Lannis Hall, MD, MPH

Breast cancer is the most common cancer diagnosed in women and the second-leading cause of cancer death. This year, approximately 250,000 women in the United States will receive the diagnosis of breast cancer, and 40,000 will die of the disease.

The good news is that breast cancer mortality rates have dropped by 40 percent in the last 25 years. The bad news is that some communities continue to suffer from unacceptably high mortality rates despite significant advances in early detection and treatment.

African-American women have a 40 percent higher breast cancer mortality rate compared to white women and, depending on where you live in the U.S., the mortality difference is even greater. African-American women in the state of Missouri – and specifically certain areas of the St. Louis region – have breast cancer mortality statistics that are significantly higher than the national average.

This urgent call to action discusses factors responsible for the alarming mortality, the rise in incidence rates, and what each of us must do to reverse the trend.   

90 percent higher mortality rate 

In the St. Louis region, breast cancer mortality rates are significantly higher for African-American women compared to white women despite having numerous health care facilities. In St. Louis County, white women have a breast cancer mortality rate of 18 deaths per 100,000 women, and African-American women have a mortality rate of 34 deaths per 100,000. Thus, African-American women have a mortality rate that is 90 percent higher than white women in the same county.

A closer review of this data, as outlined by the St. Louis County Department of Public Health, indicates that women who live in zip codes in North County, compared to women with zip codes in West and South County, have much higher breast cancer mortality rates. Some zip codes, particularly in inner North County, have rates that are 150-200 percent higher than zip codes just 10 miles west and south on Interstate 270. This is an unconscionable disparity and worthy of our immediate attention and energy.

One of the main reasons for the increase in mortality among African-American women is the later stage of diagnosis of breast cancer. At later stages of the disease, the malignant tumor is no longer confined to the breast but has spread to regional lymph nodes or other organs like liver, lung and bone.

Early mammography saves black lives 

Mammograms save lives. The benefit of early mammography screening to detect breast cancers at an earlier stage of the disease cannot be overstated. Early screening reduces mortality by approximately 30 percent in women who screen routinely. However, confusion clouds the issues of when a woman should screen and how often.

For example, The American Cancer Society now recommends that average-risk women begin mammography screening at the age of 45 rather than the age of 40. The guidelines further recommend that women 55 years or older should undergo screening every other year and that health care providers should no longer perform clinical breast exams. The U.S. Preventive Services Task Force rolled back screening even further to begin at the age of 50.

The clinical studies which support the revised guidelines were primarily conducted in Western Europe and Canada. These clinical trials, which overwhelmingly enrolled white women, were unable to assess the impact of rolling back screening guidelines for African-American women.

Women of color should be concerned about these recommendations for several reasons. African-American women have an earlier age of onset of breast cancer compared to white women. Approximately 30 percent of breast cancers in African-American women are diagnosed before the age of 50, as compared to 20 percent of white women, and more breast cancers are diagnosed in African-American women under the age of 45 than any other ethnic or racial group. Many unfortunate and heartbreaking cases of breast cancer occur in women who are in their thirties and forties, while raising young children, working, and participating fully in their communities. 

Recent data from the St. Louis County Health Department highlights the earlier age at diagnosis for women in our region; African-American women are diagnosed six years earlier than white women. The median age of diagnosis is 59 years of age for African-American women and 65 years of age for white women. Thus, in the St. Louis region, one-half of African-American women are diagnosed before the age of 59. The earlier age at diagnosis and more advanced breast cancers at the time of diagnosis demonstrate the urgency for early screening.

Because of the higher mortality rate and increase in advanced stage breast cancers in African-American women, two national organizations, the American College of Radiology and the Society of Breast Imaging, have designated African-American women as high risk. Each organization recommends a formal assessment by a health care provider to evaluate a family history of breast cancer and assess for genetic-based risk, starting at the age of 30. The purpose of this early risk assessment is to determine if women should have screening earlier with MRI or other imaging modalities. The American College of Radiology, Society of Breast Imagers and Siteman Cancer Center continue to recommend annual screening for all average-risk women to begin at the age of 40. 

Weight gain increases cancer risk

The breast cancer mortality disparity in our region is an urgent matter but equally distressing are the rising new cases of breast cancer in the African American community.

In the past, white American women had the highest incidence of breast cancer in the U.S., but lately, the rate of new cases has stabilized, while for African-American women the rate of new cases has increased. In its most recent analysis, the American Cancer Society has highlighted seven states in which incidence rates are higher in African-American women than in white women. Missouri is one of the seven states.

One of the risk factors for developing breast cancer later in life is weight gain during a woman’s adult years. Research has shown that all women – regardless of race – who gain over 20 pounds of weight after high school have a higher risk of developing breast cancer after menopause.

Issues of obesity and unhealthy weight gain are a national epidemic, but African-American women are struggling with this health issue more than any other ethnic or racial group. Over 80 percent of African-American women struggle with an unhealthy weight, which heightens the risk for breast cancer later in life. The overwhelming message is to avoid weight gain to reduce breast cancer risk.

Free breast and cervical screenings 

While health care leaders and organizations mobilize to address this mortality disparity and rising incidence in our region, one program is available that women can participate in now: Show Me Healthy Women.

Show Me Healthy Women is a Missouri program which provides free breast and cervical screenings for low-income and uninsured women who meet specific age requirements. Seventeen different hospitals and federally qualified health centers participate in the state program in the St. Louis region.

The participating health care centers are: Betty Jean Kerr People’s Health Center at Florissant, Breast Health Center - Missouri Baptist, SSM DePaul, SSM St. Clare Hospital/ SSM St. Mary’s and Mercy Hospital (in St. Louis County) and all Affinia sites, all Myrtle Hilliard sites, Saint Louis University, Barnes- Jewish Hospital and at the Highlands, Betty Jean Kerr People’s Health Center on Delmar (in St. Louis city), and Christian Hospital (full participant soon).

The Show Me Healthy Women program also enrolls women onto Medicaid if they have a diagnosis of breast cancer and require treatment. Providing medical insurance is a lifesaving benefit of the program, particularly since research has consistently shown that delays in guideline-directed care like receipt of surgery, chemotherapy, and radiation lead to significantly lower survival rates. Unfortunately, many women have not heard of The Show Me Healthy Women program and do not know they can receive a free mammogram and treatment if necessary.

Comprehensive cancer treatment center in North County

Another important advancement is the construction of Siteman Cancer Center in North County which is scheduled to open this fall on the campus of Christian Northwest Campus. Siteman Cancer Center in North County will offer comprehensive treatment services, hundreds of clinical trials, supportive personnel and programs specifically designed to assist the uninsured and underinsured. Some of the highest breast cancer mortality rates are located in nearby neighborhoods where one in four households are uninsured. A cancer center close to home will support women juggling careers, childcare and a new cancer diagnosis.

Each one of us can play a role 

Each one of us can play an essential role in encouraging our loved ones and friends to undergo screening annually starting at the age of 40 or earlier if there is a strong family history or risk of genetic-based breast cancer.

The call to action to educate women about breast health and the importance of early detection and annual screening include: churches and their health ministries, regional health care advocacy organizations, high schools, and social and service organizations aligned with community health. 

We are fortunate to have several outstanding breast cancer advocacy groups in the St. Louis region dedicated to saving lives. These organizations offer financial support like mortgage and utility payment assistance during breast cancer treatment, free screenings and an array of other supportive services. These organizations include Gateway to Hope, The Komen Foundation, The Breakfast Club, The American Cancer Society and Valeda’s Hope.

Breast cancer survival differences between African-American and white women are primarily due to socioeconomic indicators and access to health care – also known as social determinants of health. Several large metropolitan areas and states have minimal differences in breast cancer mortality rates between African-American women and white women. These regions have a common theme of expansion of Medicaid and a strong public health system.

Health equity – as defined by Healthy People 2020 – is the attainment of the highest level of health for all people. This can be our reality, but we must strategize, mobilize and legislate for a healthier St. Louis.

Lannis Hall, MD, MPH, is Director of Radiation Oncology at Siteman Cancer Center Barnes-Jewish St. Peters Hospital, Clinical Trials leader at Program to Eliminate Cancer Disparities, and assistant professor of Clinical Radiation Oncology at Washington University School of Medicine.

A special thank you to Dr. Nhial Tutlam and the St. Louis County Department of Public Health for providing cancer statistics.

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