Stark Differences in Mortality Rates Emphasize Ongoing Racial Disparities in Breast Cancer

Bridget A. Oppong, MD,

Although breast cancer mortality rates decreased by 43% from 1989 to 2020, Black women remain more likely to die from breast cancer compared with White women, according to the 2022 American Cancer Society’s update on breast cancer statistics in the United States.^1,2

Data from 2015 to 2019 showed that 133.7 White women per 100,000 were diagnosed with breast cancer compared with 127.8 Black women per 100,000. However, data from 2016 to 2020 revealed that 27.6 Black women per 100,000 died of breast cancer vs 19.7 White women per 100,000.

Bridget A. Oppong, MD, deputy director of the Center for Cancer Health Equity at the Ohio State University Comprehensive Cancer Center (OSUCCC)–James and an associate professor in the Division of Surgical Oncology at The Ohio State University College of Medicine, said differences underscore the disparities that contribute to the gap in breast cancer screening and care for the Black population, according to.

“Addressing these disparities begins with knowledge and awareness,” she said. “We hear a lot about these disparities, and we need to appreciate that the situation is still the same. Although the overall population is doing better with breast cancer, there is still a 40% mortality difference [between White and Black women]. We have a lot of work to do to ensure that we can provide care in an equitable fashion so that this disparity can be reduced.”

In an interview with OncLive®, Oppong discussed the importance of recognizing and addressing gaps in outcomes between patients with breast cancer in different racial groups. She also addressed the need for better advocacy for Black patients and advocated for improved screening guidelines to close the gap in racial disparities in breast cancer care.

OncLive^®: What do we know about racial disparities in breast cancer survival rates?

Oppong: We have seen these data about disparities for decades now. What the most recent [data] tell us is that despite long-standing efforts to reduce disparities, they still do exist.

The highlights of the data presented from the American Cancer Society are that, overall, all women are doing better as far as breast cancer survival, which is wonderful news. Since 1989, there has been a steady decline in the total mortality due to breast cancer.

However, we still see these gaps [in mortality rates], and that gap is most pronounced when comparing Black or African American women to White women. There is still a 40% difference in mortality. Ultimately, Black women are more likely to die of breast cancer, regardless of the breast cancer type or the breast cancer state. There’s a lot of work to do, as far as reducing overall disparities and breast cancer differences.

This disparity in death rates had remained at 40% or higher for a decade. What are some of the factors that may be contributing to this ongoing disparity?

What we see is that African American women tend to present later or at a more advanced stage. For breast cancer in general, the survival is higher if a woman presents at an earlier stage. Unfortunately, the literature shows that Black women are still presenting at stage III and IV, when the disease is more advanced and less likely to be cured.

These late diagnoses partially explain an increase in mortality. Other factors we see are that access to treatment is an issue, where Black women are not receiving treatment as expeditiously, or they are not completing treatment. With these factors, we see outcome differentials if patients are not adequately treated.

We also see that Black women have an increased risk of certain types of cancers that are more aggressive—most notably, the triple-negative subtype—which ultimately [have] a worse prognosis and [are] more treatment resistant to a lot of the therapies that we currently have available.

How can providers begin to address factors that contribute to disparities in access to care?

Ultimately, it is important for providers to be aware of these disparities. It is important to know and understand the data. Despite the advancement across the country and all groups, we still see these [disparities for Black women]. Further, providers must appreciate that there are social determinants of health that can impact how a woman's breast cancer is diagnosed and treated.

The social determinants of health are the social, economic, and behavioral factors that contribute to anyone’s health outcome. When I see a [patient with] breast cancer, I need to know [about] food insecurity, housing insecurity, insurance status, or employment [status]. All of these factors are going to impact how patients are going to proceed with the treatment, if they are going to complete the treatment, and how they will access different levels of appointments, treatments, and research options.

It is important to see a patient in a more holistic form, understanding all the factors for that individual. It takes some learning and experience [for clinicians] because some of these questions can be difficult [to ask patients]. As providers, it is important to put the patient at ease and ensure them that you are not going to treat them differently if they do not have a job, if they do not have insurance, or if they have certain socioeconomic difficulties.

We were trained to increase the trust of the patient, so they can [be ensured] that doctors will take care of them, regardless of social determinants. We do want patients to have that comfort and that ease. However, on the flip side, we know that all those social and personal details of any individual will impact their treatment, and not always in an adverse way. These details will create barriers as to the kind of treatments patients may be willing to accept and the kind of treatments they are able to complete.

When it comes to African American patients [with breast cancer] who we know are at risk for having a worse outcome, we need to ensure that we evaluate the social determinants of health [to allow us to] provide interventions. For example, if a patient does not have housing security, that gives me an opportunity to [provide that patient with] some of our community resources. If a patient does not have a place to live, the last thing they are thinking about is cancer treatment. We must focus on a patient’s overall environment to help women get to their cancer treatments.

Could you speak to the importance of increased access to high quality screening and treatment for these patients?

We have known about these disparities for decades, and a huge area that we have focused on is screening. Women do better if breast cancer is detected at an earlier stage. Until we have a primary prevention strategy through a vaccine or another modality, all we have is screening to prevent or at least catch things early.

There are a lot of opportunities and programs that we have to encourage breast cancer screening. Overall, we have done well when it comes to targeting the African American community, because we know that is a group that has been experiencing the worst survival statistics over the years. At [Ohio State], we have things such mobile mammography, navigators, and participation in national programs that provide free screening to women who may not have insurance or have a lapse in their coverage. All these things are very important, but ultimately there are other factors beyond access that prevent certain subgroups of women from obtaining screening.

Moreover, we have to appreciate diversity within the African American population. There’s a lot of diversity within the African American population, and moving forward, we must appreciate what those differences are in order to understand why certain women are not obtaining screenings.

For example, our institution provides a mobile van, where we go into the community to provide screenings, and there are still some women who will not want it, due to their own fears of finding [something] they don’t want to deal with, or fears that are based on myths. For example, we hear from some women that the mammogram is going to compress the breast and is going to create a problem. They’re worried about the discomfort of the mammograms. There are a lot of myths that we must address to overcome the fears of obtaining screening.

Access is still a concern. We need to ensure that women who are of screening age do obtain the necessary screening. We need to think about things such as Medicaid expansion, where we can increase the number of people who may be underinsured to get that screening. Additionally, we need to ensure that we continue funding things such as breast and cervical cancer programs to encourage screening. However, we need to address some of the cultural barriers and stereotypes that will prevent a woman from obtaining screening, even if she is able to.

This study showed that Black women have the lowest 5-year breast cancer survival rate vs all other racial subgroups for every stage of diagnosis and breast cancer subtype. Are there any genetic differences that are contributing to these statistics?

It is possible. A lot of the data, when it comes to genetics, were obtained in samples that were not inclusive. Many of the earlier studies did not include a lot of Black women. Therefore, there are certain biologic differences that we may not know of yet.

Additionally, there is a concern within the Black community of research participation. That is something I personally try to encourage whenever I do outreach and engagement within the Black community. This is to normalize research and scientific investigation.

There is a history [within the Black population] where there have been some abuses within the scientific community, including instances such as the Tuskegee syphilis experiments. This creates a lot of hesitancy with participation in research and clinical trials.

The only way to answer questions [about genetic differences in breast cancer] is through research. The only way to know if Black women’s cancers are genetically somehow different from those of White women is through research. We have work to do in increasing enrollment when it comes to minorities, especially African Americans.

Furthermore, the COVID-19 pandemic showed the level of distrust that the Black community sometimes has when it comes to accepting science and health-care recommendations. There was a lot of vaccine hesitancy, and all of that goes back to our history of us not feeling comfortable, not feeling that we can trust science, especially when it is from government. We need to continue to work on our community partnerships to work on engendering trust so that we can make advancements and have more inclusive research.

What can policymakers and health-care systems do to assist in closing these gaps and addressing these disparities?

We need to continue to push for screening and focus our efforts on populations that are behind when it comes to mammography utilization. We know that it is not, in general, all Black populations, but certain subsets [within these populations]. Black populations in urban centers or rural areas may have lower mammography utilization. We also need to look at groups of Black patients from certain immigrant groups, who, maybe due to acculturation issues, may be less likely to engage with the health-care system. Unless we tease out the diversity within a black population, it is going to be difficult to bridge the gaps in screening.

Another thing we need to do is advocate to increase coverage of screening by insurance companies. The Affordable Care Act did have some provisions to encourage insurers to provide coverage for screenings. However, there are still patients who have exorbitant costs. For our program, if patients don’t have any insurance, we can get them coverage from the National Breast and Cervical Cancer Early Detection Program.

Additionally, patients who have insurance may still have excessive copays because screening services are not 100% covered. This makes things such as Medicaid expansion helpful. All insurance companies need to know that screening is a necessity. It should be covered, and there should be pathway available to make it affordable.

Overall, we must continue community engagement to ensure we are encouraging residents to continue with screening. At Ohio State, we have an initiative called Back to Basics, which is a mass media campaign focused in the state to get people back out to screenings. The COVID-19 pandemic took patients who were potentially already under screened and created additional barriers due to lockdowns and facilities closing.

COVID-19 disproportionately impacted people of lower socioeconomic status, as well as the Black community and other minority communities. Our fear is that this is going to further worsen the divide. Patients who are already under screened now have additional barriers due to the pandemic and will be less likely to get screening.

Part of why we’re pushing this mass media campaign is to encourage people that now that the pandemic is at least under control, we need to get patients to start resuming their preventative services and getting screening for breast cancer, as well as other cancers.

How can screening guidelines help address these racial disparities in breast cancer?

We, as physicians and other health-care providers, must be up to date on the screening guidelines, and there are multiple guidelines. [Regardless of the guidelines used], providers must make sure patients are following through with [screening].

Beyond the guidelines, screening should be individualized. African American women are at higher risk of dying of breast cancer, and African American women also get diagnosed at younger ages. It important to get a woman’s personal and family history to individualize their screening. These are patients who you may want to start screening before the recommended ages of 40 or 50, depending on the guidelines that you are adhering to.

Additionally, genetic testing has been underutilized [for African American women]. A lot of the data of genetics in breast cancer, including the BRCA1 and BRCA2 mutations, [stemmed from research] that was done in populations that did not include many African American women. Previously, there was a bias among providers that Black women did not have a high carriage rate of these mutations. However, we have data that establishes that Black women can be carriers of these mutations and that there are familial predispositions. It may make sense to start screening Black women younger than the recommended ages, or at least get them to genetic counseling and testing.

Why is it important to raise awareness of disparities in breast cancer care?

Bringing awareness [to disparities in breast cancer care] is key. We need awareness when it comes to providers in the health-care system, but we also need awareness for individual patients. Black patients need to know that they are at risk.

I still hear [misconceptions] to this day [from Black women who believe they] are less likely to get breast cancer, but that is not true. [Black women] are also more likely to die of breast cancer when we do get it. It is not something that Black women can afford to be ignorant to at this stage.

We also need to increase advocacy and begin doing the research to see if it is worth screening Black women at younger ages. Black women are more likely to be diagnosed at younger ages and more likely to have aggressive cancers and interval cancers, which develop between screenings. We need to be cognizant before we generalize screening ages.

As a breast surgeon, I have plenty of young, particularly Black, female patients. These are populations that are being recommended to wait until they are at least age 50 for screenings. The frequency [of screenings] is also important, as [some guidelines] want patients to have screenings every 2 years.

There is a tremendous harm to the Black population if you adhere strictly to those guidelines. The key in all of this is that the screening recommendations have to be tailored and personalized.

References

1. Giaquinto AN, Sung H, Miller KD, et al. Breast Cancer Statistics, 2022. CA A Cancer J Clin. Published online October 3, 2022. doi:10.3322/caac.21754
2. Breast cancer death rates are highest for Black women—again. New release. American Cancer Society. October 3, 2022. Accessed October 21, 2022. https://bit.ly/3CRVAUf