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In the eighteenth and nineteenth centuries, scientists tried to justify the idea of race—and racism—using biology. 1 But genetic research tells us that all humans share 99.9% of the same DNA. 2 In fact, we can have more genetic similarity with someone of another race than with someone of the same race. Race has no basis in biology—it’s a social and political construct that has been reinforced over time by the people who benefit from it. 1
When you fill out a form or complete a survey, you’re often asked to report which racial or ethnic group you identify with. In medical research, patient-identified race is used as a descriptor when reporting patient outcomes. Research has shown that there is a gap in breast cancer survival rates between racial groups. If race is not genetic, why do some populations experience better health outcomes than others?
While there is still much to learn, public health experts say that the social determinants of health are the driving force behind health disparities. Read on to learn more about how the environment in which we live, work, and play can lead to disparities in breast cancer outcomes.
What is a disparity?
A disparity is a difference in outcomes between groups of people. Disparities are caused by systems of inequality and are related to social factors like race or gender. When a disparity exists, one group benefits more than another. For example, in the United States, there is a disparity in pay by gender: on average, men make more money than women who perform equivalent jobs.
A health disparity is a difference in health outcomes between groups of people. Health outcomes may include:
- the risk of disease or illness
- survival
- quality of life
- symptoms
Although advocates are working hard to make positive changes, health disparities persist among those being treated for cancer. In the United States, there are notable differences in cancer outcomes across race, income, and area of residence.10 While these social factors are different, practices like residential segregation have connected race, income, and geography in a complex web.
Among those with breast cancer, there are disparities in survival rates between women of color and white women. Eliminating these health disparities and others can help us move toward health equity. Health equity means everyone has equitable access to the care they need to be as healthy as possible. Closing gaps in health outcomes begins by addressing the social determinants of health.
The social determinants of health
The social determinants of health are all the conditions in which we are born, learn, play, live, work, and age. These are non-medical factors in our lives that can affect our health.3 Some factors can make a healthy lifestyle more accessible, while other factors contribute to the gaps we see in health outcomes across social groups. Long-standing practices like racism and segregation have largely influenced who is negatively impacted by the social determinants of health.
Public health professionals have grouped the social determinants of health into five categories:
1. Neighborhood and environment
The environmental conditions in which we spend our time, whether at work, school, home, or elsewhere, can affect our health. People who identify as a member of a racial or ethnic minority group or those with low income are more likely to live in environments with higher health risks. 4
Examples of these risks include:
- lack of reliable public transportation
- air pollution
- water contamination
- workplace hazards
- lack of nearby grocery stores
- noise and light pollution
- potentially harmful building materials (lead pipes, asbestos)
- limited access to green space (parks, bike paths) 4
2. Economic Stability
Economic stability is the ability to pay for the things that keep us safe and healthy. 5 These may include:
- enough nutritious food for everyone (food security)
- stable housing
- affordable childcare
Someone’s ability to get and keep a job that provides sufficient pay largely affects economic stability. 5
3. Access to quality healthcare
Quality healthcare is not accessible to all. Some barriers to getting quality healthcare include:
- no insurance
- high costs of care, even with insurance
- no transportation to appointments
- costs of prescription medicines
- no nearby medical centers 6
4. Access to quality education
Receiving a quality education can provide opportunities for employment and economic stability.7 Barriers to access include:
- costs of preschool
- underfunded schools
- social problems like bullying
- unreliable transportation
- having to miss school
- college tuition
5. Social and community context
Our relationships and the communities in which we live can contribute to our health. Crime and violence can cause unsafe living conditions, and incarceration, neglect, or drug abuse can harm family stability. Experiencing racism or discrimination in your community can cause high levels of stress.
Social or environmental stress can negatively affect our bodies by increasing our stress response. These effects are known as allostatic load. Research shows a link between systemic racism and allostatic load.8 Because this stress can increase cancer risk, racism and allostatic load may contribute to the disparity in breast cancer outcomes between privileged and marginalized groups. 8
Positive social and community factors can help build resilience to adversity and increase overall health. 9
Examples include:
- community resources or programs
- places of worship
- mental health support
- inclusive environments
Inequities in breast cancer detection
Time of detection
Early detection of breast cancer is associated with better treatment outcomes. In a national study of cancer occurrence, researchers found that early-stage breast cancer was detected in 70% of white women but only 60% of Black women.10 Hispanic women are also less likely to be diagnosed at earlier stages of breast cancer than white women. 11
Of all the women in the study, those with higher incomes were less likely to be diagnosed with late-stage breast cancer. 10
Screening
While white and Black women have similar rates of breast cancer screenings, Black women were more likely to be screened with inferior screening tools and less likely to receive supplemental screenings. White women were 12 times more likely than Hispanic women to get more than one mammogram across a five-year period. 11
Health insurance coverage contributes to differences in screening rates. In 2018, 80% of women with health insurance met the guidelines for breast cancer screening, while only 55% of those without insurance met the guidelines. 11
Making breast cancer screening more accessible and providing high-quality care to all may lead to earlier breast cancer detection in medically underserved populations.
Cancer types
Women who identify as Black or Hispanic are more likely to be diagnosed when they’re younger and more likely to be diagnosed with more aggressive breast cancers. (11,12) Compared to white women, Black women have a 65% higher rate of any HR-negative cancer and an 80% higher rate of triple-negative cancer.13
While genetic researchers are still learning about why some groups have a higher risk of developing aggressive diseases, the social determinants of health are likely involved. Our behaviors and the things we’re exposed to in our everyday lives can affect our genes. 1 People who live in racially isolated neighborhoods are more likely to have unfavorable tumor biology. Those who live in poorer neighborhoods tend to have worse outcomes and more active or aggressive tumors.
Follow-up
Research shows that women belonging to a racial or ethnic minority population are less likely to receive follow-up care after a screening. This could be due to being uninsured, worrying about being unable to afford treatment, or miscommunication between the patient and provider. 11
Treatment
Standard of care
Hundreds of studies have shown that members of racial or ethnic minority populations are less likely to receive the highest standard of care during cancer treatment.11 This may be due to implicit bias on behalf of the healthcare provider or structural racism within the broader healthcare system. Research shows that giving all patients equitable access to standard cancer treatment could greatly reduce racial disparities. 11
Seeing a provider with whom you can identify is associated with better quality of care. However, less than a quarter of Black and Hispanic/Latino adults have a provider who is the same race or speaks their preferred language.11 Making efforts to increase diversity in healthcare could improve the experiences of patients of color.
Clinical trials
Clinical trials play an important role in advancing breast cancer treatment. It’s important to have diversity in clinical trials because not everyone will respond to the treatment in the same way. Having a diverse group of participants tells us more about how effective a treatment will be in different populations. A recent analysis of clinical trial participants showed that white patients were overrepresented in the trials, while Black, Hispanic, and American Indian/Alaska native participants were underrepresented. 11
Barriers to participation in clinical trials are one of the likely causes of this underrepresentation. These barriers stem from the social determinants of health. Patients have reported that their providers did not tell them about clinical trial opportunities or that they were afraid to participate due to mistrust of the healthcare system. 11
Research shows that engaging the community in health education and providing individualized support to patients can increase the participation of racial and ethnic minority populations in clinical trials. 11
Surgery
One factor that may cause disparities in health outcomes for breast cancer patients is treatment delays. Black women with breast cancer are twice as likely as white women to have a surgery delay of over 90 days. Latinas with breast cancer who do not speak English experience longer delays between tumor biopsy and surgery than white women or Latinas who speak English. 11
Furthermore, people belonging to racial or ethnic minority groups may not receive the same level of care as white patients. People of color are more likely to have surgery in public or safety-net hospitals rather than in specialized facilities with more access to resources. Within 90 days of breast cancer surgery, Black and Hispanic women are more likely to need to go to the emergency room due to complications than white patients. 11
Studies show that the disparities in surgery outcomes will improve if everyone has equitable access to surgery that meets the standard of care. 11
Radiation
Members of racial and ethnic minority groups are less likely to receive radiation therapy and are more likely to experience treatment interruptions and longer treatment periods.11 Barriers to radiation therapy may include the cost of treatment and lack of access to treatment facilities. Research shows that making radiation treatment more accessible can help improve disparities in cancer outcomes. 11
Chemotherapy
Research shows that Black and Hispanic patients are less likely to receive chemotherapy. More diversity in clinical trials could help providers learn about how chemotherapy could be more beneficial for these populations. 11
Survival
Survival rates
One of the most notable disparities in breast cancer outcomes is the survival gap between populations. Black women with breast cancer have a 40% higher death rate than white women, 14 and Hispanic women and Latinas have a 30% higher death rate.12 The social determinants of health likely cause this survival disparity between white patients and patients of color. Institutional racism and implicit bias have created barriers to receiving needed breast cancer care.
Comorbidities
Comorbidities are other medical conditions someone has in addition to a disease or illness. In a study of women with early breast cancer, Black women were more likely to have comorbidities than white women. Black women were also more likely to have two or more comorbidities at diagnosis, including hypertension, high cholesterol, and diabetes. 15
Having one or more comorbidities along with breast cancer is associated with decreased odds of survival.16 Comorbidities may also be a barrier to participation in clinical trials. 11
The social determinants of health, including poverty, food insecurity, and environmental exposures, can make marginalized groups more susceptible to comorbidities than others. Addressing these factors could help close the disparity in breast cancer survival.
Conclusion
Patients who identify as belonging to a racial or ethnic minority population experience poorer breast cancer outcomes than white patients. Most notably, patients of color have decreased survival rates compared to white patients.
People with low income and people of color face barriers to breast cancer care during screening and treatment. Complex social factors with roots in racism create these barriers. To address these inequities, we need to make screening and treatment that meets the standard of care more accessible to everyone.
Black and Hispanic women are also more likely to be diagnosed at a younger age and with more aggressive cancers. Increased diversity in clinical trials and health research can help improve breast cancer outcomes for people from racial and ethnic minority populations.
References
- Baker B. Race and biology. BioScience. 2021;71(2):119-126. doi:10.1093/biosci/biaa157
- Genetics vs. genomics fact sheet. National Human Genome Research Institute. https://www.genome.gov/about-genomics/fact-sheets/Genetics-vs-Genomics. Published September 7, 2018. Accessed January 20, 2023.
- Social Determinants of Health. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health. Accessed January 20, 2023.
- Neighborhood and built environment. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/neighborhood-and-built-environment. Accessed January 20, 2023.
- Economic stability. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/economic-stability. Accessed January 20, 2023.
- Health care access and quality. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/health-care-access-and-quality. Accessed January 20, 2023.
- Education access and quality. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/education-access-and-quality. Accessed January 20, 2023.
- Stringer-Reasor EM, Elkhanany A, Khoury K, Simon MA, Newman LA. Disparities in breast cancer associated with African American identity. American Society of Clinical Oncology Educational Book. 2021;(41). doi:10.1200/edbk_319929
- Social and community context. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/social-and community-context. Accessed January 20, 2023.
- The state of cancer disparities in the United States: Research highlights. American Cancer Society. https://www.cancer.org/research/acs-research-highlights/cancer-health-disparities-research/state-of-cancer-disparities-in-the-united-states. Accessed January 20, 2023.
- AACR Cancer Disparities Progress Report. American Association for Cancer Research. https://cancerprogressreport.aacr.org/disparities/. Published June 9, Accessed January 20, 2023.
- What Hispanic women and Latinas need to know about breast cancer. Breast Cancer Research Foundation. https://www.bcrf.org/blog/hispanic-latina-breast-cancer-facts-statistics/. Published October 10, 2021. Accessed January 20, 2023.
- Jatoi I, Sung H, Jemal A. The emergence of the racial disparity in U.S. breast-cancer mortality. New England Journal of Medicine. 2022;386(25):2349-2352. doi:10.1056/nejmp2200244
- Black women and breast cancer: Why disparities persist and how to end them. Breast Cancer Research Foundation. https://www.bcrf.org/blog/black-women-and-breast-cancer-why-disparities-persist-and-how-end-them. Published October 5, Accessed January 20, 2023.
- Nyrop KA, Deal AM, Muss HB, et al. Racial disparities in obesity and comorbidities among women with early breast cancer. Journal of Clinical Oncology. 2020;38(15_suppl). doi:10.1200/jco.2020.38.15_suppl.e19061
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