Breast cancer incidence and outcomes exhibit significant disparities across different racial and ethnic groups, socioeconomic statuses, and geographic locations. Non-Hispanic Black women have higher breast cancer mortality rates compared to Non-Hispanic White women, despite having a slightly lower incidence rate; Black, Hispanic, and Asian/Pacific Islander women also show higher proportions of advanced-stage diagnoses compared to non-Hispanic White women [1]. Beyond racial and ethnic differences, women of lower socioeconomic status (SES) are more likely to present with advanced-stage breast cancer and have poorer outcomes. Lower SES is associated with higher breast cancer mortality rates, and these disparities persist even when controlling for race [2]. Geographically, women living in rural areas face higher breast cancer mortality rates and are more likely to be diagnosed at later stages compared to those in urban areas. There is, of course, an interplay of these risk factors that can compound risk in certain individuals. For example, rural non-Hispanic Black and Hispanic women are particularly affected, showing increased odds of late-stage diagnosis and higher mortality rates [3].

Why do these disparities exist? Given that routine screening and early detection are critical for improved survival, disparities in diagnostic mammography play a major role. Beneath racial and socioeconomic barriers to breast cancer screening and diagnostic steps lie factors such as health insurance coverage, logistical challenges, and limited access to healthcare facilities. For instance, women from lower socioeconomic backgrounds often face additional challenges such as lower health literacy, financial constraints, and limited transportation options, which impede their ability to access and complete breast cancer screening [4]. In addition, underserved women are more likely to be uninsured or underinsured, which hinders their ability to undergo regular mammography screening and follow-up diagnostic imaging when needed [5]. Perceived discrimination and mistrust of healthcare providers can deter minority women from seeking timely screening, and this mistrust can lead to diagnostic delay, resulting in more advanced stages of breast cancer at the time of diagnosis [6]. Structural and interpersonal racism further exacerbate these disparities, contributing to lower screening rates and higher mortality rates among minority women.

Efforts to address these disparities include enhancing community outreach programs, fostering trust between patients and healthcare providers, and culturally competent care. In particular, focusing on implementing radiology field-specific approaches like AI and teleradiology can help increase equitable screening rates and reduce breast cancer mortality in minority groups.

Racial and ethnic minority populations are less likely to receive standard-of-care breast cancer screening as well as diagnostic imaging after abnormal breast screening. Contributing factors identified include systemic barriers and delays, socioeconomic disparity, healthcare system characteristics, cultural and logistical barriers, and insurance or access issues.

Systemic Barriers and Delays

Studies have demonstrated that adherence to mammography schedules varies among different racial and ethnic groups. Black women generally have lower rates of mammography completion compared to White women. A 2023 study found that Black women aged 50-74 years had lower mammography completion rates (21%) compared to White women (27%) [7]. Asian women tend to have lower mammography screening rates compared to non-Hispanic White women, which may contribute to disparities in breast cancer detection and outcomes [8].

Research has not only shown racial and ethnic differences in routine breast cancer screening but also inequities in follow-up diagnostic imaging and biopsies after abnormal mammography results. The Radiology Society of Northern America (RSNA) found that racial and ethnic minority patients had reduced access to certain diagnostic technologies within 90 days following an abnormal screening. Specifically, Asian and Black patients were less likely than white patients to receive digital breast tomosynthesis; furthermore, individuals identifying as Asian, Black, or Hispanic/Latinx were less likely to undergo diagnostic imaging on the same day as their abnormal mammogram [9]. A 2016 cohort study examined factors contributing to delays in breast cancer diagnosis following abnormal screening mammograms. Among over 45,000 women across the US, Black, Asian, and Hispanic women were more likely to experience delays in receiving a biopsy, with the disparity most persistent for Black women, even after adjusting for individual, neighbourhood, and health care-level factors [10]. These studies suggest that structural and unmeasured factors like systemic racism cannot be ignored, as they contribute to diagnostic delays, later-stage cancer diagnoses, and worse outcomes.

Socioeconomic Factors

Socioeconomic factors, such as educational attainment and household income, significantly affect breast cancer screening and the receipt of standard-of-care diagnostic imaging after abnormal breast screening. Women with lower educational attainment and lower household incomes are more likely to miss mammography screenings. This trend was observed in a study using data from the Behavioral Risk Factor Surveillance System, which found that women with lower education and income levels reported higher proportions of missed mammograms [11]. A 2024 neighborhood-level study found that women living in disadvantaged neighborhoods, characterized by lower income and higher poverty rates, are less likely to adhere to breast cancer screening guidelines [12]. This is compounded by barriers such as lack of health insurance, transportation issues, and higher healthcare costs, which disproportionately affect women from lower SES backgrounds [13]. Furthermore, perceived everyday discrimination (PED) and SES are associated with mammography behavior. Black women with lower SES who report higher levels of PED are less likely to utilize mammography services [14]. This highlights the compounded effect of socioeconomic and psychosocial factors on breast cancer screening adherence.

Additionally, SES impacts the likelihood of undergoing advanced diagnostic imaging and biopsies after an abnormal screening mammogram. Women from lower SES backgrounds are less likely to receive same-day diagnostic services and biopsies compared to their higher SES counterparts [15]. Lower educational attainment and household income are associated with reduced breast cancer screening rates and lower likelihood of receiving timely diagnostic imaging after abnormal screenings, contributing to the relationship between SES and breast cancer mortality.

Healthcare System Factors

Variability in healthcare facility characteristics, such as target population, academic affiliation, and availability of on-site biopsy services, also contributes to disparities in breast cancer detection. A 2024 multilevel observational study recognized there is little research examining more than two ecological factors influencing the resolution of abnormal mammography. With data from over 25,000 women with abnormal mammograms, this study explored how patient, imaging facility, and county-level factors contribute to racial disparities in timely diagnostic resolution; Farr et al. found that Black women and Latinas were significantly less likely than White women to achieve diagnostic resolution within 60 days and experienced longer delays overall [16]. Facilities serving vulnerable populations, including racial and ethnic minorities, individuals with lower SES, and those in rural areas, often experience disparities in follow-up care, with fewer resources or longer wait times for diagnostic follow-up.

Academic affiliation and biopsy availability are also important factors to acknowledge. Facilities with academic affiliations are more likely to have on-site advanced breast imaging and biopsy services, which can facilitate timely diagnostic follow-up [17]. This availability reduces delays in diagnosis and treatment, improving outcomes for patients. The on-site availability of biopsy services is crucial for timely diagnostic resolution. Facilities without on-site biopsy capabilities may contribute to delays in diagnosis, particularly for underserved populations. Therefore, it is important to be aware of how certain healthcare system factors critically affect screening diagnosis of breast cancer.

Cultural and Logistical Barriers

Cultural and logistical barriers significantly impact breast cancer screening and diagnostic imaging, especially for American Indian or Alaska Native, Black, Hispanic, disabled, and LGBTQ+ individuals. Also, minority women often face additional barriers such as language differences, lack of transportation, and lower health literacy, which can impede timely follow-up.

Logistical barriers include transportation issues and clinic availability. Research demonstrates that many underserved populations, including American Indian or Alaska Native individuals, face challenges in accessing screening facilities due to lack of transportation [19]. In addition, inflexible clinic hours can prevent individuals from attending screenings, particularly those with demanding work schedules or caregiving responsibilities [20].

Psychological and knowledge-related barriers include fear and medical mistrust. A 2023 qualitative study in a diverse group of women found that fear of the screening process and fatalistic beliefs about cancer outcomes are prevalent among racial/ethnic minority women [21]. Furthermore, there is notable mistrust in the healthcare system that acts as a common barrier, particularly among Black women, which translates into lower screening rates [22].

From a sociocultural perspective, there are language and interpersonal barriers at play as well. Cultural beliefs and modesty concerns can deter women from participating in mammography screening [23]. Also, non-English speakers may face difficulties in understanding health information and navigating the healthcare system [24]. There is thus a complex interplay of cultural, logistical, psychological, and sociocultural barriers that contribute to persistent disparities in breast cancer screening and timely diagnostic follow-up among minority populations.

Insurance and Access Issues

Insurance status is a critical determinant of access to breast cancer screening and a significant determinant of follow-up care after abnormal mammography. Uninsured and underinsured individuals are less likely to undergo regular mammography screening and are more likely to experience delays in follow-up diagnostic imaging after an abnormal screening result. This is particularly pronounced among Black and Hispanic populations, who have higher rates of being uninsured or underinsured compared to White populations [25]. Lack of private health insurance is a significant barrier, particularly for Black and Hispanic women [18]. Community health centers, which serve a large proportion of low-income and uninsured patients, report lower breast cancer screening rates, particularly in clinics with high proportions of Black and uninsured patients; these disparities are exacerbated in non-Medicaid expansion states, where access to affordable healthcare is more limited [22]. Insurance barriers contribute to significant disparities in breast cancer screening and follow-up diagnostic imaging for Black and Hispanic individuals, leading to diagnostic delays and ultimately worse breast cancer outcomes.

It is critical to provide education and training in cultural competence and inequity awareness for nurses and doctors working in diagnostic mammography. There must be ongoing education about the language, customs, beliefs, and health practices of diverse populations. Culturally tailored education programs are essential for increasing awareness and understanding of breast cancer screening in diverse communities. The National Breast and Cervical Cancer Early Detection Program and other community-based initiatives have shown that culturally relevant education increases screening uptake by addressing specific cultural beliefs and misconceptions about breast cancer and its screening [23]. Culturally sensitive communication is also important, as adoption of appropriate verbal and nonverbal communication styles tailored to different cultural norms. Healthcare systems must prioritize the consistent use of professional interpreter services during mammography visits to bridge language gaps while avoiding ad hoc interpreters to ensure equitable outcomes that hinder access to breast cancer screening [4].

Broadly, providers must also recognize that discrimination is associated with decreased likelihood of obtaining a mammogram and anticipate mistreatment by healthcare providers can deter screening, especially among low-income Black women [6]. To apply this awareness to culturally sensitive and non-discriminatory clinical practice, radiology nurses and physicians must address specific needs of minority populations, tailoring care and screening protocols to ensure that high-risk and underrepresented patients (e.g., African American, Chinese, Latina, Muslim, and LGBTQ+ patients) are not lost to follow-up. These providers must also leverage resources from the American College of Radiology and RSNA focused on diversity and inclusion and continue to push for standardized curricula on breast health disparities for radiologists in training. Programs like the Achieving Cancer Equity through Identification, Testing, and Screening and the Mile Square Accessible Mammogram Outreach and Engagement have demonstrated that patient navigation significantly increases mammography rates and genetic risk assessments among underserved populations by providing personalized assistance and education. These programs help patients navigate the healthcare system, schedule appointments, and follow through with recommended screenings and diagnostic tests [24]. Flexible clinic hours and transportation assistance further reduce barriers to access. By offering services outside of traditional working hours and providing transportation, these programs ensure that patients who might otherwise miss appointments due to work or lack of transportation can still receive timely care [5].

In addition to bolstering cultural competencies and recognizing systemic inequities when practicing clinically, addressing the ecological factors impacting breast cancer screening and diagnostic imaging is essential. First, radiology departments should work with their healthcare institutions and pathology departments to increase the availability of on-site diagnostic services, including same-day imaging and biopsy. Ensuring that all screening facilities, regardless of location, have the capability to provide these services can help reduce delays in diagnosis and treatment. Second, academic affiliation of screening facilities has been associated with better access to advanced diagnostic services. Expanding partnerships between community health centers and academic institutions can help disseminate best practices and improve access to high-quality care. Third, given that rural areas often have fewer accredited breast imaging facilities, mobile mammography units and telehealth services can help bridge this gap by bringing screening and diagnostic services to underserved areas [5]. Finally, policy interventions and community outreach programs are necessary to address socioeconomic barriers. Legislative efforts, such as breast density notification laws and the Find It Early Act, aim to improve access to screening for underserved populations [4].

Addressing cultural competency and ecological components to breast cancer screening disparities is not a novel approach, but when combined with novel technological practices in the field of diagnostic mammography, a new model to address health inequity is created. Emerging technologies like teleradiology and AI promise to reduce breast cancer screening gaps by improving risk assessment and detection accuracy, although clinical integration requires careful evaluation to avoid exacerbating existing inequities. AI has significant potential to improve breast cancer screening by increasing detection rates, reducing false positives, and providing more accurate risk assessments. AI can be used as a tool for standardization and increased screening capacity, as it can assist or augment radiologists in interpreting mammograms, improving early detection rates. It can also reduce variability in interpretation and help deliver consistent quality across different settings, especially where human expertise is limited. However, for AI to benefit women in an equitable manner, it must be trained on racially diverse datasets and implemented widely. Models must be trained and validated on diverse datasets that reflect different racial, socioeconomic, and geographic groups; failure to do so risks embedding and amplifying existing disparities due to biased algorithms. Currently, access to AI tools may be limited (e.g., only available in certain geographic areas or to patients who can afford costs). To ensure AI reduces rather than worsens disparities, its adoption must be equitable, well-regulated, and focused on accessibility and effectiveness across diverse populations [4]. On a policy and infrastructure level, radiology departments must motivate healthcare institutions to invest in infrastructure (e.g., broadband access, data privacy compliance) and training for local professionals to support effective teleradiology and AI integration [25]. Policies promoting insurance coverage, mobile screening programs, and global training opportunities can also improve access and equity.

There is also expanded access to expertise via teleradiology. Teleradiology allows radiologists to interpret mammograms remotely, benefiting patients in underserved or remote areas with limited access to on-site specialists. It enables timely and accurate diagnoses and supports local clinicians through remote consultations and second opinions. Programs like mobile mammography units further extend access, especially in low- and middle-income settings. More globally, scientific mobility, including international exchange programs and fellowships, helps radiologists from high-resource and low-resource settings share best practices and develop culturally competent care models. Initiatives like “Radiologists without Borders” and institutional exchange programs enhance capacity-building in underserved areas and foster policy advocacy for equitable diagnostic resources [25]. As AI and teleradiology become more widely adopted and available for all groups, from low SES to minority patients to rural populations, breast cancer screening and diagnostic imaging access is enhanced, thereby promoting health equity and reducing disparities in breast cancer outcomes among underserved populations.

In conclusion, addressing disparities in breast cancer screening and diagnosis requires a multifaceted approach that integrates cultural competence, ecological awareness, and innovative technology. By recognizing the role of cultural beliefs, socioeconomic factors, and geographic barriers in shaping healthcare access, providers can tailor their practices to ensure that underserved communities receive timely, equitable care. The combination of advanced technologies like AI and teleradiology presents a unique opportunity to enhance diagnostic accuracy, expand screening capacity, and reduce disparities. AI can improve early detection and provide more accurate risk assessments, while teleradiology facilitates remote consultations and diagnoses, particularly in underserved or rural areas. Together, these novel technologies, when implemented equitably, have the potential to bridge the gaps in breast cancer care, ensuring that women from all racial, ethnic, and socioeconomic backgrounds have access to high-quality, timely screening and diagnosis. This integrated model, which combines cultural sensitivity, ecological awareness, and cutting-edge technology, offers a promising path toward achieving health equity in breast cancer outcomes, regardless of race, income, or geography.

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