• Christina Hunter Chapman, Clyde B Schechter, Christopher J Cadham, Amy Trentham-Dietz, Ronald E Gangnon, Reshma Jagsi, and Jeanne S Mandelblatt.
• Center for Clinical Management Research, VA Ann Arbor Healthcare System, and University of Michigan Medical School, Ann Arbor, Michigan (C.H.C.).
• Ann. Intern. Med. 2021 Dec 1; 174 (12): 163716461637-1646.

BackgroundScreening mammography guidelines do not explicitly consider racial differences in breast cancer epidemiology, treatment, and survival.ObjectiveTo compare tradeoffs of screening strategies in Black women versus White women under current guidelines.DesignAn established model from the Cancer Intervention and Surveillance Modeling Network simulated screening outcomes using race-specific inputs for subtype distribution; breast density; mammography performance; age-, stage-, and subtype-specific treatment effects; and non-breast cancer mortality.SettingUnited States.ParticipantsA 1980 U.S. birth cohort of Black and White women.InterventionScreening strategies until age 74 years with varying initiation ages and intervals.MeasurementsOutcomes included benefits (life-years gained [LYG], breast cancer deaths averted, and mortality reduction), harms (mammographies, false positives, and overdiagnoses), and benefit-harm ratios (tradeoffs) by race. Efficiency (benefits per unit resource), mortality disparity reduction, and equity in tradeoffs were evaluated. Equitable strategies for Black women were defined as those with tradeoffs closest to benchmark values for screening White women biennially from ages 50 to 74 years.ResultsBiennial screening from ages 45 to 74 years was most efficient for Black women, whereas biennial screening from ages 40 to 74 years was most equitable. Initiating screening 10 years earlier in Black versus White women reduced Black-White mortality disparities by 57% with similar LYG per mammogram for both populations. Selection of the most equitable strategy was sensitive to assumptions about disparities in real-world treatment effectiveness: The less effective treatment was for Black women, the more intensively Black women could be screened before tradeoffs fell short of those experienced by White women.LimitationSingle model.ConclusionInitiating biennial screening in Black women at age 40 years reduces breast cancer mortality disparities and yields benefit-harm ratios that are similar to tradeoffs of White women screened biennially from ages 50 to 74 years.Primary Funding SourceNational Cancer Institute at the National Institutes of Health.

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