As a breast oncologist with Yale Medicine, Eric Winer, MD, is on a mission to lessen racial disparities in breast cancer. And there’s one “entirely unacceptable” statistic he can’t get off his mind. “If you’re a Black American woman and you’re 20 years old, you have literally twice the chance of dying of breast cancer before the age of 50, compared to the 20-year-old white American woman who might live in the next town or over on the next street,” says Winer, director of the Yale Cancer Center, physician-in-chief of Smilow Cancer Network, and president of the American Society of Clinical Oncology. Experts think higher rates of triple-negative breast cancer (TNBC) may play a role in these mortality differences. This is an aggressive disease diagnosed nearly three times more often in Black women. It’s also found later and is deadlier for women in this group. There’s no single reason for why TNBC takes such a toll on Black women. It’s likely a complex mix of things going on. But if you’re a Black woman with metastatic TNBC, or you’re at risk for the disease, there’s a key message that experts want you to keep in mind. “While disparities exist, people should not despair,” says Kimberley Lee, MD, a breast oncologist with Moffitt Cancer Center. “Metastatic triple-negative breast cancer is treatable, and Black women respond to the treatments that we have.”Why Do Black Women Get Triple-Negative Breast Cancer More Often?
Around 15% to 30% of all breast cancers in Black women are triple-negative. According to Anne Marie McCarthy, PhD, a cancer epidemiologist and assistant professor at the University of Pennsylvania, TNBC rates are around 5% to 10% for non-Hispanic white women.
While it’s clear there are large racial disparities in rates of TNBC, “we’re not sure why that is,” McCarthy says. “Although, we have some ideas.”
Age and breast tissue density. TNBC is found more often in Black women younger than 55 who have very dense breasts. This fibrous tissue can cause an added issue with mammograms, and these machines may have a hard time snapping shots of TNBC tumors early on in these women.
Reproductive habits. Unlike other kinds of breast cancer, the odds of TNBC appear to go up with the number of babies you have. Breastfeeding seems to lower some of that risk, but Black women are typically less likely to breastfeed or may not breastfeed for as long as other groups.
Obesity. There’s some evidence it may fuel the kind of inflammation that leads to TNBC. And Black women tend to have higher levels of body fat than some other groups. But the research on the link between higher body mass index (BMI) and TNBC is mixed.
It’s important to note that people with obesity who are diagnosed with any kind of breast cancer generally have poorer health outcomes no matter their race or ethnicity.
Genes. The disparity in TNBC can’t be totally explained by non-biologic risk factors. There are likely some other genetic differences involved, but scientists haven’t found them yet. “Black and African ancestry populations are underrepresented in genetic studies,” McCarthy says.
Why Is Metastatic Triple-Negative Breast Cancer Deadlier for Black Women?
TNBC doesn’t have any hormones to target. This limits everyone’s treatment choices and chances for success. But researchers are trying to figure out if there’s something about the tumors in Black women that makes cancer in their body more aggressive from the start. But Winer thinks genetic differences are likely only a small piece of the death rate puzzle.
“I think it’s much more about racism, poverty, and lack of (health) education and access to care than it is about any biologic differences in the cancer.”
Rachel Greenup, MD, is chief of breast surgery with Yale Medicine. She studies how financial hardship affects cancer treatment and says researchers have found that Black women generally face more barriers to care across all domains. And this may create a domino effect that leads to poor outcomes for this group.
For example, Black women tend to have a lower household income, higher rates of Medicaid or no insurance, and more transportation troubles. Black women are also more likely to lose their jobs or health insurance after their breast cancer diagnosis.
Financial strain can boost your risk of dying no matter what kind of cancer you have. But for people with breast cancer, your chances of dying are “about 1.5 to 2 times higher if you go bankrupt than if you don’t,” Greenup says.
Here’s a breakdown of other things that might affect racial disparities in TNBC:
Socioeconomic status. Studies show that people with a lower socioeconomic status are more likely to be diagnosed with advanced breast cancer. This can lead to other hurdles that delay or interrupt treatment. “There are women who can’t afford child care or transportation,” Winer says. “There may be people who can’t afford the copays of certain cancer drugs.”
Less use of anti-cancer drugs. Black women are less likely to get standard breast cancer care. That includes less surgery, chemotherapy, and other treatments known to help people live longer. “We are very well aware of the disparities in the use of drugs used to treat triple-negative breast cancer in the early setting,” Lee says.
Not enough Black doctors. Black women usually get cancer care from people who don’t share their race. That can lead to some amount of medical mistrust that may impact treatment. “That mistrust is probably well-founded,” Winer says, “and relates to the underlying racism that exists in our country that we need to address.”
How to Reduce Racial Disparities in Metastatic Triple-Negative Breast Cancer
More research is needed to find the driving force behind these inequities. But here are some steps you can take to improve your cancer care right now:
Ask about genetic testing. Your odds of TNBC go way up if you test positive for the BRCA1 gene mutation, so tell your doctor if you have a strong family history of breast or ovarian cancer. They’ll help you find out if genetic counseling or testing is right for you.
Once you know you have a genetic mutation, you can act on that information. Ask your doctor about preventive strategies to manage your breast cancer risk.
Bring up breast density. Not everyone with dense breast tissue gets breast cancer. But if you’re a Black woman at higher risk of TNBC, you might benefit from breast MRIs or more frequent breast cancer screenings.
Talk to a patient navigator. These are people on your cancer team who can help you overcome personal barriers to treatment. They’ll set up child care, rides to appointments, copay assistance, or financial aid.
Ask your doctor who to talk to or reach out to the Patient Advocate Foundation. That’s a nonprofit group that gives professional case management services to people with chronic or life-threatening illnesses like cancer.
Where Is Breast Cancer Disparity Research Headed?
Scientists continue to study why Black women get TNBC at higher rates than other groups. But experts agree there needs to be an urgent focus on reducing racial disparities in breast cancer treatment.
Going forward, researchers are focusing on finding answers to the following questions:
- Are doctors offering the right treatment at the right time to Black women?
- Are doctors explaining treatment options as well to Black women as they do with white women?
- Do Black women have more trouble paying for out-of-pocket expenses?
- Is there enough follow-up from doctors in terms of the importance of early treatment that works well?
- Do Black women have tumors that don’t respond as well to common cancer drugs?
- Can community outreach boost breast cancer screenings and help people stick with treatment?
- How can we increase the number of Black and brown doctors in our workforce faster?
Experts think this awareness may bring us one step closer to finding a way to improve cancer outcomes for all women.