The complexities behind breast cancer’s racial disparities, and how to address them

Disparities exist in the diagnosis and treatment of breast cancer among black women.
Advancements in screening, diagnosing and treating breast cancer has not changed the fact that the disease does not affect all racial and ethnic groups equally.

Breast cancer deaths have declined 42 percent in the past 30 years, thanks to increased awareness, expanded and earlier screening and improved therapies. But all these advancements in screening, diagnosing and treating breast cancer has not changed the fact that the disease does not affect all racial and ethnic groups equally.

Black women continue to have the lowest survival rate of any racial or ethnic group. The five-year survival rate for a black woman with breast cancer is 81 percent versus 92 percent for white women. Black women also are more likely to die from breast cancer at any age—with young black women dying at double the rate of young white women, according to the National Cancer Institute.

Black women were less likely to have an early-stage diagnosis than white women, according to the American Cancer Society. African-American women are at an increased risk to develop triple-negative breast cancer, an aggressive subtype linked to some of the worse outcomes.

The reasons for these breast cancer disparities are many and often complex and often mirror other health disparities among ethnic groups. They include factors like socioeconomic status, differences in biology and genetics, and variations in cultural and behavioral norms.

In this article, we’ll explore:

If you’re interested in learning more about how we treat breast cancer at Cancer Treatment Centers of America® (CTCA), or if you’d like to talk with someone about your cancer treatment options, call us or chat online with a member of our team.

Genetic and biological factors

Black women are disproportionately affected by more aggressive breast cancer subtypes, such as triple-negative and inflammatory breast cancers. They’re also more likely to be diagnosed at younger ages and more advanced stages.

Several underlying biological differences influence these tendencies, says Laura Farrington, DO, Medical Oncologist at CTCA® Chicago. For one, black women are less likely to have a BRCA mutation but are more likely to have aggressive forms of breast cancer that don’t have hormone receptors for the two main sex hormones in women—estrogen and progesterone—or for the HER-2 growth-promoting protein. Without these targets, triple-negative breast cancers are difficult to treat.

“Triple-negative breast cancer, by definition, doesn’t have estrogen receptors,” Dr. Farrington says. “There are a lot of clinical trials that are studying treatments for estrogen-receptor-positive breast cancers because they have a target. There just isn’t a good target, at least not yet, for triple-negative breast cancer.”

Socioeconomic factors

According to a University of Wisconsin study, social factors, such as income levels, education, employment, living conditions and access to social and family support may significantly impact a person’s health. When it comes to breast cancer, poverty is linked to poorer outcomes among Americans, regardless of race. But black Americans are more likely to live in poverty than other ethnic groups, according the U.S. Census Bureau. Because more black people (19.5 percent) live in poverty in America than white people (8.2 percent), they’re statistically at higher risk of having poorer breast cancer outcomes.

Poverty may also be linked to a lack of education around breast cancer prevention. Low-income black women undergo breast cancer screening at significantly lower rates, which lead to a higher risk of advanced-stage diagnoses. In general, black Americans are less likely to have a regular health care provider, often live in areas that don’t provide easy health care access and may not have adequate health insurance.

“Regardless of education level, black women in the U.S. are known to have a higher rate of unemployment than white women,” Anita Johnson, MD, Chief of Surgery at CTCA Atlanta and Leader of the CTCA Atlanta Women’s Cancer Center, said in an article published by Managed Healthcare Executive. “Being gainfully employed frequently provides individuals with benefits like health insurance and paid time off. These are important contributing factors to access screening, which can lead to earlier diagnoses of cancer and subsequently better outcomes, as well as the ability to seek and maintain cancer treatment.”

Black women who live in poverty also tend to have more risk factors for breast cancer, such as a higher prevalence of diabetes, heart disease, hypertension and obesity.

“Lack of access to high-quality screening and treatment, or to clinical trials, are heavily rooted in societal inequity.Dr. Johnson says in the article. “In the long term, social reform is needed to address inequity in income, wealth and health insurance access. In the short to medium term, health systems and cancer care providers need to recognize how inequity affects their patient populations and use existing resources that do help ensure that everyone has access to current therapies instead of solely focusing on new innovations that will not be accessible to many in the population.”

Behavioral and belief factors

Mistrust of the medical profession is a major factor in higher breast cancer mortality rates among black women, Dr. Farrington says. Much of this mistrust can be traced back to the U.S. Public Health Service Syphilis Study at Tuskegee of 1932-1972. The study’s goal was to observe the effects of untreated syphilis on a group of nearly 400 black men with the disease, but the men weren’t informed of the nature of the study, and more than 100 of them died.

A Jackson State University study titled Health and Racial Disparity in Breast Cancer outlined several other factors that may contribute to poorer breast cancer outcomes among black women. According to the report, black women may be:

  • Less likely to choose surgical treatment compared to other ethnic groups
  • More likely than white women to have trouble paying for and taking prescribed medicines after surgery
  • More likely to rely on divine intervention rather than medical treatment and preventive screenings
  • Less likely to be recommended for a mammogram
  • Less likely to breastfeed, which may help reduce the risk of breast cancer, especially estrogen-receptor-positive breast cancer, Dr. Farrington says

The continued growth of the Black-White breast cancer mortality gap suggests that the current approaches to preventing or eliminating racial/ethnic disparities in breast cancer are not sufficient,” the Jackson State study says. “Therefore, new strategies and approaches are needed to promote breast cancer prevention, improve survival rates, reduce breast cancer mortality, and improve the health outcomes of racial/ethnic minorities. 

How to address racial disparities

Socioeconomic issues and behavioral factors and beliefs may explain some of the disparities between white and black women with breast cancer. So far, researchers have only begun to understand the biology that explains the higher incidence rates of aggressive breast cancers in black women.

A recent discovery of a key biomarker may help identify the root cause at the cellular level for breast cancer in some black women. Researchers found that the accumulation of the protein named Kaiso may increase a person’s risk for breast cancer growth. Named after a genre of Caribbean music that originated from West Africa, Kaiso is associated with cancers like triple-negative breast cancer and higher mortality rates in women of African heritage.

 More research is needed to determine whether Kaiso as a biomarker may help predict outcomes and guide future treatments for black women with aggressive forms of breast cancer.

And yet, black people and other minorities remain underrepresented in clinical trials on the treatment of breast cancer and many other cancers, according to a 2021 study by researchers at Harvard. Of 93 studies reviewed by researchers, 82 percent of participants were white and 10 percent were black. Other non-white ethnic groups were also underrepresented.

“This analysis found that precision oncology studies for breast, lung, prostate, and colorectal cancers vastly under-represent racial and ethnic minority populations relative to their cancer incidence in the U.S. population,” researchers wrote. “It is imperative to increase diversity among enrollees so that all individuals may benefit from cancer research breakthroughs and personalized treatments.”

In four clinical trials that led to FDA approvals for treatments, fewer than 9 percent of the breast cancer patients were black, according to the advocacy website breastcancer.org.

Increasing education, awareness and access to breast cancer screening in underserved populations should significantly help improve disparities in breast cancer mortality rates, Dr. Farrington says.

“I really wish we were doing a better job of educating young doctors and young black people in the United States on the importance of cancer screening and making it more readily available to them,” she says. “I would encourage women, especially black women, to start breast cancer screening at age 40, regardless of family history.”

Even though family history is one of the most widely known breast cancer risk factors, Dr. Farrington says it’s not always the root cause of the disease.

“I hear all the time from patients that they can’t believe they have breast cancer because they have no family history of it,” she says. “But most breast cancers aren’t hereditary. Every woman needs to get screened, not just someone with a medical history. And they need to start young.”

If you’re interested in learning more about how we treat breast cancer at CTCA®, or if you’d like to talk with someone about your cancer treatment options, call us or chat online with a member of our team.