October, even during an ongoing pandemic, is Breast Cancer Awareness Month. As breast cancer physicians, we welcome this time of year as an opportunity to look beyond the daily demands of patient care and reassess our profession’s goals and progress. How are we doing as physicians, and as health-care communities, in meeting women’s breast cancer screening and treatment needs? How can we reach more patients and deliver better care?
Approximately one in eight women will be diagnosed with breast cancer in her lifetime. Since 1990, mortality from breast cancer has steadily declined, due to earlier cancer detection via mammography and continued improvements in therapy. Unfortunately, progress has not been achieved equally across racial and ethnic groups.
Black women, in particular, experience marked inequities in breast cancer treatment and survival. Recent statistics from the American Cancer Society demonstrate widening breast cancer mortality rates between Black and white women, with a 41% higher death rate for Black women. This striking disparity reflects a combination of factors, including more advanced disease at diagnosis among Black women and differential treatment receipt. Black women experience greater socioeconomic barriers and bias from oncologists.
Black women are also more likely to develop a particularly aggressive breast cancer subtype known as triple-negative breast cancer. Twenty-one percent of breast cancers in Black women are triple-negative, compared with just 10% among white women. Triple-negative cancers carry a significantly worse prognosis, largely due to a paucity of effective drug therapies.
Despite having higher rates of triple-negative breast cancer, the subtype with the least effective treatment options, Black women remain drastically underrepresented in clinical trials. This underrepresentation hinders development and optimization of treatment regimens that may benefit this specific patient population.
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Similarly, most of the breast cancer risk assessment models — computer-based algorithms that estimate a woman’s lifetime risk of breast cancer based on her personal and family history — were developed and validated primarily in white women. These models help determine which patients carry an “elevated risk” of breast cancer, and may therefore need supplemental screening, such as breast MRI, or preventative medications, such as tamoxifen. However, because the models failed to include diverse women during development, they often underestimate Black women’s risk, preventing them from obtaining supplemental screening and treatment. Thus, the exclusion of Black women from clinical trials and risk models has widened breast cancer-related disparities.
Finally, current mammographic screening recommendations do not protect the specific screening needs of Black women. Currently, breast cancer diagnosis rates among Black and white women are nearly equivalent. However, among women under age 45, rates are higher among Black women, whose median age of diagnosis is four years younger. Thus more years of life are lost per breast cancer death among Black women.
In the U.S., annual screening mammography beginning at age 40 has been standard of care for women with an average lifetime risk of developing breast cancer. However, despite evidence showing population-level mortality reductions from initiating screening at 40, current guidelines from the United States Preventive Services Task Force (USPSTF) discourage screening women ages 40-49 and emphasize that screening this age group leads to unnecessary biopsies and patient anxiety. Although USPSTF recommendations do not directly dictate patient care, they guide the clinical practice of primary care physicians and impact screening in federal programs such as the Veterans Affairs health system, a racially and ethnically diverse patient base. While delaying screening until age 50, as recommended by the USPSTF, jeopardizes the health of all women, it disproportionately harms Black women, who are diagnosed with breast cancer at younger ages.
This October, we again ask ourselves where we’re falling short. The answer is painfully obvious. Despite continual improvements in screening and treatment, we are still failing Black women. Where do we start, and what do we need Black patients and their physicians to understand?
We want clinicians and patients alike to recognize the high-risk status of Black women, including those under age 50. Per the recommendations of the Society of Breast Imaging, we encourage Black women to undergo a breast cancer risk assessment with their primary clinician at age 30 to assess their lifetime risk of breast cancer and determine whether screening prior to age 40 is needed. In addition, while we advocate for all of our average-risk patients to initiate screening at 40, it is of particular importance for Black women to begin yearly screening mammography no later than 40. For now, insurance coverage of annual screening mammography for all women ages 40 and above remains protected under the 2021 Consolidated Appropriations Act. Until the USPSTF appropriately recognizes the high-risk status of Black women and appropriately guides screening for this group, we encourage physicians to advocate for Black women, and for these patients to advocate for themselves.
Christine Edmonds is a breast radiologist at the Hospital of the University of Pennsylvania and Oluwadamilola “Lola” Fayanju is the chief of breast surgery for Penn Medicine.