Public Health Democracy: U.S. and Global Health Disparities in Breast Cancer
Dr. Doris Browne, Program Director of the Breast and Gynecologic Cancer Research Group, Division of Cancer Prevention, National Cancer Institute
Dr. Peter Greenwald, Director of the Division of Cancer Prevention, National Cancer Institute
Dr. Lucile Adams-Campbell, Director of the Howard University Cancer Center, and Professor of Medicine
The global incidence for cancer now exceeds 1.1 million cases each year, resulting in more than 400,000 deaths annually. In both the U.S. and developing nations overall, breast cancer is the second leading cause of cancer-related deaths among women. On April 2, 2008, medical professionals, researchers, and policymakers gathered to discuss the recent research of Dr. Doris Browne, program director of the Breast and Gynecologic Cancer Research Group, Division of Cancer Prevention at the National Cancer Institute (NCI); and former Woodrow Wilson public policy scholar. Her work examines breast cancer-related health disparities, particularly among African-American, African, and medically underserved women.
Addressing the Unequal Burden of Breast Cancer
Dr. Doris Browne began the event by outlining the global burden of breast cancer, highlighting the fact that vast disparities persist despite significant progress in cancer research. The highest rates of breast cancer are in developing nations. In the United States, African-American women suffer from higher breast cancer mortality rates than Non-Hispanic whites (34/100,000 compared to 25/100,000), despite lower incidence rates. Browne attributed this disparity to poor representation of African-American women in clinical trials; lack of optimal screening, resulting in late stage of diagnosis; and an over-expression of early-onset, aggressive cancers among this population group. Research shows that African-American women are less likely than Non-Hispanic whites to receive standard treatments for cancer, even when they have the same health coverage and economic status.
Browne's most recent report focuses on estrogen-receptive negative (ER-negative), basal-like breast cancer, which represents 20 to 30 percent of all new breast cancer cases—mainly for women under the age of 50. This subtype tends to be early-onset, aggressive, large in tumor size, not responsive to endocrine therapy, and more common among African-American women than Non-Hispanic whites. Browne emphasized the importance of "focus[ing] on the tumor biology and looking at it in terms of this very aggressive disease and the answers that may be applicable in the African-American population."
In order to reduce some of these cancer disparities, Browne expressed the need to focus on and create incentives for prevention and early detection that takes biology and socio-economics into account. She advocated for prevention interventions centered on modifiable lifestyle and environmental factors, such as promoting screening at a young age and reducing obesity, which increases breast cancer risk. She also placed responsibility on the health care system, asking, "If we alter the care that is received by the minority group, would we change the outcome?"
Additionally, Browne stressed the need for more clinical data on African-Americans and breast cancer, better awareness among primary care physicians on the increased frequency of ER-negative breast cancer among African-American women, and equal access to cancer care for the medically underserved. For those underserved in developing nations, Browne called for innovation in designing low-technology alternatives to screening, detection, and treatment approaches used in the developed world. She concluded by stating, it is "our responsibility to right inequalities in health care."
An Historic Look at Cancer Disparities
Dr. Peter Greenwald, director of the Division of Cancer Prevention at NCI, applauded Dr. Browne's research, noting its "national and global importance." He explained that her research focuses on the 30 percent of breast cancer NCI has not yet been successful in understanding its development and modes of prevention. Thus, the NCI is now building an initiative under Browne's leadership to address the aggressive ER-negative subtype and its disproportionate burden among young African-American women. Greenwald reiterated the importance of addressing racial health care disparities, stating, "The color of your skin is only a weak indicator of your genes, but it's a very strong indicator—unfortunately—for a large number of people, of barriers to care . . . the barriers to care and the many ramifications of it are what we have to address."
Greenwald then gave a brief history of NCI's efforts to address racial disparities, including those found in the African-American, Hispanic, and Native American populations. He compared the low participation rates of African-American women in breast cancer clinical trials mentioned in Browne's presentation to the NCI prostate cancer prevention trial, which had only an eight percent minority participation rate. A current NCI trial has increased this proportion to 21 percent. "We're learning, but it's uphill," Greenwald said. "Unfortunately at NIH, the ‘knowing-something' more often is the aim and we have to tie it to ‘doing-something' and keep pushing." Greenwald explained that understanding the science behind cancer and disparities is only the first step; the next step is to transform this knowledge into prevention strategies that save lives.
Taking Steps to Reduce Disparities
Dr. Lucile Adams-Campbell, director of the Howard University Cancer Center, and professor of medicine, posed the question, "Are we living in a first and third world country . . . when it relates to cancer health care?" In regards to breast cancer—yes, she responded. African-Americans who have access to screening display late-stage detection similar to those in developing countries that do not have access to screening technologies. In the United States, "there often exists a differential between ethnic groups for quality, timeliness, treatment, and adherence", explained Adams-Campbell.
According to Adams-Campbell, breast cancer research is regarded by many as very advanced due to its well-developed predictive models. However, high-risk African-American women have historically been excluded from the clinical trials on which these models are based. Most data comes from women of European descent, data which, in general, is not appropriate for African-American or African women who often experience a more aggressive cancer, later-stage diagnosis, and lower survival rates. "If we believe that the high mortality rates observed among African-Americans for breast cancer are attributed to the interactions of drug treatment and co-morbidities, then we must take the appropriate steps to become more inclusive and ethnic-group specific," urged Adams-Campbell. She then expressed a pressing need for trans-global cohort studies to investigate the etiology of the disease in young women of African descent and develop models especially aimed at prevention within this group. "Racial and ethnic disparities in the U.S. are as old as the nation itself," and health outcomes reflect that, she said. The solution, according to Adams-Campbell, is a more inclusive health care system that makes a point not to leave some citizens behind.
By Kai Carter