Black Women and Breast Cancer: Why Disparities Persist and How to End Them
By BCRF | January 25, 2023
By BCRF | January 25, 2023
In the United States, breast cancer continues to be the most common cancer after non-melanoma skin cancer, and it is the second leading cause of cancer death. In 2023, the American Cancer Society (ACS) estimates that more than 300,590 new cases of invasive breast cancer and 55,720 new cases of ductal carcinoma in situ/stage 0 breast cancer will be diagnosed in women in the United States. While there has been an overall 43 percent decline in breast cancer deaths over the last three decades—thanks to gains in awareness, earlier diagnoses, and more effective treatments—there is a persistent mortality gap between Black women and white women.
Data compiled by ACS highlight the need to continue working toward closing this devastating gap. While breast cancer incidence rates among Black and white women are close, mortality rates are markedly different, with Black women having a 40 percent higher death rate from breast cancer. Among women under 50, the disparity is even greater: While young women have a higher incidence of aggressive cancers, young Black women have double the mortality rate of young white women. Advances in early detection and treatment have dramatically reduced breast cancer’s ability to take lives overall, but it’s clear that these breakthroughs haven’t benefitted all groups equally—and this disparity has remained unchanged for more than a decade.
The gap in breast cancer incidence and outcome among Black women is complex and multifactorial. Social, economic, and behavioral factors may partially account for disparities. Black women are statistically more likely to have diabetes, heart disease, and obesity, and are less likely to breastfeed after childbirth—all of which are risk factors for breast cancer. They are more likely than white women to have inadequate health insurance or access to health care facilities, which may affect screening, follow-up care, and completion of therapy.
Through continued research, it’s clear that biology also plays a role. Black women are disproportionately affected by more aggressive subtypes, such as triple-negative breast cancer (TNBC) and inflammatory breast cancer, and they are more likely to be diagnosed at younger ages and at more advanced stages of the disease.
Moreover, results from two large clinical trials—TAILORx and RxPONDER, supported in part by BCRF—have revealed distinct differences in recurrence and outcomes in Black compared to white women. BCRF investigator and study lead Dr. Joseph Sparano recently reported on the TAILORx trial, which showed that while the number of late recurrences exceeded early recurrence rates in all participants, disparities between Black women and white women were observed in early recurrences but not in late recurrences. Looking at the connection between race and clinical outcomes, RxPONDER investigators found that, despite having similar recurrence scores, Black women with HR-positive/HER2-negative, lymph node-positive breast cancer had worse outcomes compared to Asian, Hispanic, and non-Hispanic white women.
A 2017 study looking at women between the ages of 18 to 64 who were diagnosed with early-stage breast cancer found that four key factors accounted for 76.3 percent of the total excess mortality risk in Black patients: 37 percent of Black women’s excess mortality risk could be explained by a lack of private health insurance; tumor characteristics explained 23.2 percent; comorbidities 11.3 percent; and treatment differences (when it started or stopped, what was given) 4.8 percent.
In fact, a recent study led by BCRF investigator Dr. Marianna Chavez MacGregor underscored the importance of healthcare access after it found that among patients with stage 4 breast cancer, survival disparities between white women and other racial/ethnic groups were no longer present in states that expanded Medicaid (healthcare coverage for low-income Americans) after the Affordable Care Act.
According to the National Cancer Institute, disparities in cancer care can be improved in several ways, including by creating statewide cancer screening programs that are accessible to underserved populations and by addressing the biological differences in breast cancer across racial and ethnic groups. A 2019 study that analyzed characteristics of breast cancer patients on a city level showed that women with more resources (such as education and income) may be better equipped to take advantage of healthcare advances. Indeed, cities that have confronted this problem by increasing access to state-of-the art mammography facilities made significant progress in narrowing the breast cancer mortality gap between Black and white women.
The biology of breast cancer is inherently complex, which is why we often hear the phrase, “Every woman’s breast cancer is unique.” While we have made significant progress in understanding the molecular drivers of breast cancer, most studies and clinical trials are conducted in white women. Expanding Black women’s participation in research is critical.
We have only recently been able to decipher some of the underlying biology to explain the higher incidence of aggressive tumors in Black women and to identify biomarkers that could ultimately inform personalized therapies and improve outcomes for Black women diagnosed with breast cancer.
BCRF recognizes the continued need for more research to end disparities faced by Black women across the U.S. A snapshot of the current BCRF-supported projects specifically in this area include:
Drs. Christine Ambrosone and Chi-Chen Hong are studying the types of immune cells found in and around breast tumors from both Black and white women to determine if they affect tumor aggressiveness.
Dr. Fergus Couch has identified inherited mutations in breast cancer susceptibility genes that confer an increased risk of TNBC and may be important for screening in high-risk Black women. Recently, Couch and his collaborators examined gene mutations in a large, racially diverse population of American women. This study showed that mutations in the BARD1, RAD51C, and RAD51D genes, while very uncommon, appear more frequently in Black women with breast cancer and are associated with an increased risk of both TNBC and ER-negative breast cancer. Read more here.
In a cohort of 100 breast cancer patients with African ancestry, Dr. Melissa Davis is studying the relationships between social determinants of health, ancestry, the tumor microenvironment, and survival.
Dr. Laura Esserman is examining the immunological features of breast cancers in Black women to gain a better understanding of the spectrum of disease and the types of interventions that might improve outcomes.
Looking at underrepresented or understudied populations, including racial and ethnic minorities as well as older people, Dr. MacGregor is evaluating the rates of treatment completion and how treatment-related toxicities and access to care impact these groups.
Dr. Lisa Newman is conducting a pilot study to both tackle breast cancer disparities related to race and ethnicity and provide a platform for Black physicians to be more engaged in research.
Drs. Funmi Olopade and Dezheng Huo are identifying genetic factors responsible for TNBC and those that specifically predispose Black women to this aggressive disease. Dr. Olopade and colleagues were the first to discover that Black women have a higher incidence of mutations in the BRCA1 and BRCA2 genes, as well as other inherited susceptibility genes, compared to their white counterparts.
Work led by Dr. Charles Perou and BCRF collaborators has uncovered differences in the genes and gene mutations found in Black women’s breast tumors, compared to those in white women. His team is building on their findings to identify the drivers of metastatic disease, determining the adaptive immune system’s role in breast tumor progression and improve therapeutic targeting of TNBC tumors to decrease disparities in outcomes.
Utilizing data from completed and ongoing clinical trials, Dr. Priyanka Sharma is studying the relationship between race and treatment response biomarkers in TNBC. Ultimately, her research will move us closer to personalized medicine, tailoring treatments to an individual’s cancer biology.
Dr. Sparano is working to identify markers associated with a higher risk for chemotherapy-induced neuropathy, a treatment side effect that disproportionately affects Black women. He also continues analyses of the TAILORx trial and, with fellow BCRF investigator Dr. Kevin Kalinsky, the RxPONDER trial to delve into reasons for disparities in recurrence and outcomes revealed so far.
Dr. Annette Stanton is conducting research on the unique psychological experiences of Black women diagnosed with breast cancer to help them better cope and decrease depressive symptoms.
Dr. Nikhil Wagle is working to gain a better understanding of the molecular characteristics of breast cancer that develops and metastasizes in Black patients.
Dr. Walter Willett has shown that a plant-based diet—one rich in carotenoids, cruciferous vegetables, berries, fiber, and vitamin D—is associated with a lower risk of breast cancer. He is expanding this project to determine if this result applies to a racially diverse cohort (via the Southern Community Cohort Study) consisting mainly of Black women.
Dr. Eric Winer seeks to understand the interplay between lifestyle factors, obesity, and breast cancer biomarkers that disproportionately impact low-income minority women and that are associated with poorer health outcomes. His team hopes to develop and implement lifestyle weight management counseling for these women to provide equitable care for all breast cancer patients.
Last year, the World Health Organization announced that breast cancer had become the most frequently diagnosed cancer globally, with 2.3 million diagnoses in 2020—making global breast cancer research even more critical. BCRF investigators are addressing health care inequalities around the world, with a particular focus on Black women in low-resource areas. These studies have the potential to inform strategies to improve outcomes in underserved communities globally.
Drs. Lawrence Shulman and Cyprien Shyirambere have developed effective strategies to integrate early detection services into rural Rwanda’s health care system and reduce time to treatment. They are now working to expand these efforts to reach more women with the goal of reducing preventable breast cancer deaths in Rwanda and other countries.
In another project, Dr. Olopade is investigating differences in tumor biology, genetics, and health care delivery patterns that contribute to the mortality gap between Black and white women. She has expanded her studies to develop infrastructure for clinical trials in low-resource communities in Nigeria and sub-Saharan Africa. Clinical trials to test novel targeted treatments, increase access to quality diagnostic tools, and optimize the standard-of-care treatments will improve outcomes for this population and potentially others in underserved areas.
In addition to supporting the above BCRF investigators and others whose work may impact Black women in the U.S. and abroad, the Foundation grants three- and five-year career development awards. Below are the current investigators and their projects are.
Dr. Marjory Charlot is addressing the gaps Black women experience in clinical trial education and communication. Using patient- and community-based participatory research methods, her team will develop and test a mobile health app to help Black breast cancer patients prepare to discuss participating in clinical trials with their providers.
Dr. Temidayo Fadelu’s study aims to identify barriers keeping Rwandan women from completing adjuvant endocrine therapy—an effective treatment that reduces recurrence and boosts survival—and devise interventions such as text message reminders to improve outcomes.
Utilizing a comprehensive database of medical records and tumor samples from 600 patients with BRCA1/2 or PALB2 mutations, Dr. Sonya Reid is analyzing how different clinical and genetic features impact recurrence and survival across different racial groups.
In Black women with early-stage breast cancer, Dr. Mylin Torres is looking for genetic variations associated with race that may increase their risk of treatment-related comorbidities, impact treatment adherence, and contribute to worse survival outcomes.
Early- and mid-career investigators who are focused on improving disparities faced by Black women receive BCRF support in the form of one- and two-year grants. The current recipients are: Drs. Rohini Bhatia, Frederick Howard, Joannie Ivory, Kimberley Lee, Melinda Mushonga, Samilia Obeng-Gyasi, and Juhi Purswani. Read more about our commitment to diversifying the field of breast cancer research and supporting disparities-focused researchers early in their careers here.
In October 2022, to mark 30 years of The Estée Lauder Companies’ Breast Cancer Campaign, The Estée Lauder Companies Charitable Foundation announced that it would donate $15 million—the single largest corporate donation in BCRF history—to accelerate innovative research addressing breast cancer disparities. This gift ($3 million per year for five years) will fund a new BCRF research initiative studying the intersection of social determinants of health, comorbidities, and the biology of breast cancer in Black women.
Addressing and improving Black women’s representation in breast cancer clinic trials is critical to assuring equity in care. BCRF supports two large clinical trials networks that are working toward this goal: the Translational Breast Cancer Research Consortium and the Southwest Oncology Group.
A deeper understanding of tumor biology, its variations among people of different races, and the intersection of biology and social determinants of health holds the promise to improve prevention strategies, early detection, and treatment of breast cancer to reduce disparities. BCRF continues to work toward this goal.
This article was updated to reflect 2023 data and research projects.
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