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Original Investigation
June 23, 2022

Multilevel Factors Associated With Time to Biopsy After Abnormal Screening Mammography Results by Race and Ethnicity

Author Affiliations
  • 1Department of Radiology, University of Washington School of Medicine, Seattle
  • 2Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis
  • 3Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
  • 4Department of Radiation Oncology, Michigan Medicine, Ann Arbor
  • 5University of Wisconsin–Madison School of Medicine and Public Health, Madison
  • 6Department of Oncology, Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
  • 7Department of Population Health Sciences, University of Utah, Huntsman Cancer Institute, Salt Lake City
  • 8Departments of Radiology and Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
  • 9Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago
  • 10Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco
  • 11General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco
  • 12Departments of Surgery and Radiology, University of Vermont Cancer Center, University of Vermont, Burlington
  • 13Department of Economics, Applied Statistics, and International Business, New Mexico State University, Las Cruces
  • 14Kaiser Permanente Washington, Seattle
  • 15Department of Radiology, University of Washington School of Medicine, Seattle
  • 16Department of Health Services, University of Washington School of Public Health, Seattle
JAMA Oncol. Published online June 23, 2022. doi:10.1001/jamaoncol.2022.1990
Key Points

Question  Are individual-, neighborhood-, and health care–level factors associated with differences by race and ethnicity in time to diagnostic resolution following abnormal screening mammography results?

Findings  In this cohort study of 45 186 women with recommendation for biopsy after abnormal screening results, Black women had an increased risk of no biopsy within 30, 60, and 90 days after screening, adjusting for multilevel factors. The screening facility accounted for the greatest attenuation of Black women’s increased risk of no biopsy.

Meaning  These findings suggest interventions are needed to reduce systemic racism and health care system barriers to timely diagnosis after abnormal mammography results.


Importance  Diagnostic delays in breast cancer detection may be associated with later-stage disease and higher anxiety, but data on multilevel factors associated with diagnostic delay are limited.

Objective  To evaluate individual-, neighborhood-, and health care–level factors associated with differences in time from abnormal screening to biopsy among racial and ethnic groups.

Design, Setting, and Participants  This prospective cohort study used data from women aged 40 to 79 years who had abnormal results in screening mammograms conducted in 109 imaging facilities across 6 US states between 2009 and 2019. Data were analyzed from February 21 to November 4, 2021.

Exposures  Individual-level factors included self-reported race and ethnicity, age, family history of breast cancer, breast density, previous breast biopsy, and time since last mammogram; neighborhood-level factors included geocoded education and income based on residential zip codes and rurality; and health care–level factors included mammogram modality, screening facility academic affiliation, and facility onsite biopsy service availability. Data were also assessed by examination year.

Main Outcome and Measures  The main outcome was unadjusted and adjusted relative risk (RR) of no biopsy within 30, 60, and 90 days using sequential log-binomial regression models. A secondary outcome was unadjusted and adjusted median time to biopsy using accelerated failure time models.

Results  A total of 45 186 women (median [IQR] age at screening, 56 [48-65] years) with 46 185 screening mammograms with abnormal results were included. Of screening mammograms with abnormal results recommended for biopsy, 15 969 (34.6%) were not resolved within 30 days, 7493 (16.2%) were not resolved within 60 days, and 5634 (12.2%) were not resolved within 90 days. Compared with White women, there was increased risk of no biopsy within 30 and 60 days for Asian (30 days: RR, 1.66; 95% CI, 1.31-2.10; 60 days: RR, 1.58; 95% CI, 1.15-2.18), Black (30 days: RR, 1.52; 95% CI, 1.30-1.78; 60 days: 1.39; 95% CI, 1.22-1.60), and Hispanic (30 days: RR, 1.50; 95% CI, 1.24-1.81; 60 days: 1.38; 95% CI, 1.11-1.71) women; however, the unadjusted risk of no biopsy within 90 days only persisted significantly for Black women (RR, 1.28; 95% CI, 1.11-1.47). Sequential adjustment for selected individual-, neighborhood-, and health care–level factors, exclusive of screening facility, did not substantially change the risk of no biopsy within 90 days for Black women (RR, 1.27; 95% CI, 1.12-1.44). After additionally adjusting for screening facility, the increased risk for Black women persisted but showed a modest decrease (RR, 1.20; 95% CI, 1.08-1.34).

Conclusions and Relevance  In this cohort study involving a diverse cohort of US women recommended for biopsy after abnormal results on screening mammography, Black women were the most likely to experience delays to diagnostic resolution after adjusting for multilevel factors. These results suggest that adjustment for multilevel factors did not entirely account for differences in time to breast biopsy, but unmeasured factors, such as systemic racism and other health care system factors, may impact timely diagnosis.

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