’We are failing Black women’: Experts urge action to reduce disparities in breast cancer
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Black women have the highest mortality rate of all women with breast cancer in the U.S., with a significant number presenting at an earlier age of diagnosis and with more advanced-stage disease.
“It is widely known in the medical community that BRCA1 and BRCA2 mutations are prevalent in the Ashkenazi Jewish community, but what is not widely known is that they are also prevalent in Black women — and this is not new data,” Debra Monticciolo, MD, past president of the American College of Radiology and vice chair of the department of radiology and section chief of breast imaging at Baylor Scott & White Medical Center-Temple in Texas, said during an American College of Surgeons virtual press event. “We have also long known that Black women have higher death rates and that these women have a twofold increased risk for triple-negative breast cancers, as well.”
High-risk screening and risk-reduction strategies are needed to prevent and treat breast cancer in this population. To address this, the American College of Radiology and the Society of Breast Imaging updated guidelines in 2018 to include specific recommendations for screening Black women based on disease prevalence, mortality, early age at onset and genetic predisposition.
“Minority women should begin screening for breast cancer at age 40 years instead of age 45 or 50 years, as they are 72% more likely to be diagnosed with invasive breast cancer younger than the age of 50 years, 58% more likely to have advanced breast cancer at presentation younger than age 50 years, and 127% more likely to die younger than age 50 years compared with white women. We are failing Black women,” Monticciolo said.
During the virtual press event, experts discussed the barriers in access to screening and treatment faced by Black women, current recommendations for screening and the impact of strategies to decrease delays in diagnosis and treatment.
Referrals for genetic testing
Tuya Pal, MD, associate director for cancer health disparities, Ingram professor of cancer research and professor of medicine and pediatrics at Vanderbilt-Ingram Cancer Center, said that when thinking about the delivery of care pertaining to inherited cancer predispositions, clinicians should first identify individuals at high risk and then direct them to proper care, including genetic counseling and testing.
“Black women undergo genetic testing far less often than other women,” Pal said. “These women are less likely to be given recommendations for genetic testing — there is something systemic going on here. ... The hoops that Black women have to jump through in regard to insurers requiring a genetics professional to perform an assessment for genetic testing may be what reduces their chances of receiving genetic testing.”
Follow-up care is also a challenge.
“Once individuals are tested, we want them to receive guideline-adherent appropriate follow-up care,” Pal said. “However, data have shown that Black women with a BRCA mutation receive risk-reducing oophorectomy much less often than white or Hispanic women. There is a disparity here and it is imperative to get to the bottom of this.”
Clinical trial participation
Black and Hispanic individuals represent approximately 25% of the U.S. population, yet only about 5% to 8% of clinical trial participants, according to Oluwadamilola Fayanju, MD, MA, MPHS, FACS, chief of breast surgery and surgical director of the Rena Rowan Breast Center at University of Pennsylvania’s Abramson Cancer Center.
“We know that Black women are more likely to be diagnosed with triple-negative breast cancer, which is a particularly aggressive disease that is twice as common in Black women compared with white women,” Fayanju said. “As we think about orphan diseases within breast cancer, we have pockets of suboptimal outcome and disparity that are only going to be further worsened by not including the people of color who are disproportionately affected by these more aggressive cancer types, for which we have less effective treatment.”
Clinical trials have become more specific in terms of eligibility criteria, making it more difficult for Black women to participate, Fayanju added.
“If we are less likely to test Black women for a genetic mutation, then the trials that require participants to have triple-negative subtype or an HER2 subtype will not enroll Black women,” Fayanju said. “We are, therefore, underpowering our studies to understand the disease processes in these subgroups.”
Fayanju offered ways to improve the situation.
“We can move away from the ‘bench-to-bedside’ model that has been historically observed for clinical trial development,” she said. “We should instead work more with the communities that we serve and think about what types of problems they are seeing and what types of practical issues are occurring in those communities that would also benefit from clinical investigation. We also need individuals in place who can advocate for clinical trial participation who look like the communities that we are trying to target.”
The pipeline of researchers should also be considered, Fayanju added.
“There are many stakeholders in clinical research — not only those who conduct the research but also those who fund the research and the patients who increasingly advocate for what types of research should be prioritized. If there is not diversity across all of these groups, then certain types of diseases and certain groups will continue to be privileged relative to others,” Fayanju said.
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Session PS364. Improving Breast Cancer Outcomes in Black Women: Time for a Change. Presented at: ACS Clinical Congress; Oct. 23-27, 2021.
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