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IN THE NEWS
GENERAL SURGERY NEWS / JANUARY 2022
Black Women and Breast Cancer: Experts Discuss Shortcomings in Care By CHRISTINA FRANGOU
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lack women have more aggressive breast cancer at a young age than other women, and they’re more likely to die at a young age from these cancers. But they don’t have the same opportunities for screening, genetic testing, treatment and clinical trial participation, experts in oncology reported during a panel session at the 2021 Clinical Congress of the American College of Surgeons. The speakers called on all health care providers involved in women’s cancer to improve care for Black women and their families. “African American women are being deprived of maximum utilization of technologies [that can improve breast cancer outcomes],” said Lisa Newman, MD, MPH, the director of the breast program for the Weill Cornell Medicine/NewYork-Presbyterian Hospital Network, in New York City, during a press briefing at the Clinical Congress. “That’s on us—this is the responsibility of oncology providers,” she said.
Risk Assessment at Age 30 Black women face barriers at every stage of breast cancer diagnosis and treatment, and the effects ripple through their families and communities, panelists said. Debra Monticciolo, MD, a past president of the American College of Radiology and the section chief of breast imaging at Baylor Scott & White Medical Center – Temple, in Texas, said all Black women should undergo a risk assessment for breast cancer by 30 years of age. If the assessment suggests they’re at high risk for cancer, they should undergo supplemental screening, she said. “Waiting until 45 or 50 is not good for any woman, but it’s a disaster for women of color and especially for Black women,” Dr. Monticciolo said. Black women are at higher risk for aggressive cancers at younger ages, research shows. A study from Dr. Monticciolo and her colleagues found that nonHispanic Black women have a 45% higher risk for invasive cancers before age 50 than non-Hispanic white women (Cancer 2021;127[3]:4384-4392). Asian American/Pacific Islander, Native American and Hispanic women also have higher rates of early invasive cancers than white women, the study showed. Minority women are 127% more likely to die from breast cancer before they are 50 years old compared with white women, according to the study. Another study showed that Black women have a nearly threefold increased risk for triple-negative breast cancer (Cancer Med 2021;10[18]:6456-6467). As a result of the growing evidence, the American College of Radiology and Society of Breast Imaging have updated their breast cancer screening recommendations to highlight the heightened risk for Black women and other women of color (J Am Coll Radiol 2021;18[9]:1280-1288). The organizations want annual mammography screening beginning at 40 years of age for all women, but noted that delayed screening will disproportionately harm women of color.
Black Women Rarely Referred for Genetic Testing Black women do not receive enough referrals for genetic counseling and testing, said Tuya Pal, MD, a
geneticist and the Ingram Professor of Cancer Research at Vanderbilt-Ingram Cancer Center, in Nashville, Tenn. Only 36% of Black women underwent BRCA testing compared with 69% of white women in a populationbased sample of women in Florida diagnosed with invasive breast cancer at 50 years of age or younger, in a study by Dr. Pal and her colleagues (Cancer 2017;123[13]:2497-2505). Health care providers often fail to suggest genetic testing to Black women, who were 16 times less likely to receive a referral for genetic testing, the analysis showed. This gap was consistent for women treated across the state, regardless of the size and location of the clinic, according to the study. “There is something systemic going on here where these women are not being told or referred for genetic testing,” Dr. Pal said. If genetic testing confirms that a Black woman has a BRCA mutation, she’s also less likely to receive care that will reduce her cancer risk. Black women with a BRCA mutation were less likely to undergo risk-reducing salpingo-oophorectomy compared with Hispanic and non-Hispanic white women after controlling for clinical and demographic variables, the study showed. Dr. Pal said the consequences of low genetic testing rates extend beyond the immediate patient. Women’s families will not know about their risk. In addition, a lack of genetic information from Black communities affects the quality of risk assessment tools used to guide patient care, Dr. Pal said. Black, Asian and South Asian women are underrepresented in genome-wide association studies, which find associations between genetic variations and particular diseases, and they are used for polygenic risk scores that estimate a person’s risk for cancer. “If we don’t have data on Black women, these risk prediction models do not work well in these women,” Dr. Pal said.
Underrepresented in Phase 3 Trials Black women are disproportionately left out of research that guides cancer treatment decisions, said Oluwadamilola Fayanju, MD, MPHS, the chief of breast surgery and surgical director of Rena Rowan Breast Center, in Philadelphia. Black and Hispanic patients are 20% to 50% less likely to participate in clinical trials, she said. But the situation is more complicated than simple underrepresentation, she added. Black and Latinx individuals tend to be overrepresented in phase 1 trials, which have the highest risk but lowest likelihood of personal benefit for participants. Conversely, they are underrepresented on the other end of the clinical trial continuum, the phase 3 trials with the greatest likelihood of personal benefit. As a result, Black women are being treated with therapies and strategies that have rarely been tested on them, even for cancers that are disproportionately more common in women of color, such as triple-negative breast cancer, Dr. Fayanju said. “We are in danger of potentially not treating breast cancer in those who have some of the most aggressive
‘We are in danger of potentially not treating breast cancer in those who have some of the most aggressive forms of disease, but also endangering our ability to better understand these diseases and better treat them across all kinds of people.’ —Oluwadamilola Fayanju, MD, MPHS
forms of disease, but also endangering our ability to better understand these diseases and better treat them across all kinds of people,” she said. If more women of color were involved in breast cancer trials, researchers and clinicians would better understand the pathophysiology of the disease, she said. She pointed out that multiple complex factors contribute to under-participation in trials. For instance, high-income Black patients were 50% less likely to participate in trials than low-income Black patients, she said. She urged researchers to employ multipronged strategies to improve trial participation. Surgeons and researchers who are involved in clinical trials must proactively reach out to diverse populations, she said. “The truth of the matter is many people who are involved in clinical investigation have never thought about disparities in research other than simply reporting racial and ethnic differences,” she said. She said the Henrietta Lacks Enhancing Cancer Research Act, which was signed into law on Jan. 5, 2021, may improve representation in trials. The legislation requires the federal government to conduct a review of government-funded cancer research trials, including participation by underrepresented populations and the barriers to participation.
Professional Organizations and Insurance Companies Have Role Several panelists said they hope the American Medical Association will take a lead position in raising awareness about the heightened risk and poor outcomes among Black women with breast cancer. Anita T. Johnson, MD, the chief of surgery and director of breast oncology at Cancer Treatment Centers of America, in Atlanta, said insurance companies need to cover screening, testing, counseling and care related to breast cancer risk for Black women. She said these changes will improve cancer outcomes across the population. “Once we fix this issue for Black women, we fix it for all women,” she said. “We fix the late-stage disease presentations, the incidence of triple-negative breast cancer as well as the lack of screening for genetic mutations in people of color.” ■
