The U.S. offers excellent medical care, but it fails to reach many who need it.
I met Dr. Lisa Newman during the summer I was diagnosed with breast cancer — she’s the surgical oncologist who performed my lumpectomy in July 2022. Dr. Newman (though she insists that I call her “Lisa”) is the chief of the section of breast surgery at NewYork-Presbyterian/Weill Cornell Medical Center and Weill Cornell Medicine.
Dr. Newman was the first person in her family to become a doctor and says the underrepresentation of minorities in medicine was one of the reasons she decided to pursue a career in healthcare. Among her copious achievements is the establishment of the International Center for the Study of Breast Cancer Subtypes, which studies breast tumor biology associated with the complex genetics of globally diverse racial/ethnic groups.
All of this means that she’s more qualified to talk about breast cancer than pretty much anyone I know. I’m fascinated by her research on something we don’t talk about nearly enough: The disparities in cancer risks and treatment between Black and white women. Here are her must-read thoughts on this dangerous pattern.
When I was just starting out in medicine — as a general surgeon working in Brooklyn, New York, during the early 1990s — I noticed a troubling pattern. With more than 2.5 million residents, approximately half of them Black or Hispanic/LatinX, Brooklyn is the most populous and diverse NYC borough, and I treated patients suffering from all types of issues: traumatic injuries from car accidents, hernias in need of repair, and diseases like cancer. At the time, I was one of the few female surgeons in Brooklyn, and my practice attracted many women with breast problems. But I noticed some stark differences in the patients entering my office: my Black breast cancer patients tended to be younger than my White breast cancer patients, they had bulkier tumors, and their disease often resisted available treatments. And all of that meant that they were less likely to survive.
In the last few decades, the U.S. has made tremendous progress when it comes to early detection and treatment of breast cancer. Healthcare in the United States is among the most advanced in the world, and yet appalling disparities still exist in the delivery of this care. The prognosis for women with breast cancer varies wildly, and much of that is related to their race/ethnicity, socioeconomic status, education level, and location. But the most notable differentiator is race: Mortality rates from breast cancer are 40% higher among Black compared to White women.
What accounts for this startling difference? Research shows that much of it comes down to a horrifying legacy created hundreds of years ago: Our country’s colonial-era slave trade. That atrocity began a pattern of systemic racism that’s still impacting public health, and it’s compounded by the genetics of African ancestry and its association with breast tumors. But we can address systemic racism through strategic policies and improvements in access to care. Through comprehensive research, we can address the genetic issues at play, to get a better understanding of the cancer burden that diverse populations face. First, though, we need to fully understand the battle we’re facing.
We’ve made huge advances in understanding the broad spectrum of breast cancer subtypes, which helps doctors tailor treatments to each patient’s tumor. Back when I started my practice, this “personalization” was in its infancy; back then, we were also unaware of the complex factors that accounted for race and ethnicity-related disparities in breast cancer. I wanted to understand these disparities much more deeply, and so in 1997, I decided to start training in surgical oncology at the M.D. Anderson Cancer Center in Houston, Texas.
Since then, I’ve been honored to address the disproportionate burden of breast cancer among African Americans, through community-based outreach, breast-health legislative advocacy, and genetic/tumor biology research. But I’ve also been frustrated by the statistics: Black people account for approximately 13% of the American population, but only 6% of medical school graduates. These data are relevant because implicit biases and discriminatory practices in healthcare are well-documented — the White-dominated physician workforce spends less time with their Black cancer patients than their White ones, and are also less likely to offer clinical-trial opportunities to Black patients.
Improving diversity in the oncology physician workforce can reverse these trends, and will also result in a stronger healthcare system overall, by tapping into the pool of talented and brilliant minority students that historically were systematically excluded from careers in medicine. In fact, studies show that communities with a more diverse physician workforce experience improved healthcare, especially in diverse neighborhoods.
So why do Black women in the U.S. also face an uphill road when it comes to their genetic predisposition to certain cancers? As an example, take one aggressive form of breast cancer known as triple negative breast cancer (TNBC), which is common in countries of western sub-Saharan Africa, such as Ghana. In Ghana, TNBC accounts for approximately half of the tumors in women. The trans-Atlantic slave trade brought the ancestors of contemporary west Africans across the ocean, resulting in substantial shared ancestry with contemporary African Americans. As a result, TNBC is twice as common in African American women as in White American women.
While slavery may have been abolished more than 150 years ago, the consequences of systemic racism persist. They’re seen in residential racial segregation (such as the infamous process of “redlining”) and implicit biases that have left generations of Black families trapped in environments where they deal with poorly funded public schools, limited higher education and professional opportunities, and higher rates of unemployment and poverty. All these disadvantages have a cascading effect on healthcare access — and mortality rates.
Fortunately, breast radiology research has proven one powerful method to reduce breast-cancer mortality, and it’s within our control: Early detection through screening is one of the most effective strategies available. When the disease is caught as a small tumor less than 2 centimeters in size, the five-year survival rates are more than 95%. (That’s compared to an approximately 75% rate, when it comes to bulky tumors that have extended into the lymph nodes.)
Unfortunately however, Black women are less likely to undergo the most advanced forms of mammography, such as digital breast tomosynthesis (also known as 3-D mammography). This is one reason why it’s more common for Black women in America to be diagnosed at an advanced stage of breast cancer: Nearly half of their cases are diagnosed when the tumor is larger than 2cm, compared to just over one-third of similar cases among White women. Breast cancer mortality rates have been steadily decreasing in the U.S., thanks to improvements in treatment like the combined use of surgery, radiation, and medical therapies. But Black breast cancer patients are less likely to receive this type of multidisciplinary care.
When it comes to eliminating breast cancer disparities, we clearly have a long way to go. It’s a complicated path that involves improving access to the highest-quality treatment, educating providers and diversifying the workforce to improve care, and conducting robust research to deeply understand the genetic factors involved. It’s an investment, but one we can’t afford not to make in our journey to breast health equity. The lives of our friends, neighbors, coworkers, and family members depend on it.
