Activity Transcript

Erica Stringer-Reasor, MD: Hello, my name is Dr Erica Stringer-Reasor, and I'm an associate professor of medicine and a director of the breast program at the University of Alabama at Birmingham. Today, I want to welcome you to the program titled, "Minimizing Disparities in Breast Cancer to Enhance Equitable Cancer Care."

Joining me today is PharmD Allison Butts, who is the oncology clinical pharmacist manager and breast oncology clinical specialist at the University of Kentucky. She is also an associate professor of pharmacy practice and science department at the University of Kentucky College of Pharmacy in Lexington. I also want to welcome Karen Drucker to the panel, a nurse practitioner specializing in breast medicine at Memorial Sloan Kettering in New York, New York.

I want to introduce you guys to our special guest, Dr Toni Willis, who is a physician and cancer survivor. She also is the Living Beyond Breast Cancer 2022 Hear My Voice advocate. I want to welcome all of my distinguished panelists to the forum today.

We want to start with a little bit of introduction and background. We know that over 287,000 women will be diagnosed with breast cancer in 2023. What is so striking is that 1 in 8 women will be diagnosed with an invasive breast cancer in their lifetime. I think certainly many of you in the audience, as well as the panelists, will say that many of us will know someone diagnosed with breast cancer in our lifetime, whether it's a mom, an aunt, a sister, a colleague. This is a healthcare crisis and something that we certainly want to address. Strikingly, 43,000 women will die from their disease.

We want to know how we can improve these outcomes and improve the disparities among women diagnosed with breast cancer. We know that there is a health disparity crisis, particularly in the United States when you look at the outcomes for Black women vs White women. It's very apparent that Black women have much worse outcomes when they're diagnosed with breast cancer, even when you account for the same age and stage of a Caucasian woman.

I want to switch gears to Allison. Can you tell me a little bit about this breast cancer mortality in the United States?

Allison R. Butts, PharmD, BCOP: Sure. In the United States, White women have the highest incidence of breast cancer, followed by Black women. The incidence of breast cancer overall has increased only slightly, by about 0.5% per year in the past 20 years. What's a bit more alarming is that the trends in incidence have disproportionately impacted minority patients. The rates have increased more than the average in minority patient populations than in the population of White women, in other words.

Furthermore, if we look into the mortality rates a bit more, we see that mortality rates have fallen significantly over the past few decades, thanks to improved screening techniques, better treatments, and other advances. The decline in the mortality rate is pretty proportional when we compare Black women, Hispanic women, and White women, but Black women still have the highest breast cancer mortality rates, as you pointed out -- upwards of 40% higher than the mortality rate we see in White women. So, huge disparities still exist there.

Black women also have the lowest relative 5-year survival rates at each stage of breast cancer and for each breast cancer subtype, so it's something that we're seeing across the board. Looking at the trends of mortality a little more closely, what's interesting is that we see that the rates between Black women and White women were pretty similar up until 1980, and then we see a pretty stark contrast. That disproportionality hits around 1980. I'm curious as to whether you have any thoughts, Erica, on why that happened at that time?

Dr Stringer-Reasor: Towards the end of the 1980s, more standard-of-care mammography screening was enacted, and that was a major player in improving outcomes. Additionally, we saw more targeted therapies, with more clinical trials to help reduce the risk of breast cancer recurrence and to treat breast cancer, mainly with the production of tamoxifen. When more women had access to tamoxifen, outcomes improved.

The key word is access -- access to mammography and access to good, targeted therapies. There's a bit of a lack of access to care in minority populations, which may help explain some of that disparity. Karen, can you talk a little about other health disparities in breast cancer between Black women and White women?

Karen Drucker, NP, RN: Yes, compared with White women, Black women are more likely to be diagnosed at a younger age, at less than 50 years old. They have disproportionately more aggressive cancers of all subtypes. They have a higher incidence of triple-negative breast cancer and inflammatory breast cancer. They also have more advanced disease at diagnosis, with higher tumor grading, higher tumor burden, and more lymph node involvement. These all portend to worse outcomes.

Dr Stringer-Reasor: You know, one of the things we know is that any woman who walks through the door and is diagnosed with breast cancer is certainly a lot more likely to have a hormone-driven breast cancer. You know, we briefly discussed that there have been some advances in targeting hormone-receptor-positive breast cancer, but if you are Black or Latino, you are more likely be to be diagnosed with TNBC.

Currently, there are 4 main molecular subtypes of breast cancer. There are HR-positive breast cancers, meaning breast cancers driven by estrogen and progesterone. That category has been further subcategorized into luminal A and luminal B. Luminal A breast cancers are very hormone sensitive. They're typically slower growing and a little bit better behaved. We see them more in older women, and they're more likely to be diagnosed in Caucasian women.

We have 3 other particularly aggressive subtypes: There are the luminal B breast cancers, which are hormone-driven breast cancers -- but not only driven by the hormones, they're driven by other DNA markers; HER2-positive breast cancer; and TNBC. These grow within weeks to months, and these cancers may evade yearly mammograms. These are the women who are coming in between their yearly mammogram after feeling a mass 6 months later. These are very aggressive tumors and more likely to have fewer treatment options and to require chemotherapy. What's also interesting is that if you look at the incidence of just TNBC, if you're a Black woman, you're again twice as likely to be diagnosed with this highly aggressive breast cancer compared with White, Caucasian, American Indian, and Asian/Pacific Islanders.

In this discussion, we're talking a lot about race and ethnicity, and there has been a lot of discussion among investigators asking if we should really just be looking at the biology of the tumor and its aggressive subtypes because race and ethnicity subcategorizes people by their self-identification. We know that globally and in the United States, multiple people and individuals now identify by multirace, so we're truly a heterogeneous population. Will race and ethnicity be good enough anymore to define that tumor biology?

Furthermore, if we're looking at tumor biology, one of the questions is genetics. If you're diagnosed with TNBC, you're more likely to carry a genetic mutation like a BRCA1, BRCA2, or PALB2 mutation. We know that if you're diagnosed with one of those mutations, it may help the physician and their treatment team help define surgical and other treatment options for you.

There was recently a study performed in sub-Saharan Africa that showed patients and people who had Duffy gene variants were more likely they be diagnosed with TNBC. Also, when you evaluate tumor tissues, somatic drivers in the gene TP53 are a lot more likely to be seen in aggressive breast cancers and are more likely to be seen in Black women.

I think one of the discussions is access to care and utilization of genetic testing. There was a large study in Chicago noting that 30% of African American women who were qualified for genetic testing and had high-risk breast cancers did not receive genetic testing. In that study, BRCA1-mutated women who were African American under the age of 40 years had a 16.7% higher likelihood of being diagnosed with breast cancer with a BRCA1 mutation than Caucasian women.

We want to discuss a little about allostatic load. We're noticing that there are epigenetic changes in the DNA that may be modified when a person is under very stressful conditions. If someone has a cumulative effect of poverty, racism, and social isolation, these genetic markers may make them more likely to form abnormal cells and to be diagnosed with cancer. There's been a correlation with women diagnosed with breast cancer and, more strikingly, Black women having higher allostatic loads.

Allison, can you discuss a little bit about how allostatic loads may even interplay with some of the social determinants of health?

Dr Butts: Sure. For those who aren't familiar with that term, the social determinants of health are nonmedical factors that influence health outcomes. They're generally divided into 5 main groups, starting with economic and food stability. These are things like employment income, access to nutritious foods, and other factors that influence health indirectly. Neighborhood and built environment refer to things like housing and transportation. Education access and quality, as it sounds, relates to literacy, language skills, and so forth. Healthcare access and quality involves insurance coverage, things like access to clinical trials, and high levels of quality care -- a specialist level of care, at times. The fifth social determinant of health includes social and community context factors, such as support systems, discrimination, inclusivity, and stress.

 There's clearly a link between many of these forces and the ability of patients to access care, have quality health literacy to be able to understand and carry out the treatment plan that's in place, their ability to adhere to the prescribed treatment plan, manage side effects, the list goes on and on and on.

Systemic racism is related, and something I think is also important to discuss today. Systemic racism impacts many of the social determinants of health, like education, employment opportunities, access to insurance coverage, and housing. We know that Black and Hispanic people are generally underrepresented in the practice of healthcare, research fields, and at the legislative level where decisions are being made about how health care will be implemented in our country.

Lack of insurance and underinsurance are major barriers to timely quality care and contribute to the disparities that we see in breast cancer mortality rates. Black patients, Hispanics, and indigenous people are much more likely to be uninsured than their White counterparts. One study found that compared with non-elderly White women, nonelderly Black women were up to 3 times more likely to be uninsured or to have Medicaid coverage. It's important to note that when Medicaid expansion took over, access to Medicaid eliminated disparities in the 2-year survival rates between White and non-White women with stage 4 breast cancer. Related to that, Karen, can you talk a little bit more about disparities in breast cancer screening?

Ms Drucker: Sure. Well, there was another study that showed that Medicaid expansion led to a significantly increased rate of mammogram screening, which we all know affects outcomes in a positive way. As already mentioned, we know social determinants of health include lack of insurance; longer travel time to get to your health care; living in a low-income neighborhood, which usually encompasses lower socioeconomic status; and less education. These are all associated with less adherence to screening guidelines.

To further this, Black women have a longer time to biopsy after abnormal imaging, and they also have a greater delay in starting treatment after a breast cancer diagnosis. They're also less likely to be referred for genetic testing. However, interestingly, in a real-world study, they found that Black women with TNBC were just as likely to be referred for genetic testing but were 3 times more likely to decline. Toni, as a patient advocate and a Black woman, what do you think about this?

Toni Willis, MD: Well, I think this is a multifactorial problem. Certainly, lack of knowledge regarding the importance of BRCA testing is an issue. There are access issues, as mentioned before, such as having insurance, living too far from facilities, or being unable to take time off from work. Then, of course, there's medical mistrust. The data show that Black and Latinx people in the United States are less likely than White people to trust healthcare professionals and medical institutions. With genetic testing, people are often concerned about whether other aspects will be checked other than their risk for breast cancer and who will have access to that information throughout their lifetime.

Dr Stringer-Reasor: This question is for you, Toni and Karen. What have you guys been seeing in your institutions respectively during the COVID pandemic? When 2020 hit, we saw a lot of screening mammography unable to be performed. We also saw that there was this inability to do in-person genetic counseling and testing. It did bring about a little more telehealth, which expanded access to patients. What do you think about the COVID pandemic and screening mammographies? Are your institutions back on track with reportable screening?

Dr Willis: They seem to be back on track, but there was definitely fear about going to appointments and doing things in person. I must admit, I was fearful at the beginning of the pandemic even to go in for my chemotherapy treatments because of the risk, but we seem to be back on track with that.

Dr Stringer-Reasor: What do you think, Karen, at your institution? Are you guys back on track?

Ms Drucker: I think so. During COVID, we definitely saw this was going to be kind of a collateral damage situation, with women not getting mammograms. Even women who got mammograms had delays in biopsy. It was really kind of across the board. I think we are back on track though.

Dr Stringer-Reasor: Screening mammography was down by 30%, especially at our community centers, and there was limited staff as well, which was another barrier to receiving screening mammography. But it does seem that most institutions now are at 80% to 100% percent capacity. But we're certainly seeing patients that did slip through the screening process, and they're certainly entering in with more aggressive disease.

I anticipate that over the next 1 or 2 years, we're going to see more patients diagnosed with more aggressive disease. I wonder about our community involvement with having those health navigators on board to really help get people more engaged with getting screening mammography.

Dr Butts: If I could quickly add 1 more point to that. Another problem we're running into is that once you get off your annual cycle, people are missing more than that 1 year during COVID because they're out of the loop and they don't get their next appointment reminder. I think we've seen it compound beyond those initial interruptions and screening.

Dr Stringer-Reasor: Absolutely. I don't know if you guys called your doctors lately, but it's a lot of automatic processes. I called the other day to get my son an appointment and stayed on the line for 19 minutes. You know what I did? I hung up and emailed his doctor. But not everyone has that access. We certainly have to be empathetic to our patients at this time, as they're trying to get back in gear with the healthcare system.

One thing we haven't touched base on during this discussion is the real phenomena of implicit and explicit biases as they pertain to racial bias, gender bias, and these preset prejudices. We talk a lot about explicit biases. These prejudices are often highlighted in the news today, and it's really overt. What's now being highlighted is implicit bias, these individual implicit biases that we automatically have -- each and every one of us. We unintentionally lay these judgments out when we make decisions. Addressing these on an individual and at a system-based level is going to be important going forward.

Just thinking about implicit bias, an example is a patient with limited resources who comes in to see their healthcare provider team. Perhaps the medical team decides not to offer them a clinical trial because that patient doesn't have their own transportation. But the patient never said they wouldn't participate; it was the healthcare team making a predisposed judgment about what that looks like.

Toni, from an advocacy standpoint and as a Black woman, tell me about mitigating these racial biases. How do we navigate these systems in the healthcare field?

Dr Willis: Well, the most important thing for all patients, regardless of their background, is to make sure that they are getting the information they need to make educated decisions about their care. Fortunately, there are breast cancer survivors -- Black women who have seen the gap in information, support, and access, particularly for Black patients.

They filled that gap by forming their own organizations to provide information, 1-on-1 cocoaching, and support to patients. Three of the big ones that come to mind are TOUCH, the Black Breast Cancer Alliance; The Chrysalis Initiative; and Tigerlily Foundation. There are other organizations that serve all patients, but they also provide information specific to Black women, like Living Beyond Breast Cancer and SHARE Cancer Support. I think information is the key.

Dr Stringer-Reasor: Absolutely. And we know that there are going to be populations that are going to be a little bit higher risk to not be able to receive timely care or have more difficulty with compliance due to stressors in their life. There have been a lot of data on young women who are working daily and are worried about childcare or maybe caring for elderly parents. That's something that we're seeing now in the United States as patients are trying to receive their own care but are also caring for their aging parents. I think that we're going to have to, as an institution, in order to improve disparities, have more equitable resources so that patients can receive their care in a timely fashion.

Now, as we look at eliminating disparities on an even broader level, let's switch gears to just thinking about the system-wide barriers. We know that the policy for reform is going to be needed, as Allison discussed, with some of those social determinants of health and the healthcare delivery system. Karen mentioned the ability to have more statewide cancer screening, on multiple levels, for underserved populations. It's not just patients who don't have insurance, but also patients who are underinsured, which is probably also a barrier to get timely care.

Toni, I wanted to ask you just about some of the advocacy groups that you just talked about. What are they doing in the community to help improve policy reforms and educate patients or people throughout the community about cancer care?

Dr Willis: Several of those organizations are recruiting patient advocates and training them to do different aspects of advocacy: legislative policy and community advocacy. There are a lot of initiatives. They are creating webinars that are specific to minority populations and getting information out to them about breast cancer, the treatment of breast cancer, and taking care of themselves. We do community-based advocacy activities, and we're starting to use social media a lot more to reach out to breast cancer patients and to people who haven't even been diagnosed with breast cancer yet, to make sure that the information is getting out and using all of the different platforms to do that.

Dr Stringer-Reasor: We just discussed all the barriers patients may have related to breast cancer care. Let's switch gears to how we can provide solutions to our patients. One of the things that my program does is try to improve access to care and eliminate these inequities by forming multidisciplinary teams. These interprofessional teams really help 1 institution bring under 1 umbrella the oncologist, the surgeon, the radiation oncologist, the advocate, the lay navigators, the nurse navigators, the pharmacists, and the social workers to try to promote a decision on how to proceed with cancer care for our patients.

This is an invaluable way for our teams to move forward. I want to talk about how each of us utilizes these interprofessional teams to improve disparities. I just talked about some of the things, like putting that team together, but let's talk to you, Allison, from a pharmacy standpoint. Wow, I mean, you guys are really subcategorized now; you're a clinical breast oncology pharmacist. Tell me about that role and how you work with the team.

Dr Butts: Sure. I work directly with our care team in clinic, primarily. I'm seeing patients, doing education, ensuring that they have access to their medications, and doing toxicity checks. The list kind of goes on and on, depending on the day. In regard to this topic, the 2 areas that come to mind that my profession has a major role in are education and access to medications.

Thinking about education, I think the way to try to overcome some of these issues is to meet the patients where they are. We need to figure out what their hesitations are. What's going to keep them from being successful in their ability to carry out their treatment plan? What are their goals? What do they need us to do to help them be successful in managing their care and really empowering them to take control?

The other one I mentioned is access. My profession has a big role in making sure that patients can get their medications. It's great to come up with a plan and send in the prescriptions, but then you find out that the patient never was able to pick them up. Whether that's because of a physical limitation, like lack of transportation to get to their pharmacy, or whether it's an issue of cost and they need co-pay assistance or enrollment in Medicaid or Medicare, a lot of those are issues that pharmacists can bring to the table to help improve care as part of the team.

Dr Stringer-Reasor: Yes, absolutely, Allison. I mean, pharmacy has revolutionized how we treat patients and how we help patients have good adherence and compliance. My pharmacist tells me before I have even talked to the patient how compliant the patient is, even a week or two before the patient comes in to the visit. I do think that it's a very critical role. Another critical member of the team is the nurse. Karen, I'm from the South, I'm from Alabama. We always talk about everything by football. The nurses are the quarterbacks. You help run the team, and the patient is always looking for the education from the nurse, as well. Tell me about your role.

Ms Drucker: Well, nurses and nurse practitioners do have a unique role in that we generally can have more time to spend with the patients, maybe a little more intimate time. I find it to be the key to discussing and identifying individual barriers. I don't think we can assume, even based on what we know, what any individual patient has as a barrier to receiving health care. Until you know their barriers, you really can't help them. You can't assume it's this or it's that. It could be many things, or it could be only 1 thing. It's getting the patient to identify that and then allowing you to help them and building trust. Building a trusting relationship is key so that they feel that your intentions are good and you're not judging. There's no judgment.

It's also connecting these patients who have barriers with social workers, with nurse navigators, with case management, or whatever's available to help. We all know that as individuals, you can only help so much, so it's getting all the other team members involved. What's important is that we need more outreach and we need more early detection. We need more patients to be able to go to good institutions where they're getting good evidence-based care. Until that happens, we're not going to improve the inequities in breast cancer outcomes, so I think that that should be the greater goal.

Dr Stringer-Reasor: Absolutely. And then Toni, just from a patient perspective, what are patients and what are people in the community looking for to help connect them with the healthcare team, which would inevitably improve outcomes?

Dr Willis: Well, I think one of the members of the team that's probably being underutilized is the patient navigator. Most patients are only referred to a navigator if they're having a problem. There's a prescreening questionnaire that we always fill out when we come to our appointments to try to see if there are red flags that are being raised during our treatment, but I think it's often between appointments when we're having issues.

I have noticed that patient navigators are utilized in very different ways across the country. Some practices have their own patient navigators, and some use local nonprofit organizations to do their navigation. I never really needed a navigator throughout my journey, but I've talked to a lot of patients who ran into problems -- just basic things that they should have known that they didn't.

I also think that patients need to reach out to other patients because we learn so much from each other. We are the ones who are going through it. It's easier to learn from a person who has had the treatments. Fortunately, I always had someone at every stage of my treatment who had been through it to kind of talk me through it. Healthcare professionals need to realize that patients really benefit from that, and the more that you can encourage patients to connect with other patients, the smoother their journey will be.

Dr Stringer-Reasor: Absolutely. Beautifully said, Toni. There's just not enough time in this limited session to really address all the inequities, the barriers, and the solutions, but I certainly think we touched on some of those key points today.

Health care disparities, particularly in breast cancer, continue to be observed from the prevention stage to the diagnosis stage to the treatment stage. Black women continue to have a lot higher mortality than any other ethnicity or race in the United States. The etiology of the mortality gap is multifactorial. We talked about that interplay between biology, genetics, social determinants of health, and allostatic load. It's not just a one-size-fits- all. There are multiple key players that need to be addressed to eliminate this disparity. It will take a truly collaborative team to attack the barriers at a system-wide level, from policy to institutional policies to really start tackling this issue to improve outcomes for all patients.

I want to thank my colleagues on this discussion today. Allison, Karen, and Toni, thank you for this great, robust conversation. I also want to thank the audience for participating in this activity. If you could, please continue on to answer the questions and do the follow-up evaluation after this session. Once again, thank you all, and have a great day.

This transcript has not been copyedited.