With October serving as Breast Cancer Awareness Month, breast cancer continues to be the most commonly diagnosed cause of cancer deaths among U.S. women. Compared with White women, Black women historically have had lower rates of breast cancer incidence, but during the 1980s, it was found that they had higher death rates.
There’s no easy explanation
Researchers have been aware of the disparity for decades, but it has resisted easy explanation. The stakes are higher today. During the period between 2010 and 2015, for instance, the Centers for Disease Control and Prevention (CDC) found that approximately 221,000 breast cancers were diagnosed each of those years. The overall incidence of breast cancer was similar among Black women (121.5 cases per 100,000 population) and White women (123.6 cases per 100,000 population), but differences by age and stage were found. Compared with White women, breast cancer incidence was higher among Black women aged 60 years, yet lower among Black women less than 60 years of age.
The five-year time frame also found that breast cancer mortality was 41-percent higher among Black women (29.2 deaths per 100,000 population) than White women (20.6 deaths per 100,000 population). Overall, through better outreach and messaging, the diagnosis of breast cancer has actually decreased among all women, but the mortality rate has decreased significantly faster among White women.
White women more likely
to be screened earlier
During the aforementioned time frame, researchers at Boston University found that White women were more likely to be diagnosed with breast cancer because they were more likely to be screened, typically had children later, and took more postmenopausal hormonal supplements. These supplements typically feed the types of breast cancer more common in White women. Now, as many women have opted to forgo those postmenopausal hormones, the lines have converged somewhat. On average, Black women are diagnosed with the most deadly form of breast cancer (triple negative) at a younger age (median age is 58 for Black women, 62 for White women), and die at a younger age than White women (median age is 62 for Black women, 69 for White women).
Recent trends in breast cancer incidence suggest that the convergence and now equal incidence for Black and White women has been primarily because of incidence increasing among Black women—particularly among those aged 69 to 70 years—and concomitant decreasing or stable in White women. The mortality rate among Black women is approximately 40 percent higher compared with White women.
‘A perfect storm’ of issues
descending on Black women
“For years people have talked about the disparities and suggested we just need to get more Black women screened. Yet in most cases, Black women are getting screened at higher rates than White women, and they are dying more often,” said Paula Schneider, president and CEO of Susan G. Komen. “The disparity is not a simple matter of access to screening—it a perfect storm of issues that have been brewing for a long time and span across every aspect of the healthcare system and society at large.”
Schneider said Black women are dying more from breast cancer than White women are because all of the healthcare systems have failed the former “at every step in their breast cancer journey.”
Factoring biology, discrimination,
The Komen Foundation undertook a multi-year analysis and released the report “Closing the Breast Cancer Gap: A Roadmap to Save the Lives of Black Women in America.” The report found that Black women experience higher rates of death from breast cancer due to a combination of factors, including biologic factors such as the aggressive nature of certain breast cancers that are more prevalent in Black women. Black women also face barriers to early diagnosis, often receive substandard care, and experience discrimination and the consequences of systemic racism. This experience of racism, bias and barriers in the health care setting, according to the report, is felt by Black women across the country irrespective of income, education and insurance status.
Researchers at the CDC have suggested that advances in understanding breast cancer subtypes have improved awareness that Black women are more likely to be diagnosed with triple negative breast cancer (negative estrogen receptor, progesterone receptor, and HER2 status). They suggest that factor may have improved the likelihood that these Black women receive the appropriate treatment based on their cancer type.
Limited access to preventative measures
The Breast Cancer Research Foundation reported that, in 1990, Black women were 17 percent more likely to die from breast cancer than White women. Ten years later it had risen to 35 percent. By 2018, the number had risen to an astounding 43 percent. Their data has suggested that differences in access to health systems, and hence, differences in access to—and quality of—mammography and treatment are likely contributing to the problem. Earlier studies have shown that low median household incomes and a measure of segregation have correlated with the disparity.
Increased use of mammography is clearly beneficial among women of racial- and ethnic-minority groups who are at high risk of breast cancer. A recent study published by The Journal of the American Medical Association (JAMA) Network confirms this. Researchers at the University of Chicago found that 52.1 percent of women had an average risk of breast cancer, while 47.9 percent of women were at high risk. This was based on an analysis of 188 women receiving primary health care at federally qualified health centers in medically underserved regions of Chicago.
There was a reported “nonsignificant” increase in the mammography rate among those women receiving an individualized risk assessment (48.9 percent) versus women receiving usual care (38.8 percent).
“Implementation of this approach in underserved communities could promote equity in the use of mammography and reduce racial disparities in breast cancer mortality,” the authors reported.
Long-term breast cancer incidence trends for Black women indicate steady increases over the past 40 years, which have resulted in incidence rates equivalent to those among White women. The reason for this temporal trend in Black women is not well understood by researchers. The increasing trends in obesity among Black women, for instance, may suggest there might be a screening effect from increased use of mammography as well as breast mass and/or density.
Black women diagnosed much later
A new study conducted at Mount Sinai Hospital in New York City revealed that Black women receive a diagnosis at a later stage in the disease. But that’s not the only explanation for the increased death rate for Black women. The researchers found that Black women have a much higher risk of having their cancer spread, or metastasize. Metastasis is a major cause of death in breast cancer.
The New York researchers pointed to an obvious—but often overlooked—reason why many Black women are diagnosed at a later and more fatal stage: Sometimes Black women have been so busy taking care of everybody else; they don’t take care of themselves. Then, when they get to the doctor, not only do they learn they have breast cancer, but there’s a spot on their skin or spine or brain. That’s devastating news. Like practically all studies, the Black women in the Mount Sinai study were nearly six times more likely to die from breast cancer than White women.
Popular products may contribute
Breast Cancer Prevention Partners, a national science-based policy and advocacy organization, has listed a series of possible causes for the high mortality rate among Black women. It’s an unexpected inventory of products specifically marketed to Black women which may (or may not) contribute to the disease. Some of these findings have been clinically verified. The jury is still out on others:
—Skin lighteners often contain hydroquinone (a known endocrine disruptor) or worse, mercury, a known deadly carcinogen.
—Nail polish, products and treatments affect not only persons working in this profession, but clients as well who are exposed to carcinogens and endocrine disruptors in such treatments as primers and glues. These contain formaldehyde, dibutyl phthalate, hydroquinone, toluene, and ethyl/methyl methacrylate. Routine use results in miscarriages, birth defects and breast cancer.
—Hair relaxers (both lye and non-lye) are made with a base of sodium hydroxide, guanidine hydroxide, or ammonium thioglyocolate—which are high pH chemicals—that first burn the scalp and eventually seep into the skin leading to breast cancer. Post-relaxing treatments require neutralizing shampoos and conditioners that contain formaldehyde-releasing preservatives.
—Data released from cosmetic and personal care giant Procter & Gamble shows that 22.5 percent of Black women select a product base on fragrance. A commonly used ingredient in fragrance is diethyl phthalate, an endocrine disruptor. Phthalates are linked to breast cancer, developmental issues, decreased fertility, obesity and asthma.
Achieving health equity
“Health equity means that everyone has a fair and just opportunity to be as healthy as possible,” said Dr. Kim Johnson, senior director of Komen’s Stand for H.E.R. (Health Equity Revolution) Initiative. “Achieving health equity in breast cancer is going to take all of us working together to move beyond the status quo, build trust, and overcome generations of systemic racism and implicit bias that prevent Black women from getting the care they need to survive.”