Racial Disparities In Breast Cancer Outcomes

Breast cancer is the second most common cancer in women and can affect all races and ethnicities. However, there are racial disparities in breast cancer outcomes, including survival rates and recurrence. Genetics, as well as socioeconomic factors and systemic racism in the health system, contribute to these differences. 

Does race affect breast cancer outcomes?

Breast cancer outcomes differ based on race. 

Some research suggests that race is an independent predictor of five-year survival rates for triple-negative breast cancer, the aggressive subtype that Black women are more likely to be diagnosed with.¹

Black women are also more likely to be diagnosed with breast cancer under the age of 45 and to die from breast cancer overall.²

However, other research suggests that race alone can’t predict breast cancer outcomes. This may be because Black women tend to be diagnosed at a later stage when the cancer has spread. Women of other races who are also diagnosed at a later stage may have similar outcomes.³

It’s difficult to separate the biological and genetic effects of race from the social and economic effects, making it challenging to determine specifically how race may impact a person’s outcome from breast cancer.

Stages of breast cancer and the survival rate explained

The stage of cancer describes how much it has grown and spread. Doctors use the TNM system to stage cancer using the following characteristics:⁴ ⁵

T: Size of the tumor 

• T0: There is no evidence of a tumor

• Tis: The cancer is “in situ,” which means that there are abnormal cells present, but they have not grown or invaded beyond the immediate location where they first formed

• T1: The tumor is 2cm across or smaller

• T2: The tumor is between 2cm and 5cm across

• T3: The tumor is larger than 5cm across

• T4: The tumor is any size and has grown into the chest wall or skin

N: Whether the tumor has spread to nearby lymph nodes

• N0: No cancer in the lymph nodes

• N1: The cancer has spread to 1–3 lymph nodes under the arm or the breast bone

• N2: The cancer has spread to 4–9 lymph nodes under the arm or to the lymph nodes under the breastbone

• N3: Cancer has spread to at least ten lymph nodes under the arm and has grown significantly in that location or has spread both to ten lymph nodes under the arm and also to the lymph nodes under the breastbone or under the collarbone

M: Whether the cancer has spread (metastasized) to other parts of the body

• M0: No distant metastasis, meaning that the cancer has not spread beyond the breast and adjacent lymph nodes.

• M1: There is evidence of metastasis, meaning that the cancer has spread to more distant parts of the body.

Stages of breast cancer

Using the information from evaluating the tumor size, lymph node involvement, and metastasis, the stage of cancer can then be determined. The stages of breast cancer are:⁶

Stage I

• IA: Cancer is in the breast tissue (T1) but has not spread beyond that (N0)

• IB: Cancer may have spread to local lymph nodes (N1), but not farther than that (M0)

Stage II

• IIA: Cancer may have grown (T0–T2) and spread to local lymph nodes only (N0–N1) but not to more distant parts of the body (M0)

• IIB: Cancer may have grown more (T2–T3) and spread to local lymph nodes only (N0–N1) but not to more distant parts of the body (M0)

Stage III

• IIIA: Cancer may have grown (T0–T3) and spread to more local lymph nodes (N1–N2)

• IIIB: Cancer may have expanded into the chest wall (T4) and spread to local lymph nodes (N0–N2)

Stage IV 

• Cancer has spread to other organs (M1)

Survival rates and what they mean

The survival rate refers to the percentage of people with a specific cancer type and stage who are still alive after a given time. For example, the 5-year survival rate for stage 4 breast cancer refers to the percentage of people diagnosed with this cancer who are still alive five years after their diagnosis.

Survival rates are simply averages for a whole population. They don't guarantee how a specific person’s cancer will progress. Survival rates can give an idea of how long an individual cancer patient can expect to survive. However, keep in mind that many people live for a shorter or longer time than the average.

Here are the estimates for the 5-year relative survival rates for breast cancer:⁷

• Localized (no spread outside the breast): 99%

• Regional (spread to nearby lymph nodes or structures): 86%

• Distant (spread to distant organs in the body): 30%

• All combined: 91%

The five-year survival rate is 81% for Black women and 92% for White women. This gap is increasing, partly because White patients are experiencing improved outcomes while Black patients are not receiving as much benefit from newer treatments.⁸ ⁹

Response to treatment and racial disparities

White women are most likely to be diagnosed with breast cancer overall, followed by Black, Asian/Pacific Islander, Hispanic, and American Indian/Alaska Native. However, the incidence is growing among Black women.

Response to treatment

The response of breast cancer to treatment differs among women of different races. Different types of breast cancer also vary in their response rates, and race impacts the likelihood of having certain types of breast cancer.¹⁰ ¹¹

For example, Black women with a specific type of breast cancer, known as HR-/ERBB2+ and triple-negative breast cancer, are least likely to experience a complete response (meaning that there is no evidence of cancer after the treatment is completed) compared to women of other racial groups with the same type of cancer.¹²

Treatment disparities 

One possible reason for the worse outcomes in Black women is that there are disparities in the types of treatment that women of different races receive. Black women are more likely to receive inadequate treatment overall or experience a delay before their treatment starts.¹³

Recurrence rates of breast cancer

Research shows racial differences in the rates of breast cancer recurrence (meaning that the breast cancer comes back after treatment). After eight years, Asian and Black women were twice as likely to experience a recurrence of breast cancer compared to White women.¹⁴

Black women are also more likely to have tumors with less favorable characteristics. This means that their cancers are less likely to respond well to treatment. Triple-negative breast cancer, which affects Black women more often, also has higher recurrence rates.¹⁵ ¹⁶

In addition, Black women are more likely to have worse distant recurrence-free survival rates in estrogen receptor-positive breast cancer, but not estrogen receptor-negative breast cancer.¹⁷

What significantly affects the outcomes of breast cancer?

The characteristics of the tumor, as well as the type of treatment that’s prescribed, both affect breast cancer outcomes.

Cancer stage

Black women are more likely to receive a breast cancer diagnosis at a more advanced stage when the size of the tumor is greater than 2cm. Black women are also more likely to be diagnosed when the breast cancer has already spread to the lymph nodes or to distant organs.¹⁸ ¹⁹

Studies show that survival decreases as tumor size increases, especially for women with breast cancer that has already spread to the lymph nodes. Survival is also lower in those whose cancer has already spread at the time of diagnosis. This shows the importance of early detection and could help to explain why Black women experience lower survival rates than those of other racial groups.²⁰ ²¹ ²²

Hormone receptor status

Breast cancer cells sometimes have receptors for the hormones estrogen and progesterone. When the cells have these receptors, this allows certain hormonal treatments to be used, which can improve survival.²³

Black women are more likely to have breast cancer that lacks both of these hormone receptors, leaving them with fewer treatment options and reducing their likelihood of long-term survival.²⁴

BRCA mutations 

Mutations in the BRCA gene increase the risk of breast cancer. These mutations may be more common in young Black women than young White women.²⁵

Treatment

Black women are more likely to experience delays in cancer treatment or to stop treatment early. They are also less likely to obtain treatment for their cancer at all or to complete the prescribed course of treatment.²⁶ ²⁷ ²⁸

Non-modifiable risk factors for breast cancer 

Some breast cancer risk factors that can’t be modified include:

Genetics

Genetic changes can influence the risk of various types of cancer, including breast cancer. In particular, a gene called BRCA creates a protein that regulates how fast cells replicate and helps prevent tumors from developing. A mutation in the BRCA gene can cause cells to divide and replicate more frequently, increasing the risk of cancer.²⁹

Age

The risk of breast cancer increases with age. 80% of people with breast cancer are over the age of 40.³⁰

Sex

The vast majority (more than 99%) of breast cancer patients are female. However, it’s certainly possible for men to get breast cancer as well.³¹

Race

White women have the highest rates of breast cancer overall. However, Black women have an increased risk of triple-negative breast cancer.³² ³³

Breast tissue density

Women with greater breast tissue density have a higher risk of breast cancer.³⁴

Previous history of breast diseases

Women who have previously had breast cancer or other types of abnormal breast tissue are at greater risk of breast cancer.³⁵

Time of pregnancy

Women who have carried a pregnancy to term have a lower risk of breast cancer than those who have never been pregnant. However, some studies have shown that women who experience their first pregnancy over the age of 30 have an increased risk of breast cancer compared to those who are younger when they have their first pregnancy.³⁶

Previous radiation therapy

Women who receive radiation therapy for another cancer before the age of 30 are more likely to develop breast cancer later in their lives.³⁷

Factors contributing to disparities in breast cancer outcomes

Many of the modifiable breast cancer risk factors, such as obesity, excessive alcohol intake, smoking, and processed food intake, are more prevalent among racial minority populations, especially those in economically disadvantaged communities.

Some other factors that may lead to disparities include:

Limited access to screening and healthcare services

Black and Hispanic women are more likely to be diagnosed with breast cancer at a later stage when the tumor in the breast is at least 2cm across.³⁸

Part of the reason for this is because of systemic racism and the history of abuse of Black people in the health system. Because of this, many Black women have misconceptions about surgery, fear of testing, delay in seeking care, experience barriers to timely screening, and have less access to treatment options.³⁹ ⁴⁰

Research also shows that doctors are more likely to have a negative perception of people who are Black or who have low socioeconomic status. Black women are also less likely to be referred for mammograms by their doctor.⁴¹ ⁴²

Lack of insurance coverage

Black women are twice as likely as White women to be uninsured (meaning that they don’t have health insurance) or to depend on the public system, which doesn’t always provide adequate resources to get. This can make it very challenging to access breast cancer screenings and treatment.⁴³

Research has found that 37% of the excess risk of death in Black breast cancer patients is likely due to health insurance disparities.⁴⁴

Poverty

People with lower socioeconomic status are more likely to be diagnosed with breast cancer at a later stage. They are also less likely to receive breast cancer screening as well as adequate treatment if they are diagnosed with breast cancer.⁴⁵ ⁴⁶ ⁴⁷

People experiencing poverty may not have the resources, information, and knowledge needed to seek help or to obtain prevention advice. This is often because the community isn’t medically equipped. They also may be unable to take time off from work for treatment.⁴⁸ ⁴⁹

People in many racial minority groups, including Black, American Indian/Alaska Native, and Hispanic people, are more likely to live in poverty than White people.⁵⁰

Diversity and representation in the health system

Diversity and representation of minority groups in the health system, from clinical researchers to front-line cancer specialists, is important. Currently, less than 3% of oncologists in the US are Black.⁵¹

A more diverse health system could make patients more willing to seek care, follow advice, and rate their experiences better. In general, people in racial minority groups are more likely to trust the healthcare system when they see their own race represented as part of it.⁵²

What can be done to improve breast cancer outcomes for all racial groups?

Increase early breast cancer screening and timely follow-up

Screening helps detect cancer in people with no symptoms. With screening, cancer is more likely to be detected at an earlier stage, when it’s easier to treat. 

Mammograms are commonly used to screen for breast cancer. Increasing the number of Black women who receive regular mammograms could help to reduce the disparity in breast cancer outcomes between White and Black women.

Ways to increase the rate of screening may include group or one-on-one education, providing timely reminders for at-risk patients, and reducing expenses associated with receiving screening (such as travel expenses) for low-income women.⁵³

Programs that reduce disparities

A study known as Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) was a clinical trial that aimed to eliminate racial disparities in cancer. It identified specific cultural and structural barriers faced by Black people when accessing healthcare and took steps to address those issues to help more patients access the care they needed.⁵⁴

ACCURE successfully helped more Black people complete treatment, which may have narrowed the gap in survival rates between White and Black people. This showed that system-level changes can help to reduce disparities in breast cancer outcomes. In fact, both White and Black patients benefited from the interventions in the ACCURE study, showing that changes intended to reduce racial disparities can be helpful for everyone.

Increase genetic testing for minorities

Genetic testing can help identify people who are at a greater risk for breast cancer, such as women with a BRCA mutation. Black women may be less likely to undergo this genetic testing.⁵⁵ ⁵⁶

To increase the rates of genetic testing among Black women, community outreach and patient-provider education would likely be helpful.⁵⁷

Improve participation in clinical trials

Clinical trials are research studies designed to examine the safety and efficacy of new forms of treatment. Black and Hispanic women are underrepresented in breast cancer clinical trials. This could make it less likely that treatments will be developed that tend to work well for women in these populations.⁵⁸

To achieve more equitable racial outcomes, it’s important to develop strategies to increase the uptake of minority races.

What are the options to improve the prognosis for breast cancer?

Screening

The prognosis for breast cancer is best when diagnosed at an early stage. Screening is essential to catch cancer early, especially because many women don’t have symptoms in the early stages.⁵⁹

Screening is particularly important for Black women because they are more likely to be diagnosed at a later stage and to get aggressive subtypes of breast cancer. Some research suggests Black women should be screened starting at age 40 (or even earlier if they are high-risk) rather than the standard of starting at age 50.⁶⁰

Men with risk factors, such as a family history or a genetic mutation, are also often encouraged to get screened.⁶¹

Since breast cancer can return, regular screening after successful treatment is crucial, and any changes found on scans should be taken seriously. Along with screenings, receiving regular physical exams and education about symptoms that could indicate a recurrence are also important.⁶²

Maintain a healthy body mass

Studies have found that women with obesity at the time of diagnosis have a poorer prognosis and a higher risk of breast cancer recurrence. Women who gain weight during or after treatment may also be at greater risk of breast cancer-related death. Because of this, maintaining a healthy body mass is important.⁶³

Stop smoking

Smoking increases the risk of getting breast cancer. However, there may be a benefit to quitting even after a cancer diagnosis. Women who stop smoking after their breast cancer diagnosis have been found to have a reduced risk of dying from breast cancer compared with those who kept smoking.⁶⁴

Reduce or avoid alcohol

As with smoking, alcohol consumption increases the risk of breast cancer. It’s unclear whether quitting drinking after you have breast cancer will influence the outcome. However, there’s a risk that you could get breast cancer again, which is known as second primary breast cancer.

To reduce this risk, it’s recommended to limit alcohol to one or fewer drinks per day.⁶⁵

Physical activity

Physical exercise can reduce the risk of breast cancer recurrence. In fact, out of all lifestyle factors, physical activity has been shown to be the most effective at reducing recurrence risk. It’s recommended to get at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity exercise each week.⁶⁶

Dietary changes

To reduce mortality from breast cancer, it is recommended to:

• Reduce saturated fat⁶⁷

• Limit red and processed meat⁶⁸

• Reduce ultra-processed foods⁶⁹

• Increase fiber intake⁷⁰

Nutrients and supplements

Some dietary supplements that might reduce breast cancer mortality include:

• Vitamin C and vitamin D⁷¹

• Turkey tail mushrooms: These might increase the effect of chemotherapy and lead to faster immune recovery after radiotherapy.⁷²

It’s very important to discuss any vitamins or other supplements that you may be considering with your treatment team before you start taking them. Some supplements may interfere with the effectiveness of your treatment, and some can even be dangerous.

It’s best not to start taking any over-the-counter product during breast cancer treatment until after you talk about it with your medical treatment team.

The lowdown

Minority ethnic populations have worse breast cancer outcomes compared to White women. To help reduce the disparity, the healthcare system should focus on reducing modifiable breast cancer risk factors, improving access to high-quality healthcare for detecting and treating cancer in a timely and adequate manner, reducing racial bias, and improving patient education. 

Frequently asked questions

Which race has the highest rate of breast cancer?

Non-Hispanic White women have the highest rates of breast cancer in the United States. Despite this, Black women have higher rates of death from breast cancer. The breast cancer death rate for Black women is about 40% higher than for White women.⁷³

What is the survival rate for Black people with breast cancer?

The five-year survival rate for Black women with breast cancer is 81%. This means that Black women with breast cancer are 81% as likely as Black women without breast cancer to live for five years from the time of diagnosis.