Ongoing Disparity: Breast Cancer in African American Women

Costellia Talley, PhD, ACNS-BC

Costellia Talley is Assistant Professor at the Michigan State University College of Nursing in East Lansing.

Breast cancer is the most commonly diagnosed form of cancer among African American women and the second leading cause of cancer death.¹ Although white women have a higher incidence of breast cancer than African American women (123.2/100,000 versus 118/100,000), African American women have a 40% higher mortality rate.^2,3 Additionally, breast cancer mortality rates are higher among African American women than any other racial/ethnic group.

The underlying causes of breast cancer disparities are multifactorial. Higher mortality rates among African American women with breast cancer has been attributed to more aggressive tumor characteristics, lower screening rates, access to quality care, comorbid conditions, treatment- related factors, advanced stage at diagnosis, and lower socioeconomic status.^8-11 Advanced stage at diagnosis of breast cancer is a major prognostic indicator of mortality, and African American women are more likely to be diagnosed at an advanced stage than white women.¹² Disparities in breast cancer mortality rates are influenced by factors beyond race/ethnicity (Table).

Interventions designed to improve breast cancer disparities should include cancer prevention and early detection through routine screening.

Existing research underscores the importance of breast cancer screening in reducing advanced stage at diagnosis. Silber et al suggest that it would be difficult to reduce cancer disparities without reducing stage at presentation.⁶ A 5% increase in mammography use would prevent an estimated 500 breast cancer deaths each year.¹³ Reducing advanced stage at diagnosis is critically important to addressing the persistence of gradients in morbidity and mortality between African American and white women with breast cancer. Advanced stage at diagnosis influences survival and limits treatment options.

Healthy People 2020 calls for a reduction in late-stage female breast cancer.¹⁴ Mammography and clinical breast examination are the main methods for early detection of breast cancer. Currently, mammography can detect breast cancer prior to the development of symptoms in up to 90% of women. However, to be effective, breast cancer screening must be done on a regular basis and must include timely follow-up after an abnormal screening test. Despite differences in screening guidelines, both the American Cancer Society (annual mammography yearly beginning at age 40) and the US Preventive Service Task Force (biennial mammography from age 50 to 74 years) support routine mammograms.^15,16

Breast cancer prevention and screening strategies must include multiple interventions that are culturally appropriate and targeted to the unique needs of the population. Nurses are in a unique position to facilitate breast cancer prevention and early detection among patients and the public.

Table. Factors Related to Cancer Health Disparities in African Americans¹⁷

Intervention

Level Factors

Individual

Age Socioeconomic status

Cancer health literacy

Cultural beliefs (eg, fatalism, medical mistrust)

Perceived racial prejudice

Fear (eg, pain, radiation)

Spirituality

Chronic illness

Disability/mobility issues

Interpersonal

Family relationships

Lack of support

No allocated time off: work/child care/transportation

No family history

Community and Organizational

Geographic location

Access to treatment and quality of care

Lack of family physician

Long wait for appointment

Failure to refer

National and Policy

Access to screening programs

Cancer prevention education for policy makers

Nurses provide care to patients in multiple settings and across all aspects of the cancer trajectory. One of the roles of nurses is health educator, and in this role nurses can: (a) provide education about breast cancer prevention and screening; (b) help patients to sort through information and controversies (particularly in the age of information technology); and (c) provide information about healthy eating and other healthy lifestyle habits. Education must be based on evidence-based practice; therefore, nurses need to stay abreast of screening guidelines and changes that affect breast health.

Studies have shown that patient—provider communication is a barrier to screening in some populations. Nurses are known to have good communication skills and have been identified as one of the most trusted professions. Thus, they play an important role in determining what healthcare information is needed and in determining the best method of information delivery Nurse researchers must assess risk factors for breast cancer (eg, family and reproductive history) and thus can design, develop, and implement projects that address breast cancer disparities at the prevention and screening level.

Nurses play a vital role in reducing breast cancer disparities between African American and white women regardless of the role that they play: expert practitioner, educator, or researcher.

References

• American Cancer Society. Cancer Facts & Figures for African Americans 2013-2014. Atlanta: American Cancer Society; 2013.
• Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64(1):9-29.
• Centers for Disease Control and Prevention. Breast Cancer Disparities, 2012. http://www.cdc.gov/features/vitalsigns/breastcancer/. Accessed July 31, 2014.
• Aizer AA, Wilhite TJ, Chen M-H, et al. Lack of reduction in racial disparities in cancer-specific mortality over a 20-year period. Cancer. 2014;120(10):1532-1539.
• Menashe I, Anderson W, Jatoi I, Rosenberg P. Underlying causes of the black-white racial disparity in breast cancer mortality: a population-based analysis. J Natl Cancer Inst. 2009;101(14):993-1000.
• Silber JH, Rosenbaum PR, Clark AS, et al. Characteristics associated with differences in survival among black and white women with breast cancer. JAMA. 2013;310(4):389-397.
• DeSantis CE, Lin CC, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64(4):252-271.
• Byers TE, Wolf HJ, Bauer KR, et al. The impact of socioeconomic status on survival after cancer in the United States: findings from the National Program of Cancer Registries Patterns of Care Study. Cancer. 2008;113(3):582-591.
• Curtis E, Quale C, Haggstrom D, Smith-Bindman R. Racial and ethnic differences in breast cancer survival: how much is explained by screening, tumor severity, biology, treatment, comorbidities, and demographics? Cancer. 2008;112(1):171-180.
• Smith-Bindman R, Miglioretti D, Lurie N, et al. Does utilization of screening mammography explain racial and ethnic differences in breast cancer? Ann Intern Med. 2006;144(8):541-553.
• Tammemagi CM, Nerenz D, Neslund-Dudas C, Feldkamp C, Nathanson D. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005;294(14):1765-1772.
• Li CI, Malone KE, Daling JR. Differences in breast cancer stage, treatment, and survival by race and ethnicity. Arch Intern Med. 2003;163(1):49-56.
• Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the U.S. by improvements in use of clinical preventive services. Am J Prev Med. 2010;38(6):600-609.
• US Department of Health and Human Services. Healthy People 2020. 2013; http://healthypeople.gov/2020/default.aspx. Accessed May 7, 2013.
• American Cancer Society. American Cancer Society Gudelines for Early Detection of Cancer. http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed July 31, 2014.
• US Preventive Services Task Force. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2009;151(10):716-726.
• Chawla N, Kepka DL, Heckman-Stoddard BM, et al. Health disparities around the world: perspectives from the 2012 Principles and Practice of Cancer Prevention and Control course at the National Cancer Institute. J Oncol Pract. 2013;9(6):e284-289.