Hayley Thompson, Ph.D., Faculty Director of the Office of Cancer Health Equity and Community Engagement at Karmanos Cancer Institute and leader of Population Studies and Disparities, gives an overview of recent efforts to improve health equity for women of color with breast cancer and make suggestions about how to make breast cancer outcomes more equitable.

1. Improving Breast Cancer Outcomes
in Communities of Color:
Steps toward Equity
Hayley S. Thompson, PhD
Associate Center Director, Community Outreach and
Engagement, Karmanos Cancer Institute
Associate Professor, Department of Oncology, Wayne
State University School of Medicine
Detroit, Michigan

2. • Review racial/ethnic disparities in breast
cancer outcomes.
• Define and frame problem in terms of health
equity.
• Discuss potential solutions.
Objectives

3. • National Cancer Institute.
– Cancer health disparities are adverse differences between
certain population groups in cancer measures, such as
incidence, prevalence, morbidity, mortality, survivorship,
and quality of life after cancer treatment, burden of
cancer or related health conditions, screening rates, and
stage at diagnosis.
Cancer health disparities

4. Breast cancer in the U.S.:
Incidence

5. Breast cancer in the U.S.:
Stage at diagnosis

6. Breast cancer in the U.S.:
Mortality

7. Five year relative survival,
2005 – 2011
(Howlader et al., 2015; ACS Cancer Facts & Figures for African Americans, 2016-2018)

8. The cancer care continuum
Risk
Assessment/
Management
Primary
Prevention
Detection Diagnosis Cancer or
Precursor
Treatment
Recurrence
Surveillance
End-of –Life
Care
• Age
• Family hx
•Exposure hx
• Genetics
• Lifestyle
•Screening hx
• Lifestyle
counseling
• Chemopre-
vention
• Screening-
asymptomatic
• Appropriate
testing
(symptomatic)
• Imaging
• Biopsy
•Repeat
exams
• Lab tests
• Excision
• Surgery
• Radiation
•Chemo-
therapy
• Palliation
• Testing
•Follow-up care
• Palliation
•Survivorship
care
• Palliative care
•Advanced care
planning
•Bereavement
support

9. Disparities along the continuum
Risk
Assessment/Management
Detection Cancer or Precursor
Treatment
Recurrence Surveillance
AfAm women less likely to
participate in BRCA counseling
and testing compared to white
women.
(Armstrong et al., 2005;
Armstrong et al., 2003)
Latinas age 40+ years less
likely to report a mammo-
gram in the past 2 years
compared to white and AfAm
women.
(2015 National Health
Interview Survey)
African Americans and Latina
breast cancer patients less
likely to receive adjuvant
therapy or receive lower dose.
(Bickell et al., 2006,; Griggs et
al., 2003; Hershman et al.,
2005)
African American and Latina
survivors are less likely to be
adherent to guideline
surveillance.
(Lash et al., 2007; Field et al.,
2007; Schapira et al., 2000;
Keating et al., 2006;
Mandelblatt et al., 2006)

10. How do we make sense of
these disparities?
• Some causes are genetic/biological.
– More aggressive disease in African American women
(triple negative breast cancer).
– Latinas are likely to be diagnosed with larger tumors that
are hormone receptor negative.
– Such factors do not fully explain disparities.
– Disparities in mortality remained even when adjusting for
age at diagnosis, stage and grade of the tumor, year of
diagnosis, and socioeconomic status.
(Menashe et al., 2009, JNCI)

11. •NCI: “adverse differences.”
•Centers for Disease Control (CDC).
– Health disparities are preventable differences in the burden
of disease, injury, violence, or in opportunities to achieve
optimal health experienced by socially disadvantaged racial,
ethnic, and other population groups, and communities.
Evolving definition of
disparities

12. •Healthy People 2020.
– A health disparity is a health difference that is closely linked
with social, economic, and/or environmental disadvantage.
– Health disparities adversely affect groups of people who have
systematically experienced greater obstacles to health based
on their racial or ethnic group; religion; socioeconomic status;
gender; age; mental health; cognitive, sensory, or physical
disability; sexual orientation or gender identity; geographic
location; or other characteristics historically linked to
discrimination or exclusion.
Evolving definition of
disparities

13. •Health inequity.
– Differences in health that are not only unnecessary and
avoidable but are unfair and unjust.
– Due to difference in the distribution or allocation of a
resource between groups.
•Health is not only determined at the individual level of
genetics, biology, or individual behavior but at broader
societal levels (social determinants).
Focus on inequity
(Centers for Disease Control; Boston Public Health Commission)

14. Downstream determinants
 Downstream or
proximal
determinants:
Factors that are
temporally and
spatially close to
health effects.
• Examples of downstream
determinants:
o Biological/genetic factors
(e.g., gene mutations,
inflammation).
o Behavioral factors (e.g.,
cancer screening,
smoking, physical
activity).
o Psychological factors (e.g.,
attitudes mood).
• Expressed on the individual
(intrapersonal) level.
(Braveman et al., 2011)

15. Upstream determinants
 Downstream or
proximal
determinants:
Factors that are
temporally and
spatially close to
health effects.
 Upstream or distal
determinants:
Fundamental causes that
set in motion causal
pathways leading to
health effects through
downstream factors.
(Braveman et al., 2011)

16. Social-Ecological Model
•A framework for
understanding how
upstream factors shape
downstream factors
(social determinants).
•Acknowledges multiple
levels of influence on
health.

17. Societal
History, ideology,
political structure,
social hierarchies.
Community
Relationships among
organizations,
institutions, and
informational networks
within defined
boundaries. Can also
refer to neighborhood
and include
physical/built
environment.
Policy
Local, state, national,
and global laws and
policies.
Interpersonal
Social networks and
support systems include
family members,
coworkers, and friends.
Can also include
healthcare providers.
Individual
Knowledge, attitudes,
behavior,
developmental history,
demographic
characteristics (gender,
race/ethnicity,
economic status), and
health literacy.
Institutional
Characteristics of social
institutions with
organizational
characteristics and
operational rules and
regulations.
Moore et al., 2015

18. • “Differential access to the goods,
services, and opportunities of
society by race.
Institutionalized racism is normative,
sometimes legalized, and often
manifests as inherited
disadvantage. It is structural,
having been codified in our
institutions of custom, practice,
and law, so there need not be an
identifiable perpetrator.
Institutionalized racism manifests
itself both in material conditions
and in access to power.”
Racism as a societal factor
Institutionalized
racism
(societal)
Jones, 2000

19. • Legalization of a racial caste system
following Emancipation and
Reconstruction, 1870s – 1960s.
• Separate but equal.
• Outlawed by Civil Rights Act of
1964.
Public policy

20. • Jim Crow birthplace was independently
associated ER- breast cancer only for the
AfAm women born before 1965 (even
controlling for SES).
• Effect not observed for AfAm women born
after 1965 or white women regardless of
year of birth.
Jim Crow and breast
cancer

21. • Racial segregation: the physical separation of members of one
racial group from those of another group.
• As of 2010, approximately 1/3 of African Americans live in a
hypersegregated area (meeting criteria across five dimensions of
segregation).
(Massey & Tannen, 2015)
Community
Institutionalized
racism
Jim Crow
legislation
Racial segregation
(community)

22. • Studies report that breast cancer mortality among
AfAm women increased along with racial
segregation.
• Counterintuitive findings have also been reported.
– Greater AfAm segregation has ben associated with lower
breast cancer-specific mortality.
– There may be an enclave or ethnic density effect that is
protective.
(Russell et al., 2011, 2013; Warner et al, 2010; Bemanian et al., 2017).
Racial segregation and
breast cancer

23. Interpersonal
• Racial discrimination is
multidimensional.
• Everyday discrimination.
– Chronic or episodic interpersonal
discrimination but relatively minor.
– Example items: “People act as if they
think you are not intelligent”; “People
act as if they are better than you.’’
– Frequency.
• Major experiences of
discrimination.
– Acute experiences, major life events.
– Ever treated unfairly due to race on
the job, in housing, and by the police.
(Williams et al., 1997)

24. • In a longitudinal cohort study, AfAm women younger
than 50 years of age who reported higher everyday
discrimination (summary variable) demonstrated
higher breast cancer incidence.
• AfAm women who reported discrimination in three
areas (police, housing, and job) were more likely to
develop breast cancer than were women who did
not report discrimination in any domain.
Racial discrimination and
cancer
(Taylor et al., 2007)

25. • Area-level discrimination:
the proportion of total
Google searches in a
designated area
containing the n-word.
• Higher proportion of
racist searches in a given
area was associated with
AfAm cancer-specific
mortality in that area.
(Chae et al., 2015)
Area level-racism as a
proxy for racial
discrimination

26. • Among African American cancer patients (84% breast
cancer), oncologists who demonstrated higher
implicit bias had shorter interactions with patients.
• Patients and independent observers rated these
oncologists’ communication as less patient-centered
and supportive.
• Oncologist implicit bias was associated with…
– less patient confidence in recommended treatments.
– greater perceived difficulty completing them.
Racial discrimination and
cancer treatment
(Penner et al., 2007)

27. • Less access to care and supportive
services (e.g., lower screening
rates, clinical delays, less post-
treatment surveillance).
• Cultural norms that have a
defensive function (e.g., medical
mistrust, cancer care avoidance,
higher quality interactions for
same-race providers).
• Behavioral (e.g., smoking) and
affective (e.g., depression)
responses to stressors that
increase cancer risk and delay care.
Examples of pathways from societal to
individual determinants and cancer
outcomes

28. • Health equity means that
everyone has a fair and just
opportunity to be healthier.
• This requires removing obstacles
to health such as poverty,
discrimination, and their
consequences, including
powerlessness and lack of access
to good jobs with fair pay,
quality education and housing,
safe environments, and health
care.
Equity
Robert Wood Johnson Foundation & UCSF, 2017

29. • Target the multiple levels of influence that affect
health.
• Interventions occur at a number of levels
simultaneously or in close succession.
• Implementation can be complex.
• Challenging to evaluate the synergistic effects
between levels.
• Few examples of multilevel interventions in breast
cancer, although promising outcomes in other
cancers.
(Paskett et al., 2016; Davis et al., 2011; Allicock et al., 2010)
Multilevel strategies to
achieve equity

30. • The Multilevel Intervention to Increase Latina
Participation in Mammography Screening study
(Fortaleza Latina).
Example of a multilevel
strategy
(Coronado et al., 2016)

31. • Boston Racial and Ethnic Approaches to Community
Health (REACH) 2010 Breast and Cervical Cancer
Coalition.
Example of a multilevel
strategy
(Bigby et al., 2003; Clark et al., 2009)

32. Key steps to advancing
health equity
Robert Wood Johnson Foundation & UCSF, 2017

33. • “Identify important disparities that are of concern to
key stakeholders, especially those affected.”
• Community members can play a vital role at various
levels of intervention development and
implementation.
• Can ensure that interventions are tailored to unique
local culture/environment.
The involvement of
community stakeholders

34. Model of community
stakeholder engagement
• Three new Councils in Oakland, Macomb, and Genesee counties
• Currently ~ 80 members across 9 Councils.
Western Wayne
Family Health
Center - Inkster
Karmanos Cancer
Institute –
Midtown, Detroit
Project Lead: H.S. Thompson, Ph.D. Funded by PCORI Eugene Washington Engagement
Award (#2971-WSUSM); DMC (Detroit Medical Center) Foundation Health Education and
Community Benefit Grant; (PCORI) Eugene Washington Engagement Award (6252-WSU).
Michigan Cancer HealthLink Cancer Action Councils (CACs)
(formerly Detroit HealthLink for Equity in Cancer Care)
ACCESS -
Dearborn
LGBT-Detroit
VODI – Conner
Creek

35. • Capacity building.
– Council members completed a research-focused
curriculum.
• Evidence prioritization.
– Use interactive exercises to identify research priorities and
develop research questions.
• Develop research partnerships with academic
investigators.
HealthLink activities

36. • Currently preparing to work with Councils to refine a
predictive model of quality of life among African American
cancer survivors based on Social-Ecological Model.
• Focus on stressors linked to racial group membership that
result from interpersonal, institutionalized, and structural
racism and socioeconomic adversity in the U.S.
• Test the model in a large-scale study of 600 AfAm survivors.
• Results will guide targeted, multilevel interventions to
improve survivorship outcomes.
Disparities in cancer
survivorship