Breast cancer is the most common cancer diagnosed in women, accounting for an estimated 30% of all new cancer diagnoses. And while, over the last 25 years, advances in breast cancer treatment have reduced the mortality rate of women diagnosed with breast cancer by up to 34%, not all population groups have benefitted equally from these improvements.[1]
As October draws near, the annual Breast Cancer Awareness Month comes to the forefront, shedding light on the significant impact on the health related Quality of Life and the psychosocial impact of breast cancer on patients, their family and network of friends, it may be appropriate to consider the unequal access to care. Especially since, alarmingly, breast cancer continues to affect a significant number of individuals in the US, making it a prevalent health concern.
Social Determinants of Health
Although disparities in the delivery of healthcare affect all aspects of cancer management, from early prevention to end-of-life care, studies have shown that black people are more likely to die from cancers and to live the shortest amount of time after diagnosis than any other racial/ethnic group.[2][3]
For example, while white women are slightly more likely to be diagnosed with breast cancer, black women are 40% more likely to die from the disease. [2] In addition to racial and ethnic disparities, women of lower socioeconomic status are likewise to have poorer outcomes.[3]
In an effort to address health related disparities and inequality among socioeconomically disadvantaged populations, the World Health Organization (WHO) has defined social determinants of health (SDOH) as conditions in which people are born, live, work, and age.
These SDOHs are complex, integrated, and often overlapping social structures, policies, and economic systems that affect health and quality of life outcomes. In relation to breast cancer incidence, stage at diagnosis, and survival these SDOHs generally include socioeconomic status (income, education), neighborhood disadvantage, unemployment, racial discrimination, social support, and social network.* [4]
In turn, these SDOH influence the lives of cancer patients long before a diagnosis with breast cancer, and intersect with each stage of the breast cancer care continuum, impacting access to (genetic) testing, treatment, and prevention. patient populations with a SDOH that negatively impact their ability to access these health related services are generally disproportionate negatively impacted. Hence, to address these SDOH and eliminate cancer disparities, it is essential to develop effective interventions that account for the social and environmental contexts in which cancer patients live and are treated. [4]
Early detection
According to the National Breast Cancer Foundation, 1 in 8 women in the US will be diagnosed with breast cancer in her lifetime. In 2023, it is estimated that 297,790 women and 2800 men will be diagnosed with invasive breast cancer. If breast cancer is caught in its early and localized stages, the five-year relative survival rate is 99%, which is why early detection is important.
BRCA 1 and BRCA 2
According to leading data and analytics company GlobalData, ensuring widespread access to early detection methods such as BRCA 1 (BReast CAncer gene 1) and BRCA2 (BReast CAncer gene 2) gene tests remains a critical concern.
“Early detection will come from imaging, such as mammograms and MRIs, and other screening methods. An important and insightful screening method is testing for BRCA 1 and 2,” noted Alexandra Murdoch, Medical Analyst at GlobalData.
BRCA1 and BRCA2 are breast cancer genes. Mutations in these two highly penetrant genes increase the chance for cancer of the breast, ovaries and Fallopian tubes, pancreas and prostate. People who have inherited a harmful variant of the BRCA1 and BRCA2 gene also tend to develop cancer at younger ages than people who do not have such a variant, increasing their overall lifetime risks of developing breast cancer. They also are more likely to develop a second cancer if they are diagnosed and overcome breast cancer.
According to GlobalData, about 0.25% of the population carry a BRCA gene mutation. And while and estimated 13% of women in the general population are expected to develop breast cancer sometime during their lives, 55%–72% of women who inherit a harmful BRCA1 variant and 45%–69% of women who inherit a harmful BRCA2 variant will develop breast cancer by 70–80 years of age. [5][6][7][8]
Increased testing
In recent years, BRCA1 and BRCA2 testing has increased. This increase in testing is, in part, make possible as a result of lower costs and increased public awareness. However, most healthcare systems have specific rules and require prior authorization for genetic testing. And in some cases, test are only available for patients whit a higher risk (See: Genetic Testing Coverage & Reimbursement).
Benefit of Counseling
For people with a high risk of carrying a BRCA1 or BRCA2 mutation, genetic counseling is now routinely offered. At-risk individuals may receive advice to make decisions about genetic testing, screening, and prevention strategies, including chemoprevention and prophylactic surgeries. Based on the outcome, a personalize management strategy according to risk level and risk assessment is first given to the counselee using a risk prediction model. These models help predict the risk of carrying a deleterious mutation ** and the risk of developing cancer based on prespecified risk of developing breast and ovarian cancers among BRCA1 and BRCA2 mutation carriers.[6][7][8]
A 2020 study, comparing the differences in provider practices and access across a racially and ethnically diverse population of young breast cancer survivors, concluded that the involvement of a genetics health professional was associated with better adherence to nationally recommended best practices.[9]
However, when comparing non-Hispanic white, black, and Hispanic breast cancer survivors *** for cancer risk-management practices among BRCA carriers and provider discussion and receipt of genetic testing, the investigators noted that compared with non-Hispanic white, a discussion of genetic testing with a healthcare provider was 16 times less likely among black women and nearly 2 times less likely among Spanish-speaking Hispanic women after controlling for clinical and sociodemographic factors.[10]
Based on these outcomes, the authors of this study note that with the expanding importance of identifying inherited cancers, it is critical to ensure equitable access to best practices across all populations.[9]
Cornerstone
“As we navigate Breast Cancer Awareness Month, it is imperative to recognize that early diagnosis is the cornerstone of combating this pervasive disease,” Murdoch said.
“While awareness efforts are undeniably vital, true progress lies in breaking down barriers to ensure that everyone, regardless of their risk factors or medical history, has equitable access to life-saving genetic insights through tests like BRCA 1 and 2 screening,” she concluded.
We concur!
_
Note
* They also may include sexism, homophobia, ableism, xenophobia/nationalism, disparities in education, income inequality, housing insecurity, access to transportation, social isolation, food insecurity, unemployment, public safety concerns, medical distrust, immigration status, and more.
** A deleterious mutation is a mutation in which the protein product of a gene is not produced, is produced but not functional, or is produced but interferes with normal function.
*** The study included participating women had been diagnosed between 2009 and 2012 with invasive breast cancer who where 50 years of age or younger.
References
[1] Crown A, Fazeli S, Kurian AW, Ochoa DA, Joseph KA. Disparity in Breast Cancer Care: Current State of Access to Screening, Genetic Testing, Oncofertility, and Reconstruction. J Am Coll Surg. 2023 Jun 1;236(6):1233-1239. doi: 10.1097/XCS.0000000000000647. Epub 2023 Mar 27. PMID: 36971366.
[2] Gehlert S, Hudson D, Sacks T. A Critical Theoretical Approach to Cancer Disparities: Breast Cancer and the Social Determinants of Health. Front Public Health. 2021 May 21;9:674736. doi: 10.3389/fpubh.2021.674736. PMID: 34095075; PMCID: PMC8175790.
[3] Gehlert S, Kavanaugh-Lynch MHE, Fernandez Poole S. Searching beyond the Lamppost to Reduce Breast Cancer Disparities. Int J Environ Res Public Health. 2021 Jan 29;18(3):1186. doi: 10.3390/ijerph18031186. PMID: 33572721; PMCID: PMC7908502.
[4] Coughlin SS. Social determinants of breast cancer risk, stage, and survival. Breast Cancer Res Treat. 2019 Oct;177(3):537-548. doi: 10.1007/s10549-019-05340-7. Epub 2019 Jul 3. PMID: 31270761.
[5] Howlader N, Noone AM, Krapcho M, et al. SEER Cancer Statistics Review, 1975–2017, National Cancer Institute. Bethesda, MD, Online., based on November 2019 SEER data submission, posted to the SEER web site, April 2020.
[6] Kuchenbaecker KB, Hopper JL, Barnes DR, Phillips KA, et al. Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. JAMA. 2017 Jun 20;317(23):2402-2416. doi: 10.1001/jama.2017.7112. PMID: 28632866.
[7] Antoniou A, Pharoah PD, Narod S, Risch HA, Eyfjord JE, Hopper JL, Loman N, Olsson H, Johannsson O, Borg A, Pasini B, Radice P, Manoukian S, Eccles DM, Tang N, Olah E, Anton-Culver H, Warner E, Lubinski J, Gronwald J, Gorski B, Tulinius H, Thorlacius S, Eerola H, Nevanlinna H, Syrjäkoski K, Kallioniemi OP, Thompson D, Evans C, Peto J, Lalloo F, Evans DG, Easton DF. Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case Series unselected for family history: a combined analysis of 22 studies. Am J Hum Genet. 2003 May;72(5):1117-30. doi: 10.1086/375033. Epub 2003 Apr 3. Erratum in: Am J Hum Genet. 2003 Sep;73(3):709. PMID: 12677558; PMCID: PMC1180265.
[8] Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. J Clin Oncol. 2007 Apr 10;25(11):1329-33. doi: 10.1200/JCO.2006.09.1066. PMID: 17416853; PMCID: PMC2267287.
[9] Reid S, Cragun D, Tezak A, Weidner A, Moore J, Mayer IA, Shu XO, Ye F, Fan R, Vadaparampil S, Pal T. Disparities in BRCA counseling across providers in a diverse population of young breast cancer survivors. Genet Med. 2020 Jun;22(6):1088-1093. doi: 10.1038/s41436-020-0762-0. Epub 2020 Feb 18. PMID: 32066870; PMCID: PMC7275890.
[10] Cragun D, Weidner A, Lewis C, Bonner D, Kim J, Vadaparampil ST, Pal T. Racial disparities in BRCA testing and cancer risk management across a population-based sample of young breast cancer survivors. Cancer. 2017 Jul 1;123(13):2497-2505. doi: 10.1002/cncr.30621. Epub 2017 Feb 9. PMID: 28182268; PMCID: PMC5474124.
Featured image: Breast cancer. Photo Courtesey:© 2016 – 2023 Fotolia/Adobe. Used with permission.
How to Cite
DOI: https://doi.org/10.14229/onco.2023.09.20.010
Danielle Garcia, Ph.D 1
October Breast Cancer Awareness Month: Emphasizing Equity in Access to Early Detection – Onco Zine – The International Oncology Network, September 20, 2023.
DOI: 10.14229/onco.2023.09.20.010
1 Sunvalley Communication, LLC / Onco’Zine
