1. Schneider, Mary Ellen

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Breast cancer has leapfrogged over lung cancer to become the leading cause of cancer death for Black women, according to a recent analysis from the American Cancer Society. Breast cancer accounts for 18 percent of cancer deaths among Black women, followed closely by lung cancer at 17 percent, and colorectal cancer at 9 percent. The findings were reported in CA: A Cancer Journal for Clinicians as part of a special report on "Cancer Statistics for African American/Black People in 2022."

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Among the key findings was the significantly higher mortality burden for Black patients, compared with their White counterparts. Overall, Black women are 41 percent more likely to die from breast cancer than White women, despite being less likely to be diagnosed with the disease (2022; doi: 10.3322/caac.21718).


"The breast cancer mortality gap between Black and White women in the United States is extremely alarming and represents a major public health crisis," said Lisa Newman, MD, Chief of the Division of Breast Surgery at Weill Cornell Medicine/NewYork-Presbyterian Hospital Network, who was not involved in the study.


Study Details

The analysis, which is published by the American Cancer Society every 2-3 years, brings together the most recent federal data on cancer incidence, survival, mortality, screening, and risk factors for Black people in the United States, as well as projections on the number of new cancer cases and deaths in 2022. Data comes from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and the Centers for Disease Control and Prevention's National Program of Cancer Registries.


Overall, investigators from the American Cancer Society estimated that 36,430 Black men and 37,250 Black women will die from cancer in 2022. While the top causes of death among Black women are breast cancer, followed by lung and colorectal cancer, among Black men, the leading causes of death are lung cancer (22%), prostate cancer (17%), and colorectal cancer (11%).


When looking at men and women, the Black/White cancer mortality gap has narrowed for all cancers combined. For men, the gap peaked at 48 percent in 1993 and fell to 18 percent in 2019. Among women, the combined cancer mortality gap fell from its peak of 21 percent in 1997 to 13 percent in 2019. However, despite a lower incidence of breast cancer among Black women from 2014 to 2018 (127.1 cases per 100,000 for Black women vs. 132.5 per 100,000 for White women), the gap in mortality between Black and White women was 41 percent in 2019.


While the breast cancer mortality gap peaked at 44 percent in 2011, it has remained at about that level since, which is concerning, explained Rebecca Siegel, MPH, one of the authors of the analysis and Senior Scientific Director of Surveillance Research at the American Cancer Society.


"What's really concerning about breast cancer is that we don't see the disparity narrowing," Siegel said. "In most other cancers, we see a peak and then improvement. You do not see that for breast cancer. It's been consistent at around 40 percent, which is shocking when you consider the lower risk for diagnosis and advances in early detection and treatment."


Disparity Drivers

Factors contributing to the racial gap in mortality include a later stage of diagnosis, less access to guideline-concordant care, higher rates of obesity and other comorbidities, and more aggressive cancer subtypes. For example, Black women are twice as likely to be diagnosed with triple-negative breast cancer (TNBC) and inflammatory breast cancer. However, when compared with White women with the same aggressive cancer, Black women still had a higher mortality rate.


Black women are also more likely to be diagnosed with breast cancer at a later stage. While 67 percent of White women are diagnosed with breast cancer at a localized stage, just 57 percent of Black women get a local stage diagnosis. Black women also have a lower survival rate at all stages of diagnosis.


Lack of insurance is one of the barriers to accessing care, Siegel said. But even when Black women have access to mammography, they may be screened at centers with lower quality or experience substantial delays in the time between an abnormal result and the necessary follow-up care, she said. Once treatment is underway, Black patients are less likely to get care recommended in guidelines, including surgery, adjuvant chemotherapy, and radiation. "Everything is lower," Siegel said. "It really harkens back to long-term racism and a disproportionate distribution of wealth."


Discriminatory practices in housing and banking over centuries have essentially trapped Black families in neighborhoods with fewer educational and employment prospects and nutritional insecurity, all of which influence health and access to health care, Newman explained.


"These socioeconomic disadvantages must be addressed as we seek to achieve health equity, but we also have an obligation to reach this goal through breast cancer research related to the biologic and genetic factors that contribute to disparities," she said. "We cannot eliminate breast cancer disparities unless we conduct research to explain these inherent differences in susceptibility to TNBC, and we must overcome barriers to clinical research regarding this biologically aggressive phenotype so that our treatment advances can be generalized to our diverse patient population."


While most of the factors impacting racial disparities in health care will require policy and system-level changes, there are some things that individual oncologists can do, said Tuya Pal, MD, Associate Director for Cancer Health Disparities at Vanderbilt-Ingram Cancer Center, who was not involved in the analysis.


Start by being aware of important non-medical factors that impact a patient's ability to obtain and adhere to treatment, such as transportation, access to the internet, having a safe place to exercise, and being able to shop for nutritious food, she noted. "Context matters and, as we are making these recommendations in the clinical setting, we also need to consider how they can be implemented by the patient," Pal said.


Another action oncologists can take is to seek out training and education about bias in health care. Pal said she previously attended a bias training session offered to faculty at Vanderbilt, which she found tremendously helpful.


"As health care providers, it is important to understand and address any implicit biases we may have to do right by our patients," she said. "We're all the products of the society in which we grew up, but we have to understand our own context so we can improve."


Mary Ellen Schneider is a contributing writer.