This article is a part of Studio/B’s Breast Cancer Explored series, exploring the state of breast cancer in 2020 through stories from survivors, loved ones, doctors, and researchers.

Dr. Cheryl Clark, hospitalist and researcher in Brigham and Women’s Hospital (BWH) Division of General Medicine and Primary Care, and director of health equity research & intervention in the Center for Community Health and Health Equity at the BWH

“One of the sobering findings we’ve noted over the past 40 years is the gap in mortality from breast cancer, particularly between Black women in the United States and women who identify as white,” says Dr. Cheryl Clark, hospitalist and researcher in Brigham and Women’s Hospital (BWH) Division of General Medicine and Primary Care, and director of health equity research & intervention in the Center for Community Health and Health Equity at the BWH.

Black women not only have higher mortality rates than white women; recent data also suggests the number of Black women who get breast cancer is increasing at a faster rate than in the past, Clark adds. The continuing disparity in care is particularly disturbing when you consider how much better we have gotten at early detection, and at treating breast cancer successfully in general.

“Breast cancer treatments work for all women, regardless of race or economic status. But over the last five to 10 years, as breast cancer treatment has gotten better, the race and economic gap between who is doing well and who is not is actually growing,” says Dr. Karen Freund, vice chair for faculty affairs and quality improvement at Tufts Medical Center.

Dr. Karen Freund, vice chair for faculty affairs and quality improvement at Tufts Medical Center

For women to benefit from new treatments, they need to be diagnosed quickly and enter the care system in a timely fashion, Freund explains. “Women of color and low-income women are much more likely to come into the healthcare system at a later point in their breast cancer, especially here in Boston,” Freund says.

These women are also at higher risk for comorbidities such as diabetes, high blood pressure, heart problems, asthma, and obesity that put them at risk for serious illness due to COVID-19, Freund explains, so understandably, these women may be scared to risk coming to a medical facility. “We worry this group of women may have more delays either in coming in for a mammogram or coming back for cancer care,” she says.

Clark adds that Black women are more often not able to access clinical trials because of insurance issues. Furthermore, insurance issues can force people to transition from one healthcare system to another, resulting in more delays.

The COVID crisis

Clark is working to understand and mitigate the factors leading to increased rates of disease and death. You can’t do that without exploring social factors. If someone is struggling to make rent or provide food for their family, they may worry they don’t have time or money for their own medical visits and put off treatment.

Katie Finn, program manager for cancer center patient navigation at Boston Medical Center

Katie Finn, program manager for cancer center patient navigation at Boston Medical Center, says one of the most common barriers she sees is transportation—lack of it, or concern about affording it. COVID-19 makes this even more of an issue, since people with weakened immune systems due to treatment should avoid crowded places, including public transportation, if possible.

Finn notes COVID is also compounding food insecurity. People are nervous to go to the grocery store, and many are struggling financially. According to data from the U.S. Census Bureau from late July, 29 million adults say their household sometimes or often did not have enough to eat in the last seven days. Black and Latino households are more likely to experience food insecurity during the pandemic; and women disproportionately shoulder the burden of securing food.

As we address disparities in care, Clark says we must consider programs for helping women “get their basic needs met in addition to being able to get their treatment for cancer.”

The role of patient navigation

We have made incredible strides in the fight against cancer—but treatment is complicated. One way to improve treatment compliance and potentially close the gap in care is patient navigation. Patient navigators complement the medical team by helping patients identify barriers to accessing timely cancer treatment. Then, they connect people to relevant resources, explains Finn, who has worked as a patient navigator for more than 15 years.

Dr. Jennifer Haas, one of four principal investigators on the TRIP project and a practicing general internist at Massachusetts General Hospital

Multiple programs in the Boston area are exploring the benefits of this service. Freund has received an American Cancer Society (ACS) grant for her work studying the role of patient navigation in eliminating cancer disparities. Clark is an investigator for the Translating Research into Practice (TRIP) project, designed to eliminate disparities in breast cancer mortality among Black, Latina, and low-income women in the greater Boston area by addressing both medical and social determinants of health through patient navigation. Both projects use a regional approach, since women often need to visit multiple medical facilities.

“Boston is a city with a wealth of medical resources, but we know that women get lost and are sometimes shuffled between different institutions,” explains Dr. Jennifer Haas, one of four principal investigators on the TRIP project and a practicing general internist at Massachusetts General Hospital.

She believes regional collaboration between institutions will work better than having each institution try to address disparities on their own.

The way forward

Now may be the perfect time to make real progress in the fight for breast cancer care equality. The Black Lives Matter (BLM) movement has highlighted the realities of racism nationwide and invites us to speak openly about them.

“Healthcare facilities, academic institutions, and private businesses are now more comfortable with the introspection that is needed for change,” Clark says.

She believes Massachusetts needs a health care system that focuses on patient care and “balances margin and mission.” People can help make that happen by speaking up about their beliefs.

“The most important intervention is really civic engagement,” Clark says, “so getting out and voting, and making our voices heard so we can collectively decide what kind of society we want to live in.”

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