Addressing Disparities in Breast Cancer
There is hardly a person whose life hasn’t been touched by cancer in some way. Cancer, however, does not affect people equally.
As physicians and researchers explore causes and treatments for cancer, they are also uncovering significant differences, or ‘disparities,’ in the number of cases of cancer and outcomes of cancer based on race and ethnicity, on gender and age, on a patient’s geographic location, or on their personal financial means. In breast cancer, a building body of research has revealed multitude of cancer care disparities, and patients who are among the minority underserved demographic are hit the hardest.
The overall breast cancer incidence among Black and Latino populations has continued to grow even while breast cancer mortality rates have declined in some populations. Studies have shown a disproportionate number of Black women in the U.S. continue to receive late-stage breast cancer diagnoses, a point where treatment options become limited and expensive and survival rate is poor. To date, breast cancer mortality is about 40 percent higher for Black women in the U.S. than white women, despite the many advances and improvements in screenings and breast cancer treatment and care.
“Cancer health disparities is not only about finding differences in cancer care or mortality, but also addressing outcomes that are disproportionately affecting groups or individuals that face greater challenges to protecting their health for reasons linked to longstanding social, economic and healthcare inequities,” says Parisa Tehranifar, DrPH, a member of the Herbert Irving Comprehensive Cancer Center (HICCC) and associate professor of epidemiology at the Mailman School of Public Health. “As a result, many racial and ethnic minority, low income and immigrant populations carry a heavy cancer burden.”
Researchers from a range of disciplines and expertise areas at the HICCC are investigating different segments of breast cancer disparities. Many are focusing on discerning the ‘why’ behind specific disparities with the ultimate goal of proposing ‘how’ to implement change or eliminate the gaps to those in underserved populations who are disproportionately affected. In the HICCC catchment area, where 65% of cancer patients are underrepresented minorities, data has shown that disparities persist. The HICCC’s catchment area encompasses the five New York City boroughs and three neighboring counties in New York and New Jersey.
“Looking at the HICCC catchment area there is a big difference—we have a lower incidence of breast cancer than the U.S. but higher mortality rates in some areas of the catchment area like Washington Heights and the Bronx,” says Mary Beth Terry, PhD, a professor of epidemiology at Mailman who co-leads the HICCC’s Cancer Population Science program. “Why is that? Why are fewer women in Washington Heights and Inwood being diagnosed with breast cancer but of those who are diagnosed, more are dying from the disease? These cancer health inequities need to be addressed.” Dr. Terry and her research team focus on the role of environmental exposures and specifically endocrine disrupting chemicals in affecting breast cancer risk particularly in young women.
Dr. Terry also directs the Community Outreach and Engagement Office (COE) at the HICCC which strives to reduce the burden of cancer for HICCC cancer patients and their families by bringing together researchers, clinicians, and community health educators to address access barriers to cancer prevention, screening, treatment and survivorship services.
Identifying racial disparities in breast cancer represent just one piece of a complicated and challenging puzzle, and the approaches to tackle the layered components in health disparities research require a multidisciplinary one.
“In health disparities research, we already know there are differences and now we’re saying, ‘how do we close the difference’?” adds Jasmine McDonald, PhD, assistant professor of epidemiology at Mailman. “We’re moving away from determining how big the differences are. There’s this Black and white difference. There’s this male and female difference. We want to know what drove that difference.”
How some HICCC researchers are tackling different corners of health disparities:
What’s Behind Postpartum Breast Cancer?
Jasmine McDonald, PhD, who specializes in maternal health research and is a member of the HICCC’s Cancer Population Science program, is interested in understanding what drives postpartum breast cancer. Research has shown that after giving birth, women are at an increased risk of developing breast cancer, up to 10 years postpartum. A new study by Dr. McDonald and her collaborators is attempting to uncover the reasons behind this link.
For this pilot study, researchers are investigating women’s breast biology using a non-invasive imaging technique to track and measure changes in the breast during a set period postpartum. Named MAMA BOSS, which stands for the Milk Associated Markers and Breast Optical Spectroscopy Study, the project focuses on minority women during two time points—within six weeks of their first full-term pregnancy and birth.
“Changes in breast tissue, as measured through mammographic breast density—a strong risk factor for breast cancer—have shown to be associated with changes in breast cancer risk. This suggests that examining these changes in breast tissue can provide fundamental mechanistic data,” says Dr. McDonald. “Our goal is to understand what those factors are that are contributing to increased risk of breast cancer in postpartum women.”
The researchers are also examining breastmilk of women who are nursing their newborns, attempting to understand why breastfeeding mothers appear at less risk for developing breast cancer. Breastfeeding is known to mitigate cancer, including its most aggressive forms, but it is still unclear how breastfeeding practices impact the physical and structural changes in breast tissue composition.
“We know that Black women are getting more aggressive breast cancers and have higher mortality because of their differences in reproductive behavior,” says Dr. McDonald, noting that Black women breastfeed their babies at lower rates than white women. “The idea that more Black women don’t breastfeed, could that be contributing to their increased risk? How does breastfeeding protect you from cancer?”
MAMA BOSS will aim to examine the breast microenvironment while simultaneously contributing to the dearth of knowledge on postpartum breast biology.
The Toxic Side Effect of the Costs of Cancer
Defined as the harmful personal financial burden faced by patients receiving cancer treatment, the idea of financial toxicity is relatively new but becoming more of an accepted adverse “side effect” of cancer care. Patients could be hit hard by out-of-pocket costs, transportation costs, co-pays, or a potential loss of employment while undergoing cancer treatment.
A new study, led by Dawn Hershman, MD, MS, and Melissa Beauchemin, PhD, RN, is investigating financial toxicities of cancer treatment, including in breast, gynecologic, and pediatric cancers. The researchers’ goal is to develop a multi-level intervention that would address a patient’s financial burden or potential financial burden early on in their treatment, such as through effective financial screenings and financial navigation programs that can help reduce or mitigate financial toxicity.
“You can imagine, conceptually, as we learn more about financial toxicity we could both predict patients who are at risk for it but also identify high financial toxicity in the same type of way that we grade a toxicity of a drug in treatment,” says Dr. Beauchemin, a postdoctoral research fellow and program director of Columbia’s Minority Underserved NCI Community Oncology Research Program. “We worry about the families who are doing okay financially until they are hit with breast cancer and the costs of treatment and everything else that goes along with a diagnosis.”
Drs. Hershman and Beauchemin, along with collaborators in Columbia’s Departments of Obstetrics and Gynecology, Pediatrics, and the Mailman School of Public Health, will explore ways to collect and integrate patient-reported financial hardship and financial worry into the electronic health record system. Their project will test the feasibility of implementing a brief financial toxicity screening survey and will measure the effect on social work and financial support referrals. This type of system-level intervention is not yet well established at institutions, say the researchers, but could ultimately narrow the healthcare disparity in a sub-group of patients who are hit the hardest financially from their diagnosis.
“Everyone who is diagnosed with cancer is at risk for financial toxicity,” adds Dr. Beauchemin. “But the population who is at risk for disparate care – the minority underserved population - is at an even higher risk. Financial toxicity screening of cancer is not yet part of routine care but it should be.”
Ancestry, Biology, and Breast Cancer Survival
Women of African heritage suffer a higher breast cancer mortality compared to their European counterparts but there is little known yet about the biological basis for these disparities, and they remain poorly defined. In new research, Kevin Gardner, MD, PhD, professor of pathology and cell biology, and a team of collaborators are investigating molecular attributes that play a role in worse breast cancer survival based on race.
“Women of African ancestry in the United States have a 40% higher mortality from breast cancer than women of European ancestry,” says Dr. Gardner, “we want to know what are the key biological drivers for this disparity.”
In earlier observations, scientists studying a cohort of breast cancer patients of West African descent determined that a transcriptional factor that drives gene expression, called Kaiso, seemed to have higher expression or higher activity in triple negative breast cancer, one of the more lethal forms of breast cancer that recurs earlier and is often more resistant to treatment. Triple negative breast cancer occurs at nearly double the rate in women of West African ancestry compared to women of European heritage.
In this project, Dr. Gardner is taking a deep dive into the role Kaiso plays, both in the nucleus and cytoplasm of breast cancer cells, and its association with racial differences in survival outcome in several epithelial cancers. Together with a multi-disciplinary team of breast cancer pathologists, cancer biologists, computer scientists, biostatisticians, bioinformaticians and data scientists, Dr. Gardner will aim to define new prognostic and predictive biomarkers that link Kaiso to tumor progression, the immune tumor microenvironment, breast cancer outcome, and how their association differs by race.
“Although health disparities research is much more prominent in public health and population sciences, pathologists were quick to recognize the importance of social and environmental factors in disease. Discussions on this realization date back to the early 19th Century and are reflected in the work and writing of Rudolph Virchow who acknowledged the essential role played by epidemiology in understanding the etiology and pathology of disease,” says Dr. Gardner, a member of the HICCC’s Cancer Population Science program.
“Though the major focus of health disparities research is driven by the social and behavioral sciences, the elucidation of the role played by biology and how that role may be differentially influenced by genetic ancestry will be essential for improving the diagnosis, treatment, and prevention of breast cancer health disparities. ”
Optimizing Mammography Screening in Older Women
Mammography screening is the cornerstone of breast cancer prevention and the frequency of mammographies can be optimized based on a woman’s risk for breast cancer, health status, and personal preferences. Professional guidelines do not support routine mammography screening in older women (75 years or older), and recommend that older women are informed about the benefits and harms of mammography. Yet, older women continue to undergo routine frequent screenings and are seldom informed or engaged in decision making around mammography with their healthcare providers.
A study led by Parisa Tehranifar, DrPh, a breast cancer epidemiologist and cancer health disparities researcher, will assess and adapt strategies currently in place for shared decision making among low-income and racial and ethnically diverse populations in the HICCC’s local patient community, and will investigate—through interviews and focus groups with providers and decision makers—how to reduce mammography overuse and how to culturally adapt and test existing patient educational and decision making tools for mammography screenings among older Hispanic women.
“This is an understudied population and a population that has really been left out of the conversation,” says Dr. Tehranifar. “One of the things that we want to support is informed decision making for older women, an age group where the question of screening frequency or cessation has to be really individualized to the woman.”
Dr. Tehranifar, who is a member of the HICCC’s Cancer Population Science program, has assembled a multi-PI team funded by Velocity, Columbia’s ride to end cancer, that includes Rachel Shelton, ScD, MPH, a social and behavioral scientist with expertise in implementation science, health equity, and community-engaged research, and Nathalie Moise, MD, MS, implementation science expert and primary care provider dedicated to treating predominantly low income, racial minority and older adults.
“At their core, cancer health disparities are social problems that have biological and health consequences. They are complex and multi-level, and manifest in different ways, depending on what dimension of disparity or specific health outcome we're considering,” says Dr. Tehranifar. “So in all our cancer care research and services, we need to be vigilant and prepared to not only reduce the burden of cancer but reduce, and ultimately eliminate cancer health disparities. Our commitment is to do both.”