Breast cancer is less common in black women, so why do more die?

although breast cancer is less common in black women compared to white women, they have a much higher risk of dying from the disease.

In the United States, between 2014 and 2018, age-adjusted breast cancer mortality was about 40% higher among black women than among non-Hispanic white women.

This mortality gap likely reflects the fact that black women face significant barriers to obtaining timely, quality medical care compared to white women, suggest lead author Ismail Jatoi, MD, PhD, University of Texas Health Science Center, San Antonio, and colleagues in a recent opinion piece.

The article was published online June 18 in The New England Journal of Medicine.

When the team examined breast cancer mortality statistics, they found a surprise: The race mortality gap only dates back to 1980.

Before 1980, breast cancer mortality among black women was slight lower than white women, Jatoi and colleagues point out.

That year was a turning point in breast cancer treatment, as it was in 1980, both mammography screening and adjuvant endocrine therapy became available.

This was also when the mortality gap between the races began to appear.

It was the differences in access to the two new interventions that caused the divergence, as the authors suggest. Why this happened is obvious, they note.

“Black women are more likely than white women to have no health insurance or to have insufficient coverage, which has limited their access to mammography screening and adversely affected therapeutic decision-making,” researchers point out.

In addition, both mammography screening and endocrine therapy mainly benefit patients with hormone receptor (HR) positive breast cancer, which is equally common in black and white patients. However, black women have a 65% higher rate of HR-negative cancers than white women — and HR-negative tumors are often detected during the interval between mammography screening exams as palpable cancers.

Black women also have 81% more triple-negative breast cancer, so they benefited less from mammography screening and adjuvant endocrine therapy, both of which promote the detection and treatment of HR-positive breast cancer, the authors point out.

Some have suggested that the excessive HR-negative breast cancer in black women may be explained by hereditary factors. But as Jatoi and colleagues note, the incidence of HR-negative breast cancer has declined in all races in the United States since 1992.

However, the declines were slower in black women, and the incidence reduction was smaller in white women living in less affluent regions of the US compared to white women from more affluent regions.

These patterns suggest that social determinants of health not only influence access to and quality of health care, but also the development of HR-negative breast cancer, as the authors observe.

“If all people with breast cancer benefited equally from effective medical interventions, racial differences in mortality for individual tumor subtypes would largely reflect differences in incidence,” Jatoi and colleagues continue.

Still, the statistics show that the substantial racial differences in mortality for both HR-positive and HR-negative cancers between black and white women cannot be explained by differences in the incidence of either tumor alone, they write.

For example, mortality for HR-positive breast cancer is 19% higher among black women than among white women, but the incidence of HR-positive breast cancer is 22% lower among black women.

Similarly, mortality from HR-negative breast cancer is more than twice as high among black women as it is among white women — a significantly larger difference compared to the 65% relative difference in the incidence of HR-negative breast cancer between the two races.

“Universal health coverage could reduce inequalities in the treatment of cancers of all subtypes, including triple-negative breast cancer,” emphasize Jatoi and colleagues again.

“Ensuring universal access to quality medical care can significantly reduce racial inequality in U.S. breast cancer mortality,” they conclude.

The authors have not reported any relevant financial relationships.

N Engl J Med. Published online June 18, 2022. Entire text

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