Women of color more likely to receive ‘suboptimal’ breast cancer care
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Despite strides in cancer care and treatment, disparities in breast cancer outcomes still remain for women of color when compared with white women.
“Regarding treatment, the quality and timeline of care are more likely to be suboptimal for racial/ethnically minoritized women,” Christina Hunter Chapman, MD, MS, assistant professor of radiation oncology at Baylor College of Medicine, told Healio.
Healio spoke with Chapman about existing disparities in breast cancer care and diagnosis, ways to address these disparities and the potential for new treatment advancements in historically marginalized populations.
Identifying gaps in care
When examining disparities in breast cancer outcomes among women of color, it is important to specify by racial or ethnic group, according to Chapman.
“Women of color, as a group, actually need to be disaggregated to accurately answer this question because outcomes differ across racially/ethnically minoritized populations. For example, breast cancer mortality rates of Black women are the highest of any racial/ethnic group, while mortality of Latina women is lower than that of white women,” Chapman said.
A 2022 American Cancer Society report showed that Black women are 41% more likely to die from breast cancer when compared with white women and, according to the same report, breast cancer is now the leading cause of cancer-associated death among Black women in the U.S.
“Black women are more likely to have the aggressive, triple-negative subtype, for which treatment is less effective, but this still doesn't fully explain the elevated mortality. Black women are also more likely to be diagnosed with advanced stage disease,” Chapman said.
In an effort to reduce these disparities in diagnosis and screening, the American College of Radiology and the Society of Breast Imaging updated their guidelines in 2018 to include specific screening recommendations for Black women and others who may be considered high risk based on factors such as age at onset and genetic predisposition. However, the screening rates themselves are not the sole issue, according to Chapman.
“More recent data actually show that overall screening rates appear to be similar between Black and white women, but Black women are less likely to be screened with newer screening technologies and are also more likely to experience delays in workup if the screening mammogram shows something concerning,” Chapman said.
A recent study compared the risk of not undergoing a biopsy within 30, 60 and 90 days of abnormal mammography results between women of different racial and ethnic groups. The researchers found that although there was an increased risk of no biopsy within 30 and 60 days of abnormal screening results among Asian, Black and Hispanic women, Black women were the only group whose unadjusted risk for no biopsy within 90 days persisted (RR = 1.28; 95% CI, 1.11-1.47). The risk was found to persist even after adjusting for selected individual, neighborhood and health care-level factors (RR = 1.27; 95% CI, 1.12-1.44).
Addressing disparities
Chapman points to factors such as inequitable access to high-quality hospitals, providers and multidisciplinary care — driven by inequity in insurance access and racial segregation — as the reasoning behind some of these disparities.
“Broader social inequity (education, employment, neighborhood segregation) lead to higher comorbidity rates in many racial/ethnic minority groups, and these comorbidities can prevent women from being able to complete recommended courses of therapy,” Chapman said.
“Broader social inequity can also pose other barriers (inequitable work leave policies and access to childcare/elder care) and prevent women from being able to complete full courses of therapy even if there are no medical contraindications.”
Chapman also notes bias from providers themselves as a potential contributing factor.
In a national survey of breast oncology physicians, it was found that 30.6% of respondents believed Black women are more likely than white women to be noncompliant in genetic counseling and testing; 21% believed Black women require more information and guidance during the decision-making process for genetic testing than white women; and 1.8% were more likely to refer a white individual than a Black individual for genetic testing.
“Interpersonal racism from providers also likely contributes to differences in treatment recommendations and treatment delivery, as has been shown robustly in other areas of medicine,” Chapman said.
Though there are a variety of factors that contribute to differing breast cancer outcomes for women of color, there are also a number of interventions that may address these gaps in care and diagnosis, according to Chapman.
She lists universal health care coverage, Medicaid expansion and improved funding and human capital for facilities that serve racial/ethnically minoritized women as ways to potentially address these issues.
For each 10% increase in public welfare spending, there is a 6.15% increase in 5-year overall survival for Black patients with breast cancer, representing a 39% disparity reduction.
Chapman also highlighted the importance of improved social services that advance equity in employment, education and health literacy in reducing these disparities.
Treatment advances, widening disparities
Though there have been recent developments in breast cancer treatment, such as with metastatic triple-negative breast cancer, Chapman cautions that treatment advances could possibly widen existing disparities if equity is not taken into account.
“What we typically see is that new advances are often associated with widening disparities because treatments that are new, costly or more complex tend to diffuse more slowly to racial/ethnically minoritized populations unless equity is prioritized at the outset,” Chapman said.
“Even the treatments that represent de-escalation (less use of chemotherapy or shorter radiotherapy courses) might be slower to diffuse to sets where racial/ethnically minoritized women are treated because the original trials that tested them are less likely to be performed in these settings, so there may be less comfort and/or knowledge about the paradigm shifts or more financial harm to centers that already struggle financially.”
References
- Ademuyiwa FO, et al. J Clin Oncol. 2021;doi:10.1200/JCO.21.01426.
- American College of Radiology. New ACR and SBI Breast Cancer Screening Guidelines Call for Significant Changes to Screening Process.
- https://www.acr.org/Media-Center/ACR-News-Releases/2018/New-ACR-and-SBI-Breast-Cancer-Screening-Guidelines-Call-for-Significant-Changes-to-Screening-Process. Published April 4, 2018. Accessed June 24, 2022.
- Barnes JM, et al. J Clin Oncol 40, 2022 (suppl 16; abstr 6509);doi:10.1200/JCO.2022.40.16_suppl.6509.
- Giaquinto AN, et al. CA Cancer J Clin. 2022;doi:10.3322.caac.21718.
- Lawson MB, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2022.1990.
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