Breast Ca Risk Assessment by PCPs Could Help Reduce Racial Inequities

Black and Hispanic women at high risk for breast cancer were more likely to get a screening mammogram if they had previously undergone a risk assessment for breast cancer at a federally qualified primary care health center, a cohort study found. In contrast, Black and Hispanic women at average risk for breast cancer were not significantly more likely to undergo screening mammography when given the same risk assessment, the same study indicated.

Out of 90 women at high-risk for breast cancer, 51.1% sought out screening mammography following breast cancer risk assessment (BCRA) compared with 36.6% during usual care, an improvement in mammography uptake of 88% at an odds ratio (OR) of 1.88 (95% CI, 1.10-3.23; P=0.02), Candice Schwartz, MD, University of Illinois At Chicago, Illinois, and colleagues reported in JAMA Network Open.

Another 98 women were assessed as being at average risk for developing breast cancer. In this group, there was a non-significant change in mammography uptake increasing to 48.9% following risk assessment compared with 38.8% prior to risk assessment, a 37% increase in screening uptake at an OR of 1.37 (95% CI, 0.92-2.03; P=0.30) which did not reach statistical significance, the authors noted.

“Black women in the U.S. historically have had lower rates of screening mammography which leads to a higher proportion of late-stage diagnoses and lower survival rates,” Schwartz and colleagues wrote. Their study found that regular breast cancer risk assessments combined with routine preventive health “was associated with improved use of screening mammography among women of underserved racial and ethnic minority groups who had a high risk of breast cancer.”

A total of 188 women were age-eligible for mammography and were included in the analysis. The mean age of the group overall was 50.8 years; 37.2% were Hispanic; 60.6% were non-Hispanic African American, and 2.1% were from other racial and ethnic groups.

“Breast cancer risk assessment was performed by non-licensed clinic staff for all women aged 25 to 69 years who did not have a personal history of breast cancer on presentation for an annual well visit or new-patient visit with their primary care clinician,” the authors explained.

Patients were deemed high risk for breast cancer if the BCRA indicated they had any of the following features:

• A family history of breast or ovarian cancer.
• A lifetime risk of breast cancer in excess of 20%.
• A 5-year breast cancer risk greater than 1.7%.

Women who did not meet these criteria were classified as average risk.

“The primary outcome was the mammography rate during 18 months of usual care compared with the rate during 18 months after implementation of risk assessment,” the authors pointed out.

Compared with women assessed as being at average risk for breast cancer, high-risk women were more likely to be Black; to report that they had discussed breast cancer risk with their primary health provider; were less likely to correctly identify their level of breast cancer risk before knowing their results, and more likely to report a moderate or high level of worry about developing breast cancer.

In fact, fewer than half of all women at high risk for breast cancer correctly perceived their risk status compared with more than 70% of women at average risk.

“Somewhat unexpectedly, perceived risk was not associated with mammography use in the entire cohort or in either of the risk-stratified subgroups,” the researchers wrote. However, they did observe a numeric increase in mammography adherence among women who had ever discussed their breast cancer risk with a physician both in the entire cohort and in both risk-stratified groups, they added.

“These data suggest that coupling individualized risk estimated with tailored educational material and decision aids may stimulate discussion with clinicians and may be more useful in motivating engagement in breast cancer screening than simply delivering risk estimates, as done in this study,” the study authors wrote.

They cautioned, however, that a potential unintended consequence of widespread implementation of BCRA in asymptomatic women might give women a false sense of security at least for those at average risk and reduce mammography uptake. The fact that they did not actually observe this in their own study “suggests that providing individualized risk estimates might be associated with improved mammography use in women of underserved racial and ethnic minority groups regardless of risk status,” they noted.

The authors suggested that their approach warrants further study as a strategy by which to reduce racial inequalities in breast cancer mortality.

Commenting on the finding, Elizabeth Valencia, MD and Sandhya Pruthi, MD, both from the Mayo Clinic in Rochester, Minnesota, suggested that there are two potential situations in which BCRA strategies could be offered.

One when a woman sees her primary care physician for usual care concerns, and two when patients present for their screening mammogram.

“The mammogram appointment provides an important point to complete a breast history questionnaire that [provides] important information for the radiologist for imaging interpretation, diagnosis, and recommendations,” the editorialists pointed out.

When an elevated risk for breast cancer is identified, “radiology reports can include recommendations that the patient may benefit from a formal breast cancer risk assessment and patient discussion for possible supplemental imaging to improve breast cancer detection,” Valencia and Pruthi wrote.

However, any educational material or decision aids provided to patients regarding their breast cancer risk must be culturally appropriate, they cautioned, as research has shown that patient engagement and understanding of health care recommendations is better when they receive culturally appropriate material.

“Reducing health disparities in women of racial or ethnic minority groups is a public health priority,” Valencia and Pruthi emphasized and added, “Incorporation of easily available validated risk assessments into a busy primary practice is a scalable population-level strategy that will help promote health equity and change clinical practice.”

Breast cancer mortality rates for Black women in the U.S. remain 40% higher compared with those among White women.

1. Primary care breast cancer risk assessment increased mammography uptake among high-risk but not average-risk Black and Hispanic women.

2. Incorporating breast cancer risk assessment into either primary care or at the time of screening mammography could help promote health equities among racial and ethnic minorities

Pam Harrison, Contributing Writer, BreakingMED™

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