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Breast Cancer Awareness: doing more to eliminate disparities across race and class

Thu, Nov 1, 2012

Breast cancer rates have been falling in the United States over the last two decades but the American Cancer Society (ACS) says we can do better in reducing disparities across race and socioeconomic status.

This year in the United States, there will be an estimated 226,870 new cases of invasive breast cancer among women (and about 2,190 among men), according to the ACS Cancer Facts & Figures 2012. In Illinois, the estimate is 9,090 new cases of female breast cancer.

Meanwhile, deaths this year from female breast cancer are estimated at 39,510 across the U.S. and 1,650 in Illinois.

The incidence rate of breast cancer is 121.4 per 100,000 American women, down from a peak of 142 per 100,000 women in 1999. The ACS attributes the decrease to fewer women on menopausal hormone replacement therapy after publication of the Women’s Health Initiative study in 2002; this study linked the use of combined estrogen and progestin to an increased risk of breast cancer and coronary heart disease. Breast cancer rates have been stable for 2004-08, the most recent five years for which data are available.

Since 1990, the bigger drop in death rates has been among younger women. The latest five-year period shows a decrease of 3.1 percent per year in women younger than 50 but just 2.1 percent in women over 50, according to the ACS. “The decrease in breast cancer death rates represents progress in earlier detection, improved treatment, and possibly decreased incidence.”

Detected in its earliest stages, for example, breast cancer’s five-year survival rate is 93 percent; if found in its latest stage, the rate is only 15 percent. Those whose cancers are found late – when treatment is more extensive and more costly – are likely uninsured patients, or underinsured patients, from ethnic minorities. While only 1 in 10 non-Hispanic whites lack health coverage, 1 in 5 African-Americans and 1 in 3 Hispanics/Latinos are uninsured.

So it is not surprising that among uninsured women age 40 to 64 (too young for Medicare), only 36.4 had a mammogram in the past year, compared to 60.7 percent of their counterparts with health coverage. Adequately funding the Affordable Care Act is therefore a priority, ACS notes.

Obamacare aids prevention and early detection because all new insurance plans must cover “essential evidence-based preventive measures with no additional copays,” says Cancer Facts & Figures 2012. Other helpful facets of the legislation include:
- elimination of arbitrary annual and lifetime caps on coverage;
- ending discrimination based on preexisting conditions;
- increasing funding for community health centers;
- requiring qualified health plans to provide materials in appropriate languages.

Still other provisions of the Affordable Care Act include prioritization of health disparities at the National Institutes of Health; establishment of a National Prevention and Health Promotion Strategy; and a requirement that chain restaurants provide calorie and other nutrition information on menus.

Another state and federal priority for the ACS is the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Since 1991 this program has provided community-based breast and cervical cancer screening to low-income, uninsured and underinsured women, more than half from racial and ethnic minorities. Large funding cuts, however, have reduced screening rates since 2007. “Current funding allows the program to serve fewer than 1 in 5 eligible women aged 50 to 64 nationwide.” However, the ACS sees this program improving breast and cervical cancer screening among vulnerable people alongside the still-new Affordable Care Act. Its Cancer Action Network asked Congress to increase NBCCEDP funding to $275 million for fiscal 2013.

Increased early detection of breast cancer is one facet of the American Cancer Society’s 2015 Challenge Goals:
- a 50 percent reduction in cancer mortality,
- a 25 percent drop in cancer incidence,
- improved quality of life (physical, psychological, spiritual) for people with the disease.

The challenge objective specifically aimed at breast cancer would seek to raise the proportion of American women over 40 who have annual breast cancer screenings to 90 percent. Mammography usage has not changed significantly since 2000.

Other challenge objectives seek to minimize risks for the full range of cancers. They offer guidelines for sun protection, for reduced tobacco use, for better nutrition, for more physical activity, for more health education in school districts and for more early detection of colorectal and prostate cancers.

The challenge goals are comprehensive because they aim at life-changing habits for large segments of the population.

“One of the overarching themes of the American Cancer Society’s 2015 challenge goals is eliminating disparities in the cancer burden between different segments of the US population,” says the ACS 2011 stewardship report. “The causes of these health disparities are complex and interrelated, but likely arise from education, housing, and overall standard of living; economic and social barriers (such as a lack of health insurance) to high-quality cancer prevention, early detection, and treatment services.”

The report acknowledges the impact of racial and ethnic discrimination, as well as language barriers and cultural issues of immigrants.

People of lower socioeconomic status are also at higher risk of cancer because of lifestyle: tobacco use, physical inactivity, poor diet, “in part because of marketing strategies that target these populations and in part because of environmental or community factors that provide fewer opportunities for physical activity and less access to fresh fruits and vegetables,” says Cancer Facts & Figures.

Healthy food and physical activity come into play because overweight and obesity are factors in an estimated 14 to 20 percent of all cancer deaths in the U.S. “Abdominal fatness is convincingly associated with colorectal cancer, and probably related to higher risk of pancreatic, endometrial and postmenopausal breast cancers.”

Meanwhile, obesity affects more than 1 in 3 Americans – 72 million people – which officials say has impacted progress toward the 2015 Challenge Goals. According to Cancer Facts & Figures 2012, “American Cancer Society researchers reported that while the incidence of both colorectal cancer and postmenopausal breast cancer had been declining, it is likely the declines in both would have started earlier and would have been steeper had it not been for the increasing prevalence of obesity.” Physical activity, however, may reduce cancer risk because it reduces circulating concentrations of estrogen.

Family history is one constant risk factor regardless of income level. Inherited mutations, or alterations in breast cancer susceptibility genes, account for five percent to 10 percent of all male and female cancers. Most of these mutations are located in the BRCA (BReast CAncer susceptibility) 1 and BRCA 2 genes, although several other rarer genes also have been identified.

BRCA 1/2 mutations can be inherited from both the mother’s and the father’s side of the family. Among the overall U.S. population, only 1 in 800 to 1 in 400 carry the BRCA1/2 mutation, according to Susan G. Komen for the Cure. However, among Ashkenazi Jewish people with roots in Eastern Europe, 1 in 40 carry the gene.

Women with the BRCA1 gene have a 60 to 90 percent chance of developing breast cancer by age 70, and BRCA2 carriers a 40 to 85 percent chance, according to Komen for the Cure. The comparison risk for an average American woman is eight percent by age 70.

Between 8.3 and 10.2 percent of Ashkenazi Jewish people carry the BRCA1 gene, but they are not alone. The gene also shows up in 3.5 percent of the Hispanic population; 2.2 to 2.9 percent of Caucasian (non-Ashkenazi Jewish) people; 1.3 to 1.4 percent of African-Americans and 0.5 percent of Asian Americans.

BRCA2 is carried by 2.1 percent of Caucasians and 2.6 percent of African-Americans. Norwegian, Dutch and Icelandic people also have higher percentages of both genes, according to the National Cancer Institute.

Finding the gene in new ethnic groups was a surprise to researchers, according to a report in the Journal of the American Medical Association (JAMA) carried on the Medical University of South Carolina web site.

“We found that the Hispanic women had a higher prevalence of the harmful BRCA1 mutation than white women, and the highest prevalence was among young African-American women,” said study author Esther John, PhD., a research scientist at the Northern California Cancer Center in Fremont, Calif. Among all African-American women the rate of the mutation was 1.3 percent, but for those under 35 who had breast cancer, the rate was 16.7 percent, Dr. John’s group found.

Speculation about the mutation among Hispanic women focuses on Sephardic Jews who settled in Spain and may have shared the mutation with Ashkenazi Jews. While the overall rate of the mutation is low among African-Americans, the finding could explain why the disease that young African-American women get is such an aggressive form of cancer, which is consistent with BRCA1 mutations.

Dr. Christine Pellegrino, a breast cancer specialist at Montefiore Medical Center in New York City, said the study supports what she sees in her practice. “There should be a vigorous, well-defined, screening procedure for the female relatives of these women. There should be widespread use of genetic counseling in these young patients.”

One method of genetic testing involves blood tests that look for changes in the proteins used by these genes, according to the National Cancer Institute. There are no recommendations on referrals for BRCA1/2 mutation testing, but “in a family with a history of breast and/or ovarian cancer, it may be most informative to first test a family member who has breast or ovarian cancer.”

For women who are not of Ashkenazi descent, genetic testing follows patterns, such as two first-degree relatives (mother, daughter, sister) who were diagnosed with breast cancer, one of whom was under 50; or three or more first-degree or second-degree (grandmother or aunt) diagnosed with breast cancer regardless of age. Among Ashkenazi descendants, the recommendation is for any first-degree relative diagnosed with breast or ovarian cancer or for someone with two second-degree relatives on the same side of the family.

The privacy of genetic testing is protected by the Health Information Portability and Accountability (HIPAA) Act. In addition, the Genetic Information Nondiscrimination Act (GINA) protects consumers in terms of employment and health insurance. Insurance companies, however, have the right to access records of applicants for life insurance, disability insurance and long-term care insurance; they are allowed to take genetic test results into account when making decisions about coverage.

Written by Suzanne Hanney,
StreetWise Editor-In-Chief

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