Breast Cancer Diagnosis at First Mammogram Much More Prevalent in Black Women

Study calls attention to the need for screenings at age 40 or younger

Black women are significantly more likely to be diagnosed with breast cancer at the time of their first mammogram (47.6%) compared with White women (26%) and other groups (34.8%), according to a recent retrospective study undertaken by Cleveland Clinic’s Section of Breast Surgery within the Department of General Surgery. Women diagnosed on their first mammogram were more likely to be younger and have greater disease burden.

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Inconsistencies in current screening recommendations – along with shortfalls of existing screening models – may be contributing factors in later disease presentation, and consequently, increased mortality among young Black women.


Initiating annual mammograms at age 40 has proven to be the single best way to reduce breast cancer-related deaths. Despite this, screening recommendations are not consistent across medical societies and other organizations. The American College of Radiology, Society of Breast Surgeons and American College of Obstetricians and Gynecologists all recommend starting annual mammograms at age 40. The American Cancer Society advises starting at age 45. And the U.S. Preventative Services Task Force – who many PCPs follow – recommends mammograms starting at age 50.

Black women experience the highest rates of breast cancer earlier than age 50 and often present with more aggressive tumor biology. They are 42% more likely to die from the disease, so any delay in screening beyond age 40 is associated with increased risk. Although some inequities can be attributed to socioeconomic consequences of structural racism such as barriers to healthcare access and inequitable resource distribution (i.e., mammography screening and endocrine therapy), those factors alone do not explain the disparity in outcomes.

To help uncover ways to assess risk and individualize risk assessment and management, the research team sought to better understand just how much the inconsistencies in screening recommendations affect women who are diagnosed younger and with more aggressive disease. “We’re trying to understand more about cancer disparities and differentiate between factors that occur for socioeconomic reasons versus factors that can occur because there are differences in how the disease acts in different populations,” says Zahraa AlHilli, MD, study senior author and a general surgeon with Cleveland Clinic’s Digestive Disease and Surgery Institute. “Understanding these differences will help us better stratify risk.”

Study design

This retrospective cohort study included 738 women ages 40-45 who received treatment for breast cancer at Cleveland Clinic between 2010-2019. “We looked specifically at women between the ages of 40-45 because that is the age group that faces the most discordance in screening recommendations,” says Avia Wilkerson, MD, lead author of the study and a resident fellow at Cleveland Clinic

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Using the Cleveland Clinic tumor registry and electronic health record system, the researchers analyzed demographic, clinical and radiologic data for each patient. Having access to this registry enabled the researchers to understand not just the raw data but also obtain details about each patient’s diagnosis and treatment.

Study findings

The researchers’ hypothesis was that differences in screening recommendations was a contributing factor to why young Black women were presenting with later stage disease. The study data supported their hypothesis to a striking degree. Nearly half of Black women in the study were diagnosed at first mammogram – significantly more than any other racial group. Women diagnosed at their first mammogram were more likely to be diagnosed at an advanced clinical stage, and with metastatic disease.

The median age at first mammogram was 42.8 years for patients diagnosed on their first mammogram. Compared with the overall cohort of young women with breast cancer, the patients diagnosed on their first mammogram were younger and more often lacked a family history of disease. A statistically significant number of these patients had other risk factors such as high body mass indices, smoking and/or breast cancer symptoms at presentation.

These findings reinforce the fact that Black women would benefit from starting mammograms at age 40, and for those with an elevated lifetime risk, even sooner. “As a patient approaches age 40, it’s important to have a discussion about breast screening awareness, and whether they have risk factors,” says Dr. AlHilli.

Notably, current breast cancer risk assessment models were produced using data predominantly from patients of European descent. “These models don’t work well for predicting risk in women of other races,” explains Dr. Wilkerson. “In some Hispanic women it often overestimates risk while in Black women it can underestimate risk.”

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Next steps

Although new models are needed to more accurately assess each patient’s individual risk, it is clear that in lieu of these, commencing screenings at age 40 is prudent, with some women at higher risk requiring an earlier start.

In the meantime, the researchers are using the same patient cohort data gathered for this study to determine whether breast cancer diagnosis at first mammogram has an impact on shorter time to recurrence and/or overall survival. Dr. Wilkerson is also conducting translational research into the biology of breast cancer tumors and their role in breast cancer disparities.