Racial Disparities In Breast Cancer Treatment

Breast cancer is the most common cancer in the United States and worldwide, after skin cancer.¹ In the US, it’s estimated that there will be 298,000 new cases of breast cancer diagnosed and about 43,000 deaths from the disease in 2023. 

However, not everyone is affected equally. Racial disparities in treating breast cancer are prevalent.² These disparities significantly impact the prognosis and survival rate of many women from diverse racial and ethnic minority populations.

Overview of breast cancer

Breast cancer is a common disease across all ethnicities. Per 100,000 women, the rates of breast cancer in different races in the United States are:³

• 136.3 White women

• 128.3 Black women

• 107.4 Native American women

• 106.5 Asian/Pacific Islander women

• 98.5 Hispanic women

Although Black women have lower rates of breast cancer than White women, their mortality from breast cancer is 40% higher. Black women are also more likely to have metastatic cancer, higher-grade tumors, and be diagnosed with a more aggressive breast cancer subtype called triple-negative breast cancer (TNBC) subtype.⁴ Black women also have the worst survival rate of any other racial group.

Common risk factors

Some of the common risk factors of breast cancer include:⁵

• Gender: Women are more likely to get breast cancer than men. 

• Age: Breast cancer becomes more prevalent from the age of 40, except for certain subtypes such as TNBC, where it’s more common among younger women. 

• Family history of breast or ovarian cancer

• Early age of menarche (the first menstrual cycle) 

• Genetics, such as inheriting a mutation in one of the BRCA genes 

• Race and ethnicity: Certain breast cancer subtypes are more common in specific races than others. TNBC, for example, is more common among Black and Hispanic women.

• High breast tissue density 

• Being overweight or obese

• Excessive alcohol intake

• Smoking

• High intake of processed foods

• Exposure to certain chemicals

• Previous exposure to radiation 

Treatment options

Treatments considered for breast cancer include:⁶

• Surgery to remove the cancerous tissue

• Chemotherapy (drugs that destroy cancer cells)

• Radiation therapy to destroy cancer cells

• Hormonal therapy (drugs that block estrogen or its impact on cancer cells) 

• Biological/targeted therapy (drugs that target specific proteins in the cancer cells to block their growth and spread)

Disparities in breast cancer treatment 

Black people face many disparities in breast cancer treatment. For example: 

Disparities in treatment options offered to patients

There are racial disparities in the specific treatment options offered to patients. Differences in treatment have a negative impact on cancer outcomes, including more frequent recurrence and higher mortality rates.⁷

Black and Hispanic women are less likely to receive definitive local therapy, chemotherapy, hormone therapy, and radiation therapy for breast cancer.⁸ They’re also more likely to receive underdosing of chemotherapy as a result of inappropriate “capping” of doses for overweight patients. As well as this, they’re less likely to receive post-cancer dietary guidance, rehabilitation, and mental health services.⁹

Minority women are also more likely to receive healthcare at facilities that are slower to adopt innovative therapies and have less access to certain surgeries, breast reconstruction, adjuvant treatments, and targeted therapies.¹⁰ This is partly because people in minority groups are less likely to receive healthcare at facilities with a National Cancer Institute Comprehensive Cancer Care designation. 

Additionally, Black people more frequently reported they had lost insurance coverage after their cancer diagnosis, which negatively impacted their care and treatment.¹¹ Minority populations are also more likely to have unstaged cancer or aggressive types of cancer, which influences the type of treatment they receive. 

On the other hand, a patient’s knowledge of care options and attitude toward treatments also influences the treatment they receive. Due to historical medical mistrust and systemic abuse of Black people in the health system, Black women may be less likely to choose surgical options, limiting their treatment options and reducing the prospect of positive health outcomes.¹²

Differences in receiving timely treatment

Minority groups experience prolonged delays for surgery, chemotherapy, and radiation treatment. One study found that 30% of Black women wait over 60 days for surgery after diagnosis, compared to 18% of White women. Another study found that 25% of Black women experience treatment delays of more than three months.¹³

One study found that an eight-week delay in breast cancer surgery increases the risk of death by 17%, and a 12-week delay increases the risk by 26%.¹⁴

Differences in treatment adherence and completion rates

Racial differences in treatment adherence and completion rates are evident. For example, Black women are less likely to complete adjuvant trastuzumab treatment (targeted anticancer drug) and attend their outpatient medical appointments.¹⁵ Black women are also more likely to stop treatment early.¹⁶

Factors that may contribute to variations in breast cancer treatment adherence or completion rates in different racial and ethnic groups include:¹⁷

• Experiencing severe symptoms (physical and psychological) 

• Socioeconomic situation impacting their insurance status and location

• Age

• Cancer stage 

Non-adherence/discontinuation of treatment has negative impacts on long-term survival rates. A study found that disease-free survival rates are significantly lowered when chemotherapy is stopped early, showing the importance of fully completing treatment.¹⁸

Furthermore, adjuvant endocrine therapy (AET), which includes tamoxifen or aromatase inhibitors, has been shown to lower the risk of recurrence by 30% and mortality by 40% in patients with hormone-receptor-positive breast cancer. 

However, this treatment may affect races differently, hence, the rate of adherence. For example, a study reported that Black women had a higher severity of most side effects compared to White women. Consequently, adherence was 78.8% for Black women and 82.3% for White women.

Factors that contribute to racial disparities in breast cancer treatment

Many factors contribute to the racial disparities in breast cancer treatment, such as:

Biological factors

Biological factors can’t explain all of the racial disparities in breast cancer treatment, but research suggests they likely play a part. Black and Hispanic women are diagnosed with more aggressive tumors and subtypes of breast cancer, such as triple-negative breast cancer.¹⁹

The cancer cells in triple-negative breast cancer lack the estrogen and progesterone receptors that attach to these hormones.²⁰ Therefore, hormonal and other targeted drug therapies that block hormone production or interfere with the hormones’ effects on cancer cells are ineffective in treating triple-negative breast cancer because the tumors won’t respond to them.²¹ ²²

Black women were found to have a much higher predisposition for developing TNBC due to environmental and socioeconomic factors, as well as higher genetic risk factors, such as elevated expression in certain genes and enzymes.

Women with BRCA mutations are also at greater risk of developing breast cancer, including the triple-negative subtype.²³ Therefore, having these mutations means they’re more likely to develop cancer that is challenging to treat. Research shows that Hispanic and Ashkenazi Jewish women are more likely to have BRCA mutations. This helps explain why biological factors play a role in breast cancer disparities.²⁴

Socioeconomic factors 

Even after controlling for biological differences, disparities in access to cancer treatment persist. This suggests that socioeconomic and behavioral factors also play a role in breast cancer disparities.²⁵

Research shows that lower-income and uninsured cancer patients experience difficulties accessing cancer care. Unfortunately, due to historic and present discrimination impacting their access to equal opportunities, minority groups are more likely to have lower socioeconomic levels. Consequently, they frequently receive inadequate and disparate treatment, leading to worse health outcomes.²⁶

Cancer treatment is expensive, and the development of new therapies which are now used alongside traditional treatments means that breast cancer patients are experiencing higher costs. This is a particular concern for Black women, who are twice as likely to be uninsured and rely on public insurance than White women and therefore may be unable to afford cancer treatment. 

Having a lower socioeconomic level also negatively impacts people’s employment status, education, neighborhoods, work and living conditions, and access to healthy foods and quality care. Overall, this will increase their risk of being exposed to unhealthy environments, with higher levels of chemical exposure, stress, and adopting unhealthy habits, elevating their risk of developing breast cancer and influencing the success of treatment.

Health system factors

Structural and organizational differences in the healthcare system influence racial variation in breast cancer treatment, quality of care, and health outcomes. For example, the distance to a healthcare facility may modify the relationship between race and the guideline-recommended treatment, such as chemotherapy and radiation therapy.²⁷

Differences in the quality of care received also generate racial disparities. Black patients have worse access to well-trained healthcare providers and are more likely to be treated by physicians who lack measurable skills, board certification, and technical resources. A study found that physicians of Black patients believed they couldn’t provide the best care to their patients. Bias from health providers is also evident.²⁸

Delayed diagnosis and advanced stage at diagnosis

Being diagnosed with breast cancer at a late stage negatively impacts treatment options and prognosis. The five-year survival rate for local breast cancer is 99%, but it’s only 27% for breast cancer that has metastasized (spread to other areas of the body).²⁹

Black and Hispanic women are more likely to be diagnosed with breast cancer at a regional or distant stage, leading to worse outcomes.³⁰

Early screening is essential. However, current screening guidelines don’t consider racial differences in the average age at diagnosis.³¹ One study found that 37.5% of Black women with breast cancer presented under the age of 50 years, compared to 23% of White women.³²

Despite this, the United States Preventive Services Task Force (USPSTF) recommends women at average risk of breast cancer undergo screening every second year from the age of 50. This means that by the time they have a screening, Black women are more likely to have already developed breast cancer and be at a much later stage, leading to worse prognosis and greater racial disparities in the outcomes of the disease.

Women of color are also more likely to experience longer wait times between an abnormal mammogram and receiving biopsies to confirm the breast cancer diagnosis, impacting the timely initiation of their treatment. 

It’s important to note that survival differences between Black and White women persist even when they’re diagnosed at the same stage.³³ Therefore, delayed diagnosis only partly explains racial disparities in breast cancer treatment. Other contributing factors likely exist. 

Research also shows the gap in survival is still evident after controlling for tumor characteristics, comorbidities, and hormone receptor and HER2 status.³⁴ Again, this indicates that factors such as treatment differences must play a role in generating outcome disparities, not just biological and tumor characteristic differences.   

Addressing racial disparities in breast cancer treatment

Research must focus on developing interventions to reduce racial disparities in breast cancer screening, diagnosis, and treatment. Ways to do this include:

Partnerships: The Center for Disease Control and Prevention has projects that partner with researchers at organizations to develop strategies that achieve equity.³⁵ For example, the New York City Cancer Outreach Network in Neighborhoods for Equity and Community Translation (NYC CONNECT) aims to reduce disparities by addressing systematic racism and studying the effects of it, investigating patient navigator programs, and sharing ideas with other communities. 

To overcome the disparities in treatment recommendations, it’s important to increase the use of patient navigation services, establish standards for the timeline between diagnosis and the start of treatment, and improve access for everyone to multidisciplinary breast cancer care.³⁶

Strategies to improve adherence to hormone therapy have been investigated and could involve reducing co-payment, increasing the availability of generic drug alternatives, and subsidizing treatment for low-income women.³⁷ Reducing the side effects of treatment as much as possible is also crucial.³⁸

Access and availability: One way to improve the uptake of mammograms is to offer transport to mammograms and provide mobile mammogram units at neighborhood community centers.³⁹

Studies have found that equal treatment is associated with equal outcomes. Therefore, interventions that enhance treatment uptake can help reduce disparities.⁴⁰

Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) was a program that explored effective ways to enhance access to cancer treatment in minority races. Key interventions included training nurses how to understand and respond to struggles faced by Black patients, such as medical mistrust, miscommunication with physicians, access to affordable transport, financial hardships, and difficulty taking time off work. The program also developed ways to support patients who miss appointments or don’t receive treatment in an expected timeframe.

Taxi vouchers and assistance with paying bills are some of the ways access to treatment could be enhanced. One studyfound that racial disparities in colorectal cancer incidence and mortality were significantly reduced when patients enrolled in a program that covered treatment costs and involved special outreach efforts for African Americans and a nurse navigator system.⁴¹

Education: Providing educational seminars about breast health and mammogram information is recommended to increase screening uptake.⁴²

Another recommendation is to provide women of color with health education materials describing the importance of lifestyle modifications.⁴³ These should be specifically targeted to the needs of racial minorities. Lifestyle modifications (such as eliminating unhealthy foods, quitting smoking, high intake of fruits and vegetables, and maintaining energy balance) are important to consider because they can impact treatment efficacy and reduce side effects and complications relating to treatment. 

For example, research has found that it’s beneficial to educate breast cancer patients on the importance of being physically active from the time of diagnosis and during treatment.⁴⁴ Alongside education, it’s important that they’re fully supported to stay active during this process. 

Likewise, it’s also important to educate healthcare professionals on reducing bias and meeting diverse population treatment needs. Research shows that cultural competency training in oncology healthcare professionals can be effective.⁴⁵

Diversity in clinical trials: Promoting diversity in clinical trials can help build trust in the healthcare system, promote fairness, and generate essential knowledge on how treatments work for different people.⁴⁶ To increase diversity, we must reduce barriers to involvement, such as offering transportation and parking vouchers and better compensation. 

Increasing minority representation in all areas of society, from politics to healthcare and research, is also important.⁴⁷ Racial minority representation in decision-making roles can help ensure racial disparities are well-studied, fully addressed, and ultimately eliminated.⁴⁸

The lowdown 

Minority populations are disproportionately impacted by breast cancer. This is a topic of ongoing study, but research consistently shows that disparities in treatment and health outcomes exist. Biological differences, socioeconomic disadvantages, healthcare system factors, and delayed diagnoses likely work together to produce treatment disparities and, subsequently, higher mortality rates. 

Moving forward, early screening access and offering high-quality and timely treatment options for racial minority women with breast cancer must be improved so that more equitable outcomes can be achieved.