Breast Cancer: Stacking The Odds Against African-American Women

Most diseases don't discriminate, but for African-American women, the odds are against them when it comes to breast cancer.

LET THE STATISTICS TELL THE STORY

In 2014, more than 27,000 new cases of breast cancer are expected to occur among African-American women and of those about 6,000 women will die. Today, breast cancer is the second most common cause of death among African-American women, surpassed only by lung cancer, according to Sisters Network® Inc., a National African American Breast Cancer Survivorship Organization that is committed to increasing local and national attention to the devastating impact that breast cancer has in the African American community.

For African-American women under the age of 45, the mortality rate of breast cancer is higher in African-American than in Caucasians, according to the American Cancer Society's African-American 2013-2014 Cancer Facts Study. The median age of diagnosis is 57 years for African-American women, compared to 62 years for Caucasian women.

The statistics stacking the odds against African-American women can go on, but the two questions that come to mind is why is this form of cancer so prevalent among African-American and what is being done to shift the odds in the opposite direction.

"The statistics for breast cancer in African-American women are a major concern", said Clifford L. Deal, III, MD, chairman of the Department of Surgery at Henrico Doctors' Hospital in Richmond. "While research continues, we are committed to early detection, public awareness and excellent clinical care that we would expect for our family members."

There are many factors to consider when dealing with breast cancer among the African-American population. Do some women die because there has been a delay in diagnosis due to poor health care access? Are there genetic and race-specific factors contributing to this? Is it an issue of education about early detection?

"The answer to all of these is probably yes," Deal noted. "And 'yes' to a whole bunch of other things we don't yet understand."

WHAT WE KNOW AND DON'T KNOW

African-American women tend to have a more aggressive form of breast cancer.
Cancers are "graded" by how they compare with normal cells; some cancers appear and act very much like normal cells. These cancers grow slowly, are able to take up hormones and proteins, and spread to other spots after relatively long periods of time. They tend to form in older women.

On the other hand, aggressive cancers have cells that are wildly abnormal. They are very bizarre when examined with a microscope; they may be unable to interact with some or all of the hormones and proteins normal cells need. They occur more frequently in younger women, and grow and spread quickly.

One form of aggressive breast cancer is known as "triple negative." There are tiny receptors on the surface of breast cells, which allow them to bind the female hormones estrogen and progesterone. Cancer cells which are able to bind these hormones are considered to be "hormone positive," a good prognostic sign. There are also receptors that capture a protein known as HER2; as with hormones, if these receptors are not present, the patient is "HER2 negative." When the patient is "triple negative," she is considered to have an aggressive and fast-moving cancer.

What makes these "triple negative" cancers so hard to treat? Many of the treatments for breast cancer rely on treatment that targets the receptors, carrying the medication directly to the cells. If there are no receptors, treatment plans have to rely on other good, but non-specific techniques. For an unknown reason, triplenegative breast cancers are more common in younger African- American women.

Breast cancer is the most common cancer among African-American women.
The overall lifetime rate of breast cancer in African-American women is lower than in other American women (11% per year compared to 13% per year), but it is by far the most common form of cancer in African-American women. The rate increased alarmingly in the 1980s, but upon review of the data it was revealed that most of the extra cases were probably due to greater availability of mammography, finding cases that wouldn't have been found until much later. The rate is still creeping up, however. Why it is still rising is unknown.

It's usually impossible to tell an exact cause in any individual woman, but population studies have shown that socioeconomic factors may be at play.

There may be dietary and environmental exposures that are associated with breast cancers. High fat intake, cigarette smoke and alcohol consumption are known to be risk factors in all women; some researchers feel that the lifelong poverty, which sometimes accompanies these habits, may affect the genetics and disease development of breast cancer.

The breast cancer death rate in African-American women is about 1/3 higher than in other American women.
Studies have shown that the overall survival rate for breast cancers in non-African-American women is around 90%, while it is only 78% in African-Americans.

Scientists know that breast cancer in African-American women tend to be more aggressive, diagnosed later, and may be harder to treat, but the reasons are complicated and not completely clear. Access to medical care is improving, but is still not as available in some groups, leading to delays in diagnosis. This, combined with the tendency for more aggressive cancers, may be one factor.

EARLY DIAGNOSIS IS CRITICAL

As in all women, early diagnosis is critical in beating this disease. One group helping to bring awareness to the disease, along with working to change the odds in the African-American community, is Sisters Network® Inc. Both locally and nationally, the nonprofit organization is run by African-American women, who are survivors of breast cancer, and promotes the importance of support, breast health education, advocacy, and research through many local events and programs.

The Sisters Network Central Virginia, Inc. Chapter was formed in January 2005. Fifteen survivors and 12 associate members saw the need for an additional chapter in Central Virginia. Its mission is to increase local and national attention to the devastating impact that breast cancer has in the African-American community.

"I'm a 14 year survivor and I've been given a second chance to make a difference in our community," said Zelma Watkins, the founder of the local Sisters Network Central Virginia, Inc. affiliate chapter. "My testimony and experience, along with others in our group, have led to an early diagnosis for many. We know first-hand that early detection saves lives."

So, how can one detect breast cancer? According to the Sisters Network, there are lots of things women can do to protect their breast health and find breast cancer early, such as: Monthly Breast Self-Exam (BSE), clinical breast exams, mammograms, ultrasounds, and Breast Magnetic Resonance Imaging (MRI).

Monthly Breast Self-Exam (BSE)
Women 20 years and older should perform this simple test a week or so after their menstrual cycle starts. You may find it easier to do the exam in the shower when your skin is soapy and slick, but you can find a lot of information online and in your primary care location on the best technique to use.

Clinical breast exams
A healthcare provider should examine the breasts every three years in women between 20 and 39 years of age, and every year in women 40 years and older. Healthcare professionals are trained in this technique and will carefully examine your breasts and make notes as to what is present, in order to compare them with the prior and next exams.

A breast surgeon will usually perform a clinical exam when there is a risk of cancer in younger individuals, or when there is an area of concern, because not all cancers are visible on mammograms or ultrasounds.

Mammograms
While all women 40 years and older should have a mammogram each year, if your mother or sister has had breast cancer, you may need to start having your mammograms earlier and more frequently. The first one is particularly important because it will set a "baseline" view, which can be used to compare and look for suspicious changes.

Ultrasound
If a lump is felt on breast self-exam or clinical breast exam, you will be given an ultrasound exam. This is a simple test that lets the doctor tell whether the lump is a simple fluid-filled cyst – which is not dangerous – or a solid mass that needs to be investigated further.

Breast Magnetic Resonance Imaging (MRI)
This is an accurate, but expensive test, which is generally not needed for most patients. Your doctor will likely recommend it if you have a strong family or personal history or very dense breasts.

What should I do if I'm diagnosed with breast cancer?
There are several kinds of physicians who will be on your treatment team. These will probably include a:

  • Surgeon who specializes in breast cancer and leads the team during the early phases of treatment.
  • Medical oncologist, a doctor who specializes in medications for cancer
  • Radiation oncologist, a doctor who specializes in radiation treatment for cancer
  • Pathologist who will look at your tissue cells, biopsies and lab results
  • Radiologist
  • Nurse navigator

The more common kinds of surgical treatment include:

  • Lumpectomy: removal of the lump with a cuff of surrounding normal tissue, usually performed when the cancer is relatively small and the chances of it spreading are low. When a lumpectomy is performed, "Breast Cancer Therapy" usually includes a type of radiation given to treat the remaining areas of breast tissue.
  • Mastectomy: removal of the entire breast. This is usually performed when the cancer is larger or more widespread.
  • Sentinel Lymph Node Dissection: a dye is used to see how normal lymph fluid – which can carry cancer cells – drains to the nodes under the arm. The first one or two nodes that "light up" with the dye are removed and examined for any sign of cancer cells; if there are none, the chance of the cancer spreading elsewhere is very low. The results are used to help guide your further treatment.

"A lumpectomy is a smaller operation and is performed on an outpatient basis," Dr. Deal says. "The incision will usually heal within a week or so, and after it's well-healed, further cancer treatment will be given if required by your individualized treatment plan."

A slender needle might be inserted into the lump with local anesthesia so that the surgeon can accurately locate it, and the mass and its surrounding tissue will be removed. Depending upon the size of the lump and the size of the breast, the breast may have a slight indentation or be slightly smaller than the other one, but changes in bra sizes are unusual. Lumpectomy is the most commonly performed surgery for breast cancer, with or without lymph node removal; the survival rate for this procedure is the same as for breast removal (mastectomy) and is used in most patients.

The rest of your treatment will depend upon the findings of your surgery, your age and the characteristics of your cancer. If you need further treatment, it may include chemotherapy, radiation therapy, hormonal therapy or special "targeted therapy." Your medical team will consider all of these factors, and will explain why and how everything will be done, and what you should expect. Should you need reconstructive surgery following other treatment, your surgeon will help you decide on the kind of reconstruction and the timing that is best for you.

"We as healthcare providers have the common goal of getting you through surgery and treatment as effectively and easily as possible," Dr. Deal said. "You've done the right thing; you have your diagnosis and now we will work together to do everything we can to make sure that you have a long, healthy and happy life."

Community Events and Activities
These are all tests, health-care procedures and programs that the Sisters Network Central Virginia Chapter discusses during various community events and activities. One of the group's annual events is the Gift for Life Block Walk®, which will take place Sept. 27, 2014 at the New Bridge Baptist Church on Nine Mile Road in Henrico County.

The walk allows breast cancer survivors to partner with volunteers and canvass door-to-door to distribute breast health education brochures, a resource list, and a pink ribbon. The community has an opportunity to meet survivors, hear their stories and experience their triumph over breast cancer. Last year the group visited more than 1,000 homes in the Randolph community and plans to increase that number this year, according to Watkins.

"We go door-to-door and cover every house possible." Watkins said. "We are talking to the women of the household about the steps to early detection. There's a resource list for where they can go for help, as well as mammograms and we will provide information about our organization in case they need additional help or have questions."

Just knowing the signs and symptoms can help with early detection of breast cancer, also increasing the chance of survival. It's important to see your care provider immediately if you notice any of these symptoms (see sidebar). While most are not cancer, it must be ruled out promptly for both your health and your peace of mind.

What are the risk factors?
Risk factors in individual women are very difficult to determine. There is a set of known potential contributors, but over 70% of women with breast cancer did not fall into any of the known risk groups. That being said, general good health and good sense require awareness and care when the risk factors are concerned. Some things can't be modified, but some can.

  • Gender – most breast cancers occur in women, but it also occurs in men
  • Aging
  • Family history and genetics
  • Personal history of cancer, especially breast cancer
  • Dense breast tissue – making lumps hard to feel or see on imaging
  • Hormone replacement therapy after menopause
  • Excessive use of alcoholic beverages
  • Obesity
  • Poor nutrition
  • Absence of physical activity

CONTRIBUTING DOCTOR
Clifford L. Deal III, M.D. is a general surgeon with Richmond Surgical. He also serves as chairman of the Department of Surgery at Henrico Doctors' Hospital and is a clinical assistant professor of surgery in the Division of Trauma and Critical Care Surgery at Virginia Commonwealth University in Richmond, Virginia.