Addressing racial disparities in breast cancer

By Candy Lurken, principal, Deloitte Consulting, LLP

Health inequities are pervasive across gender, age, and income, but are particularly apparent along lines of race. October is Breast Cancer Awareness month; Global Health Equity Week begins October 25. As these two events intersect, let’s examine some of the racial disparities in breast cancer, explore why they exist, and look at what health care stakeholders are doing to address them.

An estimated 1 in 8 women will be diagnosed with breast cancer in their lifetime. While Black women have slightly lower incidence rates compared to white women, they have a 42% higher mortality rate. Among women under 50, the disparity is even greater.¹ The reasons for this are multifaceted, complex, and can be found at every turn along the patient journey. Here are a few of them:

Triple-negative breast cancer (TNBC): Black and Hispanic women are more likely than white and Asian women to be diagnosed with this aggressive and deadly cancer. Moreover, Black women are 28% more likely to die from TNBC than are white women who receive the same diagnosis, and are more likely to be diagnosed with later-stage cancer than are women of other races.² Black women diagnosed with this cancer also tend to be younger.³ While there are fewer therapies available that target TNBC, a recent study concludes that higher death rates among Black women is more likely linked to racial disparities in access to health care—not genetics.⁴

Drivers of health: The drivers of health (also known as social determinants of health) such as income, education, location of residence, and the quality of social-support networks can account for 80% of health outcomes, according to our report, Activating health equity. Air pollution, limited access to healthy food, and inadequate access to green space are all factors that can increase the risk of cancer. In addition, Black women are more likely than white women to be uninsured or have limited access to health care facilities, which could have an impact on screenings and follow-up care. Black women are also less likely than white women to have a regular doctor or to make regular doctor appointments.⁵ That could be due to a lack of health insurance, limited access to a medical facility, or a general distrust of the medical system.⁶ Lastly, a 2016 study found that Black women were about 44% less likely than white women to be prescribed certain pain medications after a mastectomy.⁷ Moreover, a separate study published in the Journal of the National Cancer Institute found that Black women are more likely than white women to have difficulty paying for and taking prescribed therapies after surgery.

Behavior and lifestyle: Black women are more likely than white women to have diabetes, heart disease, or to be overweight or obese—all risk factors for breast cancer. In addition, some chemicals used in fragrances, hair relaxers, skin-lighteners, and other personal care products (and certain cleaning products) have been linked to cancer.⁸ Women who work in the beauty sector or cleaning services—as well as consumers who use certain home and beauty products—could be exposed to these carcinogens. Black women are also less likely than white women to breastfeed after childbirth, which can help reduce the risk of breast cancer. The decision not to breastfeed is sometimes tied to cultural barriers and negative connotations of wet-nursing, slavery, and medical exploitation.⁹ Low-income Black women are also more likely than white women to return to work sooner after giving birth, which can make breastfeeding more difficult.¹⁰ In addition, 45% of hospitals that have adopted policies that support breastfeeding are concentrated in cities where Black people comprise 3% or less of the population. Black women are also more likely than white women to be introduced to formula in the hospital, which is associated with lowered breastfeeding rates.¹¹

How are stakeholders addressing health equity?

Achieving health equity will likely require all key players to intentionally and deliberately develop strategies and activities that advance health equity as an outcome. To do this, they should root out racism both within and outside the health care system to break the cycle of inequity. Health disparities in outcomes should not be, and do not have to be, driven by racism and bias. Here’s a look at how some stakeholders are trying to address disparities in breast cancer:

• Health plans: Health coverage plays a significant role in determining the stage at which breast cancer is detected. Nearly half (47%) of racial and ethnic disparities in the stage of cancer at diagnosis can be attributed to being uninsured or insured by Medicaid, according to an analysis of more than 177,000 breast cancer patients.¹² A more recent study estimates that racial disparities in breast cancer survival could be cut by more than half if Black women got mammograms every other year starting at age 40.¹³ Many health plans are taking steps to boost preventive measures. BlueCross BlueShield of Illinois, for example, is encouraging its network providers to help educate members about the importance of screening and the unique risks that impact Black women.¹⁴
• Medicaid: While 37 states and the District of Columbia expanded Medicaid eligibility (as called for by the Affordable Care Act), the increased access to coverage has yet to reduce mortality rates among Black women diagnosed with breast cancer, according to one study.¹⁵ However, another study concluded that late-stage detection rates were notably lower among Black women in states that expanded Medicaid. All 50 states provide Medicaid coverage for women who are diagnosed with breast cancer through the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program.
• Biopharma companies: Many of the newer therapies being developed for breast cancer target TNBC. Companies are also working to improve diversity in their clinical trials, according to upcoming research from the Deloitte Center for Health Solutions. In June, Genentech, a member of the Roche Group, announced a coalition of clinical research sites that will work to improve diversity in the company’s oncology clinical trials by focusing on recruitment and retention approaches.¹⁶ Pfizer and other pharmaceutical companies are working with the American Cancer Society to fund efforts to reduce racial disparities and improve outcomes among women with breast cancer.¹⁷ On October 5, Merck announced that it was collaborating with the breast cancer advocacy community to highlight the unique challenges Black women face when diagnosed with TNBC.¹⁸
• Health care providers: Health equity was a top priority among health care executives this year, according to our research. However, many hurdles need to be overcome. One health system executive said that doctors often pride themselves on being inclusive and sensitive to health equity. However, data indicates that Black women are far less likely than white women to receive mammograms. While doctors might remind all female patients (regardless of race) to get a mammogram, a patient who has never had one might not see the value. Those patients might need to have a personal conversation with a clinician about the importance of mammograms and help scheduling one at a convenient time and location.

The drivers of health, behaviors, education, lifestyle, and decisions made by clinicians and health care stakeholders can all contribute disparities in breast cancer. Breaking this cycle of health disparities in breast cancer should start with the acknowledgment that disparities exist. Health care stakeholders should consider making a long-term commitment—not just of dollars but also of leadership, resources, and accountability—toward drastically reducing health inequities or eliminating them altogether.

Endnotes:

1. Black women and breast cancer: Why disparities exist and how to end them, Breast Cancer Research Foundation, January 14, 2021; American Cancer Society, Cancer Facts & Figures for African Americans 2019-2021, Feb. 10, 2021

2. TNBC deadlier for Black women, partially due to lower surgery, chemotherapy rates, BreastCancer.org, May 18, 2021

3. TNBC deadlier for Black women, partially due to lower surgery, chemotherapy rates, BreastCancer.org, May 18, 2021

4. Comparison of the prevalence of pathogenic variants in cancer susceptibility genes in Black women and non-Hispanic white women with breast cancer, JAMA Oncology, May 27, 2021

5. Black women and breast cancer: Why disparities exist and how to end them, Breast Cancer Research Foundation, January 14, 2021

6. Why are Black women less likely to stick with a breast cancer follow-up treatment? National Public Radio, October 9, 2018

7. Black women with advanced-stage disease less likely to get certain supportive care medicines than white women, BreastCancer.org, May 26, 2016

8. Fragrance, Breast Cancer Prevention Partners, November 4, 2020

9. The historical, psychosocial, and cultural context of breastfeeding in the African American community, Breastfeeding Medicine, February 12, 2021

10. Breastfeeding gap widens between black and white U.S. babies, Reuters, October 9, 2019

11. US hospitals hinder Black women’s breastfeeding, Women’s eNews, August 29, 2014

12. Disparities with the detection of early-stage breast cancer, JAMA Oncology, January 9, 2020

13. Identifying equitable screening mammography strategies, Annals of Internal Medicine, October 19, 2021

14. Help close the disparity gap for Black women and breast cancer, BlueCross BlueShield of Illinois, April 1, 2021

15. Did expanding Medicaid reduce differences in breast cancer death rates between Black and white women, BreastCancer.org, August 6, 2020

16. Genentech launches oncology clinical trial diversity alliance, press release, June 23, 2021

17. The American Cancer Society and Pfizer launch community grants focused on racial disparities in breast cancer mortality, press release, January 27, 2020

18. Merck and Emmy-Nominated Actress Yvonne Orji Unveil Uncovering TNBC, Highlighting the Challenges Faced by Black Women Diagnosed with Triple-Negative Breast Cancer, press release, October 5, 2021

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