Deep Dive into Breast Cancer Disparities
Tuesday, July 30
Our understanding of the epidemiology of breast cancer is constantly expanding, but there is still much to be discovered. Research has shown that there are significant differences between black and white women in terms of their experience with breast cancer. To gain insight into this issue, it is essential to understand what epidemiology is and how it highlights the health disparities between these two groups.
Disclaimer: Funding for this webinar was made possible (in part) by the State of New York. The views expressed in written webinar materials or publications and by speakers and moderators do not necessarily reflect the official policies of the State.
Key Takeaways From Webinar:
- Breast cancer survivorship is something that you will see disparities in. But these disparities, now that you see them, and you know them, you can look out for them.
- When you're getting clinical care, or getting medication, or interested in a clinical trial. Make sure you're expressing your voice and not just taking things status quo, because these disparities do exist even at the survivorship phase.
- Be knowledgeable and then fight for your equity and getting what you need.
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Q&A - Most Pressing Questions Answered by our Expert:
- What % of women enrolled in bc clinical trials are black women? And, What barriers are there to them enrolling/participating? And, What can be done to increase that %?
- What do you think is the single biggest driver (of all these you've mentioned) in causing disparities in survival outcomes?
- Do you know who or what organizations decide what clinical trials are needed for black people?
- To move towards this ancestry standard in research, does that mean all women need genetic testing? won't that create another disparity in terms of access?
General trends are that Black people represent 5-7% of cancer clinical trials; however, looking at FDA approval of 92 immunotherapies and the 113 studies that led to their approval, 2% were Black. However, I think overall numbers range from 2-7%. For black women in breast cancer clinical trials, about 2-5%. From the AACR Cancer Progress Report – here is an infographic of what can be done to increase participation. See Attached Infographic
I do not think there is just one. Just like air pollution isn’t just exposure to PM2.5 or hair product use is not just limited to phthalate exposure – disparities do not happen in a silo.
Clinical trials participation is based on the studies inclusion criteria. Sponsors and the lead clinician may and can mandate a certain percentage representation from certain demographic groups.
When diagnosed with cancer, a genetic profile is done and from that profile one can look at markers to determine genetic ancestry. It will not be a separate test. However, it could be a barrier for use if the use of it is not put into standard of care with accountability measures.
00:00:00:00 - 00:00:10:20
Unknown
welcome, welcome. We're going to get started. So today's webinar is called Deep Dive into Breast Cancer Disparities.
00:00:10:22 - 00:00:54:10
Unknown
I am Megan-Claire Chase and I am SHARE's Breast Cancer Program Director and host of Our BC Life Podcast. Plus, I'm an eight year invasive lobular breast cancer survivor. Now, before the presentation begins, I'd like to tell you a little bit about Share. We're a national nonprofit that supports, educates and empowers anyone diagnosed with breast or gynecologic cancers and provides outreach to the general public about signs and symptoms because no one should have to face breast, ovarian, uterine, cervical or metastatic breast cancer alone.
00:00:54:12 - 00:01:06:09
Unknown
For more information about upcoming webinars, support groups, podcast, and our helplines, please visit our website at sharecancersupport.org
00:01:06:09 - 00:01:27:06
Unknown
So now I'd like to hand it over to Dr. McDonald to introduce herself. Dr. McDonald, the screen is yours. Hello. Thank you so much for being here today. I'm going to just jump right in because we have a lot to cover just as a brief overview.
00:01:27:07 - 00:02:07:16
Unknown
I am from Columbia University. I'm an associate professor at Columbia University in the field of epidemiology. I especially rise in breast cancer epidemiology. As someone who looks at how does breast cancer come about? What is the mechanisms that are important for us understanding how breast cancer comes about such that you can target breast cancer? And today I'm going to take a deep dive into the area of breast cancer disparities and to really understand how we as a nation understand disparities.
00:02:07:18 - 00:02:40:06
Unknown
It's really important that we understand some of the terminology. So bear with me as I kind of ground you in the concepts of disparities. And then also, what is our nation's overview when it comes to breast cancer epidemiology. So this journey will consist of us defining the problem, understanding breast cancer, understanding how disparities arise, but not only how they arise, but why do they persist?
00:02:40:08 - 00:03:20:21
Unknown
And then looking at some approaches to reducing cancer health disparities. So first topic is epidemiology. Many of you already know what epidemiology is because of COVID 19, but specifically, I just want to ground everyone to understand that really, without epidemiology, we can't really understand health disparities because it's how the diseases affect the health and illness of populations versus primary care, which determines the individual Epidemiology is about the illness within the population.
00:03:20:23 - 00:03:58:13
Unknown
And so it's the way we study and measure to really understand and address health disparities. Now, that's what epidemiology is. So what is cancer? So cancer pretty much is about a cell ensuring that it can live and be immortal without relying on any of the endogenous signals, endogenous mechanisms that a cell needs. So it becomes independent. It's able to have its own growth signals.
00:03:58:18 - 00:04:32:21
Unknown
It's able to create its own blood vessels, it's able to move, is able to replicate itself. It's able to not outlive tose, which is to actually burst open where the cell dies and it's able to be insensitive to our endogenous immune system's signal to stop growth. So for the most part, it's like that independent child that goes off in the world and never comes back.
00:04:32:23 - 00:05:03:03
Unknown
It's completely independent and then one of the things that I really like about Ithaca Mercury, who is a a professor at Columbia University, he wrote The Emperor of All Maladies Is, which is a biography of cancer. And the phrase is, if we seek immortality, then so too, in a rather perverse sense, does the cancer cell. So that means that the cancer cell is trying to live forever.
00:05:03:05 - 00:05:41:03
Unknown
So now let's define disparities. So we've defined epidemiology. We've defined what cancer is. Now let's look at disparities. So disparities is really a measurement of difference. So cancer disparities are differences in cancer measures that could be the number of new cases that the nation sees in a year. The number of total cases that are in the U.S., the number of deaths in a year screening stage.
00:05:41:09 - 00:06:17:24
Unknown
So it's really looking at the whole population and understanding these measures across different populations. Now, cancer disparities can also be seen when out comes are improving. For example, if you're seeing an improvement in mortality, but they're not shared with other groups. And then when we think about what those groups are, we often define groups by sociodemographic. So social characteristics, race, ethnicity, geographic location.
00:06:18:00 - 00:06:44:24
Unknown
As many of you mentioned, during different areas. So what we would do to understand cancer in your area would be looking at what is the cancer, new cases in your geographic area. And then we'd say, okay, now what is it across these different other social groups? Or we'll say like, okay, in your area compared to some other people's area.
00:06:45:01 - 00:07:18:05
Unknown
Just to understand where the differences, where the disparities. But with all of those definitions, we know that epidemiology is the study of disease. We know cancer is very straightforward, does not know the definition. Epidemiology. The goal of cancer is just to persist. The goal of cancer is to be immortal. It is not defining who, when, how someone gets cancer.
00:07:18:05 - 00:08:03:22
Unknown
It has one goal. Then how is it that cancer is pretty much nondiscriminatory, but disparities exist? So let's start with understanding what is breast cancer in globally and nationally to really understand how do cancer disparities arise. So globally, breast cancer is very one of the number one diagnosed cancers among women. And pretty much you see here that this is the number of females that are estimated to be diagnosed in a year.
00:08:03:24 - 00:08:44:13
Unknown
And then this is the estimate for those who are dying of the disease. And what you can see is that the darker color means the higher rate of those being diagnosed with breast cancer. And then the lighter color is the lower means that the rate of mortality or dying from the disease is lower. But if you see in parts of Africa, while rates are much lower than it is for the U.S., there's much higher mortality for the U.S. While we have over about 287,000 new cases.
00:08:44:15 - 00:09:22:07
Unknown
The fact is we have less or deaths than other nations, but it's still not acceptable. The quote you often hear about the U.S. is that one in eight. So if you think about your network of people, one in eight women will develop breast cancer in their lifetime. So when we think about breast cancer over time, because breast cancer is actually they've seen breast cancer and mummified humans.
00:09:22:12 - 00:10:02:01
Unknown
So 3000 B.C., they've seen cancer. We've been really tracking cancer nationally since like the 1970s. And so if we focus here on breast cancer epidemiology, this is the incidence which is being diagnosed with breast cancer. And so in the dark blue, we have white and in the light blue, we have white a black. And what's interesting is that even starting from the 1970s, we see that white women were more likely to be diagnosed with breast cancer.
00:10:02:03 - 00:10:31:24
Unknown
And black women were less likely. Now that we're looking at our current century, black women have not really improved at all with the incidence or developing new cancers, but there has been improvement for white women. So now the difference that we used to see in the 1970s where black women had a less likelihood of being diagnosed. Now that's pretty much gone.
00:10:32:01 - 00:10:58:03
Unknown
And black and white women are diagnosed at pretty much almost the same rates. It's only 4% lower incidence. And here we're looking at the incidence across different races and ethnicity, because it's important that we understand that it's not just black white differences. It's the fact that black women have health disparities compared to pretty much all races and ethnicities.
00:10:58:05 - 00:11:30:07
Unknown
So here we're looking at American Indian and Alaskan Native Asian, Pacific Islander and Hispanic. And the incidence that being diagnosed is in the light pink dying from the disease is in the dark pink. And if you see black, they have the highest rate of mortality, even though they have a lower incidence rate than white women. Now, if we see here, this is for everyone.
00:11:30:09 - 00:12:03:11
Unknown
But we also see there's a higher death rate for not just black, but American Indian and Alaska native. Despite having a lower rate of being diagnosed with the disease. This is a true disparity. So why like how did that come about? That white women were having higher rates, but yet now we're at equal rates? Like how did that come about in history?
00:12:03:13 - 00:12:32:14
Unknown
Well, I love this phrase that came from an article that I read when I first started as a post-doc. And it was all about like, how do health disparities arise? Well, they arise when there is something you can do. At the moment, you can't do anything. Then everyone's in the same boat. There's everyone's going to sink. If there's no treatment, then you get the disease.
00:12:32:14 - 00:13:05:03
Unknown
You die from the disease. Cancer is not going to discriminate at all. But the moment that there's something that humans can do, that medicine can do. That technology is what creates that discrimination. So this is looking at in the what and the blue white women and the deaths from breast cancer over time. And this is the time period where there is not much you could do in the 1940s.
00:13:05:05 - 00:13:46:13
Unknown
It wasn't until the introduction of the endocrine targeted trial in the 1970s and then the actual implementation of these therapies into standard care in the 1980s and the 1990. Sorry that we start seeing these vast differences. So right here, everyone's in the same boat. 1980 comes about, you know, everyone's pretty much in the same boat. There's clinical trials going on about the first endocrine targeted therapies for breast cancer, but it's not standard of care.
00:13:46:14 - 00:14:18:16
Unknown
So not everyone's getting it. But the moment you get to the point where the 1990s, which is here, that it's available, it's a technology that should be available to all. That's when the disparities start arising and they get steeper and greater. So before 1980s, black women actually had a slightly lower mortality rate. Not I mean, it was pretty much the same 1980s rates were actually equal.
00:14:18:18 - 00:14:48:02
Unknown
But the moment we hit our current period when there was technology to reduce the rate of death, that's when we started seeing these disparities. So when there is something you can do. Health disparities arise. Now, when we're thinking about breast cancer, there are racial differences in mortality where, compared with their white peers, black women are diagnosed at earlier ages.
00:14:48:04 - 00:15:21:18
Unknown
Later stages with more aggressive tumor subtypes and tumor features are less likely to receive stage appropriate treatment. Have a lower stage first stage, which means if you compare a white woman and black woman at the same stage, black women have a greater likelihood of dying compared to white women. And they also, when we think about survivorship, black breast cancer survivors experience a higher burden of co-morbidities.
00:15:21:19 - 00:15:50:24
Unknown
These are things like cardiovascular disease or diabetes, things that are not just cancer, but actually are co-morbid on top of cancer. And they also experience a poor quality of life. So what is going on? Like, why is this the case? Well, the fact of the matter is a lot of people have suggested that, well, these differences are just by subtype.
00:15:51:00 - 00:16:18:05
Unknown
It's just that's all it is. Black women are more likely to get hormone receptor negative breast cancer, which means that you've heard of triple negative breast cancer, which means is e estrogen receptor negative progesterone receptor negative, as well as her two new negative. But when we think about like hormone receptor negative, we're mainly talking about the main hormone receptor estrogen.
00:16:18:07 - 00:16:43:18
Unknown
And so we see here there are differences in rates. So here is women that are white and this is non-Hispanic black. And then if we look at hormone receptor positive breast cancer, which is in the blue and the light blue, we see that which is the most easiest to treat because there's a receptor that drugs can attach to.
00:16:43:20 - 00:17:21:21
Unknown
White women have a higher frequency of developing hormone receptor positive. But when we look at hormone receptor negative unless released, focus on the purple, which is triple negative breast cancer, we see that there's far more triple negative breast cancer for black women than there is for white women. Black women have a 65% higher rates of being diagnosed with hormone receptor negative and an 81% higher rate of being diagnosed with triple negative compared to white women.
00:17:21:23 - 00:17:55:09
Unknown
So we see that. But let me let you know, this is something where is this disparity or is this biology? Well, this is something where we are seeing these higher rates of aggressive tumor subtypes, but we also see the aggressive tumor subtypes in white women. So let's keep going to explore more of these differences. So black women are known to be diagnosed with breast cancer at younger ages.
00:17:55:11 - 00:18:34:21
Unknown
But what we've seen over time, this is looking at age specific breast cancer across ages and this is specifically looking over time from 1976 to 2009, using a registry that a counts for many different cancers across our nation and is considered population level data. And what we see is that in this little blue box from ages 25 to under 45, there is this rise in the rates of breast cancer being diagnosed.
00:18:35:01 - 00:19:08:05
Unknown
Now we think of breast cancer as a disease of older age. That's why the rates are so much higher at older ages. But there are young people now getting the disease. And what we see here is that this this is the age at diagnosis. So between 1976 to 2009, every year, those who were aged 25 to 34 every year saw a 2% increased risk of developing breast cancer.
00:19:08:05 - 00:19:46:05
Unknown
So think about compound interest. So 2% every year from 1976 to 2009, there was an increase of young women being diagnosed. But the fact of the matter is that that differs by race and ethnicity. So while we're seeing overall an increase in early age onset breast cancer, the highest rates are among black women who see a 3.5% increase compared to non-Hispanic white, which sees a 2.7%.
00:19:46:07 - 00:20:13:08
Unknown
They also looked at geographic and they see that there is a higher rate being diagnosed within cities versus non cities. So young onset breast cancer is on the rise and black women are once again experiencing the higher rates. Now, this is looking at okay, well, there's different types of breast cancer. Like we said, we're looking at hormone receptor negative.
00:20:13:08 - 00:20:55:24
Unknown
We know that black women have a higher frequency of developing that disease. But recent studies suggest that when we look from 2010 to 2016 and we look at luminal A and luminal B, and for simplicity, these are hormone receptor positive breast cancers. And they're asking the question, well, if we see that there is this increase in early age onset of breast cancer, women being diagnosed under the age of 45, and we see that there are higher rates in certain racial and ethnic groups.
00:20:56:01 - 00:21:30:23
Unknown
What is the subtype like? What are we really seeing? And so one would think it would be triple negative breast cancer, right? Because that's the cancer that's most commonly not commonly, but that is a higher diagnosis rate within black women. But what they show is that in women, 25 to 39, for those with hormone receptor positive, non-Hispanic black women are experiencing increased rates of this subtype hormone receptor positive.
00:21:31:00 - 00:22:12:15
Unknown
The breast cancer subtype, that's the easier to treat 40 to 54. We're seeing the same thing. Black women are experiencing an increase of being diagnosed with estrogen receptor positive. In fact, during this time period, triple negative breast cancer has stayed pretty much the same, if not a little bit decline for ages 40 to 54. So what we're seeing is that the rise in early onset, you know, it's really estrogen receptor positive, which is the easier to treat breast cancer, but yet we're still seeing differences.
00:22:12:17 - 00:22:48:14
Unknown
So this quote came out of the American Cancer Society and it's annually they look at breast cancer death rates and specifically across the nation. And they have an entire booklet that really explores cancer in black individuals. And they said, we have been reporting the same disparity year after year for a decade. Breast cancer rates are highest for black women.
00:22:48:16 - 00:23:21:05
Unknown
Again, the differences in death rates, with all the differences I just showed you with all of the difference in biology of like who gets hormone receptor negative aged onset, the differences in death rates are not explained by black women having more aggressive cancers. It is time for health systems to take a hard look of how they are caring differently for black women.
00:23:21:07 - 00:23:54:09
Unknown
So despite me showing you all of those difference in how breast cancer presents, cancer is cancer. It's not discriminatory. It's it's trying to survive. It's trying to live. Some cancers are more aggressive than others. Yes. But the fact of the matter is that the mortality that we see is not because black women have more aggressive cancers, is not because black women are diagnosed at later stages, is not because black women are diagnosed at younger ages.
00:23:54:11 - 00:24:25:19
Unknown
And then this just kind of shows you looking at survival by subtypes. Like I mentioned here, this is looking at five year survival rates by stage at diagnosis, and this is for all subtypes. So hormone receptor positive hormone receptor negative. And what this shows you is that if we look at localize, so catching it early, it's not metastasize or catching it early.
00:24:25:21 - 00:24:58:02
Unknown
We see here that white women are almost nearly 100% are more likely to live for five years once being diagnosed. But for black women, it's below everyone else. It's 96. If we look at regional state, it's in the breast still, but is not at the site that I'm at first developed, we see that once again, black women have lower mortality rate than everybody.
00:24:58:08 - 00:25:27:23
Unknown
The higher mortality rate than everybody, less survival. And the trend goes on. And then when it's unstaged, that's kind of one of those things like it may be the time where like there's just nothing you can do. But the fact of the matter is, across every single stage. Comparing apples to apples, black women still have a lower survival.
00:25:28:00 - 00:25:57:21
Unknown
So what is going on? Why do these disparities exist? Not only why do they exist, but why have they persisted to time after time and year after year, again and again? So now I'm going to show you some information from this amazing report. And this from the American Association for Cancer Research. And it's their cancer progress report that just came out this year.
00:25:57:23 - 00:26:41:17
Unknown
And it's titled Understanding and Addressing Drivers of Cancer Disparities. And part of that document, they had this great figure that really goes into disparities that are experienced in the cancer care continuum. But not only that, it talks about drivers of health that are related to culture, behavior, the environment you live in, psychosocial, clinical, but that's also influenced by racism, discrimination, segregation, structural inequities, social societal injustices.
00:26:41:19 - 00:27:17:05
Unknown
So you start here living your life, being oppressed or suppressed by these factors which may impact how much money you make or where you live or your ability to run outside and have walking or doing exercise. And then you develop cancer. But in developing cancer now, you also have disparities in early detection, the treatment and the survivorship, which all leads to adverse health outcomes.
00:27:17:07 - 00:27:45:24
Unknown
So these are just the categories that we'll go through because you all will have access to the recording. I tried to make sure that while there's going to be a lot of detail on the slides about the ACR Cancer progress report, I'm not going to go into every single textual fact, but this is why cancer disparities persist. Yes, it started because there was something we could do about it.
00:27:46:01 - 00:28:31:14
Unknown
There was a drug that was standard of care. But why does it keep occurring? Well, let's talk about the social determinants of health, also known as SD. H socioeconomic status, 44% higher mortality. What is that's referring to women diagnosed with breast cancer. This is region this is talking about geographic during 2007 to 2016 at a Florida cancer center who were living in the most disadvantageous neighborhoods at 44% higher mortality from breast cancer compared to those living in the most advantaged neighborhoods.
00:28:31:16 - 00:29:14:14
Unknown
So just socioeconomic status alone played a role in surviving being diagnosed with breast cancer. And this is looking at some other key social drivers like living under poverty, health care status, food insecurity, crowded households, educational attainment. And really what they're trying to showcase is the percentage of individuals that are living under these circumstances. In 2022, while 945, about 9.5% of white were living under poverty, 17% for black and Hispanic were living in poverty.
00:29:14:16 - 00:29:57:11
Unknown
When you think about health care status and we think about uninsured adults, while 7% of white are uninsured, it's 19% and 21% for Hispanic and Alaska, American Indian, Alaskan Native, respectively, and so forth and so on and so on. So when you're living amongst these social drivers, there is going to be a biological component as well as a access component when you're diagnosed or when you develop and when you're diagnosed with cancer.
00:29:57:13 - 00:30:28:08
Unknown
Now, there's also access to health care. Now, this is based off of health insurance coverage. This is looking at inequities in health care systems and services. And it goes through affordability, availability, accessibility, the accommodations that you receive as a patient and the acceptability, you know, the quality of care this provided to you regardless of your personal attributes such as race.
00:30:28:10 - 00:31:08:00
Unknown
So if we look at this, this is looking at the social determinants, health, wage, access to health care, and this is looking at the delay or the non receipt of needed not optional needed medical care. And what we see is that the uninsured this is like this is like needed medical care. So there was a delay for those uninsured not being up to date with colorectal cancer screening, which is universal non insured 78% did not are not up to date.
00:31:08:02 - 00:31:45:05
Unknown
And then breast cancer screening, 70% of those who are uninsured are not up to date. So these are things where this screening catching disease early helps with survivability. But the fact of the matter is being uninsured or even in this case, having Medicaid or other public makes how it makes you have a less likelihood of being up to date with your screening, as well as having a delay, is mainly for uninsured.
00:31:45:07 - 00:32:18:12
Unknown
So now let's talk about biological factors and genetics. So I really wanted to focus on this because many people will say, cancer is all genetics. The fact of the matter is that cancer is genetic. It absolutely 100% is. It's not all genetics. And what you have to understand is that there is not one gene that is deterministic to developing cancer, not even broccoli.
00:32:18:12 - 00:33:09:02
Unknown
One or berocca to the breast cancer genes. Even they do not 100% guarantee that you develop cancer. Sorry, I still have a house though. And so when we're thinking about the biological factors, it's really important that you know not yes, it is genetic, but it's not the only some things that we see when it comes to social determinants of health and biology and genetics is that we see that African-American women, as I said before, have higher rates of higher frequencies, a triple negative breast cancer, but they also have quadruple negative breast cancer, which is having the lack of an androgen receptor as well.
00:33:09:04 - 00:33:39:23
Unknown
And these women who are diagnosed with triple negative breast cancer are more likely to also biologic, only have quadruple negative breast cancer and is likely to be earlier onset. So in this way we're thinking about the biology. If we know that black women have a higher frequency of ten B, C and we know that those with TMD C are more likely to also have quadruple negative.
00:33:39:24 - 00:34:11:22
Unknown
And we know that that type of cancer is associated with being diagnosed at an earlier age than biologically. That makes sense, right? That's why that's that's the social determinants of health related to the biology of the cancer you develop. We also look at tumor characteristics and the difference in hormone receptors. But these are also influenced by social determinants, by socioeconomic status, by environmental conditions.
00:34:11:24 - 00:34:50:05
Unknown
When we think of evolution, that also plays a role as a relates to the type of genetics that one has based off of the evolutionary influence. So this is important mainly because of the concept of precision oncology or precision medicine, which is the right treatment at the right time for the right person. And when we have clinical trials, the whole purpose of clinical trials is to develop a drug that would fit the individual with a disease.
00:34:50:05 - 00:35:27:10
Unknown
But now with genetics, it's really to develop a drug that is specific to the genetic composition of that person's disease. Now, from stage, from preclinical, which is mouse studies, you know, that's just really understanding the concept of the drug. But once we move into human populations from phase one through phase three, to look at the safety, the dosing as well as the efficacy of the drug, historically black people are not included.
00:35:27:10 - 00:36:06:06
Unknown
Black women, black men are not included in these trials. So by the time we get to actually rolling that drug out, we are used, we are in the queue to get the drug. But we were never in the development of that drug. And so this is looking at, I found very interesting the participants in trials supported by NIH, National Institute of Health Centers and Institutes tax dollars pay for the National Institute of Health Research in clinical trials.
00:36:06:08 - 00:37:03:12
Unknown
And so if we see here, I'm just going to go here with black African-American. In 2013, we had 12.2% and in 2018 only 13.5%. But yet in whites we have 52.9% and we moved up to 60%. Something's not adding up. And then if we this is all NIH institutes now let's just focus on the National Cancer Institute, NCI, where all of the cancer research takes place that but that's by the government that I get funded for to do my research as an external investigator, if we look at the share of black participants in clinical trials by and I age institutes and this orange right here is the NCI, we see that for black participants it
00:37:03:12 - 00:37:45:01
Unknown
barely ever. If it all goes above 10%, there's a problem because if we're not represented here, but we're given the drug here and post-marketing says the drug is safe and effective, then we have all of these people that don't have have the genes that the drugs were developed for. So while the drug was developed for this person's gene were predominantly they're of European descent within these clinical trials, what do we do?
00:37:45:05 - 00:38:20:06
Unknown
What do black men and women do? So it's the right treatment at the right time for the right person. Pinder When it comes to persons of color, now, one thing is really important to know is that they're trying to move away from race as a proxy for a biological attribute. The new framework for looking at population descriptors and genomics is looking at ancestry, looking at human genetic variation.
00:38:20:08 - 00:38:58:09
Unknown
So making sure you include enough diversity within your clinical trials so you're getting a diverse amount of genetic diversity, which is what we need to make sure we're developing drugs that work for everyone. And when we think about ancestry, it's quite important. This is looking at specifically, sorry, lung cancer and when we look at lung cancer, they're looking specifically at EGFR gene because it's commonly mutated in lung cancer.
00:38:58:11 - 00:39:46:06
Unknown
So this is what is used to target lung cancer patients. So since EGFR is a gene that's commonly mutated drugs, target EGFR, but if you look at ancestry, Africans only have an Africa. We only see 10% of EGFR mutations, whereas if we look at Peru, it's at 50% or East Asia, it's at 50%. So the fact of the matter, this is all based off a ancestry of where you you migrated to, where you were taken, where you evolved to.
00:39:46:08 - 00:40:27:20
Unknown
And this just showcases that while we focus on EGFR as a target for molecular therapy, for lung cancer, for those of African descent, this may not even be helpful with only 10% having this mutation. And that brings me to Dr. Melissa DAVIES. This work, who is now at Morehouse School of Medicine, where she has gotten a $25 million award to really understand the societal, the ancestral, the molecular and the biological analyzes of these inequalities that relate to cancer.
00:40:27:22 - 00:40:55:21
Unknown
And so it's called sambi, and it's going to generate a database that looks at all of these measurements, not in silo, but together to really understand the cause and the influence of disparate cancer outcomes and underserved populations of African descent. And this is going to take place globally such that there is going to be populations of African descent all around the world.
00:40:55:23 - 00:41:38:02
Unknown
Now, let's talk about the social and built environment. We also know that historically structural racism is also associated with how one develops and how one survives breast cancer. This is looking at redlining, which is where historically those who were allowed to live in certain areas that were more prominent versus not. And what was very interesting about this study is that this is looking at white women here, and this is those living in the best versus the most hazardous.
00:41:38:04 - 00:42:20:11
Unknown
And if you look here, you see that. All right. So living in the best neighborhood versus the most hazardous, this point, three four is protective. So white women who were living in areas of structural racism fared better. They have their they have they're less likely to have late stage, less likely to have high grade tumors, less likely to get negative breast cancer, less likely to die, even when we look at still desirable versus hazardous.
00:42:20:11 - 00:43:11:18
Unknown
So still looking at like not living in the best neighborhoods, they still fare better. If we look at definitely declining versus hazardous, it's marginal, but they're still doing better. White women are doing better in areas of historical structural racism as it relates to breast cancer, even than black women. And this is also looking at persistent mortgage discrimination. And it was found that when you look at non-Hispanic black women, higher mortality rates were seen regardless of where they lived, regardless.
00:43:11:20 - 00:43:50:02
Unknown
Whereas for non-Hispanic white women, it was 2.2 times more likely that they die of breast cancer in areas with persistent mortgage discrimination. So in this case, if they were living in a worse environment, white women fared worse, but black women fared worse no matter where they lived. And there's also stress because stress is associated with inflammation, which is a marker for greater cancer risk.
00:43:50:04 - 00:44:28:08
Unknown
We also know there's modifiable risk factors like exercising. But if you are trying to do the best that you can and have and abide by these modifiable behaviors like eat a high fire diet, not smoking, the fact is that racial and ethnic minority populations live in crowded spaces and compared to white individuals, there's a greater proportion of those belonging to these groups and it can actually increase their exposure to cancer risk because of secondhand smoke.
00:44:28:10 - 00:45:12:11
Unknown
Now, there's a lot that people are doing around environmental exposures. And I've talked previously about, you know, the air there's air pollution, there's water pollution. I talked about the environmental injustice of beauty and the fact of being overburdened by chemical exposures based off of your beauty practices and your hair practices. But lastly, you know, there is hope. All the things I just said that are coming from the American Association Cancer Research Progress report, these approaches are being developed and are actually in action to address the drivers of health and reduce cancer disparities.
00:45:12:13 - 00:45:41:12
Unknown
And they're within the realm of three pronged approach policy, community and research. Now, I'm not going to go into each different prong, but the fact of the matter is that each prong from pilot C, like healthy People 2030 and the Affordable Care Act to the community, making sure we have patient navigation and programs that empower patients to make healthier choices.
00:45:41:14 - 00:46:23:21
Unknown
And the research where we're looking at a multiethnic cohort or making sure we're expanding clinical trials to be in underserved communities so that they're not commuting too far to be in a clinical trial. All of this is very important in us reducing the burden of preventable cancer. And when we think about this, this is the panel of people who and there are many others who are involved in this progress report, but I encourage you to look at this progress report because it really does impact our understanding of the biology.
00:46:23:23 - 00:47:08:15
Unknown
How does the biology play a role, how the social drivers of health play a role, and how those structural drivers play a role in understanding the not just understanding, but addressing to mitigate cancer health disparities? Thank you. Woo! wow. Dr. McDonald. I want us to get right into some some questions here and stellar, stellar presentation, so in-depth.
00:47:08:17 - 00:47:39:23
Unknown
I'd love to ask you like one of our questions is, is the is this statistic worldwide or is it a United States statistic? Thick black women have a 40% higher mortality rate from breast cancer than white women. So that statistic is specific for the U.S. where they have like a 4% reduced risk of being diagnosed, but a 40% greater likelihood of dying.
00:47:40:00 - 00:48:05:15
Unknown
And that's for the U.S., because every nation has its own. Like if you go to Europe, some European countries, you're not even allowed to take race into consideration. You can't use black, white. And then if you go to Africa, what you'll see like in Ghana, they'll see it's more geographical. So you'll see urban communities versus the suburban or the farm communities.
00:48:05:17 - 00:48:49:19
Unknown
The urban communities have higher rates. So it really depends on regional, but that statistic is specific for the United States. Okay, I'm reading this one. It says Latina is are also disproportionately impacted by incidence and mortality. Classifying us as white denies the precise data needed. So what are your thoughts on that? Yes. So when they say non-Hispanic Latin X, that is mainly including not the European Spaniard nations, so it's not including Spain, it's because that is true.
00:48:49:19 - 00:49:29:23
Unknown
And Spain goes on how the census goes as white. But if you are from Puerto Rico or the Dominican Republic, a non European Spanish nation, then you fall into Hispanic by the census. Now, what I've experience doing my research in Washington Heights is that many don't define themselves as a race. So when you have a choice, some Dominican women will say that they are Hispanic, but they will not put a race.
00:49:30:00 - 00:50:11:18
Unknown
And that does create challenges. When we're thinking about how we're aggregating this data, are we analyzing this data? Where are our Latina women? And so what we've trying to move towards is intersex and all identities where you can have more than one race, you can have more than one ethnicity, such that you're not pigeonholing people. But I say that that's a very hard thing to do on a national basis because, like I said, epidemiology is for the population and how you identify is where the resources go.
00:50:11:20 - 00:50:42:05
Unknown
So that creates a challenge. But I definitely hear what you're saying, and it's very true. I mean, unfortunately, even when I have to submit information to the end to the National Cancer Institute for my study, I have to say. Unidentified for those Hispanic women who refuse to report their race. So if they selected or is that why we now have the selection of multiracial or biracial or.
00:50:42:07 - 00:51:09:01
Unknown
Yeah, but they are, but they're not, as you can be, multiracial and be so many different things. Right? Right. So really, the multiracial is great, but nationally we need to understand where do the resources need to go? And so that may be by location, that may be by race, it may be by multiracial. But that's what Epidemia is about.
00:51:09:01 - 00:51:52:12
Unknown
They're trying to define you to figure out where the resources need to go. But the defining of people has never been a good thing in our nation. Right. Right. I want to make sure I definitely get to this question. So, you know, we're at share and we have a lot of patient advocates. And for those patient advocates who are white, what are let's see, what efforts can they do to help encourage when they're talking to someone of the black community or Hispanic Latinx community?
00:51:52:14 - 00:52:19:19
Unknown
What are some things that they can do to help encourage them to enroll in a clinical trial? If someone you know who looks like them is not available? Yes. So and that's the challenge because you you really want to know somebody who's been through it, that you they understand your culture. What I would say is, listen, listen to their hesitancy is coming from.
00:52:19:19 - 00:52:44:18
Unknown
That's the first step. But their hesitancy is based off of culture. Then it is your duty to say, okay, well, there is shared Latina that I can connect you with or, All right, I understand that. Let me connect you with this person at this hospital. This other person. Maybe it's travel, you know, maybe it's like I don't I just I can't travel all the way there.
00:52:44:23 - 00:53:12:10
Unknown
Well, then you can address that, because that's not dealing with race or ethnicity whatsoever. So the first thing to me to like, get that cultural divide is to listen to where the hesitancy comes from and try to connect them with that person or that resource to mitigate that hesitancy. Ooh, I like that. Well, I like that. Yes, I had this question as well.
00:53:12:10 - 00:53:42:05
Unknown
Can you explain what quadruple negative breast cancer is? Again, that I honestly I wrote that down as well. I was like, I have never heard that. Yes. So Clayton Yates from Tuskegee University, who's now at Hopkins, looked at the androgen receptor. So when we think these are all hormone receptors, estrogen progesterone, her to knew Herceptin and androgen, we've really just looked at the three.
00:53:42:07 - 00:54:14:12
Unknown
First we just looked at estrogen or you extract the receptor positive or negative and that was it. Then we started looking at estrogen receptor positive progesterone receptor, and then that's where we got the Illumina luminal, B and some other things. And then we learned about Herceptin, which was great because that's how we got the drug. So HER2 knew this to be a very aggressive non surviving disease, but now we have Herceptin.
00:54:14:14 - 00:55:01:02
Unknown
So in your clinic when you get go to get diagnosed, you have those three. In the United States, it's not everywhere. You have those three, you will not be assessed for androgen receptor. But what has been found in research is that those who are lacking the estrogen receptor, the HER2 new receptor, the progesterone sector are also lacking the androgen receptor and it is more likely that when you're missing all four, you're going to be diagnosed at earlier ages.
00:55:01:04 - 00:55:32:16
Unknown
So black women are more likely not. Black women have a higher rate of being diagnosed with triple negative breast cancer, Doing those biologically with children that of breast cancer are more likely to be quadruple negative breast cancer. Ding. Those are quadruple negative breast cancer or more likely to be diagnosed at earlier ages, which all aligns with black women.
00:55:32:18 - 00:56:00:12
Unknown
Because black women are diagnosed more frequently with triple negative breast cancer, and they're diagnosed more frequently at younger ages. So that's a biological. But the point you will not get tested for the androgen receptor in the clinic. It's not standard of care. Okay, goodness, we're getting close to time, but I want to ask just another few questions here.
00:56:00:12 - 00:57:01:24
Unknown
So let's see. I think you covered that. So what what single change do you think can make the biggest difference? And closing the despair cities in and survival outcome gap like what could what could what is a single change that could occur? Racism. But I mean, that's very big. So what I think needs to be put in place is structural policies that work that automatically preclude the ability for you to have racial discriminatory acts when it comes to screening, treatment, survival, and then like clinical trials, like there should be more outreach in the clinical trials because no one organization decides who can be in a clinical trial.
00:57:01:24 - 00:57:40:03
Unknown
It could be Pfizer saying, Hey, Columbia, I'm going to pay you to do a clinical trial. Here's what you have to do. It needs to be diverse. But Columbia then should go into the community, right? Maybe the clinical trial needs to be in the community hospitals and not at the medical center. So it's there's not an organization that decides the people who are conducting the person, the principal investigator of the clinical trial and the protocol that they follow is what designates who gets in like who they're approaching.
00:57:40:08 - 00:58:11:15
Unknown
And then there's other things like sometimes like what it's been is that co-morbidities, like high blood pressure, diabetes, that can exclude you from a trial. And oftentimes that excluded those who were from marginalized communities. So we need to also stop restricting and we need to be inclusive. We need to stop saying male female, like those with a uterus, you know, those are the prostate and such that people feel welcomed and comfortable coming into a clinical trial.
00:58:11:17 - 00:58:38:19
Unknown
So I think it's across the whole continuum, but it's really going to take some of the systemic and structural policies such that it's an expectation and a rule and not just a nice thing to do. Right. And really meeting meeting the people that you're trying to reach, meeting them where they are. Yes, working with them. Okay. So we are actually on a little over here.
00:58:38:21 - 00:59:05:14
Unknown
I'll send you the rest of these questions, everyone. We were just getting lots and lots of questions here, so I'll make sure that those get answered document. Donald, I just want to thank you on behalf of everyone here trending today and who will ultimately listen to the recording. Thank you so much for your time, your expertise, the patient friendly way you explained things.
00:59:05:14 - 00:59:12:14
Unknown
Thank you so much. This is so in-depth, everyone. I just have one more question. What are like the
00:59:12:14 - 00:59:35:10
Unknown
the biggest takeaways for patients with this presentation? What you want them to take away? You know, today I want you to take away that, you know, breast cancer survivorship is something that you will see disparities in. But these disparities now that you see them and you know them, you can look out for them.
00:59:35:12 - 01:00:02:12
Unknown
So when you're getting clinical care or getting medication or interested in a clinical trial, make sure you're expressing your voice and not just taking things. Status quo, because these disparities do exist even at the survivorship phase. So being like knowledgeable and holding that and then fight for your equity and getting what you need.
01:00:02:12 - 01:00:05:10
Unknown
Thank you so, so much,
01:00:05:10 - 01:00:22:13
Unknown
Also, make sure to check out Cher's website for upcoming educational programs, podcast episodes and support groups. And don't forget to follow us on social media as well. And please take a moment to complete our survey. That's at the end of our webinar.
01:00:22:13 - 01:00:49:03
Unknown
The survey will pop up in the browser when we end the webinar, and the link will also be sent in our follow up email as well. And all surveys are anonymous. Everyone, this concludes our presentation and thank you again. Dr. McDonald. You're amazing and I hope everyone has a great rest of your day and week. Thank you. Bye bye bye.