Social Drivers of Guideline-Discordant Breast Cancer Screening by Age and Mortality Risk

Understanding social drivers of mammography screening is critical to implementing breast cancer screening guidelines that maximize benefits and minimize harms across diverse populations. We examined racial/ethnic, socioeconomic, and geographic patterns in guideline-discordant underscreening and overscreening according to guidelines based on age and mortality risk.

We used 2022 Behavioral Risk Factor Surveillance System data and major screening guidelines to define screening participation. Underscreening captured mammography in the past 2 years among women ages 50 to 74 years. Overscreening included any mammography beyond age 74 years or among women ages 50+ years with high mortality risk. We used modified Poisson regression to examine screening by race/ethnicity, regular healthcare provider access, and metropolitan, educational, and marital status.

Among 88,326 women ages 50 to 74 years, compared with non-Hispanic (NH) White, NH American Indian/Alaskan Native [adjusted prevalence ratio (aPR) = 0.88, 95% confidence interval (CI), 0.79-0.97] and NH women of unknown race (aPR = 0.86, 95% CI, 0.78-0.94) were less likely to be screened, whereas NH Black (aPR = 1.11, 95% CI, 1.09-1.13) women were more likely. Among 31,477 women ages 75+ years, NH Black women were more likely to be screened than NH White women (aPR = 1.07, 95% CI, 1.01-1.14). Among women with high mortality risk, NH Black (aPR = 1.20, 95% CI, 1.12-1.28) women were more likely to be screened than NH White women. Screening was lower among women with more limited socioeconomic resources regardless of age or mortality risk.

Findings reveal social drivers of underscreening and overscreening and the need for equitable breast cancer screening delivery.

This work calls for strengthening implementation and de-implementation efforts to optimize breast cancer screening.