Disparities in Breast Cancer Prevention and Care

While breast cancer survival rates have improved in recent years,1 not all populations have benefited equally. For a range of at-risk populations in the U.S., differences persist in breast cancer incidence, mortality, and survivorship.2 Understanding the forces that drive these disparities is the first step to closing the gaps in prevention and treatment.

Who Is at Greater Risk, and Why?

At-risk populations include low-income and medically underserved groups, especially those in remote geographical areas, as well as members of certain racial and ethnic minorities. These communities are more likely to lack health coverage3 and have less reliable access to medical information. They also may face a variety of linguistic, cultural, and socioeconomic barriers to obtaining preventive cancer care and treatment.

 

Combine all of this with an increasingly complex health care system, and it's not difficult to see how breakdowns in service can occur across the breast cancer continuum.4

Among African-American women, for example, breast cancer rates are rising. Women in this group are 40 percent more likely to die from the disease than Caucasian women, despite the fact that African-American women have historically exhibited lower incidence rates.5African-American women are also more likely to have longer periods of time between screenings, making cancer diagnosis at a later stage more likely, and longer intervals between an abnormal mammogram and diagnosis.6

Other ethnic populations are disproportionately affected as well:

  • Latina women are diagnosed with more-advanced breast cancer at earlier ages. Additionally, the mortality rate among this population is 20 percent higher than Caucasian women.5
  • Compared to Caucasian women, rates of non-invasive breast cancer for Latina women are decreasing at a slower pace.5
  • Native American and Alaska Native women have the lowest five-year breast cancer survival rate (63 percent, versus 91 percent for Caucasian women).5
  • In California, the breast cancer mortality rate for Asian-American and Pacific Islander women is rising.7

The causes of disparities are complex and often interrelated. One factor may be the lack of primary care providers who can recommend preventive screenings.8 This issue is exacerbated by the current provider shortage in America — one that is particularly dire in rural areas.9 Having a dedicated health care provider has been shown to increase the likelihood that a person will receive preventive services, such as mammography,10 on a routine basis. Having a dedicated health care provider has also been linked with reduced health disparities between Caucasians, African-Americans, and Hispanics, regardless of insurance status or income.11

Another obstacle is lack of awareness surrounding breast cancer risks and screening methods. A disproportionate number of minority populations live in poverty,12 and individuals at an economic disadvantage are less likely to have access to the information needed to make sound decisions about their personal health.13 One study found that many Native American women younger than age 40 felt they did not have adequate information about breast cancer risks and screening guidelines. Some believed they did not receive proper instructions regarding breast self-examination. Others said they were not given information about mammograms or were told to wait until the age of 40. Still others expressed concern over confusing technical terms, which made it difficult to grasp breast cancer information provided to them.14

Other barriers to breast cancer diagnosis and treatment include:

  • Lack of health insurance.
  • Language and cultural differences. 6
  • Lack of transportation to and from health-related services. 7
  • Poor medical care resulting in under-treatment, over-treatment, or mistreatment. 5
  • Mistrust of the medical community.

Discrimination related to class, race, and citizenship may also affect breast cancer care. 5 10 Patients from minority populations are more likely to report being on the receiving end of negative attitudes throughout the health care process.15 There is a growing body of evidence suggesting that racial bias and discrimination in health care contributes to poor physical and mental health for minorities. This includes self-reported experiences, indicating that a patient's perception is as important as the reality. Experts suggest that health providers and professionals actively promote awareness of unconscious biases and practice sensitivity toward patients of all racial and ethnic backgrounds.16

Women in minority groups do not participate in potentially beneficial clinical trials as often as Caucasian women do. Though participation of various minority groups in clinical trials is important in helping to ensure a drug's safety and effectiveness, minority groups are consistently underrepresented in U.S. clinical trials17. Only 5 percent of trial participants are African-American,18 while Hispanics make up only 1 percent.19 The reasons for lack of participation vary. Some minorities are distrustful of clinical trials and worried about sharing intimate details of their health. Often, materials used in a trial are not translated into multiple languages or lack sensitivity to religious beliefs. From a practical aspect, some participants have no transportation to and from clinical sites, or cannot afford to take time off work.18 Regardless of the reason, underrepresentation of minority populations in clinical trials means that minority women have less access to the latest life-saving breast cancer therapies.20

Closing the Disparity Gap for At-Risk Populations

Traditionally, the response to breast cancer disparities has involved promoting awareness around early detection and broadening access to preventive screenings. However, these solutions don’t account for a variety of factors that may inhibit certain populations from seeking preventive care, such as language barriers or lack of transportation to and from appointments.22 Providers, as well as state, local, and organizational-level initiatives, must address the circumstances that create gaps in the breast cancer continuum of care.

Below are some recommended strategies to help decrease the disparities among at-risk populations.

At the state, local, and organizational level: Increasing breast cancer screening rates for at-risk populations will require improving access to primary care, removing financial hurdles such as high out-of-pocket costs, and mitigating language barriers.22

The Centers for Disease Control and Prevention recommends that state and community health agencies work with health care systems and insurers to educate women and providers about timely, high-quality breast cancer care. Outreach strategies can help women in at-risk populations understand why screenings are important and what to expect if results come back abnormal.23 Another approach that shows promise is placing peer educators and patient navigators in underserved areas. This helps at-risk women adhere to breast cancer screening recommendations, as well as follow-up tests and treatment.24

At the provider level: Health care providers who work with at-risk communities and diverse cultures, such as Family Nurse Practitioners (FNP), should be trained to better understand and anticipate the needs of those populations. FNPs must make sure patients receive recommended tests and treatment, carefully explain test results, and make specialist referrals as needed. They can commission office staff to remind patients of upcoming appointments and track the progress of those who require follow-up testing or treatment. In some cases, providers may be able to assign a patient navigator — an individual who guides patients through the complex cancer care system step by step to ensure they receive timely diagnosis and treatment.25

At the patient level: If women cannot afford a mammogram, they should reach out to their local health department or community health center for assistance.14 Organizations such as the American Cancer Society offer a variety of resources to help cancer patients and their loved ones, including lodging programs, transportation assistance, and patient navigators. The National Breast and Cervical Cancer Early Detection Program provides uninsured, underserved, and low-income women with timely screening and diagnostic services.

Moving Forward

Reversing the serious disparities in breast cancer prevention, treatment, and mortality rates requires more than quick, one-size-fits-all fixes. In order to combat the disease, the health care system must account for at-risk and underserved populations, and tailor solutions to address their unique challenges. FNPs and other primary care providers have the power to close the disparity gap by arming themselves with up-to-date breast cancer education and resources, and by learning to recognize signs of potential disparities in the care and outcomes of their own patient populations.

By further educating fellow practitioners, communities, and patients about the cultural and socioeconomic divides among patient populations, providers can help break down the barriers so that women in all communities can lead healthier lives.

Learn more about breast cancer prevention, detection, and risks.

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4127611/

2. http://www.cancer.gov/about-nci/organization/crchd/cancer-health-disparities-fact-sheet#q1

3. http://kff.org/disparities-policy/issue-brief/health-coverage-by-race-and-ethnicity-the-potential-impact-of-the-affordable-care-act/

4. http://www.focr.org/sites/default/files/images/focrbcwhitepaper.pdf

5. http://www.cancer.org/cancer/news/news/report-breast-cancer-rates-rising-among-african-american-women

6. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6145a5.htm?s_cid=mm6145a5_w

7. http://www.bcaction.org/site-content/uploads/2010/11/Disparities-and-Breast-Cancer.pdf

8. https://ww5.komen.org/BreastCancer/DisparitiesInBreastCancerScreening.html

9. http://www.ncsl.org/research/health/meeting-the-primary-care-needs-of-rural-america.aspx

10. http://cebp.aacrjournals.org/content/17/11/2913.full.html

11. http://www.commonwealthfund.org/usr_doc/mead_racialethnicdisparities_chartbook_1111.pdf

12. http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/hprr/womens%20health/racialethnicpatternsofcancerincidenceandmortality.ashx

13. http://www.huffingtonpost.com/2015/06/29/racial-inequality-health-care-black-v-white_n_7164140.html

14. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780408/

15. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855001/#CR3

16. http://health.usnews.com/health-news/patient-advice/articles/2016-02-11/racial-bias-in-medicine-leads-to-worse-care-for-minorities

17. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm349063.htm

18. http://www.fda.gov/downloads/ScienceResearch/SpecialTopics/WomensHealthResearch/UCM334959.pdf

19. http://www.forbes.com/sites/johnlechleiter/2014/04/09/closing-the-diversity-gap-in-clinical-trials/#64715bf53c91

20. http://www.breastcancer.org/risk/factors/race_ethnicity

21. http://bcaction.org/our-take-on-breast-cancer/inequities-and-social-justice/#_edn19

22. https://ww5.komen.org/BreastCancer/DisparitiesInBreastCancerScreening.html

23. http://www.cdc.gov/vitalsigns/breastcancer/

24. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6145a5.htm?s_cid=mm6145a5_w

25. http://www.insightnews.com/2013/10/14/breast-cancer-disparities/