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Quality of care, genetics possible factors in racial breast cancer differences
(WebMD) -- In Faith Fancher's house, high in the hills above San Francisco Bay, her cat Lazarus tiptoes around the living room. Here and there, framed photographs testify to Faith's 27 years as an award-winning TV news reporter.
As in television, each picture tells a story: There's Faith, smiling as she wins a journalism award. There's Faith, tanned and glowing during a trip to Mexico. There's Faith in a black halter dress, looking just like Whitney Houston with her tousled hair and red lipstick.
But look at Faith Fancher herself today, and you see a different woman.
The woman in the photographs is bald now, curled up on the sofa with Lazarus and wearing an old pair of blue sweat pants. Her hair is gone -- all of it, even her eyebrows. "I haven't shaved in eight months," says Fancher, laughing ruefully. "I look like a peeled egg."
Like her tousled hair in the photo (actually a wig), Fancher's slinky halter was also an illusion, carefully fitted to hide her port, a plastic tube surgically inserted into her chest through which chemotherapy drugs drip into her bloodstream. Only the red lipstick remains, a vivid reminder that Fancher, 49, is very much alive despite two bouts with breast cancer.
Diagnosed in 1997, Fancher had a mastectomy. Then last June, she found "a little pimple" in her reconstructed breast, in which a small amount of tissue had been allowed to remain. It was cancerous; Fancher had a lumpectomy, chemotherapy and radiation, which left her too weak to work or even putter in her garden.
Yet she continues to make the rounds of luncheons and fund-raisers, fired by a simple fact that she repeats again and again: While African-American women are less likely than white women to get breast cancer, they are much more likely to die from it.
"It knocked me for a loop," says Fancher, who spends much of her time now lobbying for more money for early-detection programs, including mammography and breast self-exam. "I mean, my first thought was, why are we dying?"
Growing racial discrepancy
Why, indeed. A study by National Cancer Institute (NCI) researchers, published in the journal Archives of Family Medicine in November 1999, revealed an alarming increase in the already troubling gap between black and white mortality rates due to breast cancer, from 16 percent in 1990 to 29 percent in 1995. And the NCI data show that the five-year survival rate for black women with breast cancer is 71 percent, compared with 87 percent for white women.
Experts have traditionally explained the discrepancy in survival rates by noting that African-American women tend not to seek help until their cancers are already at an advanced stage. But the authors of the NCI report found that mortality among black women during the 1960s and 1970s was actually lower compared with that of whites. In 1981, mortality for whites began to drop sharply in response to more aggressive screening programs and better chemotherapy protocols.
And that leads to a disturbing conclusion, says Dr. Otis Brawley, one of the study's authors: that African-American women have somehow been cheated out of the advances that have taken place over the past 20 years in mammography, chemotherapy and powerhouse drugs such as tamoxifen.
Brawley blames poor access to health care and lower standards of care for black women. "While we have evidence that equal treatment yields equal outcomes, we also have evidence that in breast cancer there is not equal treatment," says Brawley, who is also head of the NCI's Office of Special Populations. "A lot of black women do not get nearly as good treatment for breast cancer as do white women."
One problem is screening: Despite steady increases in mammography use by black women during the 1980s and 1990s, an article in the Journal of the National Cancer Institute in March 2000 said that black women are still less likely than white women to have access to low-cost screening programs where they live.
Genetics a possible factor
But others point to a possible genetic cause. "When you look at the biology of the tumors that are often found in African-American women, the tumors are a little bit more aggressive, and the cell types are much more atypical than (those of) the average white woman," says Dr. Charles J. McDonald, a cancer specialist and immediate past president of the American Cancer Society (ACS). Heredity also appears to play a role in why black women get cancer at a younger age, he says.
According to NCI data, African-American women are more likely to be diagnosed with cancer before they are 40, when cancers are most aggressive; more likely to be diagnosed at an advanced stage; and less likely to survive five years after diagnosis. Clinical studies report that black women also are up to twice as likely to be diagnosed with breast cancers that are estrogen-receptor (ER) negative, meaning they resist popular estrogen-blocking drugs, such as tamoxifen, which work by starving ER-positive tumors of the hormone they need to grow.
It all adds up to a puzzling scenario that contrasts sharply with the overall decline in cancer deaths since 1991. Among black women from 1986 to 1997, cancer incidence rose and mortality fell only slightly, whereas among white women incidence has remained relatively steady and mortality has dropped.
While unequal access to health care and poor quality of care are often cited as the reasons behind these numbers, it is tumor biology -- the idea that there may actually be a "black" breast cancer that strikes earlier and grows faster -- that prompts the most fear among African-American women. Studies have yet to prove it exists, though anecdotal reports suggest a genetic link.
Zora Brown was just 21 when she sought out a doctor and told a tale so devastating it could have been a Greek myth: breast cancer in four generations, including her great-grandmother, her grandmother, her mother and three sisters.
"My doctor threw her papers up in the air and said, 'Good Lord,' " says Brown, 51, founder of the Breast Cancer Resource Committee, a Washington, D.C.-based advocacy group. Brown's doctor then got on the phone, calling an oncologist, a surgeon and an internist, who agreed to serve as Brown's medical team.
That team was ready in 1981, when Brown was diagnosed with cancer in her right breast, and again in 1997 when cancer was detected in the left. After two mastectomies, Brown says she is "fit and healthy." But a niece, Lea, died of breast cancer last year at the age of 29, and Brown says most of the women in her family have tested positively for BRCA-1, the gene linked to breast cancer.
Brawley says that Brown's case illustrates an uncomfortable truth: While she may be genetically predisposed to breast cancer, it's certain she would have died without good care. "And there's a bunch of black women who don't get optimal therapy," he says.
The fact that black mortality rates have stubbornly refused to drop in recent years, Brawley says, could be due to higher rates of poverty and obesity among black women, which make them more likely to develop cancers as well as less likely to get good care.
Meanwhile, he worries that talk of a "black" cancer could hurt women on the other end of the income scale. "I meet a whole lot of educated black women (with ER-positive tumors) who won't take tamoxifen because they hear that it hasn't been proven in African-Americans," Brawley says.
For Faith Fancher, the answer is to push early detection, a strategy that helps all women of all colors, particularly those at high risk. "I believe in mammography -- that's how I found my first cancer," says Fancher. "And I believe in breast self-exam -- that's how I found the second one."
She also pushes practical help: Her nonprofit group, Friends of Faith, pays for cab fare and child care so that women with cancer can get the treatment they need. Such "micro-grants," she hopes, will make a difference. "If we are worried that black women are dying at a high rate," Fancher says, "we ought to do something about it."
© 2000 Healtheon/WebMD. All rights reserved.
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