The reasons Black women are more likely to die from breast cancer than white women are complex, but the disparity is, in fact, surmountable. The solutions aren't easy or quick, but they do exist. If this is a problem that doesn't need to—and shouldn't—exist, why does it?
Unequal access to health care
As with any cancer, early diagnosis is key to successful treatment, and the fact that white women tend to be diagnosed at an earlier stage of breast cancer than Black women exposes a major problem from the get-go. "It's really a matter of the benefit of being screened in a mammogram, which is how we screen for breast cancer," says Nicola Finley, MD, an integrative physician at Canyon Ranch Tucson. "Unfortunately, Black women [tend to be] diagnosed for all cancers when they're at a more advanced stage. This leads to a higher mortality rate, because there are more obstacles and barriers in terms of treatment at a more advanced stage."
Health-care access is a huge driver of this disparity, says Jennifer Sims, PhD, an assistant professor at Jackson State University's School of Public Health who wrote an academic paper about health and racial disparity in breast cancer. "Black women tend to have limited access to quality health care, and the reason for this is because they tend to have a lower economic status," she explains. Black women are statistically more likely to live in poverty than white women, which not only affects insurance access but also access to transportation, the ability to take time off work, and arrange child care—all of which impacts a person's ability to seek care in the first place.
Thus, many Black women are forced to wait to go to the doctor until there's something visibly wrong, says Dipali Sharma, PhD, a professor of oncology at Johns Hopkins University. "One of my colleagues and I were discussing this very topic the other day and she told me about a Black women who had a breast tumor that was literally coming through her skin. But she kept waiting and hoping it would just go away on its own because it was difficult for her to take off of work," Dr. Sharma says. "Often, by the time Black women come to the clinic, their cancer is already stage three or four." (Research supports this observation.)
New research also suggests once a breast cancer diagnosis is given, Black women face longer delays to starting treatment and longer treatment times than white women. "Even among women with low socioeconomic status, we still saw fewer delays among white women, underscoring the disparate experience of Black women, who appear to experience unique barriers," said lead author Marc Emerson, PhD, in a press release about the study. These delays could affect outcomes, since the longer cancer goes untreated, the harder it is to eliminate. More research needs to be done to understand exactly what's contributing to these delays, but the authors theorize that specific financial and transportation barriers could be at play.
Bias in the medical community
Even when Black women are able to get to the doctor, Dr. Sims says they often face medical racism that impacts their care, regardless of social status. In her book, Invisible Visits: Black Middle-Class Women in the American Healthcare System, Tina Sacks, an assistant professor at UC Berkeley's School of Social Welfare, discusses the many challenges Black middle-class women face in trying to get doctors to take their concerns seriously. This can lead to them being less likely to get further medical testing and screenings when they're needed. To her point, a Journal of Clinical Oncology study found that Black women, regardless of their risk level, are less likely than white women to undergo genetic testing for the BRCA1/2 gene—aka the gene associated with breast, ovarian, and pancreatic cancer—in large part because physicians are less likely to recommend it to them.
"Some doctors see breast cancer as a white woman's disease more than a Black woman's disease, so they may not screen Black women as often." —Jennifer Sims, PhD
"As a Black woman, when I see a doctor, I always make sure to present myself in a particular way," says Dr. Sims. "Most of the time when a doctor sees me, they see a Black woman and nothing else. I always make sure they know I did my research beforehand so they take me seriously. I tell them I'm an assistant professor and have a PhD and studied at Harvard Medical School. In doing so, I tend to be treated differently than my sister, who has the exact same doctor as I do." This is an example of the type of bias most white women will never experience.
Additionally, Dr. Sims says some Black women feel judged by doctors, which affects their interest in seeking care. If someone has had a negative experience with a doctor who made them feeling shamed, judged, or discriminated against in the past, they are less likely to make check-ups and appointments a priority, she says.
A lack of research
Even if the playing field was level, and women of all races had the same access to unbiased health care, Black women would still be at a disadvantage when it comes to their survival. Sandra Luyindula, MD, a primary care physician at Proactive MD, says that Black women are more likely than white women to be diagnosed with triple-negative breast cancer, a subtype of the disease that is linked to a worse prognosis than other subtypes. (It makes up 10 to 15 percent of all breast cancer cases.)"Triple-negative breast cancer is two to three times more common in Black women under the age of 60," she says, adding that it is also more aggressive and has a higher likelihood of recurrence than other types of breast cancer.
Sadly, Dr. Luyindula says we still don't know why this type of cancer is more common in Black women. "Triple negative breast cancer is certainly being studied, but [researchers] haven't figured it out yet," she says. And there aren't many treatment options that work for it, either. Dr. Sharma explains that not only is triple-negative breast cancer aggressive, it doesn't respond to hormone therapy or targeted drugs.
"There definitely needs to be more therapy options for women with triple-negative breast cancer," Dr. Sims says. "There is a new drug that came out this year, Trodelvy, but what's interesting about that particular drug is that the clinical studies didn't actually include many Black women." This is unfathomable to her. "Triple-negative breast cancer predominately affects Black women, so why aren't they part of the clinical studies?"
This shows that racial bias isn't limited to the doctor's office; it permeates research institutes and clinical trials as well. "There's this untrue belief that Black women don't want to participate in medical studies, but the truth is, we need to make it easier for them," Dr. Sharma says. "For example, at Johns Hopkins, often we give study participants a gift card as an incentive to participate in studies. But when we issued surveys, we learned something that keeps them from participating is the cost of parking, which can be $20 or $25. So something as simple as giving them a free parking sticker can make it easier for people to participate in studies."
Of course, study participants also need transportation, childcare, and the ability to take time off of work. Rather than writing off a population, "we really need to ask what can be done to make participating in studies easier, and then do what's necessary to meet the needs," Dr. Sharma says.
How to overcome racial disparities in breast cancer death rates
More inclusive clinical studies will lead to better treatment outcomes for Black women diagnosed with breast cancer, but that alone is not enough. We need multilayered solutions that match the complexity of the problem.
To start, Dr. Sims says doctors and health-care providers should go through implicit bias training. "Some doctors see breast cancer as a white woman's disease more than a Black woman's disease, so they may not screen Black women as often, even if they are showing the same symptoms as a white woman," she says. "A lot of this bias is unconscious. You may think you have no bias toward Black women, or even women in general, and then you take an implicit-bias test and you see that you are biased."
"Most of the time when a doctor sees me, they see a Black woman and nothing else." —Dr. Jennifer Sims
Patient advocates and, in some cases, interpreters can also benefit Black women navigating a cancer diagnosis, and perhaps improve their survival chances. Dr. Luyindula says that at her practice, all patients—regardless of race or socioeconomic status—are assigned a patient advocate who ensures they have everything they need to continue treatment, including transportation. She adds that patient advocates can also help address a patient's concerns about their ability to come to treatment appointments, access to healthy foods, or other health concerns—all questions a doctor might not be able to fully answer during a time-pressed appointment. Meanwhile, an interpreter can help patients overcome language barriers to get the answers they need to make decisions about their care—which can help improve outcomes, too.
More effort needs to be made for breast cancer prevention to be equitable, too. Mammogram screenings, which are the first line of defense again breast cancer, need to be more accessible to more people where they're at. Dr. Sims says she's seen creative solutions for this problem, like volunteer organizations hosting cancer screenings at predominantly Black churches. Another solution could be free mammogram screenings at various workplaces, so it doesn't require taking time off work to be screened.
These solutions are just a start, but with time they can make a difference. "There needs to be creative solutions to meet needs at an individual level because not everyone has the same needs," Dr. Luyindula says. "This is a big, multifactorial issue. We need to understand every component to treat this issue as a whole."
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