Q&A: Black, white breast cancer mortality disparity greater than ever
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Despite years of study and advances in breast cancer treatment, Otis Brawley, MD, professor of oncology at Johns Hopkins School of Medicine, said the disparity between the mortality rates of Black and white patients has never been greater.
However, he said there are indications that the causes for this may be more socioeconomic than racial, with issues going in unexpected directions — from mammogram vans to societal attitudes about breastfeeding, and beyond.
Healio spoke with Brawley about the current state of study into the socioeconomic disparity in breast cancer rates and outcomes, and what’s being done to address them.
Healio: What differences have we seen in breast cancer outcomes between patients of different socioeconomic backgrounds?
Brawley: Most of the data has been done by race, but the racial data actually is reflective of socioeconomic status, especially when we talk about Black/white. People who are Native American, Hispanic — which is an ethnicity instead of a race — and Asian have lower rates of breast cancer overall. Some of that is due to social issues as well. Blacks and whites had the same death rate in the 1970s. And then there became a disparity in the early 1980s. ...
Some of the reasons for that Black/white difference are heavily socially driven. For example, Black women are more likely to have more aggressive forms of breast cancer — 20% to 22% of Black women with breast cancer have triple-negative disease, which is harder to treat, compared with 12% of white women. Some people think that might be related to an area of geographic origin issue. But there's also a lot of data — some of it done in Scotland, where there are no Black people — to show that these genetic differences are driven by social determinant.
For example, women having lots of children in their teen years and early 20s and not breastfeeding actually increase the risk for triple-negative breast cancer 30 or 40 years later. Women who don't have children, or women who don't have children until after the age of 30 have increased risk for estrogen receptor-positive disease. And so, frequently, we ask why is it that a higher proportion of Black women have triple-negative disease? We should be asking, why is it a lower proportion of white women don't have triple-negative disease?
And the answer, literally, is Black women do something that causes triple-negative disease — not breastfeeding. Some of that is social. If you have a job, it's hard to breastfeed. When I was a medical student at the University of Chicago 40 years ago, we used to send every unwed Black mother who just had a child home with a case of Enfamil. So, the system — and when I say the system, I'm including food stamps, and so forth — encourages women not to breastfeed, not realizing that 25, 30, 40 years later, that increases your risk for the bad kinds of breast cancer.
And who is it who doesn't have children or delays having children until after 30? That's women who go to college and have a career, and start launching their career in their 20s. And they actually do something that increases their risk for HER-positive, non-triple-negative breast cancer. These are social determinants that we don't normally think of. Most people think of social determinants think about differences in screening and we can talk about that as well, as well as differences in quality of treatment received.
Healio: Can you elaborate on the screening differences and their impact?
Brawley: You look at the ENGAGE data from the CDC, about 60% of Black women and 60% of white women over the age of 50 are getting screened for breast cancer. But if you start unpeeling the onion, you'll find that for poor women, the quality of the screening is oftentimes not as good as among middle class and upper middle class. Some people stop with, “The proportions are the same, that's good.” But I'm interested in the quality of the screening.
One element of the quality where we frequently fool ourselves is there's a lot of screening going on with mammogram vans these days. Mammogram vans, by and large, are unable or don't try even to find last year's mammogram or the year before for comparison. So many — not all— of these mammogram vans are providing lower-quality mammography. Mammogram vans don’t go in the middle-class and upper-middle-class neighborhoods and offer services; they go into the poor inner city or the poor rural areas and offer services. And, by definition, because they don't try to find previous mammography, they are offering lower-quality services.
It's not a race thing. We actually have good studies that show that for Black and white women in equal-access systems like the Kaisers or the Henry Ford Health System in Detroit, equal treatment yields equal outcome. Race is not a factor in outcome. But what is a factor is social determinants and access to quality care. Now, when you get to treatment, there are some quality treatment differences by race, and some of them are because of poverty or social economics, or issues with insurance.
A huge issue with getting good adequate care is lack of transportation, which is a much more common issue for poor people. If you're getting radiation to the breast, you have to go every day, Monday through Friday, for 6 weeks. We have a large number of poor people who drop out because of transportation issues. Some of it can be education as well. A higher number of less educated people refuse therapy for fear that the therapy is going to actually spread the cancer. We hear, “If you operate on women, you spread the cancer.” We hear that a lot, actually.
But getting back into the cost issues, we have some very expensive drugs now. Some of the CDK4/6 drugs can cost $10,000 to 12,000 a month, and a lot of people think they have good insurance, but then they find out their good insurance will pay 80% of the cost of the drug. And 20% of $12,000 is an awful lot of money to a retiree. It’s an awful lot of money to me!
Other issues that we run into — this is huge Black/white one — 70% of Black women in the United States have obesity, and our drugs are dosed by body mass index. Many of us dose women with obesity as if they were at ideal body weight, not real body weight, and we may be underdosing. One of the reasons why we use ideal body weight, instead of real body weight, is if you if you use real body weight, many of us are afraid we're going to cause side effects with the chemotherapy. This is a quandary we've had in oncology ever since we've had good breast cancer chemotherapy, which started about 35 years ago, and it's unresolved.
Healio: Where do you see research into these topics moving in the future?
Brawley: If you look at the results from Kaiser, Henry Ford Hospital, some of the cooperative group studies, the biggest, most important research that needs to be done is on how to get adequate care to all people. It’s with the exception of that dosing, heavy people versus lean people issue. There doesn’t need to be much research, except how do we get the tools that we already have to everybody in order to decrease the disparity.
We still need to do research because women still die of breast cancer. So, we need to still find new treatments. But where we have treatments, the issue overwhelmingly is a failure to get the treatments that we have to people who are poor.
By the way, one thing I didn't mention that we should mention, is there's a wonderful modeling study from the National Cancer Institute that was published about 10, 12 years ago that shows of the 45,000 or so women who die of breast cancer every year, about 10% die because of a failure to either get screened, failure to follow up on screening or failure of the screen tests to be read.
That failure to be read can be because they didn't look at previous mammography — 20% to 25% of that 45,000 die because of failure to get adequate care. The number of people who die of breast cancer because of failure to get adequate care after diagnosis is two to two and a half times the number of people who die because of failure to screen. Indeed, one of our great problems in this country is there's a huge emphasis on screening. There is not the same emphasis on getting adequate diagnostics and adequate treatment once the screen is abnormal.
Healio: What initiatives are underway to address these disparities?
Brawley: It's getting harder and harder because money to try to address these inequities is drying up. And sometimes our efforts are a bit misguided. A number of cancer centers around the country have purchased these mammogram vans, and they put the names on the side — they’re mobile billboards. They are going through cities with university branding, but these mammogram vans oftentimes provide inferior services. The message is frequently “get a mammogram,” not “get a high-quality mammogram.” And the message really also should be getting into a program of routine high-quality mammography. ...
The most important intervention that we've had over the last 25 years to try to lower the disparity was the Affordable Care Act. And, keep in mind, Senator, then-Governor Mitt Romney introduced the Affordable Care Act in Massachusetts around 2000. And because it takes 10 years or so for people with breast cancer to die, and since we're 24 years out from his introducing that in Massachusetts, we actually have good data in Massachusetts.
As I mentioned, it’s socioeconomic and not race. There are five states in the United States where there's no Black/white disparity and death rate. Massachusetts is one of them. They're all up in the Northeast. But, nationally, the Black/white disparity is greater today than it has ever been.
Healio: Is there anything else you’d like to add?
Brawley: There's a lot of people who tend to focus on race and if the biology is different by race. And this worries me sometimes. I hear Black doctors and Black women talk about Black breast cancer and white breast cancer as if they are different diseases. The truth is, when you look at the molecular biology of breast cancer, 20% to 22% of women who call themselves Black will have triple-negative disease whereas 12% of white women have triple-negative disease. But it's not ‘Black breast cancer. Oprah Winfrey actually started calling it Black breast cancer. But 12% of white women have what Oprah calls “Black breast cancer.” And even among those women, equal treatment yields equal outcome among equal patients. Sometimes it's harder to find equal patients to compare, due to differences in obesity, numbers of patients and socioeconomic standing, so you're still going to end up with differences because those are not equal patients being compared. What we need are studies to figure out how to get all people adequate, high-quality care.
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