Who Lives and Dies: Breast Cancer’s Social Determinants
Breast cancer is the most common cancer amongst women— making up 30% of cancer that women are diagnosed with [1, 2]. It is very likely you know someone afflicted with it. Fortunately, advancement in treatment, early detection, and prevention has led to a 42% decrease in breast cancer deaths through the decades . However, there are evident racial and socioeconomic disparities demonstrated through breast cancer incidences and mortality rates in the US.
While breast cancer statistics shared with patients typically address the general population of breast cancer patients, these numbers tend to vary amongst racial groups. Compared to White women, minority women under 50 years old have a 72% higher chance of diagnosis of an invasive breast cancer and a 127% higher chance of death . In addition, when comparing women under 50 years old, Black women were twice as likely to die due to breast cancer . One of the reasons behind these differences is the presence of systemic racist practices and policies that still lie within our system. For example, redlining and allocation of healthcare resources and food options allow segregation to persist and create health inequities against Black people . As a result, Black women were more likely to be diagnosed with risk factors of breast cancer)diabetes, heart disease, and/or obesity . Not only does this raise the prevalence of breast cancer in Black women, but also the level of danger of breast cancer.
HR-positive/HER2 negative breast cancers, a subtype of breast cancer yielding the least dangerous prognosis, were found to be 23% higher amongst White women and 45% higher for Hispanic and American Indian/Alaska Native women over 20 years old than Black women of the same age range . On the other hand, triplenegative breast cancer subtypes were more prevalent in Black women under 50 years of age . As these statistics have demonstrated, it is necessary to raise awareness of these issues to decrease health inequalities and make significant improvements for breast cancer treatments amongst disadvantaged racial groups.
Increased rates of breast cancer in Asians (especially those under 50) have also been observed . In addition, Asians were observed to have lower rates of mammography testing, which impacts incidence and survival . Compared to White women with a mammography testing rate of 68.06%, Asian women had an overall rate of 65.79% . There are a number of reasons for this difference. For example, Asian women can experience language barriers that create conflicts in communication and education, leaving them uninformed or misinformed about the importance of mammograms . Age also plays a role; older women are more reluctant to undergo mammography testing . Additionally, Asian culture holds a principle of “modesty” that may dissuade them from mammography testing despite its importance in detecting breast cancer .
These barriers between racial groups demonstrate the need for healthcare interventions and policies to address them and promote health equity for breast cancer.
Other aspects regarding socioeconomic status are also responsible for the health inequalities of breast cancer. A key disadvantage of US healthcare is the lack of universal health insurance, leaving US citizens responsible for health costs. As a result, women with lower socioeconomic statuses are more likely to lack access to quality health insurance and be subjected to a higher risk of breast cancer due to the decreased incentive to partake in mammography tests to detect breast cancer [1, 5]. Education provides individuals with health literacy, communication skills with health providers, and access to higher income opportunities . Income and employment are also important in that they determine if individuals can maintain needs such as food, housing and other services. Additionally, higher employment status comes with benefits like healthcare insurance, sick days, and schedule flexibility . However, because women of low socioeconomic status often have poor education, income, and/or employment status, they may lack these benefits and therefore, carry much higher risk of breast cancer than women of higher status. A study regarding socioeconomic inequalities of premature breast cancer mortality demonstrated that US counties of lower income and educational attainment levels and higher unemployment rates had a higher mortality rate of breast cancer . Both before and after the Affordable Care Act of 2010—a policy allowing expansion of Medicaid amongst states— was passed, higher mammography screening rates and lower breast cancer incidence were more present in states with Medicaid expansion than states without . Therefore, it is evident that these disparities have significant impacts on marginalized groups regarding breast cancer, and more needs to be done to close the gaps between groups of different socioeconomic statuses.
As aforementioned, mortality rates of breast cancer have overall diminished greatly, but that does not lessen the effects of breast cancer on minorities and low-income populations. The US healthcare system must recognize these inequalities and take proper action in hopes of providing the best treatment for breast cancer that it can for them.
1. Gehlert, S., Hudson, D., & Sacks, T. (2021). A Critical Theoretical Approach to Cancer Disparities: Breast Cancer and the Social Determinants of Health. Frontiers in Public Health, 9. https://www.frontiersin.org/article/10.3389/fpubh.2021.674736
2. Ellington, T. D. (2022). Trends in Breast Cancer Incidence, by Race, Ethnicity, and Age Among Women Aged ≥20 Years—United States, 1999– 2018. MMWR. Morbidity and Mortality Weekly Report, 71. https://doi.org/10.15585/mmwr.mm7102a2
3. Black Women and Breast Cancer: Disparities and Research | BCRF. (n.d.). Retrieved March 15, 2022, from https://www.bcrf.org/blog/black-womenand-breast-cancer-why-disparities-persist-and-how-end-them/
4. Hendrick, R. E., Monticciolo, D. L., Biggs, K. W., & Malak, S. F. (2021). Age distributions of breast cancer diagnosis and mortality by race and ethnicity in US women. Cancer, 127(23), 4384–4392. https://doi.org/10.1002/cncr.33846
5. Jang, M. K., Chung, D. W., Hamlish, T., Rhee, E., Mathew, A., Li, H., & Doorenbos, A. Z. (2021). Factors Influencing Mammography Uptake Following a Screening Intervention among Asian American Women: A Systematic Review. Journal of Immigrant and Minority Health, 23(6), 1293– 1304. https://doi.org/10.1007/s10903-021-01172-0
6. Mammography screening disparities in Asian American women: Findings from the California Health Interview Survey 2015-2016. | Journal of Clinical Oncology. (n.d.). Retrieved March 15, 2022, from https://ascopubs.org/doi/abs/10.1200/JCO.2021.39.15_suppl.e18568
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