One in eight women will be diagnosed with breast cancer during her lifetime and one in 39 will die from the disease, according to the American Cancer Society.
Those numbers are worse in Georgia, where breast cancer accounts for 30% of new cancer cases among women, according to the Georgia Department of Public Health. The highest concentration is in metro Atlanta, where breast cancer is the leading cause of cancer among women: more than 8,000 women were diagnosed last year and approximately 1,350 women died from the disease.
For Black women, however, the numbers are even starker. According to the American Cancer Society, Black women have the highest breast cancer death rate, as well as higher incidence rates than white women under age 40. Black women also are more likely to die from breast cancer at every age.
“Breast cancer is the most commonly diagnosed cancer in black women and the second leading cause of cancer deaths,” said Laura Makaroff, senior vice president of prevention and early detection for American Cancer Society, adding that breast cancer death rates are about 40% higher in Black women compared to white women. “This disparity is largely due to more advanced stage at diagnosis, higher prevalence of other co-morbid conditions including obesity, tumor characteristics that respond less favorably to treatment, and variation in access and adherence to high-quality cancer treatment.”
Many studies being conducted in the metro area and nationwide examine these disparities in diagnosis, treatment and support among women with breast cancer. Other breast cancer researchers in Atlanta are working to identify new treatments and overcome other challenges.
Breast cancer disparities are magnified in Atlanta, according to Ilana Graetz, associate professor in Emory’s Rollins School of Public Health’s Department of Health Policy and Management.
The city “faces the highest Black and white disparity in breast cancer survival rates among the 50 largest cities in the country,” she said. “Black women in Atlanta are more than twice as likely to die from the disease within five years compared to white women.”
Graetz’s research aims to provide information on how various points in treatment may contribute to increased mortality for black women. Her goal also is to find interventions to reduce this disparity, she said.
One of her two studies combines patient-reported symptoms with insurance data to study racial disparities in breast cancer outcomes. Her other study is a five-year randomized controlled trial testing the efficacy of an app being used by breast cancer patients taking adjuvant endocrine therapy.
Her first study uses existing data collected from electronic medical records, insurance claims data from Medicare and Medicaid, and patient reported symptoms collected during routine care.
Graetz currently is recruiting for the app trial and collecting data by reviewing charts, administering surveys and using an electronic medication adherence monitoring device, a pillbox with a cellphone chip that tracks every time the pillbox is opened.
“While we do not have results yet, in a pilot trial, we found that using the app for eight weeks improved medication adherence and lowered symptom burden,” Graetz said. “We are hoping that by standardizing patient-provider communication, we can improve outcomes and reduce racial disparities in medication adherence.”
Lauren McCullough is assistant professor of epidemiology at Emory University’s Rollins School of Public Health and a member of the Cancer Prevention and Control Research Program at Winship Cancer Institute. McCullough’s studies focus on the epidemiology of breast cancer related to obesity and exercise, as well as on disparities in breast cancer outcomes.
McCullough said she has discovered that some researchers and medical professionals believe that most Black women get triple-negative breast cancer, which is breast cancer that doesn’t have estrogen or progesterone receptors and doesn’t create significant amounts of the protein HER2. While triple-negative cancers are twice as likely to occur in Black women than white women, triple-negative breast cancer in fact is not the leading type of breast cancer in Black women, McCullough explained.
“Most black women do not get triple-negative breast cancer,” McCullough said. “Seventy percent of black women get ER-positive or HR-positive breast cancer.”
Part of McCullough’s work is trying to discover why Black women are dying disproportionately from ER-positive breast cancer compared to white women with the same type of cancer, even those with similar socioeconomic profiles.
“A Black woman that lives in a neighborhood that has high socioeconomic status is twice as likely to die as a white woman living in a high socioeconomic neighborhood,” she explained. “This is counterintuitive for most people, because they think if a woman has income, insurance, if she lives in a high socioeconomic neighborhood, if she has access to care, they should be seeing the same outcomes, but they are not. Why are [Black women] doing worse?”
McCullough said her hope is more research into outcome disparities will help save more lives.
“We are trying to do better surveillance long-term to better see where women are falling through the cracks in this cancer that we actually have good treatments for,” she said of ER-positive and HR-positive breast cancers. “Nobody needs to come up with a new treatment. We’ve got them and they work. We just have to figure out why these Black women are still dying.”
Black women too are disproportionately represented in breast cancer trials.
“Trials are mostly sponsored by the big pharmaceutical companies, so most trials are going to exclude you if you have a pre-existing condition,” McCullough said. “Eighty percent of black women are overweight or obese. If the trial calls for women of ideal weight, there is not going to be a whole lot of representation from the Black population, or if the trial says you can’t have Type II diabetes or hypertension, 30 percent to 50 percent of Black women have those conditions, so they are automatically excluded from those trials.”
Drug trials and other breast cancer research must be designed with the population that will be treated for that type of cancer, McCullough said. “It is really important because we need to know, are these things really going to work or is a woman going to be on this for six weeks and have an adverse reaction?” she said. “If they were a part of the trial, we would know that.”
Breast cancer treatments and outcomes also carry disparities within the Asian American community, according to Eun-Ok Im, senior associate dean for research and innovation at Emory University and Edith Folsom Honeycut Endowed Chair professor. Im is leading a federally funded NIH/NCI study testing a technology-based information and coaching/support program to improve breast cancer survivorship among Asian American breast cancer survivors.
“Asian American breast cancer survivors frequently carry serious physical and psychological burden,” Im explained. “They seldom report their symptoms, delay seeking assistance until they could not tolerate anymore, and rarely seek support due to their cultural values, attitudes, beliefs and language barriers. Thus, they tend to have a lower quality of life and fewer resources for information and support compared with whites.”
As Asian culture is patriarchal, women typically are overseeing all household tasks and child issues, “which frequently make them physically and psychologically burdened in addition to their symptoms and pain,” Im added.
Unless health care providers tackle the “cultural hesitance” of Asian American patients, they will continue to suffer through symptoms that could be easily treated, she said.
In partnership with Pfizer Inc., the American Cancer Society developed a grant program to assist communities in finding solutions to breast cancer disparities. Through a competitive process early this year, nine awardees from across the nation were selected.
“Addressing and reducing disparities in breast cancer mortality will require a multi-pronged, multi-sector approach,” said Makaroff of the American Cancer Society. “Equalizing outcomes for all women facing breast cancer will require solutions addressing the entire patient journey, including improved care coordination between primary and specialty care, timely access to follow-up mammography and consistent access to high-quality cancer care. Genetic counseling and testing are also important factors to address in improving breast cancer survival for all women.”