Beyond Mammograms: The Quest for Early Detection and Equal Healthcare
In August 2015, I received my mammogram results. I was relieved to read "dense breasts" and not "suspicious findings." Tossing the results aside, I went on with my day and life. Little did I know that five months later, during a routine self-exam, I would discover a suspicious, fingerling potato-sized welt under my right breast. What I wasn't told regarding my mammography results was that dense breasts increase the risk of breast cancer diagnosis twofold. Five months had gone by while the cancer grew unabated to stage 2B.
Why was I kept in the dark about the significance of dense breasts? Why weren't preventive healthcare measures offered to ensure early detection and avoid a devastating diagnosis? Unfortunately, this lack of awareness isn't uncommon.
The degree of density was never disclosed to me nor that dense breasts could obscure breast cancer. The degree serves as a weather forecast, offering insights into the condition of our breasts. Picture a plane representing a potential tumor in the sky. On a sunny day, the plane stands out distinctly, just like a detectable tumor. On a partly cloudy day, most of the plane or tumor is visible, though not as clear. However, on a cloudy day, you sense the presence of an object, but it remains vague and suspicious. Similarly, highly dense breast tissue is akin to a mostly cloudy or overcast day, where nothing is discernible except for the density itself.
Women with dense breasts are at an increased risk for a breast cancer diagnosis and are more likely to have a false negative mammogram; something could be lurking, but the radiologist reading a mammogram can’t always tell. In those cases, you should ask your doctor for an additional screening study with more sophisticated imaging — an MRI and/or an ultrasound.
In spite of being a healthcare executive for over a decade, I, like most Black women, did not have additional screenings, which could have meant an earlier diagnosis and curative treatment instead of what turned out to be an aggressive HER2+ breast cancer that ultimately metastasized to my brain.
That is my story. That is unacceptable. Black women refuse to be invisible in the conversation about our own health, and it's beyond time for us to be provided with better, more appropriate care.
While the overall U.S. breast cancer mortality rate has decreased by 46 percent since the 1990s, the decline for Black women is a dismal 26 percent. Women with dense breasts experience higher rates of interval cancers that emerge within a year of a normal mammogram. In 2019, 38 states mandated patient notification of breast density. But unfortunately, my state was not among them. This raises a pertinent question: why are Black women less likely to be referred for supplemental breast screening despite the lack of racial variation in breast density?
According to a 2020 study, “Minority women with dense breasts are less likely to be ordered supplemental breast imaging. Further research should investigate physician and patient behaviors to determine barriers in supplemental imaging. Understanding these differences may help reduce disparities in breast cancer care and mortality.”
Throughout my journey, I've found strength through community support. We are working together to educate Black women on what to do if their mammogram results say dense breasts:
- Have a baseline risk assessment performed by your doctor, by age 25, to determine if screening earlier than age 40 is needed. New American College of Radiology guidelines call for earlier and more intensive screening for high-risk women, "particularly Black and Ashkenazi Jewish women." Black women are considered high risk, without exception, due to higher mortality from breast cancer, higher grade tumors, and higher risk of BRCA1 and BRCA2 genetic mutations, amongst other factors.
- Make sure your mammogram is a DBT type (Digital Breast Tomosynthesis). This is also referred to as a 3D mammogram.
- Talk to your doctor about your mammogram results including the level of your breast density (heterogeneous or extremely dense). Mammography remains a critical necessity for good breast health. Get screened at a frequency and age according to your own risk factors. Starting at age 25-30, ask your doctor if you're at high risk for breast cancer. In July 2021, the American College of Radiology reclassified Black women as high-risk.
- Document your biological family health history and share it with your doctor(s). As a Black woman, a family history of breast, prostate, pancreatic, and ovarian cancers on your mother's and father’s side of the family can increase your risks. The more your biological family history is documented (it is optimal to know the condition and age, if possible), the more your screening can be closely monitored, perhaps at an earlier age than the average, and the more likely your insurance will cover additional screenings.
- Understand the laws in your state regarding insurance coverage for additional screenings and the disclosure of the level of density. Maryland, for example, passed two bills covering genetic and genomic testing and coverage for additional screenings at no cost. I proudly testified for both bills and met with my state legislators. You should too. To register to be trained on using your voice for these changes, contact my breast health equity organization Touch4Life to join our B-HAVE™ (Breast-Health Advocate Voices for Equity) initiative. By September 2024, the FDA will require breast density notification for all women in the U.S.
- Perform self-exams of your breasts regularly. If menstruating, remember to do so when you put away your cycle gear (tampons, pads, etc.) after your period. If you are post- or perimenopausal, pick a day of the month (e.g., your birth date) and go for it! Look and feel your breasts. If you want to see how to perform a self-breast exam, you can view a nurse practitioner as she walks you through the process.
Black women have been neglected for far too long under the weight of healthcare disparities. The healthcare industry must recognize our unique risks and vulnerabilities, offering us the same attention and care given to others. It's time to come together, share our stories, and demand a brighter, healthier future for all Black women. Let us refuse to be invisible any longer and take the steps necessary to reclaim our health because our lives truly matter.
Black Women Are Missing Out on Life-Saving Triple-Negative Breast Cancer Treatment
Triple-negative breast cancer (TNBC) disproportionately affects Black women in the U.S., contributing to higher breast cancer mortality rates in this population. A recent study published in the JAMA Network Open has revealed significant racial disparities in the administration of immunotherapy, a treatment that improves outcomes in early-stage and metastatic TNBC.
What is Immunotherapy?
Immunotherapy is a type of cancer treatment that uses the body’s own immune system to fight cancer cells. It involves using biological or chemical factors that change the immune system or the patient’s response to tumor cells. In the context of TNBC, immunotherapy often involves the use of immune checkpoint inhibitors, like atezolizumab and pembrolizumab, which work by blocking proteins that stop the immune system from attacking cancer cells.
Why is Immunotherapy Important for TNBC?
In the context of cancer, clinical trials are essential for developing and improving life-saving treatments like immunotherapy. They provide a structured way to test the safety and effectiveness of new therapies and can offer patients access to cutting-edge treatments that are not yet widely available. However, clinical trials must include diverse patient populations, including Black women, to ensure that the findings apply to all who may benefit from these treatments.
Immunotherapy has been shown to significantly improve outcomes for patients with TNBC. For metastatic TNBC, studies have demonstrated that immunotherapy in combination with chemotherapy can improve overall survival. In early-stage TNBC, immunotherapy has been shown to increase the rate of pathologic complete response (pCR), which is the absence of any signs of cancer in tissue removed during surgery after treatment. Achieving pCR is a key indicator of treatment success and is associated with better long-term survival.
Racial Disparities in Immunotherapy Use
The study, which analyzed data from 10,724 patients with TNBC between 2019 and 2021, revealed that while immunotherapy use has increased overall, Black patients with metastatic TNBC are less likely to receive this treatment compared to White patients. This disparity persists even when socioeconomic factors are taken into account.
Researchers found that immunotherapy use increased from 5.5 percent in 2017 to 38.8 percent in 2021 for metastatic TNBC, and from 4.2 percent in 2017 to 48.0 percent in 2021 for early-stage TNBC. However, the increase was lower among Black patients.
The study also found that socioeconomic factors play a role in the disparities seen in early-stage TNBC treatment. When factors such as insurance status and treatment facility type were considered, the differences in immunotherapy use between Black and White patients were no longer significant.
The authors of the study suggest that there may be other unmeasured factors contributing to the lower use of immunotherapy in Black patients with metastatic TNBC, such as racial differences in PD-L1 status (a protein that affects how well immunotherapy works), differences in the tests used to determine PD-L1 status, or differences in access to biomarker testing.
Triple Negative Breast Cancer (TNBC): Treatment Options and What to Expect
Triple Negative Breast Cancer
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Advances in Breast Cancer Research
NCI-funded researchers are working to advance our understanding of how to prevent, detect, and treat breast cancer. They are also looking at how to address disparities and improve quality of life for survivors of the disease.
This page highlights some of what's new in the latest research for breast cancer, including new clinical advances that may soon translate into improved care, NCI-supported programs that are fueling progress, and research findings from recent studies.
Early Detection of Breast Cancer
Breast cancer is one of a few cancers for which an effective screening test, mammography, is available. MRI (magnetic resonance imaging) and ultrasound are also used to detect breast cancer, but not as routine screening tools for people with average risk.
Ongoing studies are looking at ways to enhance current breast cancer screening options. Technological advances in imaging are creating new opportunities for improvements in both screening and early detection.
One technology advance is 3-D mammography, also called breast tomosynthesis. This procedure takes images from different angles around the breast and builds them into a 3-D-like image. Although this technology is increasingly available in the clinic, it isn’t known whether it is better than standard 2-D mammography, for detecting cancer at a less advanced stage.
NCI is funding a large-scale randomized breast screening trial, the Mammographic Imaging Screening Trial (TMIST), to compare the number of advanced cancers detected in women screened for 5 years with 3-D mammography with the number detected in women screened with 2-D mammography.
Two concerns in breast cancer screening, as in all cancer screening, are:
- the potential for diagnosing tumors that would not have become life-threatening (overdiagnosis)
- the possibility of receiving false-positive test results, and the anxiety that comes with follow-up tests or procedures
As cancer treatment is becoming more individualized, researchers are looking at ways to personalize breast cancer screening. They are studying screening methods that are appropriate for each woman’s level of risk and limit the possibility of overdiagnosis.
For example, the Wisdom Informed to Screen Depending on Measures of Risk (WISDOM) study aims to determine if risk-based screening—that is, screening at intervals that are based on each woman’s risk as determined by her genetic makeup, family history, and other risk factors—is as safe, effective, and accepted as standard annual screening mammography.
WISDOM is also making a focused effort to enroll Black women in the trial. Past studies tended to contain a majority of White women and therefore, there is less data on how screening can benefit Black women. Researchers are taking a number of steps to include as many Black women as possible in the study while also increasing the diversity of all women enrolled.
