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. 2023 Nov 1;32(11):1531-1541.
doi: 10.1158/1055-9965.EPI-23-0330.

Sources of Disparities in Surveillance Mammography Performance and Risk-Guided Recommendations for Supplemental Breast Imaging: A Simulation Study

Rebecca A Hubbard  1 , Toyya A Pujol  2 , Elie Alhajjar  3 , Kossi Edoh  4 , Melissa L Martin  1
Affiliations

Sources of Disparities in Surveillance Mammography Performance and Risk-Guided Recommendations for Supplemental Breast Imaging: A Simulation Study

Rebecca A Hubbard et al. Cancer Epidemiol Biomarkers Prev. .

Abstract

Background: Surveillance mammography is recommended for all women with a history of breast cancer. Risk-guided surveillance incorporating advanced imaging modalities based on individual risk of a second cancer could improve cancer detection. However, personalized surveillance may also amplify disparities.

Methods: In simulated populations using inputs from the Breast Cancer Surveillance Consortium (BCSC), we investigated race- and ethnicity-based disparities. Disparities were decomposed into those due to primary breast cancer and treatment characteristics, social determinants of health (SDOH) and differential error in second cancer ascertainment by modeling populations with or without variation across race and ethnicity in the distribution of these characteristics. We estimated effects of disparities on mammography performance and supplemental imaging recommendations stratified by race and ethnicity.

Results: In simulated cohorts based on 65,446 BCSC surveillance mammograms, when only cancer characteristics varied by race and ethnicity, mammograms for Black women had lower sensitivity compared with the overall population (64.1% vs. 71.1%). Differences between Black women and the overall population were larger when both cancer characteristics and SDOH varied by race and ethnicity (53.8% vs. 71.1%). Basing supplemental imaging recommendations on high predicted second cancer risk resulted in less frequent recommendations for Hispanic (6.7%) and Asian/Pacific Islander women (6.4%) compared with the overall population (10.0%).

Conclusions: Variation in cancer characteristics and SDOH led to disparities in surveillance mammography performance and recommendations for supplemental imaging.

Impact: Risk-guided surveillance imaging may exacerbate disparities. Decision-makers should consider implications for equity in cancer outcomes resulting from implementing risk-guided screening programs. See related In the Spotlight, p. 1479.

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Conflict of interest statement

The authors have no conflicts of interest.

Figures

Figure 1.
Figure 1.
Directed acyclic graph (DAG) representing hypothesized causal relationships between race and ethnicity, primary cancer and treatment characteristics, and social determinants of health (SDOH) and second cancer occurrence and surveillance mammography performance in women with a personal history of breast cancer. Nodes and edges in gray represent factors not incorporated into simulation studies.
Figure 2.
Figure 2.
Simulation results for surveillance mammography false-positive probabilities overall and stratified by race and ethnicity in simulated populations of women with a personal history of breast cancer. Box plots provide medians (black bar), 25th and 75th percentile (box), observations within 1.5 times the interquartile range above and below the 25th and 75th percentile (whiskers), and outliers (points) computed across 10,000 simulation iterations. Panel A provides results for the scenario with no differences in characteristics by race and ethnicity. Panel B provides results for the scenario with only variation in primary cancer and treatment characteristics by race and ethnicity. Panel C provides results for the scenario with only variation in social determinants of health (SDOH) by race and ethnicity. Panel D provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity. Panel E provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity as well as differential error in second cancer ascertainment. PI = Pacific Islander.
Figure 3.
Figure 3.
Simulation results for surveillance mammography sensitivity overall and stratified by race and ethnicity in simulated populations of women with a personal history of breast cancer. Box plots provide medians (black bar), 25th and 75th percentile (box), observations within 1.5 times the interquartile range above and below the 25th and 75th percentile (whiskers), and outliers (points) computed across 10,000 simulation iterations. Panel A provides results for the scenario with no differences in characteristics by race and ethnicity. Panel B provides results for the scenario with only variation in primary cancer and treatment characteristics by race and ethnicity. Panel C provides results for the scenario with only variation in social determinants of health (SDOH) by race and ethnicity. Panel D provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity. Panel E provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity as well as differential error in second cancer ascertainment. PI = Pacific Islander.
Figure 4.
Figure 4.
Simulation results for the proportion of women meeting a threshold of predicted surveillance mammography sensitivity <50% overall and stratified by race and ethnicity in simulated populations of women with a personal history of breast cancer. Box plots provide medians (black bar), 25th and 75th percentile (box), observations within 1.5 times the interquartile range above and below the 25th and 75th percentile (whiskers), and outliers (points) computed across 10,000 simulation iterations. Panel A provides results for the scenario with no differences in characteristics by race and ethnicity. Panel B provides results for the scenario with only variation in primary cancer and treatment characteristics by race and ethnicity. Panel C provides results for the scenario with only variation in social determinants of health (SDOH) by race and ethnicity. Panel D provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity. Panel E provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity as well as differential error in second cancer ascertainment. PI = Pacific Islander.
Figure 5.
Figure 5.
Simulation results for the proportion of women meeting a threshold of predicted second cancer risk >2.5 per 1000 overall and stratified by race and ethnicity in simulated populations of women with a personal history of breast cancer. Box plots provide medians (black bar), 25th and 75th percentile (box), observations within 1.5 times the interquartile range above and below the 25th and 75th percentile (whiskers), and outliers (points) computed across 10,000 simulation iterations. Panel A provides results for the scenario with no differences in characteristics by race and ethnicity. Panel B provides results for the scenario with only variation in primary cancer and treatment characteristics by race and ethnicity. Panel C provides results for the scenario with only variation in social determinants of health (SDOH) by race and ethnicity. Panel D provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity. Panel E provides results for the scenario with variation in primary cancer and treatment characteristics and SDOH by race and ethnicity as well as differential error in second cancer ascertainment. PI = Pacific Islander.
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References

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