‘Leveling the field’ in breast cancer treatment
Dalliah Black, M.D., assistant professor of Surgical Oncology, never planned to become interested in racial disparities in breast cancer treatment and outcomes.
Still, as a young African-American woman in medical school in the 1990s, she was often asked why outcomes were worse for black and other minority patients with breast cancer.
She didn’t know and wasn’t quite sure the differences were really there.
But as she continued her education and launched her career as a breast cancer surgeon, she saw a disturbing trend. Black and Hispanic women weren’t reaping the same gains in treatment outcomes as white women.
Even though breast cancer is slightly more common in white women (13%) than in black women (11%), according to a recent report by the American Cancer Society, black women had a 40% higher death rate.
And though death rates for breast cancer have declined over the last 20 years, the death rates for white women decreased twice as much. The American Cancer Society reports that the overall survival rate in black women diagnosed with breast cancer was 78% compared to 90% in white women, from 2002 to 2008.
“Reasons for the disparity in breast cancer survival between black and white women are complex and currently not known. It’s likely related to differences in screening to detect cancers when they’re most treatable, differences in treatment and other factors,” Black says.
Understanding the disparity
To better understand factors surrounding the disparity, Black and her colleagues evaluated how the underuse of a surgical procedure to stage breast cancer – the sentinel node biopsy – can have a significant effect on women’s outcomes and quality of life.
The sentinel node biopsy was developed in the 1990s to identify the first lymph nodes to which breast cancer cells might spread. These nodes are selectively removed to determine the cancer stage instead of removing all of the lymph nodes under the arm – an extensive procedure called the axillary lymph node dissection.
Sentinel node biopsies benefit patients because they have a much lower risk of lymphedema – swelling that occurs after surgery due to a blockage in the lymphatic system. Lymphedema often results in arm swelling, heaviness, pain and decreased range of motion.
Because of its benefits, the sentinel node biopsy became the preferred method of staging early breast cancers, a standard of care recognized by many groups such as the National Comprehensive Cancer Network.
Yet Black and her colleagues’ study found that fewer black women than white women received the sentinel lymph node biopsy from 2002 to 2007.
Although the use of the sentinel node biopsy to stage early breast cancer increased from 45% to 73% among black patients, white patients were more likely to have the minimally invasive procedure, with an increase from 58% in 2002 to 85% in 2007.
In addition, the study uniquely showed that by receiving the more extensive node dissection instead of the sentinel biopsy, black patients had the highest rates of lymphedema at 18%.
But for black patients who received the recommended biopsy, lymphedema rates were just 9%, which is similar to those of white patients.
“These findings highlight that as improvements in breast cancer treatments are developed, there also must be improvements in getting information to physicians and patients so that all patients may benefit from the advances,” Black says.
Other factors influencing outcomes
Beyond insurance coverage and socioeconomic level, two additional factors ultimately influence health outcomes: access to high quality care and level of involvement in one’s own care.
A study by Sinai/Avon noted that women in certain cities have better outcomes no matter their race. For example, both white and black women in New York City fared better than women in many other cities, possibly due to better access to specialty hospitals.
Once women seek medical care for suspected breast cancer, “the diagnosing and treating physicians matter,” Black emphasizes.
Black also says patients should feel comfortable asking questions about their breast cancer care. For instance, if the physician recommends a surgical excision to evaluate an abnormality, ask if a breast needle biopsy can be done.
Or, if the physician doesn’t recommend a sentinel node biopsy, patients should bring it up with the surgeon. Using techniques like this can decrease complications typically associated with more invasive procedures.
To complete treatment and have the best long-term outcomes, Black encourages patients to voice their concerns and bring up any side effects to their physicians early and often. In fact, she appreciates patients who arrive for appointments ready to discuss treatment options.
“I’m glad when a patient brings a list of questions,” she says. “Better yet, bring someone you trust to advocate for you.”
Patients should also talk to their breast cancer team about other issues or priorities that may affect their care, she adds.
For most breast cancer patients, good outcomes and fewer complications can be achieved when both the patient and health care team work together.
Black’s advice to newly diagnosed or recurrent breast cancer patients:
1. Do your homework. Use reputable websites like the National Cancer Institute, American Cancer Society and Komen Foundation.
2. At your appointments, ask questions about your treatment options. If possible, bring a trusted companion to take notes.
3. Follow the treatment plan to improve your outcomes.
4. Talk to your doctor about other issues that may affect your care.
5. Consider a clinical trial to help further understand differences in breast cancer and further develop improved targeted therapies.
6. Build a support group around you and keep a fighting spirit.