By Suzanne Batchelor
Thursday, November 11, 2004
Many questions remain unanswered about racial and ethnic disparities in breast cancer, but now researchers have an important biological clue that may lead to better breast cancer treatments, especially for African American women.
(WOMENSENEWS)--An African American woman is less likely to get breast cancer than a white woman, but more likely to die from it. For her, breast cancer often comes at a younger age and in more dangerous forms than for other U.S. women.
No one knows for sure why breast cancer racial and ethnic differences exist, but now doctors and researchers have an important biological clue.
Dr. Beth A. Jones of Yale Cancer Center in New Haven, Conn., found that a breast tumorcharacteristic called "p53" is four times more common in African American than white women. P53 tumors are harder to treat.
"Women with p53 alterations don't have the same response to standard chemotherapy treatment," explained Jones. "One study suggested using higher-dose chemotherapy."
The p53 gene mutation belongs to the tumor itself; it is not part of the woman's genetic inheritance.
"I feel that both women and physicians need to realize that breast cancer can occur more aggressively and at earlier ages in African American women," Jones told Women's eNews. "It's critical for all women to be diagnosed early, but for African American women to follow the most stringent guidelines: start screening at age 40 with annual mammograms and clinical breast exams."
Jones' population-based study, published online in September's Cancer journal, also confirmed earlier findings that African American women are more likely than white women to be diagnosed younger, to have later stage tumors and more aggressive disease.
In Jones' study population, the average age at diagnosis was 52 for African American and 58 for white women, "consistent with national data," said Jones, with more African American women than white diagnosed before age 50. Jones' team examined the breast cancer tumors of 145 African American and 177 white women.
Jones said other researchers have found breast cancer in African American women tends to be more aggressive and to develop at earlier ages than in white women. Her study confirmed those findings, but is the first to identify a molecular difference in the more aggressive tumors.
Jones and colleagues also found that African American women are more likely than whites to have tumors with other "poor prognosis" factors, such as lacking estrogen or progesterone receptors (termed 'ER-negative' and 'PR-negative'). That limits treatment because some cancer drugs target those receptors: Tamoxifen, for example, treats ER-positive tumors.
Latinas were not included in Jones' study. The greatest disparity in surviving breast cancer is between African American and non-Hispanic white (Caucasian) women, according to the American Cancer Society, with Latinas having both a lower incidence rate and better survival rate than blacks and whites. American Indian/Alaskan Native and Asian/Pacific Islander women have the lowest breast cancer mortality rates.
The study compared three tumor factors associated with poorer prognosis in 145 African American and 177 white women. The p53 difference appeared regardless of factors including how far along the tumor was at diagnosis, socioeconomic status (by education, income and occupational ranking), history of smoking, severe obesity and environmental exposures.
"It's very important that this not be a message that instills fear," cautioned Jones. "We're another step along the road in figuring out how to address disparities."
And, important as tumor differences are, Jones said, socioeconomic and healthcare differences may also play a role in African American women's breast cancer death rate.
"The big issue is access to treatment," said Dr. Debbie Saslow, director of breast and gynecologic cancer for the Atlanta, Georgia-based American Cancer Society, who nonetheless hailed Jones' p53 news as a step toward new therapies.
"One study in the military showed if women with breast cancer have the same treatment, African Americans did just as well as the white women. There's some suggestion that equal treatment means equal outcome," said Saslow. Women in the U.S. military receive the same healthcare coverage regardless of race or ethnicity.
"And if there is access, are they taking advantage of the access?" Saslow asked. She said socio-economic factors, such as not having health insurance that pays for the recommended mammogram and annual breast exam, may deter many African American women from care, as does a more pervasive fear and denial about cancer influences many to postpone checkups and screening.
Fear and fatalism about cancer are more common in African American than white communities, Saslow said studies show, including fears that having breast cancer makes a husband or boyfriend more likely to leave or that surgery causes cancer to spread.
"There's not much we can do about the biological differences, but a lot we can do about those differences," said Saslow. "Get screened every year and if your mammogram finds something, go get the follow-up and go get the treatment."
African American breast cancer survivors have taken up the challenge in their communities, organizing to enhance women's access to care.
Karen E. Jackson, a 10-year breast cancer survivor, founded the nonprofit, Houston-based Sisters Network Inc., a national education and outreach organization for African American breast cancer survivors, in 1994. The original 15 have grown to 3,000 members in 39 local chapters across the United States.
"We have a pin called 'Stop the Silence' because originally the silence within our community was deafening," said Jackson. "The silence on all kinds of cancer, but specifically breast, prostate and colon."
The network encourages African American women to make full use of screening and treatment resources. Each chapter compiles information on local resources, discussing it door-to-door each October in a national block walk.
"You have to ask the right questions to get the right answers," explained Jackson. "For example, clinical trials. If you hadn't heard the term you wouldn't know to ask, what clinical trials are available in my area that I could fit into? Or if you didn't know there exist pharmaceutical companies who have assistance programs for your treatment medications, you wouldn't know to ask your doctor to enroll you."
It's not just under-served or low-income African American women who need help, Jackson said.
"It could be a woman working full time with insurance, but there's a problem with the system, it is not always geared to give you the best results. It's called institutional racism. Add on top of that the other disparities that exist. Knowledge is power."
Treatment discrepancies may result from doctors not knowing that African American women need annual breast exams and mammograms starting at age 40 instead of age 50, as recommended for white women, and thus failing to catch breast cancer early; from women themselves not seeking the recommended checkups and being diagnosed at a later stage of breast cancer; and from other factors that are unclear.
Jackson pointed to 'normal' but racially biased practices African American women changed.
"As much good as the American Cancer Society does, it used to be when a woman needed a prosthesis, they were all what were called 'flesh' colors, but whose flesh? Until African American women asked for them, no one gave a thought to it. It was the same with the 'Look Good, Feel Better' program."
Founded by the Cosmetic, Toiletry and Fragrance Association industry group and sponsored by the American Cancer Society and National Cosmetology Association, the 15-year-old "Look Good, Feel Better" service provides free makeovers and cosmetics to help women cope with appearance-related changes from cancer treatment.
"Our women would be there and there would be no makeup for us," said Jackson.
Such slights have diminished over her ten years of activism, said Jones, "but that's a long time for something as simple as that."
"Sisters Network gives the African American woman a place where she can go and feel comfortable, get knowledge and share her knowledge," said Jackson.
Jackson's advocates won't lack for work. On the heels of Jones' research came news that African American women are less likely to receive breast reconstruction after mastectomy than are women of other races. The study, published August 23 online in the journal Cancer, found that the cancer surgeon, plastic surgeon and the patient "may all contribute" to the racial disparity.
Suzanne Batchelor is an independent journalist, writing most often on health and science.
Cancer: Interdisciplinary International Journal of the American Cancer Society:
Genetic Mutation Linked to More Aggressive Breast Cancer Found More Often in African-Americans:
Sisters Network Inc.: