In the United States, Black women continue to face the most significant breast cancer disparities. While overall breast cancer incidence remains slightly lower among Black women than white women, Black women are more likely to develop aggressive forms of the disease at younger ages and experience worse outcomes.
For years, researchers have pointed to social determinants of health, barriers to care, and systemic inequities as contributors. While these factors are critically important, emerging research suggests they may only be part of a much larger equation.
Tuya Pal, MD, a clinical geneticist and researcher supported by the Breast Cancer Research Foundation (BCRF), said that the future of breast cancer equity may lie in understanding how inherited genetics, tumor biology, ancestry, and social drivers of health interact.
New research efforts are attempting to answer questions that previous studies have been unable to address with breast cancer outcomes among Black women.
Historically, Black Americans have been underrepresented in medical research. Furthermore, Black women haven’t been properly represented in genomic research. Most genomic studies have primarily included populations of European ancestry, although African ancestry populations possess the greatest genetic diversity globally.
Excluding Black populations limits researchers’ ability to understand breast cancer risk across all groups. This lack of representation creates two problems: findings may not be broadly applicable, and researchers may miss potential discoveries entirely.
“If we don’t do research across all populations, we’re not going to get answers that are broadly relevant across all populations,” Dr. Pal said.
Increasing diversity in medical research isn’t simply a health equity issue; it’s a scientific necessity for improving outcomes across diseases and conditions.
The burden of breast cancer is generally lower among Black women overall, but that pattern reverses at younger ages. Overall, breast cancer rates in women under 50 are rising by about 1.4 percent to over 1 percent each year. Black women are more likely than their white counterparts to develop breast cancer before age 50 and are more likely to be diagnosed with aggressive disease.
Researchers believe biological and social factors drive these disparities.
To better understand what’s causing the higher incidence of breast cancer in Black women, Dr. Pal and her team specifically enroll women diagnosed at age 50 or younger.
Dr. Pal’s research is part of a larger initiative that combines data from multiple studies, making it one of the largest U.S.-based datasets focused on Black women with breast cancer. Her team’s recent study found that many young Black women, including those with hormone receptor-positive disease, had biologically aggressive tumor subtypes that are typically associated with poorer outcomes.
Because Black women are disproportionately impacted by younger-onset and more aggressive forms of the disease, age shouldn’t create a false sense of reassurance.
When screening patients for breast cancer – particularly Black women – clinicians should maintain a heightened awareness of breast cancer risk in younger Black women and consider family history, genetic testing eligibility, and other risk factors alongside routine screening recommendations.
The most promising research to advance understanding of breast cancer disparities examines both biology and the environment simultaneously.
Traditionally, researchers have focused on either genetics or social determinants of health alone. The BCRF-supported Health Equity Initiative (HEI) aims to integrate multiple areas, including:
Researchers are not trying to determine whether biology or social factors matter more. Rather, they’re trying to understand how these factors interact, and how they may influence treatment decisions for Black women with breast cancer.
Genomics is more than just a patient’s inherited cancer risks. Dr. Pal’s research examines two characteristics: germline DNA (the DNA a patient is born with) and tumor genomics (DNA and RNA changes within the cancer itself). Germline DNA helps researchers study inherited cancer susceptibility, assess ancestry, and identify mutations linked to increased cancer risk. Researchers analyze tumor genomics to identify tumor mutations, gene expression patterns, and molecular drivers of cancer growth.
In Dr. Pal’s studies, approximately 12 to 14 percent of participants carried inherited breast cancer-associated mutations. Researchers also found that higher levels of West African genetic ancestry were associated with worse disease-free survival in some patient populations, suggesting genomic ancestry may offer insights beyond self-reported race.
“More recently, we published [a study] about how West African ancestry was associated with worse outcomes,” Dr. Pal said. “We also looked at disease-free survival, and [West African ancestry] was particularly strong in those with HR positive disease.”
For clinicians, it’s important to understand that race alone is an imperfect measure. Genomic ancestry may offer more clinically meaningful insights into disease biology.
Increasing clinical trial participation shouldn’t fall solely on the patient. Many Black patients are often willing to participate in research but are never asked. Clinicians play an important role in ensuring patients know about research opportunities that may benefit them.
Through research, Dr. Pal and her team also identified a large racial disparity in genetic testing among women. “We were able to find out that the largest predictor of getting tested is your provider telling you to get tested,” Dr. Pal said. “When we looked at who was told by their provider and who wasn’t, there was a huge disparity. There were way more white women who were advised to get genetic testing [than Black women].”
Similar patterns can influence whether Black women participate in clinical trials.
Acknowledging these barriers could help address low participation rates. Childcare responsibilities, transportation challenges, time away from work, and restrictive eligibility criteria are just a few burdens Black women can face when considering participating in medical research.
Comorbidities may also serve as an underrecognized barrier to research participation. “There are some comorbidities that track ethnicity or race that exclude certain populations from being able to participate or being eligible,” Dr. Pal said. Researchers may be seeking a “clean” or “uncomplicated” population, and many Black patients may not meet the criteria, as they have a higher prevalence of comorbid conditions, including diabetes, hypertension, chronic kidney disease, and obesity.
Dr. Pal said that many investigators are using AI, informatics tools, and electronic health records to help keep track of who is (and isn’t) being included in clinical trials. Over time, these tools may help identify gaps in clinical trial representation across multiple diseases and conditions and redesign recruitment strategies appropriately.
However, clinical trial discussions often start in the exam room. Ensuring equity in medical research requires clinicians to inform eligible patients about clinical trials and other research opportunities.
As research continues, clinicians can take several actions in standard clinical practice. In primary and oncologic care, Dr. Pal said that eligible young Black women with breast cancer should be offered genetic testing.
Genetic testing, which is typically covered by most insurance plans, offers many benefits for patients and clinicians alike, including:
Clinicians can also be intentional about trial discussions. Proactively discuss research opportunities, avoid assumptions about patient interest, and address participation barriers early.
Building trust is critical not only for increasing treatment adherence, but also for encouraging a patient to explore other opportunities that could improve outcomes for their condition, which is especially relevant for Black women with breast cancer.
Decades of research have identified significant breast cancer disparities affecting Black women, but the reasons behind those disparities have not been explored in depth until more recently. Emerging evidence suggests that inherited genetics, ancestry, tumor biology, and social drivers of health all influence outcomes, particularly among younger Black women.
Researchers hope that these insights will translate into more personalized treatment strategies and ultimately improve survival for Black women with breast cancer.
As researchers continue to uncover how genomics, ancestry, and social drivers of health intersect, clinicians can help close longstanding gaps in breast cancer outcomes by ensuring equitable access to genetic testing, discussing clinical trials consistently, and recognizing that effective care requires attention to both biology and lived experience.
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