In 2015, Philadelphia boasted one of the highest breast cancer screening rates in Pennsylvania. It ranked third among the 10 largest U.S. cities with 82% of women age 50 to 74 having received a mammogram in the previous two years, according to the city's community health assessment.
While good news for the city, the incidence and outcomes data generated by the screening campaign painted a harrowing picture for at least one subpopulation: Women from west Philadelphia had the highest breast cancer mortality rate in the city and surrounding suburban areas, despite lower rates of the disease.
Main Line Health's Lankenau Medical Center, which serves the community where more than 70% of the population is black and the average annual income is less than $30,000, decided to tackle what it saw as one of the root causes of the disparity. It moved to step up its already extensive mammography outreach campaign to include women under age 50.
And that made the program unique. Federal guidelines have recommended against routine screening for women under that age since 2009.
The rejection of federal guidelines in west Philadelphia is a response to a long-standing conundrum in cancer care: Race and ethnicity are closely correlated with survival rates, especially with breast cancer. Though black women are less likely to contract the disease, those who develop breast tumors are 42% more likely to die than their white counterparts.
Researchers have not come up with conclusive reasons for this disparate outcome. Yet many public health and civil-rights advocates point to one possible cause: the evidence that young black women are more likely to contract the disease than their white counterparts. Not only are black women under age 40 more likely to develop breast cancer than women from other racial groups, those under 35 have more than twice the breast cancer incidence rate compared with white women the same age, according to a 2009 National Institutes of Health-funded study published in the journal Seminars in Oncology.
And that has put a target on the latest recommendations from the U.S. Preventive Services Task Force, or USPSTF, whose guidelines for tests such as mammograms determine whether plans sold on the Affordable Care Act exchanges must offer the services free of charge.
“This is a civil-rights issue,” said James Rawlings, a clinical instructor of epidemiology at Yale and health chair of the Connecticut state branch of the NAACP.
Black women should be explicitly deemed “high risk, so that they immediately qualify for screening and mammography at younger ages and don't run into problems with insurers,” he said. The NAACP's national board plans to review the issue during its convention in July.
The USPSTF guideline writers did not find sufficient data to conclude that earlier screenings would reduce delays in treatment or the mortality disparities found in black women. “We just don't have enough information, one way or another, to tell us that,” said Dr. Kirsten Bibbins-Domingo, chair of the USPSTF and a professor of medicine and epidemiology at the University of California at San Francisco.
These subpopulations have been “worryingly understudied,” she said. The task force is required to follow the existing evidence.
About 12% of U.S. women develop breast cancer. Each year, more than 40,000 women die from the disease. The overall death rate has dropped 36% since 1989, which specialists attribute to an increase in mammography screening over the past three decades. The American Cancer Society estimates that such screenings reduce the risk of death from breast cancer by 20%.