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Challenges with TNBC Influenced by Racial Disparities
Drs Derek van Amerongen, Soyini Hawkins, Roxie Cannon Wells, and Sharon Deans highlight triple-negative breast cancer among underrepresented patient populations.
Derek van Amerongen, MD, MS: Moving on from the topic of cervical cancer to breast cancer, one of the straddling statistics is that, in terms of triple-negative breast cancer, which as we know is one of the more aggressive and more difficult to treat cancers, black women have a significantly higher incidence than white women. Again, I’d be interested to hear your comments on why this is, how this relates to racial disparities, and what are some of the challenges that that represents.
Soyini Hawkins, MD, MPH, FACOG: Triple-negative breast cancer has a disproportionately higher incidence in black women. And that subtype of breast cancer actually can be more aggressive and have a bit of a worse prognosis. And so, what is happening, because we have now, with the advancements of the ACA [Affordable Care Act], that we have covered mammogram screening for women over the age of 40, triple-negative breast cancer is actually commonly diagnosed in the younger population of black women. But if they’re not getting screened until 40, we’re missing the mark. So again, the cascade becomes that they’re getting their diagnosis at a later stage of their disease process, which impacts their treatment options, and impacts their final outcomes. The question becomes we have made provisions to make sure we’re getting screened based on all of our screening guidelines, but if we’re missing this important population of women with poor prognosis, what more can be done? Are we educating the providers to make sure that they’re screening appropriately on an individual basis? Not just blanket-ly you’re over 40, let’s do it. You’re under 40, are we making sure that we have good information about family history? Are we making sure that we’re sending patients to genetic counseling so that we can strategize as to what might be the best interventions for them? Not in a wasteful way. We don’t have to. We’re not going to screen everyone blanket-ly like that because they’re African American but they’re definitely markers that we could be using to make sure that we’re not missing out on this important population.
Derek van Amerongen, MD, MS: Dr Wells, what is your organization doing to address this?
Roxie Cannon Wells, MD: I think you make an excellent point. Are we finding or are we screening early enough within our population? And I think that’s a great point for all of us to take back and to really think about what it looks like. But again, it really boils down to education as to why this is important. It also boils down to taking as much access as you can to the communities, and you mentioned mobile units before. I don’t know that they have the 3D on the mobile units now, but it at least gives us an opportunity for people to have the opportunity to have screening. It really boils down to taking screening to the community. Taking education to the community. Having pastors talking about women getting mammograms, which often is uncomfortable because there’s a disproportionate share of men pastors as opposed to women pastors in communities. But I am finding that they are more open and more receptive to talking about it. Having health fairs at churches. Not only to check for finger pricks or what have you, but can you have an expert there that can help women understand the importance of breast cancer? For us, it really is getting out to the community. We can stay within our 4 walls and expect people to come to us, but that’s what’s been happening for decades and it’s clearly not working. So it’s time to really take what we have out to the community so that they can be better prepared from an educational standpoint. And last but not least, we talked about partners earlier helping with deliveries and understanding what pregnancies were about. I think having those conversations with partners early about breast cancer for their significant others and even, for them, in some cases, for men. I think that that’s important as well.
Derek van Amerongen, MD, MS: Dr Hopkins, a moment ago you mentioned the genetic component that is part of triple-negative breast cancer and there was a recent JAMA [Journal of the American Medical Association] study that demonstrated variability in the rates of triple-negative breast cancer at the state level, which I found particularly intriguing. Dr Deans, you’re focused in your role on population management and population health. What do you think are some of the implications of that research?
Sharon Deans, MD, MPH, MBA: It’s a couple of things. One of the things we look at is the cost-effectiveness of screening and we look at it in the general population. And I often wonder if we should pull the African American population out and look at their rate of screening to the rate of diagnosis of breast cancer, which would justify screening black women earlier because of this diagnosis of triple-negative breast cancer. That’s the first thing. The other thing I think that we need to take into consideration in all of this, in the Chung Chow health outcomes in chronic disease diagnoses. Again, what we saw in the pandemic, is it unroofed the fact that in minority populations presenting later in the disease state. So it appears. The thought is that they’ve had this for a really long time, and they have ignored it. But there’s something called allostatic stress and I was telling you earlier, I round with the nurses in GO [gynecology] and OB [obstetrics] in the plan. So we round inside the plan, just like we do in clinical medicine, on our patients that are hospitalized and on our OB patients. And they do a screening called PHQ-9 [Patient Health Questionnaire], which is a screening for depression. I hear these profound social stories and then their PHQ-9 is 0. I was like how can that be? I feel bad hearing the story. How can that be? And I said guys, “We’re not using the right tool. We need to screen for stress, stress is a precursor to depression.” And one of the nurses introduced to me these studies around allostatic stress and what it shows is that folks that are under this constant everyday stress, like many minorities experience in the United States, just navigating on a daily basis as a minority. As an immigrant coming into this country, coming from Nigeria, where you would spend 2 weeks in bed after you deliver a baby and then come here, and you’re expected to get up and go right at it a few days later. Immigrants from Asia and other parts of the world that are navigating language and everything else. There’s a stress that occurs with that navigation that has a physiologic impact. And these people are sicker. They get sicker faster, and their disease progresses faster because of this. But the measurement is a physiologic measurement. You would have to take catecholamine levels and things like that. It’s just an interesting concept when I think about things like triple-negative breast cancer, preeclampsia, and eclampsia, and our moms when they present diabetes and hypertension in our general population, asthma in our kids. I think that there’s this stress accelerates their disease response. So taking a look at that from a population health level and when you go back to medical school, implanting that in the teaching process, that these people could potentially be sicker so that our threshold for diagnosis should drop. Our threshold should be much, much lower to diagnose and treat folks. Most African Americans need to be on 2 to 3 anti-hypertensives. Should we be doing that earlier rather than later? You meet somebody for the first time and their blood pressure is elevated. You put them on one medicine. Maybe you should start them on 2 or put them on 1 for a short period of time, bring them back in, and put them on the second one. I think there are some implications for allostatic stress. But I also think using the general population screening should be pulling black women out and looking at them as a separate population, their rate of screening, and rate of diagnosis to justify screening them sooner for triple-negative breast cancer because the impact is huge.
Soyini Hawkins, MD, MPH, FACOG: It’s huge.
Sharon Deans, MD, MPH, MBA: You have children who lose their moms at an early age, and even with that loss, it’s a maternal child health. We lose a mom, and a baby is 1 week old. The studies show their milestones are slowed down. All of the bonding, everything is slowed down. So [there are] tremendous, tremendous impacts for generations to come.
Soyini Hawkins, MD, MPH, FACOG: And we did it with colorectal cancer. We began to screen African Americans at 45, ahead of the general population, and then we saw that that recommendation was subsequently rolled out to the entire population. It definitely can be done and it’s necessary. It goes back to the beginning of our discussion about the inclusivity of disproportionally underrepresented populations in our research studies. That’s the only way that we’ll be able to, with a fine-tooth comb, carve out exactly what is happening for these demographics of women, to make sure that their care could be catered to them just as everyone else receives.
Roxie Cannon Wells, MD: Can I go back to triple-negative breast cancer and education? How many people in our community think breast cancer is breast cancer? How many have actually heard the term “triple-negative breast cancer” and they understand what it means, and they understand that it’s more aggressive? So again, in everything that we’ve talked about, ensuring that communities are educated is extremely important. And one thing I will say is that when I came through medical school, we talked about the cost of health care. And we were talking about the cost of health care, we were taught in medical school from a financial perspective. But as I’ve matured in my practice and I’ve actually gotten out and taken care of patients or what have you, the cost of health care far exceeds finance. It is morbidity. It is mortality. It is losing moms and missing milestones. It is so much more. And I truly, truly believe we will never ever, ever decrease the total cost of health care until we deal with health care disparities across the board. I don’t think we’ll ever get there.
Derek van Amerongen, MD, MS: Those are really important comments.
Transcript edited for clarity.
