Race is a touchy subject in America, and for good reason: It seems every day there’s more news about racial inequality and social injustice in so many areas. Unfortunately, racial inequities carry over to the world of breast cancer, too.
The American Cancer Society reports that across the board, a woman living in the United States has a 12.4 percent (or 1 in 8) lifetime risk of being diagnosed with breast cancer. But, when you look a little deeper at who those 12.4 percent are, the distribution is not the same across all races, with the greatest disparity between non-Hispanic white women and non-Hispanic black women. From 2011 to 2015, the ACS reports the overall breast cancer incidence rate in black women was 125.5 cases per 100,000 women, while the incidence rate in non-Hispanic white women was more than three points higher at 128.7. However, despite this lower incidence rate, black women are more likely to die of the disease than white women. Between 2011 and 2015, “the five-year relative survival rate was 83 percent for black women and 92 percent for white women,” the ACS reports.
[See: 7 Innovations in Cancer Therapy.]
Why this disparity exists has “been of interest to the breast cancer community for almost 20 years,” says Dr. Dawn L. Hershman, professor of medicine and leader of the breast cancer program at the Herbert Irving Comprehensive Cancer Center at New York-Presbyterian Columbia University Medical Center. “Why is there a racial disparity in outcome, especially when there’s often a lower incidence of breast cancer in African-American women? Why would they have a higher risk of dying?”
The reasons, it seems, are “multilayered and multifaceted,” says Dr. Kristi Funk, breast cancer surgeon, author of “Breasts: The Owner’s Manual,” and co-founder of the Pink Lotus Breast Center in Beverly Hills, California. “Not all of them will apply to all African-Americans and some will have importance for an individual that will be irrelevant to another. So it gets really complicated quickly, and on top of it all we don’t have all the answers.”
Among the things we do know: Black women tend to be diagnosed with breast cancer at later stages of the disease and at younger ages than white women — 58 is the median age of diagnosis in black women as opposed to age 62 in white women. Black women are also more often diagnosed with a very aggressive form of the disease called triple-negative breast cancer, a subtype that does not rely on hormones to fuel its growth.
“When you look at the subtype of the cancer, the one called triple-negative is associated with more aggressive, enhanced biology and has the highest death rate of all subtypes except for inflammatory breast cancer,” Funk says. A 2017 study from the ACS reported that of the 80 percent of breast cancers that are invasive, about 12 percent of them are classified as triple-negative. However, incidence rates for triple-negative breast cancers are twice as high in black women — 24 cases per 100,000 — as compared with white women — 12 cases per 100,000, “so [black women] are more than twice as likely than whites to get the most aggressive subtype of breast cancer,” Funk says.
Obesity rates and breast density, “a mammographic reading of how much of the stuff that actually makes breast cancer — ducts and lobules — is inside your breast, as opposed to fat which doesn’t get cancer,” Funk says, also tend to be higher among African-Americans. Both of these factors can elevate a person’s risk for developing breast cancer.
Still, even when all these factors are controlled, Funk says the evidence shows that “African-Americans still do more poorly than whites when it comes to surviving breast cancer. “And this, to me, gets into inherent biological differences that have to do with the invasiveness of breast cancers in women of African versus European ancestry.”
In treating these cancers, there could be a biological gap between white and black patients, too. Dr. Bhuvana Ramaswamy, breast medical oncology division director at The Ohio State University James Cancer Hospital, says the clinical trials that bring those treatments to market may not be doing enough to assess how drugs work in different populations. For many drugs currently available to treat breast cancer, “most of the clinical trials had very few minorities enrolled in the studies. So what we’re doing is taking a drug that works in a predominantly Caucasian population and then giving the same drug at the same dose that’s established as effective” to people of other races and assuming that they will work just as well. But that could be an incorrect assumption. She says testing drugs with an eye toward race and ancestry might show that certain drugs will work better at different doses or frequencies for one or another person. “Maybe this drug needs a bigger dose. Maybe this doesn’t get metabolized the same way. Those questions need answers,” she says.
[See: What Not to Say to a Breast Cancer Patient.]
Hershman echoes the idea that we need more information about how treatments work in different populations. “Even when we look at patients enrolled in clinical trials who are getting the exact same treatment at the exact same stage, we still see a disparity in outcome and that may be due to differences in biology. If we have a better understanding of what those biological differences are, we might be able to personalize treatment a little more effectively so we’re giving treatment that really matches the biology of the cancer. Maybe that can also reduce disparity,” she says.
But while biology appears to be a factor, it doesn’t tell the whole story, Ramaswamy says. “When you look at this on a state-by-state basis, there are a couple of states that do have much less of that disparity and there are other states that have very stark differences in mortality.” These variations are “related to access and immediate treatment options and appropriate treatment. Because if it’s all just biology, there shouldn’t be a lot of state-by-state difference.” The states with the highest disparities are Louisiana, Mississippi and Wisconsin.
Getting all women screened appropriately is one thing, but going beyond that and getting women who’ve been diagnosed with breast cancer appropriate care quickly is still a problem in some cases, which can be further complicated by communication and cultural differences. Particularly among immigrants and refugees, language and culture can be a barrier to care, Funk says, because “certain cultural beliefs might lead to a delay in diagnosis and care.”
Education could help solve some of these issues, Hershman says. “Making sure that there are enough education initiatives so that patients from all different socioeconomic and educational backgrounds understand the importance of adjuvant therapy,” or treatments that are given alongside the main treatment, could help patients have better outcomes. She says it’s also important to educate all patients on “the importance of hormonal treatment” that often continues for years after other treatment protocols have ended so that they don’t discontinue treatment early and increase their risk of a recurrence. “And then you can try to eliminate financial factors that stop people from getting high quality treatment.”
Socioeconomic factors are not equal for all breast cancer patients, and for those who lack the financial means to cope with the expense of cancer treatment, getting appropriate care can be difficult or financially impossible. That’s where organizations like Pink Lotus Foundation, of which Funk is founding ambassador, may be able to help by providing free care to certain patients. “People are dying now because they lack access because they don’t have insurance or they’re underinsured and they aren’t going to spend $2,000 to find out what that lump is.” Finding a way to help cover the cost of care for patients who need that assistance might also help narrow the breast cancer mortality gap.
[See: A Tour of Mammographic Screenings During Your Life.]
At its most fundamental level, preventing breast cancer before it starts is the best way to influence outcomes. Therefore, for people who don’t yet have breast cancer, watch your weight, eat right and get plenty of exercise. Meanwhile, researchers will continue searching for clues as to why racial disparities persist in breast cancer mortality and look for ways to mitigate them. Ramaswamy says that more funding should be directed toward studying this “issue of disparity, both in incidence and outcomes. I think we need to focus the next decade on [researching this]. We’ve gotten so much better in understanding cancer, but we need to now make sure the playing field is equal for everybody,” in terms of treatment and access to care.
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Why the Death Rate From Breast Cancer Is Higher Among Black Women originally appeared on usnews.com
