Regular mammograms are key to early detection

Breast cancer affects one in eight women in the U.S. and is the second most common type of cancer diagnosed in women, after skin cancer.

The good news is that breast cancer death rates slowly fell each year from 2008 to 2017. But more screening could help those rates drop faster.

How it happens

Breast cancer happens when cancerous cells form in the breast tissue. Health experts don't know exactly why cancerous cells form in the breast in some women but not others. However, they do know some of the risk factors, such as older age, smoking, and a family history of the disease.

Estimating risk

Some women who don't seem to have common risk factors may still develop the disease, while other women with a known risk factor may never develop it. This is why regular screening, such as mammograms, is key. Treatment for breast cancer is most effective and provides the best chance of survival when the disease is caught early.

Screening rates

Screening rates are increasing in some groups of women in the U.S. But for other groups, the rates are declining. According to the National Cancer Institute, screening rates have increased slightly among Hispanic women, but have dropped among other groups, including Asian women, women in rural areas, and women with public health insurance or no health insurance.

Who is more likely to get it?

• Breast cancer is most common in middle-aged and older women.
• Women aged 45 to 54 make up nearly 20% of new cases. Women aged 55 to 74 make up 51% of new cases.
• The rate of new cases of breast cancer is highest in white women, followed by African American women. Breast cancer death rates are highest for African American women—40% higher than for white women.

How to lower your risk

The key is to get regular exams and screening. You can't do much about risk factors like age or family history of breast cancer. But there are other things you can do. These include:

• Controlling your weight. Those who are obese have a 20% to 40% higher risk of developing breast cancer compared with women whose weight is in the normal range.
• Limiting alcohol. Even one daily drink can raise your risk.
• Getting regular exercise.
• Quitting smoking.

In the United States, women from diverse racial and ethnic groups continue to suffer from breast cancer disparities. African American and Hispanic/Latino women, in particular, experience a great burden from breast cancer (in incidence and mortality) compared to the general female population in the U.S.

For example:

• African American women diagnosed with breast cancer are less likely to survive five years after diagnosis (their survival rate is 71% compared to 81% survival rate of non-Hispanic White women).
• Breast cancer is the leading cause of cancer death among Hispanic and Latino women.

October 2, 2019, by NCI Staff

Men may be more likely than women to die after being diagnosed with breast cancer, particularly during the first 5 years after diagnosis, a new study suggests.

In the study, the 5-year overall survival rate after a diagnosis of breast cancer was 77.6% for men, compared with 86.4% for women, researchers reported in JAMA Oncology on September 19.

The findings add to previous research showing differences in death rates between men and women with breast cancer while also providing information about some of the factors that may contribute to the disparity between the sexes.

One factor identified by the authors was the lack of adequate treatment for many men with breast cancer, a phenomenon known as undertreatment. Another was the later diagnosis of the disease in men than in women.

Differences in clinical characteristics, such as the types and stage of breast tumors, age at diagnosis, and cancer treatment between men and women with breast cancer played a major role, accounting for 63% of mortality disparity, the researchers reported. However, after all those factors were accounted for, male patients still had 19% higher chance of dying than female patients within 5 years of diagnosis.

“We were not able to investigate other known or suspected contributors for the disparity in death rates in this study, such as compliance to cancer treatment, tumor genetics, and lifestyle factors, such as obesity, smoking, and alcohol use,” said Xiao-Ou Shu, M.D., Ph.D., of Vanderbilt-Ingram Cancer Center, who led the research.

“If we want to learn more about why outcomes of male breast cancer differ from those of female breast cancer, then we need more studies that focus on men with the disease,” Dr. Shu continued. These studies should include multiple outcomes, such as cancer remission, recurrence, and death rates from breast cancer and all causes, she added.

Focusing on Men with Breast Cancer

Fewer than 1% of breast cancers diagnosed each year occur in men, noted Alexandra Zimmer, M.D., of the Women’s Malignancies Branch in NCI’s Center for Cancer Research, who was not involved in the study.

“So far, we have been mostly lumping men with breast cancer and women with breast cancer in clinical trials and evaluations,” Dr. Zimmer said.

As a result, the treatment of male breast cancer has largely been based on studies involving women with the disease, she continued.

“The results of this retrospective study suggest that men with breast cancer deserve dedicated studies that will help us to better understand the biology of the disease in males,” Dr. Zimmer said.

Higher Death Rates, Later-Stage Cancers

To conduct the analysis, Dr. Shu and her colleagues used information from the National Cancer Database to compare death rates for 16,025 men and 1,800,708 women who were diagnosed with breast cancer between 2004 and 2014.

The National Cancer Database, which is sponsored by the American College of Surgeons and the American Cancer Society, includes more than 70% of newly diagnosed cancer cases in the United States.

In the study, men had higher death rates than women across all stages of breast cancer, even after the researchers adjusted for differences in patients’ clinical characteristics, such as the type and stage of disease, treatments received, age, race/ethnicity, and access to care.

In addition, the study found that a larger percentage of men than women were diagnosed with advanced-stage disease, which the researchers said could be attributed to a lack of awareness of and screening for breast cancer in men.

A higher percentage of men than women in the study had stage IV breast cancer at diagnosis (5.8% versus 3.8%), for example.

Despite having more aggressive disease overall, male patients were more likely than women to be undertreated, the researchers found. For instance, men were less likely than women to receive radiation therapy, including those who had breast-conserving surgery.

Clinical characteristics and undertreatment explained only about two-thirds of the difference in mortality. “Hopefully, future studies will be able to identify additional factors,” said Dr. Shu.

Unanswered Questions

As with all retrospective studies, Dr. Zimmer noted, the analysis had limitations. For example, the researchers lacked detailed information about treatment, such as which types of chemotherapy had been used.

What’s more, the National Cancer Database does not include information about the cause of death or the recurrence or progression of cancer.

“This study should be used mainly as a way to generate hypotheses for further studies, rather than to establish any firm conclusions at this point,” said Dr. Zimmer.

One of the messages of the study for men who are experiencing symptoms of breast cancer, she continued, “is to look for help and to consider treatment as soon as possible.”

February 26, 2021, by Nadia Jaber

The Oncotype DX test, which helps guide treatment decisions for women with early-stage breast cancer, may be less accurate for Black women than for non-Hispanic White women, a new study suggests.

The test measures how aggressive a woman’s breast cancer is and helps her and her doctor decide if she should get chemotherapy after surgery. Oncotype DX works by looking at the activity of a group of genes in the tumor and calculating a score between 0 and 100. The score predicts the risk of the cancer coming back, which can help gauge the patient's risk of dying from breast cancer.

The new study showed that, overall, Black women had higher Oncotype DX scores than White women. And among women with similar scores, Blacks were more likely than Whites to die of breast cancer. The researchers also determined that the test was not as good at predicting the risk of breast cancer death for Black women, according to the results published January 21 in JAMA Oncology.

These findings “raise the question of whether the test is less accurate [at] identifying which [Black] patients need chemotherapy,” noted the study’s leader, Kent Hoskins, M.D., of the University of Illinois at Chicago.

Dr. Hoskins and his colleagues are currently exploring that question. But until then, current medical practices for recommending chemotherapy based on Oncotype DX scores shouldn’t change, he said.

“The larger message here,” Dr. Hoskins stressed, “is that as we develop new tests like this, it’s really important that the study populations have greater racial diversity because there really can be differences that influence the performance of these tests.”

“That’s a broader problem in biomedical research in general—underrepresentation of racial and ethnic minority groups,” he added.

Does Oncotype DX Work for Everyone?

The Oncotype DX test is widely used to guide treatment decisions for people with a type of early-stage breast cancer, known as ER positive or hormone receptor positive.

But relatively few Black women participated in the studies that were done to develop and validate the test, Dr. Hoskins explained. That made the researchers wonder how well the test actually performs in Black women, he said.

The team looked at data from a specialized database developed by NCI’s Surveillance, Epidemiology, and End Results (SEER) Program. The database includes information on more than 86,000 breast cancer patients from across the country who had Oncotype DX test results available. About 74% were White, 8% were Black, and 9% were Hispanic. All of the women had early-stage ER-positive breast cancer.

Black women were more likely than non-Hispanic White women to have a high score (greater than 25) on the Oncotype DX test, the scientists found. But even after taking into account age, tumor size, and whether there was cancer in the lymph nodes—factors that are linked with more aggressive breast cancer—Black women were still more likely to have a higher Oncotype DX score.

That finding “tells us that Black women, for unknown reasons, develop biologically more aggressive tumors. We don’t know why that is and that’s one of the areas we’re investigating,” Dr. Hoskins noted. NCI’s Breast Cancer Genetic Study in African-Ancestry Populations is also exploring how genetics and biology contribute to breast cancer outcomes among Black women.

Tumor characteristics (such as certain genetic changes or immune system changes) that might occur more frequently in Black women may be missed by Oncotype DX because the test was developed using very little information from Black patients, pointed out Christopher Li, M.D., Ph.D., of Fred Hutchinson Cancer Research Center, an expert on breast cancer disparities who was not involved in the work.

Biggest Disparity for Lowest Risk Cancers

Oncotype DX scores are grouped into three categories that reflect a patient’s risk of their cancer returning. Scores under 10 indicate a low risk, while those between 11 and 25 are intermediate risk, and scores 26 and above are considered high risk.

Most patients with low and intermediate risk scores get hormone therapy after surgery, whereas those with high scores get chemotherapy in addition to hormone therapy.

Within all three risk groups, Black women were more likely than Whites to die of breast cancer during the follow-up period (a median of 4.5 years), the research team found. This pattern was seen only in women with breast cancer that hadn’t spread to the lymph nodes (what’s known as node-negative breast cancer).

Although there seemed to be no racial or ethnic differences in breast cancer death rates for women with cancer that had spread to the lymph nodes, there wasn't enough data in this group to make a firm conclusion, Dr. Hoskins said.

For women with node-negative breast cancer, Blacks with low risk scores were more than twice as likely to die of breast cancer than Whites with low risk scores. Black women with intermediate or high scores were also more likely than Whites with similar scores to die of breast cancer, but the difference was slightly smaller (1.6 and 1.5 times more likely to die, respectively).

These results partially confirm preliminary findings from the TAILORx trial, a clinical study of more than 10,000 women who received breast cancer treatment based on Oncotype DX test results.

Dr. Hoskins and his colleagues also calculated how well Oncotype DX predicts the prognosis—specifically the risk of breast cancer death—for women with node-negative breast cancer in each racial/ethnic group. They found that the test had a lower accuracy for Black women than White women, meaning it was not as accurate at predicting death from breast cancer.

This finding suggests that the test may need to be “recalibrated” for Black patients, Dr. Hoskins explained. It’s possible that further studies may find that there “should be different cut points for recommending chemotherapy in racial/ethnic minority women,” he said.

Real World Data

Using NCI’s SEER database is a strength of the study because it captures data from the real world, Dr. Li noted.

But a caveat is that the database has only tracked participants for about 4.5 years, noted Joseph Sparano, M.D., and Otis Brawley, M.D., in an accompanying editorial. That’s a relatively short amount of time, Dr. Hoskins agreed, because ER-positive breast cancer can return up to 20 years after surgery.

Another limitation is that the database didn’t include information on whether the women took hormone therapy as prescribed. Studies have shown that Black women are more likely to skip doses of or stop taking hormone therapy, which can affect the risk of cancer recurrence and death from cancer.

The Root of Breast Cancer Disparities

There are many glaring differences between the outcomes of Black and White women with breast cancer. For example, Black women are more likely to be diagnosed with advanced cancer and to die from it.

This study “adds an additional layer to our understanding of breast cancer disparities,” Dr. Li said. “But we have yet to understand what factors are contributing to the differences observed,” he added.

The conditions where people are born, live, work, and play (known as the social determinants of health) “are clearly the root causes of health disparities and undoubtedly play a role in why we saw that mortality disparity in the study,” Dr. Hoskins said.

Greater poverty and segregation in communities, institutional racism, and limited access to high-quality medical care all contribute to unequal health outcomes for Black Americans, Drs. Sparano and Brawley noted. For breast cancer in particular, these factors can make it more likely for Black women to delay or stop treatment.

Biology and genetics likely contribute to breast cancer disparities, as well, the editorialists wrote. For example, women of African heritage have higher rates of certain side effects from chemotherapy, leading them to take lower doses.

Dr. Hoskins and his colleagues are delving into some of these possibilities. They’re currently taking a closer look at social determinants of health to see how they might be influencing Oncotype DX scores.

December 21, 2021, by Nadia Jaber

Although there have been significant improvements in cancer treatment and prevention through the years, a stark reality remains: In many communities, Black people with cancer don’t live as long as White people with the disease.

A collaborative group is tackling this problem head on, making system-wide changes in how cancer centers manage patient care to directly address some of the key drivers of this disparity. A recent study showed that their approach has the potential to help shrink differences in how long Black and White patients with early-stage lung and breast cancer live.

The potential benefit, the study showed, even goes beyond that, by improving survival for all patients with these two cancers.

Experts largely agree that the biggest reason for the long-standing difference in survival is structural and cultural barriers—such as difficulties affording co-pays on medicines and poor communication about treatment side effects—that make it harder for Black patients to complete their cancer treatment. So, the group created a comprehensive program that proactively identified and addressed structural and cultural barriers for every patient.

The program, called Accountability for Cancer through Undoing Racism and Equity (ACCURE), put “systems in place that act as safety nets to help make sure no patient falls through the cracks, whether they are Black or White,” said one of the study leaders, Matthew Manning, M.D., a radiation oncologist at Cone Health Cancer Center in Greensboro, North Carolina.

The group had previously shown that ACCURE helped Black and White patients complete cancer treatment at equal rates. New data from the study suggest that the approach may narrow differences in 5-year survival rates between Black and White patients with breast or lung cancer.

“Other research projects have addressed what can be changed in vulnerable communities or what health behaviors can be changed by individuals,” said Christina Yongue, M.P.H., a former project manager for ACCURE and a professor at the University of North Carolina Greensboro. The novelty of ACCURE, she said, is that it intentionally addresses the changes cancer centers can make within their own institutions to ameliorate racial disparities.

“It’s a moment of awakening that we can make a difference to improve the quality of care that patients receive,” she said.

Ms. Yongue and Dr. Manning reported the findings at the American Society for Radiation Oncology and American Public Health Association annual meetings on October 25.

A multilevel approach to tackling cancer disparities

ACCURE’s beginnings grew out of the Greensboro Health Disparities Collaborative, a diverse group of leaders from the Greensboro community who conduct research and create programs to make health outcomes more equal by race. In the late 2000s, the organization led focus groups with community members to identify barriers to cancer care and to brainstorm potential solutions.

“ACCURE was an implementation of those solutions,” Dr. Manning said. In addition to experts from the Greensboro Health Disparities Collaborative, the NCI-funded study involved researchers and staff from Cone Health Cancer Center, the Universities of North Carolina at Chapel Hill and Greensboro, the University of Pittsburgh Medical Center, and Sisters Network Greensboro.

The intervention included three main parts to improve the rate of treatment completion. The first was a set of nurse navigators who were trained to understand and respond to the struggles Black patients often face, such as mistrust of the medical establishment, miscommunication with their doctors, limited access to transportation, financial hardships, and difficulties taking time off work. These navigators met face to face with each participant several times during the study.

Second, a program was created to alert these nurse navigators in real time if a patient missed an appointment or didn’t meet an expected treatment milestone (such as surgery within 90 days of their first appointment). A nurse navigator then acted as a patient advocate to see what issues the patient was facing and if they could be resolved with available resources, such as free transportation to and from appointments; telehealth visits; rescheduling appointments; advice on pain management; or financial assistance for utilities, rent, or gas.

And third, to enhance accountability, clinical teams were updated monthly on the rates of treatment completion among Black and White patients. That’s a shift from the cancer centers’ standard practice of viewing outcomes individually or independent of race, Ms. Yongue explained.

Many studies focus on single barriers to care, “but this was a multilevel intervention study that explored patient and provider factors in real time in order to make the necessary adjustments,” said Veronica Chollette, R.N., of NCI’s Health Systems and Interventions Research Branch, who oversaw ACCURE’s funding and progress.

Improving survival for everybody with cancer, regardless of race

The new analysis included more than 1,400 people who had been diagnosed with early-stage breast or lung cancer between 2013 and 2015 at a Cone Health facility, and who participated in ACCURE. For comparison, the researchers looked at the outcomes of about 2,000 patients with early-stage breast or lung cancer who had been treated between 2007 and 2011 and who did not participate in ACCURE.

To see if the intervention helped Black patients live as long as White patients, the team looked at the percentage of patients who were still alive 5 years after their diagnosis.

Before ACCURE was introduced, there were small differences in the
5-year survival rates between Black and White people with lung and breast cancer (2% for breast cancer and 6% for lung cancer). With the implementation of ACCURE, survival rates increased for both Black and White people. In addition, the small gaps in survival rates between Black and White patients seemed to shrink (to 0% for breast cancer and 2% for lung cancer).

The study groups were not big enough to show a statistically significant difference in survival rates between Black in White patients before ACCURE, Dr. Manning noted.

But given that the survival rates for Black patients substantially improved with ACCURE, the team believes the intervention has the potential to resolve survival disparities. A larger study would be needed to confirm that, Dr. Manning added.

Addressing barriers to cancer treatment

Most cancer centers have resources to help patients, such as taxi vouchers and assistance paying bills, Dr. Manning explained. But the centers often don’t know which patients need these resources until they’ve already fallen off track.

“What ACCURE did was make it standard operating procedure to identify what those barriers are for everyone. That way we didn’t have to be reactive—we could be proactive,” he said.

The old way of doing things also put the blame on the patient, Ms. Yongue said. Those who frequently missed appointments or didn’t complete treatment used to be called “noncompliant patients,” Dr. Manning added.

“If we can look at it at the institutional level, rather than blaming individual patients, then it changes the conversation,” he said. “I think ACCURE helped to show us that that can be successful.”

Beyond cancer, the team is confident that this sort of approach could help resolve long-standing racial disparities in other areas of medicine, such as diabetes, hypertension, and pregnancy and childbirth complications.

Ms. Chollette agreed. The approach “could be modified to local needs and tailored to address health disparities observed with other cancers,” she said.

For example, she continued, “rural populations are quite challenged with adherence to care due to structural, geographic, and environmental barriers. I think this model could be applied to rural areas where we are seeing health disparities in cervical cancer including low HPV vaccine uptake.”

The ACCURE model is already being adopted in other parts of the country. The study researchers are currently helping various health institutions and private corporations design similar programs to address disparities in their communities.

December 6, 2021, by Elia Ben-Ari

Researchers have developed a new tool to estimate the risk of breast cancer in US Black women. The team that developed the tool hopes it will help guide more personalized decisions on when Black women—especially younger women—should begin breast cancer screening.

Compared with White women, Black women in the United States are younger at diagnosis, on average, and are more likely to be diagnosed with aggressive or advanced forms of breast cancer. They also are more likely to die from breast cancer than women of all other racial and ethnic groups.

These disparities, or inequalities, are thought to reflect the interplay of many factors, from tumor biology to matters like income, diet, access to quality health care, and other factors related to systemic and structural racism.

Called the Black Women’s Health Study Breast Cancer Risk Calculator, the new tool uses information on a woman’s medical, reproductive, and family history to estimate her chance of developing breast cancer over the next 5 or 10 years. This information is gathered from an online questionnaire that a woman and her health care provider can complete together.

Like other questionnaire-based breast cancer risk models, the new model is only moderately good at predicting whether or not an individual woman will go on to develop breast cancer, the researchers cautioned.

But it “could help guide decisions about whether Black women should consider screening for breast cancer [starting] at age 40 versus 50, or even earlier [than 40] if they have very high risk,” said Anne Marie McCarthy, Ph.D., of the Perelman School of Medicine at the University of Pennsylvania, who was not involved in the research.

“A major goal is for younger Black women to have a chance to have breast cancer detected and treated at early stages, so that fewer will die of the disease,” said Julie Palmer, Sc.D., of Boston University School of Medicine, who led the effort to develop the new model.

Published October 8 in the Journal of Clinical Oncology, the NCI-funded effort builds on previous models that estimate breast cancer risk in Black women, in large part by including additional risk factors.

Most existing models for calculating a woman’s risk of breast cancer were developed and tested with data mainly from White women and don’t work as well for Black women, Dr. Palmer said. “But for a long time, there weren’t enough data out there to develop and test a robust model for predicting breast cancer in Black women.”

“This [tool] helps address a critical gap in breast cancer risk prediction,” said Emily Conant, M.D., chief of breast imaging at the Hospital of the University of Pennsylvania, who was not involved with the work.

Developing the Risk Calculator

There is a lot of confusion about when women should be assessed for their risk of breast cancer and when they should begin screening for the disease, Dr. Conant explained. Existing guidelines from medical groups vary in the age at which they recommend starting screening: Some advise starting at age 50, while others recommend beginning at age 45 or 40.

All guidelines, however, emphasize the need for patients and their health care providers to talk through these issues—known as shared decision-making—especially for women younger than 50.

The new risk model is intended to help inform these discussions for Black women and their providers, Dr. Palmer and her colleagues explained.

To develop the model, they used data from US Black women who had participated in three large population-based studies of breast cancer. About half of the women in each study self-identified as Black. The studies, which compared women who developed breast cancer with those who did not, collected information on risk factors, such as a family history of other cancer types and whether a woman breastfed her children.

The team then tested the model’s performance using 15 years of health data from nearly 52,000 participants in the Black Women’s Health Study, an ongoing study co-led by Dr. Palmer.

Overall, the ability of the new model to predict the likelihood that an individual Black woman would develop breast cancer was similar to that of the most commonly used models for predicting breast cancer risk in White women. The new model performed best for Black women under age 40. And these younger women are most in need of a personalized tool to guide decisions about screening, Dr. Palmer said.

In addition to estimating an individual woman’s 5- and 10-year risk of developing breast cancer, the online risk calculator provides information on the average risk for US Black women of the same age.

“Women with a family history of breast cancer are especially concerned about risk, and this model could be used to help put their risk in context,” said Ruth Pfeiffer, Ph.D., a risk prediction expert in NCI’s Division of Cancer Epidemiology and Genetics (DCEG), who helped develop the new model.

The model could also be used to identify Black women who are eligible to participate in studies of ways to prevent breast cancer in women at very high risk of the disease, Dr. Palmer said.

When these studies are launched, “we want to make sure that good tools [to identify potential participants of all races and ethnicities] are available to researchers developing those studies, so that those most likely to benefit have a fair chance to be included,” she explained.

In addition, Dr. Palmer and her colleagues wrote, the model could guide decisions on whether to refer some Black women for genetic testing that looks for inherited changes known to increase the risk of breast cancer.

Room for Improvement

Unfortunately, “many primary care doctors don’t use questionnaires that predict breast cancer risk because they have so many demands on their time,” Dr. Palmer said. “But breast cancer is life changing for young women who get the disease, and many young Black women are diagnosed with and die from it before they reach the ages at which screening is typically recommended," she continued. “We’re hoping that primary care practices will start using the new tool to identify those who might benefit from earlier screening.”

In the future, Dr. McCarthy said, an online version of a questionnaire such as the one used in the new study might be built into an electronic health record. Then, to save time, a woman could fill out the questionnaire online before her appointment and the doctor could easily review the results in her record.

“We still have a long road ahead to develop better models for all women,” Dr. Pfeiffer said. “Right now, the big hope for [improving] risk prediction is to incorporate information on genetic markers that are associated with increased risk.”

Along those lines, DCEG is conducting the Confluence Project in collaboration with multiple breast cancer consortia to analyze genomic data from 300,000 women with breast cancer and 300,000 without, including women of different races and ethnicities. A parallel effort is the NCI-funded Breast Cancer Genetic Study in African-Ancestry Populations. Data from the two studies will be used to develop and validate risk scores based on inherited genetic changes that can then be integrated into this model as well as into future models that will be developed through a more recent NCI-funded project.

Risk models could also be improved by including information on the amount of dense breast tissue an individual woman has, which is a known risk factor for breast cancer, Dr. Conant said. However, that would require having at least one previous mammogram.

Achieving Equity in Breast Cancer

Dr. Palmer and others agree that screening is just one part of addressing disparities in breast cancer. “Patient navigation programs, as well as cultural competency training for providers, can lead to more equitable access to optimal cancer care for Black women, a major factor in mortality disparities,” she said.

Other researchers are also using modeling to help develop more equitable care. A recent study used computer models to try to identify equitable screening mammography strategies for Black women in the United States. The findings suggest that screening Black women with mammograms every 2 years starting at age 40 is the best strategy for reducing disparities in breast cancer deaths.

But ideally, researchers agreed, decisions on when to start screening should be made on a more individual basis rather than based only on someone’s age.

Dr. Pfeiffer noted that two large ongoing studies are comparing the effectiveness of breast cancer screening based on current guidelines versus a woman’s individual risk. They are the Women Informed to Screen Depending on Measures of Risk (WISDOM) study in the United States, which is funded in part by NCI, and the international My Personalized Breast Screening study.

“This [new model] is one step toward personalized cancer prevention, which includes detecting disease early to improve health outcomes,” Dr. Pfeiffer said. We talk about tailoring cancer treatment, but we should tailor prevention, too.”

Early and increased clinical trial participation can help

 Worta McCaskill-Stevens, M.D., M.S., studies breast cancer's impact on diverse populations.

Worta McCaskill-Stevens, M.D., M.S., has spent much of her career advancing research that supports women with breast cancer, and the inclusion of underrepresented and underserved populations in clinical trials.

At the National Cancer Institute (NCI), Dr. McCaskill-Stevens explores how race impacts cancer outcomes, especially in African American women, who are 40% more likely to die from breast cancer than white women.   

As part of her work, Dr. McCaskill-Stevens helps oversee NCI breast cancer studies throughout the country. Most recently, she and her team at NCI helped launch a nationwide screening trial for breast cancer patients. They hope to better understand whether 3D mammography is better at diagnosing advanced breast cancers than the current 2D technology.

Why is this new screening trial so important? 

We haven't had a screening trial for decades. Women are being asked whether they want to have a new 3D mammogram instead of the older 2D one. We don't have the evidence that the more expensive [3D] technology is really better. This trial will help women make more informed decisions. It will look at whether 3D mammograms are better than 2D ones at finding advanced, life-threatening cancers over five years of screening. The trial will also provide us with more data to compare the risks of the two technologies. This includes whether a 3D mammogram's more complete view of the breast results in fewer or more false positives [when results say there is cancer when there actually isn't] than 2D does. If there's no difference, there would be limited data to support using the more costly screening procedure. 

Why are there continued differences among racial groups in breast cancer outcomes?

The racial disparity in terms of breast cancer death is continuing. African American women are about 40% more likely to die from breast cancer compared with white women, even though white women get breast cancer at a higher rate than African American women. Less access to medical care is a significant issue for African American women. They come into treatment very late in the disease, and their rate of aggressive, triple-negative breast cancer—the subtype with the poorest prognosis—is higher than in other racial groups.  

More minorities are being represented in clinical trials of breast cancer treatments. Why is that important? 

"African American women are about 40% more likely to die from breast cancer compared with white women."

- Worta McCaskill-Stevens, M.D., M.S.

It's very important. One of the reasons I came to NCI as a breast oncologist was to be able to look at racial disparities and see the differences in risk, screening, treatment, and survivorship. We are seeing that African American women's participation in breast cancer trials has increased. The trials have also changed. There are fewer very large trials and more focus on subtypes of cancer that are more aligned with higher incidence rates among African American women, especially triple-negative breast cancer. I am also encouraged that these women are joining the trials, because data suggest early treatment is more effective, especially for aggressive cancers.

Hispanic and Latina women have a lower death rate from breast cancer than white women, but breast cancer is still the leading cause of cancer deaths for those groups. Hispanic women and the general Hispanic population are younger than other racial and ethnic populations. Knowledge about screening, language barriers, and access to care are important factors to consider when thinking of Hispanic women. Communication to Hispanic women needs to consider the fact that it is a very diverse population with differences based upon country of origin and past knowledge about breast cancer.

NCI note: NCI places a high priority on answering the questions about optimal breast cancer screening and management, and has a working group to review accrual to the trial mentioned in this article, Tomosynthesis Mammographic Imaging Screening Trial (TMIST). During this review, the trial is fully open, both for women who are already participating and those who are interested in enrolling. New screening sites continue to open. NCI thanks the women who are and will be enrolled in TMIST for their participation.