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For Breast Cancer Awareness Month in October, tennis star Serena Williams went on a musical video singing the song "I Touch Myself" while covering her breasts with her hands. It was simply to remind women of the importance of regular chest examination and awareness of any changes.
"Yes, that put me out of my comfort zone," Williams, 37, wrote on Instagram. "But I wanted to do it because it's a problem that concerns all women of all colors, all over the world."
In fact, breast cancer disproportionately affects some groups in the United States more than others. According to a report from the Breast Cancer Research Foundation, black women are now 42% more likely to die of breast cancer than white women.
Despite similar cases of breast cancer in white women and black women in the United States, black women often suffer from the disease at an earlier age and are more likely to die of their disease at all ages. This disparity was first recognized thirty years ago in the statistics of the National Cancer Institute and it still persists today.
In September, the American Association for Cancer Research released its report on the state of progress in cancer, highlighting the challenge of disparities in cancer treatment. Despite new advances in screening and treatment, and with an overall 39% decrease in the number of cancer deaths in 26 years by 2015, it is disconcerting that some Americans are not doing as well as they are. other victims of breast cancer. What explains these differences?
Like many big questions in medicine, the answer is complex. Some of these factors may be of genetic origin and many of them may be related to broader social and structural institutions. Here we break down the main factors.
Possible differences in cancer biology
As Williams points out, and as is generally the case for all cancers, breast cancer is detected as early as possible. This is based on the understanding that catching cancer when it is located (just within), before it has had the chance to spread, leads to much better results. For example, the treatment of localized disease has a survival rate of 99% five years after diagnosis, compared to only 27% in the distant and metastatic forms of the disease.
This idea itself is not surprising, but what is astounding is that black women have a lower incidence of localized diseases than white women, even though black women have comparable rates of detection. breast cancer by mammography. Although some believe that the data overestimate the mammography rates among minorities and especially among the elderly, people are looking for other explanations for these differences, in addition to screening.
One of the reasons that black women may have worse breast cancer outcomes is rooted in a difference in genes. Although breast cancer is considered a single disease, there are many subtypes. Scientists are increasingly recognizing, through genetic detection, the type of cancer a woman is suffering from, and each of these subtypes is likely to present different risks and outcomes. They also respond differently to therapy.
Scientists are trying to look closely at the different genetic makeup of cancer cells to understand if biology plays a role in determining different outcomes in American communities. Although the genetic evaluation of cancers is only in its infancy, we already know some things. It is well established that black women are much more likely than white women to have triple negative breast cancer. It is a type of cancer that does not respond to three of the most common hormones that usually cause the growth of breast cells – estrogen, progesterone and human epidermal growth factor – and is notoriously more aggressive and difficult to treat.
However, the link between genes, the environment and the disease is complex and often constitutes a game of chicken or egg. It has been shown that a number of risk factors (diet, socioeconomic status, body mass index, history of pregnancy, etc.) also affect the incidence and outcomes of breast cancer; which leads some to wonder whether these factors in turn play on genetics.
But the fact that racial disparities can be mapped geographically in communities known to be poorer and more segregated is evidence that differences in cancer outcomes can not be attributed to molecules.
Structural systems at stake
To understand the disparities in breast cancer in America, one must understand the broader structural inequities that exist and their multiple effects, ranging from the diversity of health care behaviors to access to health care and burden of disease.
Racial inequalities at the social level have shaped systems significantly. Access to safe housing, transportation, quality education and jobs, as well as the availability of fresh fruits and vegetables are all elements of everyday life that are based on racial and economic lines in the United States. -United.
Poverty can lead to a host of health problems and illnesses, including obesity, that can negatively affect the breast cancer landscape of women. Studies have shown that economic status largely explains disparities in breast cancer outcomes. Black women with breast cancer are more likely to have other health problems that can complicate their disease.
Lower socio-economic status has also been associated with a reduction in the recommended chemotherapy and radiation therapy rates. This may be due to a lack of access to care, for example due to health insurance or the lack of transportation. States and cities that have improved their insurance coverage have seen a reduction in disparities in breast cancer between black and white women.
In recent decades, there has been little research in breast cancer research among black women. Even now, minority communities are less likely to participate in cancer trials that will shape future approaches to treatment.
Where to go from here
The first step in solving the problem is to recognize that disparate race outcomes are a problem in the United States. Doctors, scientists and national agencies are committed to discussing and eliminating disparities in breast cancer.
The reasons why breast cancer disproportionately affects black women in the United States are at a complex intersection between genetic and social factors. Additional research and attention should bring nuanced interventions from different perspectives, including ongoing research on genetic therapies and how social forces continue to shape health outcomes.
Amisha Ahuja is a Resident in Internal Medicine at Thomas Jefferson University Hospital and a contributor to the ABC News Medical Unit.
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