Racial Disparities in Breast Cancer Diagnosis and Treatment

Kimberly’s Korner: Investigating the Health and Racial Disparities in Breast Cancer (Part II)

Background

There seems to be a gap in both access and treatment for black women when it comes to breast cancer treatment, and I am interested in understanding why that is. There are many reasons why I chose this topic; firstly, I have a grandmother who has battled breast cancer twice. Sadly, it was not until I was well into adulthood that I truly understood her experience and her illness and the way in which my family, an immigrant family at that, viewed her treatment process. Secondly, interning for a few Breast Cancer advocacy groups has allowed me to push aside my cultural perception of cancer and illness, and give access to a more realistic and honest approach to it. In this 3-part series (Screening, Diagnosis/Treatment, and Survivorship), I aim to guide you through the screening process all the way to survivorship, and the barriers that black women may encounter when diagnosed with Breast Cancer.

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In Part I of Kimberly’s Korner, we explored some of the reasons for screening discrepancies. They not only include low socioeconomic status and lack of insurance, it also include cultural and relational reasons; even specific biological characteristics of the tumor can account for differences in screening results for women of color. Together, all these pieces, and so much more, can contribute to the late-stage diagnosis for African American cancer patients during the screening process.

Diagnosis and Treatment

There has also been a considerable amount of discussion around the argument as to whether differences in diagnosis and treatments are based on race or socioeconomic status. The effect of race and socioeconomic status on breast cancer diagnosis and treatment leaves African American women at a greater risk of dying from the disease. There is considerable evidence suggesting that economic disparities or disparities in insurance coverage are the cause of breast cancer diagnosis, treatment, and survival more than the assumed construct of race (1). However, most of the current literature around this topic proposes that racial disparities occurring in breast cancer diagnosis and survival persist even when socioeconomic status is controlled.

The Insurance Problem

Though we touched on it in Part I, the type of insurance, or lack thereof, a woman has plays a major role in the way that she seeks treatment. For many poor, underserved women of color battling with breast cancer, lacking insurance coverage may even be the reason why they discontinue treatments or chemotherapy. Both the presence and type of health insurance can be important determinants of one’s cancer stage at diagnosis. Access to health care, the most appropriate kind, is a privilege. Irregular breast cancer screenings and failure to detect and respond to the symptoms are all outcomes of socioeconomic factors like poverty and access to healthcare.

A 2015 study[1] found that in non-Hispanic whites with government insurance, there was a significantly shorter diagnostic time than in non-Hispanic African Americans with government insurance, with the average times being 12 and 39 days, correspondingly. The research also found that privately insured non-Hispanic whites also had considerably shorter diagnostic times than privately insured non-Hispanic African Americans. At the end of the study, the authors concluded that other barriers associated with race and ethnicity influenced access to quality and timely healthcare for African Americans than lack of health insurance alone.

Treatment Barriers

Besides insurance plans and late diagnoses, some may say that treatment of breast cancer is the most physically daunting and exhausting stage of the ‘journey’. The underlying differences at the stage of diagnosis and treatment are socioeconomic status (again). As we mentioned in Part I, African American women at lower socioeconomic levels have been linked with lower survival rates.

Delay in seeking out treatment for one’s breast cancer symptoms is viewed mainly as patient-initiated. But healthcare barriers like a lack of cultural competency from healthcare professionals and limitations to cancer surveillance systems can widen the gap and delay African American women from getting the help and services they need to survive breast cancer. “Healthcare system barriers that may lead to African American women delaying [treatment] include differences in access to preventative health care…; inadequate continuity of care; the inconvenience of health care facilities’ available hours, days, and location; cost of service; lack of transportation”(2).

Once an African American woman has been through screenings, gotten her diagnosis, and is now at the stage of treatment, there are still obstacles and barriers that she must overcome. The author, Patricia Bradley, makes a strong statement. Things that other racial groups, like whites and Asians, may deem simple and straightforward, like ‘lack of transportation’, can be life or death for others. Strangely enough, a comprehensive report from the IOM (Institute of Medicine), found that even when racial and ethnic minorities in the United States had their insurance status, income, age, and severity of condition similar to that of a white person, they still received lower quality health care.

This introduces both cultural competency and racism as barriers. It is really the job of healthcare systems to realize that diverse communities and populations learn, perceive, treat, and understand illnesses differently. Different populations have varying needs, and not all groups of people respond to the same methods of treatment. Right now, there are interventions that focus on African American women, and they are designed to address the individual behavior barriers to breast cancer care, but it is not all on the patients and the health care system. Health care providers and oncologists play a vital role in connecting African American women, and any other racial minority group, to screenings, treatments, support, and breast cancer education. Already disadvantaged in their communities and schools, cultural groups are faced with disparities in the one place where they are supposed to be taken care of, regardless of their skin color—the healthcare system.

Racial Biases Affecting Cancer Treatment

Racism and prejudice are substantial system-related barriers resulting in overdue treatment. More times than not, racism is a result of institutional and systematic attitudes and choices that, unfortunately, create a culture of discrimination, and the healthcare workers are influenced. Experiences of racism for African American women are often seen as cumulative, where new encounters are interpreted based on past experiences with racism, knowledge of others' experiences of racism, and the simple, systematic nature of racism. However, racism is a touchy subject for all non-minorities or people in powerful positions. It is a challenge for clinicians and researchers to understand historically based realities of racism and the impact of the situations that underlie African Americans’ deep sentiments of distrust in health care providers, healthcare systems/programs, and research. This leads to disparities when it comes to receiving test results, access to follow-up services, and/or getting assistance in treatment decisions.

Cultural competence, which is the set of information and practical skills needed to appropriately deal with ill patients and families who belong to different cultures, ethnicities, and backgrounds, today, is increasingly considered a key factor in health care practices. Cultural competency is key for healthcare providers as they must understand why women in communities of color with breast cancer choose to wait so long to seek treatment. Or why some conventional ways of treatment may not be an option for them.

White women are often held and regarded as the standard of normalcy and universality, while blacks are the opposite—deviant from the norm. This, in a sense, is a form of subtle racism. “African Americans are disproportionately represented in mortality and morbidity statistics for medical problems such as cancer; they are, however, underrepresented in treatment and prevention trials” (1). Perceived

racism may play a major role in the underutilization of screening activities and influence subsequent negative health outcomes. However, acknowledging the systematic racism and prejudices in healthcare treatments among women in communities of color can save lives.

Cultural competency, which can greatly lessen disparities and reduce the burden of unequal breast cancer treatment, is difficult and complex to make universal. The relationship of culture to illness is composite. A considerable amount of breast cancer treatment research has been conducted, but with limited success for African Americans compared to other ethnic groups. Therefore, new strategies and approaches are needed to promote breast cancer prevention, improve survival rates, reduce breast cancer mortality, and ultimately improve the health outcomes of racial/ethnic minorities. In addition, it is vital that leaders and medical professionals from minority population groups be represented in decision-making in research so that racial disparity in breast cancer can be well-studied, fully addressed, and ultimately eliminated in breast cancer (3).

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References:

(1) Bradley, Patricia K (2006). Breast Cancer in African American Women. In African American Women’s Health and Social Issues. Catherine Collins, ed. Pp 36-42. Westport: Praeger Publishers.

(2) Daly, Bobby and Olufunmilayo I. Olopade (2015). A Perfect Storm: How Tumor Biology, Genomics, and Health Care Delivery Patterns Collide to Create a Racial Survival Disparity in Breast Cancer and Proposed Interventions for Change. CA: A Cancer Journal for Clinicians.

(3) Yedjou CG, Sims JN, Miele L, et al. Health and Racial Disparity in Breast Cancer. Adv Exp Med Biol. 2019;1152:31-49. doi:10.1007/978-3-030-20301-6_3