's Race/Ethnicity and Socioeconomic Status

Christoph I Lee  1   2 , Weiwei Zhu  3 , Tracy Onega  4 , Louise M Henderson  5   6 , Karla Kerlikowske  7   8   9 , Brian L Sprague  10   11 , Garth H Rauscher  12 , Ellen S O'Meara  3 , Anna N A Tosteson  13 , Jennifer S Haas  14 , Roberta diFlorio-Alexander  15 , Celia Kaplan  7 , Diana L Miglioretti  16   17
Affiliations
Comparative Study

Comparative Access to and Use of Digital Breast Tomosynthesis Screening by Women's Race/Ethnicity and Socioeconomic Status

Christoph I Lee et al. JAMA Netw Open. .

Abstract

Importance: Digital breast tomosynthesis (DBT) has reduced recall and increased cancer detection compared with digital mammography (DM), depending on women's age and breast density. Whether DBT screening access and use are equitable across groups of women based on race/ethnicity and socioeconomic characteristics is uncertain.

Objective: To determine women's access to and use of DBT screening based on race/ethnicity, educational attainment, and income.

Design, setting, and participants: This cross-sectional study included 92 geographically diverse imaging facilities across 5 US states, at which a total of 2 313 118 screening examinations were performed among women aged 40 to 89 years from January 1, 2011, to December 31, 2017. Data were analyzed from June 13, 2019, to August 18, 2020.

Exposures: Women's race/ethnicity, educational level, and community-level household income.

Main outcomes and measures: Access to DBT (on-site access) at time of screening by examination year and actual use of DBT vs DM screening by years since facility-level DBT adoption (≤5 years).

Results: Among the 2 313 118 screening examinations included in the analysis, the proportion of women who had DBT access at the time of their screening appointment increased from 11 558 of 354 107 (3.3%) in 2011 to 194 842 of 235 972 (82.6%) in 2017. In 2012, compared with White women, Black (relative risk [RR], 0.05; 95% CI, 0.03-0.11), Asian American (RR, 0.28; 95% CI, 0.11-0.75), and Hispanic (RR, 0.38; 95% CI, 0.18-0.80) women had significantly less DBT access, and women with less than a high school education had lower DBT access compared with college graduates (RR, 0.18; 95% CI, 0.10-0.32). Among women attending facilities with both DM and DBT available at the time of screening, Black women experienced lower DBT use compared with White women attending the same facility (RRs, 0.83 [95% CI, 0.82-0.85] to 0.98 [95% CI, 0.97-0.99]); women with lower educational level experienced lower DBT use (RRs, 0.79 [95% CI, 0.74-0.84] to 0.88 [95% CI, 0.85-0.91] for non-high school graduates and 0.90 [95% CI, 0.89-0.92] to 0.96 [95% CI, 0.93-0.99] for high school graduates vs college graduates); and women within the lowest income quartile experienced lower DBT use vs women in the highest income quartile (RRs, 0.89 [95% CI, 0.87-0.91] to 0.99 [95% CI, 0.98-1.00]) regardless of the number of years after facility-level DBT adoption.

Conclusions and relevance: In this cross-sectional study, women of minority race/ethnicity and lower socioeconomic status experienced lower DBT access during the early adoption period and persistently lower DBT use when available over time. Future efforts should address racial/ethnic, educational, and financial barriers to DBT screening.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Lee reported receiving grants from the National Cancer Institute (NCI), grants from GE Healthcare to his institution, personal fees from GRAIL, Inc, for service on a data safety monitoring board, research consulting fees for service on a data safety monitoring board, textbook royalties from McGraw Hill, Inc, Wolters Kluwer, and Oxford University outside the submitted work, and personal fees from the American College of Radiology for work on the editorial board of the Journal of the American College of Radiology. Ms Zhu reported receiving grants from the NCI and the Patient-Centered Outcomes Research Institute (PCORI) during the conduct of the study. Dr Henderson reported receiving grants from the NCI, National Institutes of Health (NIH), during the conduct of the study. Dr Kerlikowske reported receiving grants from the NCI and PCORI during the conduct of the study and serving as an unpaid consultant for GRAIL, Inc, for the STRIVE (Staff Time Resource Intensity Verification) study. Dr Sprague reported receiving grants from the NIH, PCORI, and Lake Champlain Cancer Research Organization during the conduct of the study. Dr O’Meara reported receiving grants from the NIH and PCORI during the conduct of the study. Dr Tosteson reported receiving grants from the NCI, NIH, and PCORI during the conduct of the study. Dr Kaplan reported receiving grants from the NIH during the conduct of the study. Dr Miglioretti reported receiving grants from the NIH and PCORI during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Access to and Use of Digital Breast Tomosynthesis (DBT) at Screening Visit Over Time
A, Calculated from 2 313 118 screening examinations included in the analysis. B, Calculated from 631 800 screening examinations in which DBT was obtained over digital mammography at time of imaging by years since facility-level DBT adoption.
Figure 2.
Figure 2.. Digital Breast Tomosynthesis (DBT) Access at Screening Visit by Sociodemographic Characteristics Over Time
Unadjusted proportions of screening examinations in 2011 to 2017 for which DBT was available at the facility level at time of imaging are calculated based on year and race/ethnicity (A), rurality of residence (B), educational level (C), and cohort quartile of zip code–based median household income (D). GED indicates General Educational Development.
Figure 3.
Figure 3.. Digital Breast Tomosynthesis (DBT) Use If Available During the Screening Visit by Race/Ethnicity, Educational Level, and Income Level Over Time
Data are calculated as relative risk of obtaining DBT over digital mammography when both modalities were available at time of screening by race/ethnicity (A), educational level (B), and income quartile (C) and by year since facility-level DBT adoption. Error bars indicate 95% CIs.
See this image and copyright information in PMC

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References

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