The statistics are sobering. Black women are 38% more likely to die from breast cancer than white women despite having slightly lower incidence rates. They are three times more likely to be diagnosed at stage 3 or 4 when they skip regular mammograms. And they are still far less likely to be offered genetic testing, even when their risk factors demand it.
For Dr. Sonya Reid, a breast medical oncologist and researcher at Vanderbilt University Medical Center in Nashville, Tennessee, these numbers are not just data points. They are the driving force behind her work to close a gap that has resisted progress for far too long. From access barriers to tumor biology to clinical trial representation, Dr. Reid is asking the questions that the medical community can no longer afford to ignore.
New research from the Breast Cancer Research Foundation shows that Black women who don’t receive regular mammograms are three times more likely to be diagnosed with stage 3 or 4 breast cancer. What’s driving this gap in screening?
Factors that are contributing to the differences we see in outcomes are multifactorial. Number one, we know that access to optimal screening matters, so for patients that are not able to access nearby screening resources, but not only access to nearby screening, but access to follow-up care once an abnormality is found on a test, being able to then get a callback and get a biopsy and additional screening, if indicated, is critical to make sure we’re able to catch cancers before you start feeling a lump or before you’re having symptoms.
So access, number one, is crucial, but also the type of insurance, again playing back to access, matters. So for patients that are underinsured or uninsured, they are not able to access optimal screening resources, and we know that plays into what we see when we look at different screening rates by race and ethnicity.
Localized breast cancer has a 97% five-year survival rate compared to just 24% for stage 4. What can be done to catch more cases early when they’re most treatable?
Of course, screening. Making sure we have screening resources available to all our patients in all communities, rural and urban, that are convenient to patients as well. Making sure that patients are able to access screening maybe after hours, if they’re not able to access screening in the daytime, or even on weekends. We know that that matters just for that convenience, so that patients that perhaps don’t have jobs that would allow them to take time off to get screening can actually make that appointment. Not only that one appointment for your initial screening, but again, that follow-up is critical as well. So really making it convenient to patients matters.
Black women are 38% more likely to die from breast cancer than white women, despite slightly lower incidence rates. What factors are contributing to this survival rate gap?
That data, we have hoped over the years, should be declining, because we have done so much when we think about breast cancer research, kudos to several of our organizations, even the Breast Cancer Research Foundation, which really fuels a lot of the advancements. But what we’re seeing, despite advancements and an improvement in survival overall, we’re actually seeing no improvement in that gap between Black and white patients.
We’re actually seeing that Black patients are still almost 40% more likely to die from breast cancer. If we have advancements in therapies and we’re not able to give those therapies to all patients, regardless of background, regardless of where you live, then we’re going to see a widening in that gap. So we have to make sure that whatever advancements we have in diagnostics or in therapeutic advancement, they are actually being distributed and made available to all our patients, regardless of how you look. Coming back again to access, making sure that all our patients have access to high-quality care is critical.
But also, we know that there are differences in social determinants of health. Where you live plays into that. Whether you have insurance, and what type of insurance you have to be able to access a high-quality center that provides adequate screening, treatment, and diagnostic services, all plays a role. But we also know from more recent research that there are differences in tumor biology, so the type of cancer that you have based on race. We now know that Black patients are more likely to have triple negative breast cancer, which is a more aggressive form of breast cancer, and one that is usually diagnosed at younger ages as well.
Even for Black patients diagnosed with hormone-positive breast cancer, they’re usually diagnosed with a more aggressive form. And then we think about genetics, and we know that the genetics of your tumor and the genetics from your DNA can differ as well. So social factors, biological factors, and germline and genomic factors all come together to affect prognosis and worsen outcomes for Black patients with breast cancer.
Black women are less likely to be offered genetic testing despite earlier diagnosis and higher mortality rates. Why is early risk assessment so important?
We know that genetics is critical, especially when it comes to identifying patients that are at high risk for developing breast cancer. Being able to offer genetic testing, which then identifies a patient with a gene that makes them high risk for developing breast cancer, such as the BRCA1 or BRCA2 gene, gives that patient access to screening before age 40. That is critical, especially based on what we said earlier, that Black patients are more likely to be diagnosed with young onset breast cancer.
Being able to utilize that genetic test information that says this patient is at risk of developing breast cancer before they would have otherwise reached the age of 40 means you now have a patient at age 30 who is able to access screening, whether that be a breast MRI or breast ultrasound, to be able to detect a breast cancer before they develop a mass that is palpable. Being able to diagnose a breast cancer when it is stage 1 versus a stage 3 or 4 cancer significantly changes a patient’s survival, because we are more able to cure breast cancer when there are no symptoms.
How can we improve access to genetic testing?
Number one, awareness. Making sure that patients know this information in the community, even before they have a diagnosis of breast cancer, so that patients are able to advocate from the primary care setting. Making sure that patients know about this information starts with community awareness and education, whether through social media or making sure that system providers are having those discussions with patients when they see them on an annual basis.
I always start with making sure you are seeing your doctor once a year. It is a simple thing, but it is a critical thing, because that is how you are able to tell your doctor about a risk assessment tool or genetic testing. Can I get genetic testing? Am I eligible? Is it indicated? Is it for me? Your doctor knows your history and your family history, because this is not something for all patients.
But depending on your family history, which changes over time, maybe five years ago when you saw your doctor you did not meet the criteria, but perhaps someone in your family was diagnosed with breast cancer over that period. Hence why you go every year and update that medical history, because all of that plays into whether you will now qualify for early risk assessment, which of course would change whether or not you get screening earlier than age 40.
You’re also working to increase Black participation in clinical trials. Why is that critical for ensuring new treatments are effective?
All of our therapies are available for all our patients. So when we think about how we study those drugs, it really should be representative of who will get access to those treatments. We need to make sure these therapies are going to be available to all patients, regardless of background. Should we not be testing these therapies in these patients and making sure that we have representation across the board, regardless of race or ethnicity?
We know that that is a struggle for our minority communities because of a lot of mistrust, but also because of access. A lot of clinical research happens at big academic centers, yet 80% of our patients get their care in the community. Clinical trials and research are often not available in those small community hospitals, but that is where a lot of our patients, especially in the minority community, are receiving their care.
So we really have to make sure that clinical trials and research opportunities are available to patients right in their community, right in their backyard, so they do not have to leave their community to go to a big academic center. That is just not feasible, because a two to three hour drive and disruption of life, especially when you may have more frequent visits in a clinical trial, makes it nearly impossible. Really trying to make sure that we have these trials in the community where our patients are getting their care routinely is critical to ensuring adequate representation, especially of our Black patients.
When should women start screening, and how often?
If you don’t remember anything else I say, at age 40 everyone should start screening, and I do recommend screening every year. Pick a month, whether it is your birthday, whether it is the top of the year, a time that you will remember. Starting at age 40, the average person should start screening.
However, if you have a family history of breast cancer, or you have some risk factor that you and your primary care doctor deem would make you at a higher risk for developing breast cancer based on maybe prior treatments or something else in your personal history, that age may be even earlier. For you, it may be at age 30, based on that risk factor. But the latest is age 40, and that should be on an annual basis.
Where can people find the full research and connect with you?
The Breast Cancer Research Foundation, bcrf.org, would be the site that I would direct everyone to to find the full citation of the research, so you can dig deeper into what that research article entails. And I practice at Vanderbilt University Medical Center. I am one of the breast medical oncologists here in Nashville, Tennessee.