“Black women are 40 percent more likely to die from a breast cancer diagnosis, period,” says Dr. Vivian Bea, board-certified general surgeon and chief of breast oncology at New York Presbyterian Brooklyn Methodist Hospital. That statistic should make you think. why is that? “We know these data,” says Dr. Bea, “we know there are disadvantages, and now it’s up to us to say, ‘How can we fix this?'” We spoke with a surgical oncologist and reconstructive surgery specialist to gain a deeper understanding of where the disparities in breast cancer care come from and how we can move them to high and low levels.
Statistics show that BIPOC women are at a systemic disadvantage when it comes to health care delivery. why is that?
Research shows that Hispanic adults are less likely than other Americans to have health insurance and receive preventive care. Other research shows that Asian Americans and Pacific Islanders are the least likely to have a personal physician. But why?
“It’s multifactorial,” says Dr. Bea. “There are patient-related factors, system-related factors, and physician or provider-related factors.” It explains that environmental and social determinants can significantly affect a person’s ability to obtain health care. For example, “What does the hospital look like in your community? How is quality care available to you from a citizen’s point of view?’
At a fundamental level, there is systemic racism that infects many aspects of our society, including health care, Dr. Nyama Sillah, specialist in cosmetic, plastic and reconstructive surgery. She notes that there may even be an implicit bias on the part of caregivers that gets in the way. Dr. Bea adds that access to food can also be a factor. “From a breast cancer perspective, we know obesity is associated with breast cancer risk, as well as other health problems,” she says, explaining that people in food deserts are at higher risk.
How does this specifically affect BIPOC women with breast cancer?
It’s often an access problem. “BIPOC women don’t always have a PCP or access to screening that can detect cancer in its early stages,” explains Dr. Shillah. It is important to consider how easy it is for patients to get an annual mammogram. Dr. Bea says black women are not consistent when it comes to mammograms. “Maybe one year they get sick and the next year they don’t, and in the interim they may develop breast cancer and then they’re subsequently diagnosed at a later stage,” says Dr. Bea. “We also know that BIPOC women don’t get quality mammograms as often as other races.” For example, black women are less likely to get 3D mammograms, which are more accurate at detecting breast cancer, says Dr. Bea
The alarming fact is that black women are twice as likely to be diagnosed before age 45, says Dr. Bea. But some organizations don’t take that into account when they suggest mammograms start at age 45, she notes. In this regard, the discrepancy may come from physicians and providers who are not well-acquainted with the disparities that affect BIPOC women when it comes to breast cancer.
A 2016 study found that oncologists whose tests showed greater implicit racial bias had shorter interactions with their black patients. Additionally, their patients rated the interactions as less supportive and had less confidence in the recommended treatment. More than 60 percent of black women say they have had a negative experience with health care.
But it’s not just differences in external structures that lead to higher numbers of black women dying of breast cancer, it’s also the biology of the tumors
“Black women are twice as likely to be diagnosed with triple-negative breast cancer, which has a worse prognosis, and even at every stage of breast cancer, black women have worse survival. [rates]” says Dr. Bea. “This means that at stages one through four, a black patient diagnosed has worse survival.”
Multidisciplinary care improves survival
Dr. Bea believes that to increase survival rates, we need more patients to have access to multidisciplinary care, including a breast surgical oncologist, a medical oncologist, a radiation oncologist, as well as someone well versed in genetic testing. However, not all women have access to a provider camp – this is where community outreach comes in.
Education on both sides can make things better
Dr. Sillah says it’s essential to educate the healthcare community about implicit bias. In addition, she is passionate about educating the BIPOC community about the disease, screening recommendations, reconstruction rights, and more so that they can advocate for themselves when needed.
Experts say we need more national policies
While Dr. Bea says that while there have been great advances in the past decade to help make mammography screening more accessible, she knows more needs to be done. Dr. Bea says there needs to be a national cancer policy, not just state by state, to ensure access for all women.
Professionals must recognize the differences and adapt to them
Dr. Bea urges professionals to take responsibility for these differences and do something to bridge the gap. Sometimes equality means giving someone extra support to get the treatment they need, she explains. “This means hospital systems can invest in nurse navigators who can help a patient navigate the system and get all the care they need right away.” We know there is a delay from diagnosis to treatment,” says Dr. Bea. “Finding ways we can reduce that time can improve outcomes.”
All of this is transferred to breast implants and reconstruction
A Dartmouth study found that black women were 55 percent less likely to undergo breast reconstruction, regardless of the type of hospital they attended. It’s not often offered as an option. Additionally, for BIPOC women diagnosed at later stages of cancer, it may affect whether they are a candidate for implant reconstruction. For example, “if they need radiation, sometimes autologous reconstruction is recommended,” says Dr. Shillah.
We need more diversity in clinical trials
BIPOC women are underrepresented in clinical trials. Considering that Dr. Bea points out that doctors can’t always truly say that a recommended drug or treatment will fully cure the cancer a patient has because it hasn’t been studied. It encourages more BIPOC women to participate in clinical trials. Greater participation could encourage “physicians to understand the barriers in health care systems, to understand the barriers and trust issues that have developed over centuries because of the systemic racism that exists in the United States,” says Dr. Bea.
Dr. Sillah says mistrust of medical professionals by the BIPOC community can hinder treatment. “Increasing representation of BIPOC women in clinical trials to ensure research finds community-specific treatments” can help ensure treatments are safe and effective for everyone, adds Dr. Shillah.
Patients tend to have a deeper connection with their doctor or provider when they look like them. According to Dr. Bea makes up less than one percent of the black female surgeon medical workforce. “If we understand that we can improve health care through representation, then as a nation we must work to improve diversity and representation in medicine for all BIPOC women,” says Dr. Bea, specifically plastic surgeons in relation to breast changes.
“Not every BIPOC woman will have another BIPOC woman as plastic surgery, so that sometimes means a lack of trust and a lack of being offered certain plastic surgeries, or even being offered plastic surgery periods,” says Dr. Bea. Advocacy is a major barrier to both breast cancer and traditional care, she notes.
Dr. Bea says one solution is to invest in programs that mentor diverse young people in the medical industry, so the health system will ultimately more accurately reflect the people it serves. “More diversity in medical school and thus in the workforce so that we have physicians (also nurses, PA/NPs) and caregivers who look like other BIPOC women and understand them on a personal level,” says Dr. Shillah.
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