Breast Cancer and Best Practices: Factors That May Affect Care

Many women get breast cancer. But the disease is deadliest for non-Hispanic Black women. And when it comes to metastatic breast cancer, women of color are less likely to get timely treatment that follows national guidelines. 

According to Grace Suh, MD, medical director at Northwestern Medicine Cancer Center Delnor, lack of access to health education and regular medical care is a big part of what’s fueling this disparity. And medical centers are actively trying to find and fix differences in breast cancer screening, diagnosis, and treatment that fall along racial lines. 

“Regardless, despite all these efforts, there still remains a significant gap in health equity,” Suh says, “And we recognize that.” 

Here’s some of what we know so far about what affects breast cancer treatment in women of color. 

What Are Best Practices for Metastatic Breast Cancer?

Medical experts get together and agree on what kind of treatment is best for certain diseases. These national guidelines are usually referred to as best practices, standard of care, or standard therapy. 

Systemic drug therapies are typically the go-to for breast cancer that’s spread to other parts of your body, also known as stage IV or metastatic breast cancer. But there may be a benefit to surgery and/or radiation therapy for some people. 

Treatment of metastatic breast cancer typically includes one or more of the following drugs: 

Hormone therapyChemotherapy Targeted therapyImmunotherapy

But metastatic breast cancer isn’t the same in everyone. 

“In general, it’s actually multiple different diseases,” says Sarah Schellhorn, MD, a breast oncologist with Yale Cancer Center and Smilow Cancer Hospital and an associate professor of medicine at Yale School of Medicine. “And we tailor therapy based on biology and what’s driving the cancer.” 

The types of drugs your doctor chooses for you depend on things like whether your cancer is aggressive, fueled by hormones, or tests positive for HER2 (a protein that helps cancer cells grow). But they’ll also consider how treatment will impact your overall health and well-being.

Which Health Conditions Affect Breast Cancer Treatment?

Treatment can shrink your tumors, lessen symptoms caused by cancer, and help you live longer. But these are strong drugs that come with side effects. Sometimes a pre-existing medical problem can influence the type of treatment your doctor thinks is best. 

“One of the problems is you have to be healthy enough to receive chemo,” Schellhorn says. “And that’s not really a yes or no question. But you want to be able to give enough chemotherapy that it treats the cancer but not too much that it actually harms someone or decreases their quality of life.” 

Here are some health conditions that may affect your breast cancer treatment:   

Cardiovascular risk factors. Common cancer treatments can be “toxic to the heart,” Schellhorn says. For example, some therapies can make it hard for your heart to pump blood, or they may speed up other heart and blood vessel problems. 

Heart issues caused by cancer drugs may go back to normal if you ever stop treatment. 

But if you already have a weak heart or are at risk for cardiovascular disease, your doctor may need to delay your care while they talk things over with your cardiologist. Or they may opt for a nonstandard treatment with fewer cardiac risks.

In general, Black and Hispanic women are more likely to already have other health issues that impact the heart and blood vessels. Those typically include: 

Obesity DiabetesHigh blood pressure

Diabetes. Cancer drugs may cause or worsen neuropathy. That’s a nerve condition common among people with diabetes. It causes problems like numbness, tingling, and weakness, usually in your fingers and toes. 

“If somebody has diabetes, I would be very cautious about prescribing a medicine that can cause or worsen their neuropathy,” Suh says. 

Drugs given alongside chemo, like steroids, can also cause your blood sugar to spike. 

Autoimmune conditions. Immunotherapy drugs “rev up” the immune system to kill cancer cells, Schellhorn says. But that can cause other issues if you’re one of the 10% to 30% of people with cancer who already have an overactive immune system. 

That means your doctor may think twice about giving you newer drugs like immunotherapy if you have lupus, rheumatoid arthritis, multiple sclerosis, or other autoimmune conditions. 

Other Factors That Affect Breast Cancer Treatment

Here’s a breakdown of a few more reasons why women of color may not get standard care when it comes to metastatic breast cancer: 

Barriers to care. Due to racial disadvantages, many Black people live in poverty. And low-income women are less likely to have a regular doctor, health insurance, or easy access to follow-up breast cancer care. 

And some women of color may not have jobs that offer paid time off or medical leave. “People do forgo care or delay it because they can’t afford to stop working,” Suh says. 

Physician bias. Studies show some doctors look down on Black people and those from poorer backgrounds compared to white or people with a lot of money. But we need more research to know how this kind of judgment might fuel racial and ethnic differences in breast cancer treatment. 

There’s no evidence that doctors routinely choose nonstandard treatments because they’re worried people can’t pay for it. But is it possible? 

“I’d love to say that never happens because we’re blind to cost,” Schellhorn says. “But I’m sure it does.” 

Fear of treatment. According to Suh, communities of color often face a lot of stigma when it comes to mental health treatment. And someone with unmanaged anxiety or depression may say no to chemotherapy, surgery, or other standard of care therapy.

 “Often, we’ll try to encourage (people) and help alleviate some of these fears,” Suh says. “But if their anxiety is crippling, sometimes they’ll opt not to go for care. And they’re also lost to follow-up.” 

How to Advocate for the Best Breast Cancer Care

There’s still a long way to go to reduce racial disparities in breast cancer treatment. But there are steps you can take to get the best care. 

Ask for treatment details. You may not know what standard of care is for your type of breast cancer. But it’s fine to ask your doctor about it. Go a step further and get them to explain exactly why you’re getting one treatment over another. 

“I very much try to have that conversation,” Schellhorn says. “Here’s what the standard of care is. Here’s what I’m worried about using standard treatments with you. Here’s why I think another breast cancer treatment option is better for you.” 

Bring up personal hurdles to treatment. Financial strain may not be top of mind for your cancer doctor. But it’s something you should bring up. No one should delay or avoid treatment because of cost. Your cancer care team can help you apply for drug assistance programs or find the funds another way. 

“There is a whole wealth of resources that may be out there that we can tap into,” Suh says. “But it doesn’t happen automatically.” 

You can also tell your doctor that you’re having problems in other ways not specifically related to the cancer itself. Ask to speak with a social worker, navigator, or financial counselor if you need: 

Mental health supportHelp with childcareTransportation to and from treatment Healthy food for you and your familyAssistance with your housing or utility billsLegal or financial helpInterpreter services 

Keep the conversation going. You may need to constantly weigh the pros and cons of drug side effects and your quality of life. And when it comes to if you want to continue treatment, the final decision lies with you. 

“Some (people) say, listen, I don’t want to get chemotherapy. Other people say, I want to live as long as possible,” Schellhorn says. “That’s a very personal decision that requires a frank conversation with the (person) and the oncologist.” 

Photo Credit: Jose Luis Pelaez / Getty Images

SOURCES: 

Grace Suh, MD, medical director, Northwestern Medicine Cancer Center Delnor.

Sarah Schellhorn, MD, breast oncologist, Yale Medicine; chief ambulatory officer at Smilow Cancer Hospital; associate professor of medicine (medical oncology), Yale School of Medicine. 

Advances in Experimental Medicine and Biology: “Health and Racial Disparity in Breast Cancer.”

National Cancer Institute: “Standard of care,” “Study Tests Immunotherapy in People with Cancer and Autoimmune diseases.” 

American Cancer Society: “Treatment of Stage IV (Metastatic Breast Cancer).”

Circulation: “Cardiovascular Disease  and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association.” 

CDC: “Health, United States Spotlight: Racial and Ethnic Disparities in Heart Disease.” 

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