Breast cancer risk estimation models identify women who are at high risk based on a variety of factors, and women who are identified as being at high risk may be able to reduce their chance of breast cancer through preventative measures such as prophylactic surgeries or chemoprevention medications. However, uptake of these preventative treatments varies among racial groups, new research from The Ohio State University finds that racial disparities in healthcare are to blame.
Breast cancer risk estimation models identify women who are at high risk based on a variety of factors, and women who are identified as being at high risk may be able to reduce their chance of breast cancer through preventative measures such as prophylactic surgeries or chemoprevention medications. However, uptake of these preventative treatments varies among racial groups, and new research from The Ohio State University finds that racial disparities in healthcare are to blame.
The research team, led by Tasleem Padamsee, PhD, assistant professor of health services management and policy at the university, conducted 50 in-depth, semi-structured interviews with African American and white women who had elevated breast cancer risk. The interviewers asked about the women’s experiences with risk, risk management, and decision-making. “We wanted to understand what women’s experiences are like, how they make choices, and what influences those choices,” said Padamsee in a statement.
Among the participants, 7 women, all of whom were white, had already chosen to undergo prophylactic oophorectomy, which is recommended for all women aged 35 to 45 years who carry the BRCA mutation. Another 2 women, both white, were considering the surgery. Four women, all white, had undergone prophylactic mastectomy, and 1 additional white woman and 1 African American woman were considering the procedure. Chemoprevention was chosen by only 3 women, 2 of whom were white and 1 of whom was African American. Genetic testing was used by 67% of the white interviewees versus 20% of the African American interviewees.
As the authors point out, in order for women to avail themselves of cancer-preventative options, they must first be aware of that such options exist. Among the 50 women, all 30 white women had heard of genetic testing before the interview, while 15% of the African American women had not heard of this option. Among the African American women who were aware of genetic testing, only 18% had been tested (versus 67% of white women).
Most participants in the study had heard of prophylactic mastectomy, but the proportions of women who expressed awareness were unequal: 93% of white women versus 70% of African Americans had heard of the option. With respect to prophylactic oophorectomy, white women had again more often heard of option, but both groups were less aware of it than of prophylactic mastectomy.
Fewer women had heard of chemoprevention; just 57% of white women and 20% of African American women had heard of this option.
“If specific, detailed knowledge about individual prevention options is the necessary precursor to using them, then more general information about breast cancer risk and risk-management is the underlying layer that makes that specific knowledge possible,” write the authors, who point out that African American women had less access to specialists who can provide such information.
While 70% of white women had seen at least 1 specialist about their increased risk, only 15% of African American women had done so, and were more reliant on their primary care providers (PCP) to offer information. Some African American women reported that their PCPs even refused to offer genetic testing or preventative treatments. White women who relied on PCPs for information were more likely to be told of their options or referred to a specialist, while the PCPs of African American women usually only recommended that the patients begin to receive mammograms early. Finally, while one-third of white women reported seeking a second opinion, no African American women reported having done so.
The interviewees also demonstrated differences in their risk-related knowledge; when asked whether it is possible to alter cancer risk, 80% of white women identified at least 1 risk-reduction method, versus 45% of African American women. White women more often discussed clinical interventions (50%) than African American women (15%), and African American women somewhat more frequently discussed the use of lifestyle methods (65% versus 43% of white women) to reduce their cancer risk.
“Considerable research remains to be done to confirm the patterns found in this study,” wrote the authors, “and to more deeply understand the origins of gaps and challenges that systematically disadvantage African American women.” The evidence in the paper suggests, however, that “researchers and clinicians aiming to prevent cancers and deaths among women at elevated risk must attend to the layers of information that underlie women’s risk-management decisions, and to racial disparities in a wide range of decision-making dynamics.”
Padamsee TJ, Meadows R, Hils M. Layers of information: Interacting constraints on breast cancer risk-management by high-risk African American women [published online December 27, 2018]. Ethn. Health. doi: 10.1080/13557858.2018.1562053.