African-American women and men are less likely to survive breast cancer than Caucasian patients. Part of the explanation is that African Americans tend to have more aggressive types of breast cancer. However, there is some evidence that such patients have worse outcomes even when they have more indolent, hormone-responsive disease. When black women are carefully matched to similar white women with respect to breast cancer subtype, tumor size, age, access to health insurance, and other prognostic factors, their survival remains worse. Disparities in treatment according to race are part of the explanation. Nevertheless, African-American breast cancer patients can take several important steps to improve their outcomes in addition to adopting a breast cancer diet based on this website.
African-American women are less likely to survive breast cancer
African-American women are less likely to develop breast cancer than Caucasian women, although their rates have been catching up in recent years. However, when black women do get breast cancer, they are more likely to have advanced disease at diagnosis and are less likely to survive:
- One study of changes in breast cancer-specific death rates over time found that the age-specific rate of death from breast cancer has been declining. However, black women are not experiencing the same improvements in outcomes, as shown by a death rate in 2006 that was 38% higher than that of white women.
- Another study that focused on rural patients in South Carolina reported that the five-year survival was approximately 78% among African-American women compared to 89% for Caucasian women. When analyzed according to disease characteristics, black women were found to have significantly higher mortality than white women for the same type of tumor.
- A study designed to investigate factors associated with breast cancer progression during chemotherapy found that race (as well as the more expected advanced tumor stage and negative hormone receptor (ER-/PR-) status) independently predicted disease progression.
- Another study reported that African-American women who obtained a pathological complete response to neoadjuvant chemotherapy (which normally is associated with a favorable prognosis) were far more likely to relapse than other women.
- A study designed to determine if cancer survival differences persist after adjusting for clinical, demographic, and treatment variables reported that African-American race was associated with increased mortality in patients with early-stage premenopausal breast cancer, early-stage postmenopausal breast cancer, and advanced-stage ovarian cancer, after adjustment for prognostic factors. Ten-year overall survival rates for African-American compared to all other patients were 68% compared to 77% for early-stage premenopausal breast cancer and 52% compared to 62% for early-stage postmenopausal breast cancer.
More aggressive breast cancer subtypes, worse prognosis
Part of the explanation for the lower overall survival for African-American breast cancer patients is that they tend to have more aggressive types of breast cancer:
- A study that analyzed data concerning 276,938 Caucasian and 21,681 African-American breast cancer patients in the California Cancer Registry found that African Americans (median age: 57 years) tended to be younger than Caucasians (64 years) at diagnosis. While Caucasians were more likely to develop breast cancer, the incidence rate was highest for African-American women when only women younger than 44 years of age were considered. African Americans also had higher incidence rates of stage III and stage IV disease at diagnosis and a higher incidence of triple negative breast cancer at all ages.
- A study that examined the recurrence pattern of women with stage I-III breast cancer who were treated according to current guidelines (i.e., received appropriate care) reported that the recurrence rate at each stage was higher in African-American women compared to women of other ethnic groups.
- A study designed to investigate the associations between benign breast disease and risk of breast cancer reported that older African-American women are at greater risk for progression to breast cancer from benign breast disease.
- African-American women have the highest risk of inflammatory breast cancer (IBC), a very aggressive form of breast cancer, of any U.S. ethnic group. One study reported that median survival time for African-American IBC patients was shorter than for IBC patients generally.
Although the reasons for the more aggressive disease profile of African Americans have not been established, it is clear that there are genetic differences between ethnic groups with respect to breast cancer. Triple negative disease is more prevalent in Africa than in the U.S. One study concluded that there is increasing frequency of triple-negative breast cancer among breast cancer patients according to their degree of African ancestry.
Disparities in breast cancer treatment
While not all studies are in agreement, there is ample evidence of disparities in care according to race. Socioeconomic status appears to be an important barrier to receiving optimal breast cancer care, even taking account insurance inequalities, but this accounts for only part of the problem. A number of studies have been performed to attempt to establish how African-American race is related to treatment:
- A study that compared the time from breast cancer diagnosis to the initiation of treatment between insured African-American and Caucasian women in Michigan reported that black women experienced a longer average time to the beginning of treatment than white women (31.1 compared to 21.5 days). Other studies have demonstrated that extended treatment delays are associated with poorer prognosis.
- A study that examined the relationship between race and treatment delays among 250,007 breast cancer patients in the National Cancer Database found that African-American patients had higher risks of 30, 60, and 90-day treatment delays compared with Caucasian patients.
- A study that investigated factors associated with prolonged time between surgery and the start of chemotherapy reported that African-American women had higher risks of delays of at least 60 days and 90 days compared with Caucasian women.
- One study that analyzed Maryland breast cancer data for characteristics associated with receipt of radiotherapy after lumpectomy reported that African-American women were more likely not to receive radiotherapy. Radiotherapy after lumpectomy is the standard of care — omitting radiation substantially increases the risk of breast cancer recurrence.
- Another study of 34,080 women in a national Medicare database also quantified racial disparities in the use of radiation treatment after lumpectomy. Approximately 74% of Caucasians and 65% of African Americans received radiation treatment after surgery. Differences in treatment between white and black women were found to vary according to geographic region. Black patients in areas of the northeastern and southern U.S. had the lowest rates of radiotherapy (57% in these regions).
- A study that was designed to determine whether female breast cancer treatment varied between white and black patients in the Department of Defense system reported that black women were significantly less likely than white women to receive chemotherapy or anti-estrogen treatment (aromatase inhibitor or tamoxifen) for regional stage tumors.
- A study that evaluated black-white differences in receipt and completion of chemotherapy for breast cancer in rural southwest Georgia found that black patients were less likely to complete chemotherapy.
- A study that examined treatment by breast cancer type found that black women with ER+/PR+ disease were less likely than white women to receive anti-estrogen treatment (27.3% compared to 37.2%).
What can African-American women do to improve breast cancer survival?
The combination of aggressive disease and problems with timing and inadequate treatment appear to account for a great deal of the relatively poor prognosis of African-American women. Therefore, reducing treatment delays and ensuring that patients are not under treated should improve the outcomes of black women. Oncologists and medical centers need to improve their procedures so that African-American patients receive timely and appropriate treatment. Black women can take the following steps to improve their outcomes:
- If at all possible, have your breast cancer care at a breast cancer center of excellence or the best cancer center in your local area. Some of these centers have special programs for disadvantaged women.
- Make your breast cancer treatment a priority in your life. It is a matter of life and death. Do your best to complete every aspect of your treatment. Get the help that you need to do this from family, church and friends. Some states have special financial assistance for breast cancer patients.
- Get a referral to the physician who will be in charge of the next phase of your treatment as soon as possible. For example, if you start with breast surgery, get a referral to a medical oncologist from the surgeon as soon as possible and make the appointment immediately. Similarly, if it looks like you are going to need radiation treatment, get a referral to a radiation oncologist from your oncologist and make the first appointment as soon as possible. If faced with a long appointment delay, call back frequently to see if an appointment has opened up. The time between phases of treatment (surgery, chemotherapy, radiation, anti-estrogen treatment) should be measured in weeks, not months.
- Ask each physician that you see what treatment is standard for your type and stage of disease so that you can compare this to the treatment that is eventually offered.
- Make sure that your oncologist is aware of your commitment to treatment. Unfortunately, studies have found that African-American patients are less likely to keep appointments and complete treatment than white patients. Therefore, there might be a tendency on the part of some oncologists to assume that African-American women, especially ones of limited income, will not be able to undergo extensive treatment such as radiation. It's certainly unfair and may be awkward for you, but it could be important for you to communicate your ability to undergo treatment in order to be offered the best possible care for your situation.
- If you have a lumpectomy, it should be followed by radiation treatment. If you cannot participate in up to six weeks of daily radiation treatment, a mastectomy might be a better choice.
- If you have an aggressive form of breast cancer (triple negative, HER2 positive, inflammatory breast cancer, large tumor size, multiple positive lymph nodes, any breast cancer under age 45), you need aggressive treatment. This is likely to include chemotherapy. Again, your life is at stake. Even if he or she gives you a choice, your oncologist will have an opinion as to what would be best for you and will tell you if pressed. Make the tough choice.
Breast cancer patients are often surprised to discover that there is only loose coordination between the various doctors involved in their care. Typically, there is noone in charge of your case (somehow, it turns out, you are in charge). Even if a patient care coordinator exists, you might find that part of this person's role is to help ration care in institutions that are stretched thin. Trust could work against you in that case. Therefore, you must keep track of all aspects of your care and push (nicely but persistently) for timely and appropriate treatment as necessary.
Joining a breast cancer support group could also be helpful. This doesn't have to be at your breast cancer center. Pick one closer to home if it's more convenient and would have more African-American participants. Your oncologist is not likely to give you much of the emotional support you need (this is not an issue of race - oncologists are giving the best of themselves to patients, which is their expertise in designing and administering treatment, and it's not their job to provide much of this kind of support). A well-run support group can be very helpful not only as a safe place to vent your feelings, but also as a source of information.
Below are links to recent studies on this topic. For a more complete list of studies, please click on African-American.