Black Women and Breast Cancer
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FACT: Black women tend to be diagnosed with breast cancer at younger ages than White women. Access to equitable care is critical to receiving timely diagnoses and treatment.
The Center for Disease Control and Prevention (CDC) reports that among women, breast cancer is the second most commonly diagnosed cancer and is the second leading cause of cancer deaths among women in the United States.
Although there has been a decline in breast cancer mortality due to increased awareness and screenings, the disparity in regards to Black women has remained the same, according to the American Cancer Society.
The Breast Cancer Research Foundation reports that for a number of reasons, including social and economic factors, fewer Black women get the breast cancer surgery, radiation, and hormone treatments that are needed in comparison with white women, and starting treatment in a timely manner is less likely for Black women.
The American Cancer Society estimates that in 2025 there will be 316,950 new cases of invasive breast cancer, 59,080 new cases of non-invasive breast cancer, and 42,170 new deaths from breast cancer.
Triple-negative breast cancer (TNBC) is a type of aggressive breast cancer that primarily affects young Black women.
Black women have 5% lower breast cancer incidence than White women, but 38% higher mortality, largely because of later diagnosis and barriers to accessing high-quality treatment.
Black women have the lowest survival rate for every stage of breast cancer.
During a recent interview, former CDC Director Thomas R. Frieden, M.D., M.P.H, explains that, “Although we are making progress reducing deaths from breast cancer, we have much work to do to reduce preventable deaths, particularly among African-American women.” He went on to say, “Only when every woman receives adequate screening, timely follow-up, and high-quality treatment, will the full benefit of breast cancer screening be achieved.”
What is Breast Cancer?
Besides adipose tissue (fatty tissue), the inside of a breast is made up of four main parts: lobes, lobules, ducts, and connective tissue.
- Lobes - glands that store and produce milk
- Lobules - glands inside lobes that contain milk producing cells
- Milk ducts - tubes that carry milk to the nipple
- Connective tissue - surrounds and holds the lobes and ducts together.
Breast cancer is a disease in which breast cells grow uncontrolled. The type of breast cancer diagnosed depends on which cells become cancerous and whether or not the cancer has spread. Non- or pre-invasive breast cancer is one that has not grown into the rest of the breast tissue, whereas invasive or infiltrating breast cancer is used to describe cancer that has spread into the surrounding tissue.
Kinds of Breast Cancer
According to the CDC, the most common types of breast cancer are:
- Lobular carcinoma in situ (LCIS) - a non-invasive or preinvasive cancer that starts in the lobules - this rarely becomes invasive, but it is a risk factor for developing breast cancer later on.
- Ductal carcinoma in situ (DCIS) - this cancer is non-invasive or pre-invasive and starts in a milk duct.
- Invasive ductal carcinoma - cancer that begins in the cells of a milk duct and has spread outside of the ducts into other parts of the breast tissue. This is considered a “true cancer,” and it is the most common type of breast cancer.
- Invasive lobular carcinoma - a type of cancer that began in the lobules and then spread to the surrounding breast tissue. This is also considered a “true cancer,” and it is the second most common type of breast cancer.
Stages of Breast Cancer
Stage 0: The cancer is non-invasive or pre-invasive, also called carcinoma in situ, and contained within the lobules or milk ducts.
Stage 1: The cancer is localized to the breast, typically a small tumor, and it may have spread to nearby lymph nodes.
Stage 2: The tumor is larger than in Stage 1, it may have spread to more lymph nodes, and it could still be considered localized to the breast.
Stage 3: The cancer has spread more extensively within the breast and lymph nodes, potentially involving nearby tissues like the chest wall or skin.
Stage 4: The cancer has spread to distant parts of the body beyond the breast and lymph nodes.
Symptoms of Breast Cancer
Some people experience early signs of breast cancer, whereas others may not. Common signs of breast cancer include:
- New lump in breast or underarm
- Thickening or swelling of part of the breast
- Irritation or dimpling of breast skin
- Redness or flaky skin in nipple area or breast
- Pain in any area of the breast
- Nipple discharge other than breast milk
If you present with one or more of these symptoms, it is important to meet with your doctor for a professional opinion. If you do not present with any symptoms, it is still important to attend your regular breast screenings.
Black Women and Breast Cancer
Due to increased awareness, earlier diagnosis and more effective treatments, there has been an overall 44% decline in breast cancer deaths over the last three decades. However, according to the Breast Cancer Research Foundation (BCRF), there is a persistent mortality gap between Black women and their counterparts. The BCRF finds that despite having a lower breast cancer incidence of 5%, Black women have a 38% higher breast cancer mortality rate, a disparity that has remained stagnant for the past decade and is even greater for women under 50.
While advances in early detection and treatment have greatly reduced the mortality rate of breast cancer overall, it is clear that all groups have not benefited equally. The disparity in breast cancer outcomes among Black women may be caused by multiple factors. Factors including having other conditions at the same time (comorbidities), and social and economic conditions play a role in the gap. For instance, Ahmedlin Jemal, PhD, found that a combination of factors such as a lack of insurance, comorbidities, tumor characteristics, and treatment differences accounted for 76.3% of the total excess risk of death in nonelderly Black patients. Of this statistic, a lack of insurance alone accounted for 37%.
Furthermore, Marianna Chavez MacGregor, MD., and her team found that the survival disparities between Black and White women were greatly reduced in states that expanded Medicaid–healthcare coverage for low-income Americans after the implementation of the 2010 Affordable Care Act. Inadequate health insurance often causes a delay in critical screening, treatment, and follow-up care. This delay can be extremely harmful, especially when considering more aggressive types of cancer such as triple negative breast cancer. Any delays from screenings to treatment can allow cancer to grow unchecked.
Triple-Negative Breast Cancer (TNBC)
TNBC is a type of aggressive invasive breast cancer that accounts for 10-15% of all breast cancers. Its name refers to the lack of HER2 proteins and receptors for estrogen and progesterone, the American Cancer Society states. Black women are disproportionately affected by TNBC, especially those who are younger than 40 or have mutations in their BRCA1 or BRCA2 genes. The BRCA1 and BRCA2 genes are genes involved in controlling both breast and ovarian cancer. Anne Marie McCarthy, PhD., and her team found that Black women had nearly a three-fold increased risk of TNBC. Additionally, Dr. McCarthy found that TNBC was less likely to be detected by regular screening and more likely than other subtypes of breast cancer to be diagnosed as interval cancers–breast cancers that are found between routine mammogram screenings.
Dr. McCarthy also reports that TNBC has a lower survival rate because of its tendency to grow quickly, its increased likelihood to have spread before it has been found, and its higher probability of return after treatment. Unfortunately, because of its triple-negative characteristic, there are also fewer treatment options. Hormone therapy or targeted therapy treatments, like tamoxifen or trastuzumab, are not very effective at treating patients with TNBC because of its lack of HER2 proteins or receptors of estrogen and progesterone that the drugs target. Fortunately, chemotherapy is still an effective option as it does not rely on these specific proteins or receptors. According to the CDC, the goal of chemotherapy is to kill cancer cells wherever they may be in the body and lower the chance that the cancer will continue to grow or come back.
Immunotherapy is a newer, promising treatment for TNBC because it helps the immune system recognize and attack cancer cells. Some TNBC tumors produce a protein called PD-L1, which helps them hide from the immune system. FDA-approved drugs like pembrolizumab (Keytruda) and atezolizumab (Tecentriq) block this protein, allowing immune cells to fight the cancer more effectively. These drugs are used with chemotherapy and have shown success, especially in patients with PD-L1-positive TNBC or high-risk early-stage disease, finds Sushmitha Sriramulu, PhD. While not all TNBC patients respond to immunotherapy, researchers are working on new combinations of drugs to improve treatment options.
If you have any questions in regards to treatment for TNBC or any kind of cancer, it is important to reach out to your healthcare providers for professional medical advice.
Breast Cancer Prevention and Risk Factors
Many factors over the course of a lifetime can have an impact on the risk of developing breast cancer. Although some factors such as age or family history cannot be changed, there are steps people can take to help reduce their risk. According to the CDC, you may be able to lower the risk of breast cancer by:
- Getting screened for breast cancer regularly
- Maintaining a healthy weight
- Being physically active
- Letting your doctor know if you have a family history of breast cancer or mutations in your BRCA1 or BRCA2 genes
- Limiting the amount of alcohol you drink
- Breast-feeding, if you can
According to the National Cancer Institute, genes, lifestyle, and the environment play a major role in increasing or decreasing the risk of getting cancer. Risk factors for breast cancer include, but are not limited to:
- Hormone replacement therapy: Combination hormone replacement therapy is associated with an increased risk of developing breast cancer. Studies of the use of estrogen alone after menopause have had mixed results, according to the ACS.
- Obesity: Excessive fat tissue can increase the chance of breast cancer by raising estrogen levels.
- Drinking alcohol: Alcohol can change the way the body metabolizes estrogen, which can cause an increase in estrogen levels. Higher estrogen levels are linked to an increased risk of breast cancer.
- Genes associated with breast cancer: Women who inherit BRCA 1 and BRCA 2 gene mutations associated with breast cancer have an increased risk. See the section below for more information about these genes.
- Reproductive history: Early menstruation, starting menopause at a later age, giving birth at an older age, or never having given birth all increase the amount of estrogen introduced to breast tissue, thereby increasing the risk of developing breast cancer.
- Endocrine disrupting chemicals (EDCS): EDCs are chemicals that can interfere with the body’s natural hormones, particularly estrogen, and are known causes of breast cancer, finds Ashlie Santaliz Casiano, PhD. People are commonly exposed to EDCs through food packaging, cookware, fabrics, and personal care products.
- Social determinants of health (SDOH): SDOH are non-medical factors that influence health outcomes, such as, but not limited to, socioeconomic status, racism (including medical racism),education, neighborhood environment, employment, and social support networks. Steven Coughlin, PhD, MPH., found that these factors can contribute to the development of breast cancer.
Note: Penn Medicine explains that around 80% of breast cancers are considered “estrogenic,” meaning they have estrogen receptors on their cells and their growth is promoted by the presence of estrogen. These are called estrogen receptor-positive (ER-positive) breast cancers. This is why some risk factors involve the hormone estrogen or estrogen mimicking chemicals.
Women aged 25-30 should receive a detailed breast cancer risk assessment to determine their risk of developing breast cancer within their lifetime. Risk assessments are often conducted by primary care providers, genetic counselors, or specialized breast health centers, though practices vary by location. Generally during a risk assessment, the physician will collect information like breast tissue density, family history, and current patient conditions to input into a tool that mathematically calculates an individual’s risk.
Learn more about BRCA genes:
Breast Cancer Screening
Recommendations for screenings from medical providers may be different depending on whether they are at an average or a high risk of developing breast cancer. This depends on their risk factors. A person with an “average risk” of breast cancer is someone without a specific personal risk of breast cancer like a genetic mutation known to contribute to breast cancer or a strong family history of breast cancer. Below are the general recommendations from The American Cancer Society (ACS) for women at an “average risk” of breast cancer:
- If you are aged 40 to 54: You should have a mammogram every year.
- If you are older than 55: Your provider may tell you that you can switch to receiving mammograms every other year, but you may also choose to continue having them every year.
- Screenings should continue as long as the person is in good health and expected to live at least ten more years.
The ACS recommends that high-risk patients receive both a mammogram and a breast MRI annually.
Learn more about breast cancer screening techniques below:
2023 Mammogram Recommendations from the U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force (USPSTF) is an “independent, volunteer panel of national experts in disease prevention and evidence-based medicine.” On May 9th, 2023, the USPSTF updated their recommendation for breast cancer screenings to advise all asymptomatic people assigned female at birth to begin getting biannual mammograms at 40 years old instead of at 50. The new recommendation stems from a 2% increase in breast cancer diagnoses among women in their 40s and persistently high mortality rates among Black women. Screening 10 years earlier has the potential to save thousands of lives as cancer growth may go undetected for years.
Dense Breast Tissue & Cysts
Dense breast tissue refers to breast tissue that has more fibrous or glandular tissue than fat tissue. The CDC explains that about 50% of women have dense breasts, with about 10% of women having “extremely dense” breasts, where almost all tissue in their breasts are fibrous or glandular.
Dense tissue appears white on a mammogram, which is the same color that tumors show up as, making it more difficult to detect cancer in these women. According to Priscilla Slanetz, MD., mammogram sensitivity drops from 90-95% in breasts with more fat tissue to 60-70% in those with extremely dense tissue. Additional imaging tests, such as a digital breast tomosynthesis or MRI, may be recommended for high-risk individuals with dense breasts to improve cancer detection rates. However, in April of 2024, the U.S. Preventive Services Task Force (USPSTF) concluded that there is insufficient evidence to prove that the benefits of additional breast cancer screenings outweigh the harms for women with dense breast tissue after an otherwise negative mammogram screening. Dr. Slanetz states that dense breast tissue is a minor independent risk factor for breast cancer, but it does not cause cancer.
Like dense tissue, breast cysts may also complicate breast cancer detection. Breast cysts are fluid-filled sacs that can develop in the breast tissue. They are usually benign (non-cancerous) and are quite common, especially in premenopausal women. Cysts can vary in size and may feel tender or painful, but the ACS reports that they do not increase the risk of breast cancer and usually go away on their own.
On a mammogram, a cyst can look like a lump, similar to how a tumor might appear. However, a few cysts usually do not impair the ability to detect cancer on a mammogram, unless an individual has more than 10, which is very rare, says Dr. Slanetz. A breast ultrasound can typically differentiate between fluid-filled cysts and solid masses that might require further investigation, explains the Mayo Clinic.
Treatment
Different types of treatment are available for patients with breast cancer. The primary treatments include surgery, chemotherapy, radiation therapy, hormone therapy, targeted therapy, and immunotherapy; the specific treatment plan depends on the stage and characteristics of the cancer and will be determined by a medical team based on individual circumstances, the National Cancer Institute explains.
Key types of breast cancer treatment include:
- Surgery - The most common initial treatment, involving removal of the tumor, which can be done through a lumpectomy (removing only the tumor) or mastectomy (removing the entire breast).
- Chemotherapy - Using drugs to kill cancer cells, often administered through intravenous infusions and may be used before or after surgery depending on the stage of the cancer.
- Radiation therapy - High-energy rays used to target and destroy cancer cells remaining after surgery, often focused on the breast area.
- Hormone therapy - Medication that blocks the hormones estrogen and progesterone which can fuel the growth of certain breast cancers.
- Targeted therapy - Drugs that target specific molecules on cancer cells, allowing for more precise treatment.
- Immunotherapy - A newer treatment that helps the body's immune system recognize and attack cancer cells.
Some treatments are standard while some are still being tested in clinical trials. A clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
For more comprehensive information on breast cancer treatment, please go to the National Cancer Institute by clicking here.
How can I find a low-cost or free mammogram?
If you don’t have insurance or your insurance doesn’t cover mammograms, the resources below may help you find a low-cost or free mammogram.