Breast Cancer in Black Women: Physicians Do Not Know Enough

In response to my blog post on June 7, 2021, "Why Do We Treat Early Breast Cancer Like It's the Dark Ages?" I received this tweet:

My immediate thought was, "I don't know!" I should have known. I am not a breast specialist, but the fact that in the US the rate of breast cancer death in Black women is higher than in White women (27.8 vs 19.4 per 100,000) even though the incidence of the cancer is lower (12% vs 13% lifetime risk), and that triple-negative breast cancer is more common among Black and African American women than in any other subgroup, these should be tested on oncology boards that instead chose to ask me about ureteral cancer (so rare I can't even find US statistics for incidence; Denmark says about 0.3 per 100,000 person-years).

In verifying the statistics above, I am disheartened to see that the probably best-known foundation for breast cancer research in the US appears to be blaming the higher rates of triple-negative disease on the behavior of Black women, right after truthfully saying that we do not know the cause of the difference. "Although the reasons for racial and ethnic differences in rates of TNBC aren't clear, some lifestyle factors may play a role. Compared to white and non-Hispanic white women, Black and African American women tend to: 1. Have lower rates of breastfeeding. 2. Carry excess weight in the abdomen area. Both of these factors may be linked to an increased risk of TNBC." They do provide citations for this discussion, thank goodness, but in a barely one-page summary of the entire topic of race and ethnicity differences in breast cancer, do we really need to mention this?

If you are going to bring it up, why not present the evidence that body habitus does NOT play a role? The only thing we know for sure is that the explanation behind high rates of triple-negative breast cancer in Black women involves an extremely complex interplay of genetic and epigenetic factors. If we are not going to discuss all of the other variables involved, as is done in this paper, for example, we most certainly should not bring up the ones that, in isolation, appear to blame these women for their disease.

So, given this discouraging start in giving a thoughtful answer to an excellent question, I decided I would spend time reading about the evidence touching on this specific question: How do we interpret the data in this study as it pertains to Black women?

After extensive reading, here is what I ultimately told Touch, The Black Breast Cancer Alliance:

An excellent question that I shouldn't have failed to ask myself. Thank you. That study was done in Sweden. Race was not tabulated. Africa as birth place was grouped with many unrelated locations, so the answer is unclear, but a small number. I don't know the authors to ask.

We do know that in the U.S. mastectomy is more common in Black women but when we account for the severity of disease at diagnosis, this is no longer true.

In other words, we need to correct that proportion by ensuring that Black women have preventive care and screening appropriate to their increased risk, and that abnormal results are followed up in a way that empowers them to pursue good workup.

Messages of Hope: Health Communication Strategies That Address Barriers Preventing Black Women From Screening for Breast Cancer

Realizing the promise of breast cancer screening: clinical follow-up after abnormal screening among Black women

When we compare stage-matched groups of Black women, the good outcomes for breast conservation remain: recurrence and survival are the same in mastectomy and breast-conservation groups.

In further good news, contralateral prophylactic mastectomy, which does NOT increase survival, is less common among Black women. Heartening in a country in which Black bodies have so often been treated as disposable.

Thank you so much for your question. If there are topics you'd like to see discussed over at the Medscape Oncology Blog I am all ears. I would love to use that as a place to get your questions and perceptions in front of an even wider audience. #diversityinclinicaltrials

I'm not sure if the folks at @TouchBBCA read my reply. I'd love to hear their opinion! But I am grateful for their engagement through social media with practicing doctors whose education has left them incompletely prepared in regard to this important topic. I am certainly a better-informed physician because of them.

(As an aside, I'm wondering if we shouldn't mandate that all science writing be done in tweets. The terseness would be appreciated on the receiving end, at least over here.)

What are your ideas for improving medical education in regard to health disparities?

Please join the discussion below, but if you need to communicate with me offline you can reach me at Medscape-Blogs@webmd.net.

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