Disparities in TNBC: Screening, Diagnosis, and Management: A Panel Discussion

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Dr. Bardia:
Welcome to this episode on disparities in triple negative breast cancer related to screening, diagnosis, and management. Joining me today are Dr. Hurvitz and Dr. Kalinsky. So let's start with why is this important. Dr. Kalinsky, why are disparities particularly important in the field of triple negative breast cancer.

Dr. Kalinsky:
Yeah, you know, I think it is really an important topic and one that is increasingly recognized. I think specifically for triple-negative breast cancer, it's because we see this particular subtype of breast cancer occurring more commonly in younger women, in women who are non-Hispanic Black, so I think that, you know, when we have studies that are evaluating activity in patients who are non-Hispanic Black, making sure that they are well-represented in clinical trails and have access to the drugs in the same way is critically important. And today there was a report that came out from ACR just talking about disparity and how this help approach this, and it's like a 100 plus page report, and I think it just highlights across tumor subtypes, not just breast cancer, across tumor subtypes, all of the issues, whether it's biology, whether it's access, whether there are other kind of underlying issues. It really does represent the importance of addressing the issue, but in particular triple negative breast cancer.

Dr. Bardia:
Thank you, Dr. Kalinsky, you highlighted a very important point and for triple negative breast cancer it's really important given the aggressive tumor biology. In terms of management, Dr. Hurvitz, are there any barriers in terms of management, enrollment in clinical trials, specifically for African-Americans?

Dr. Hurvitz:
Yeah I think that as a nation we are very poor at enrolling many minority groups, but especially Black Americans. They tend to be less than 10% of clinical trial enrollment, and it's really unacceptable actually if we are evaluating drugs that are going to be utilized widely regardless of race, we must incorporate every race into our clinical trails so that we can know with certainty that the drugs have the same safety profile and the same efficacy profile because there are unknown genetic and pharmacokinetic and pharmacodynamic factors that play in based on genetics, and that is linked to race. So I think it's a huge area of unmet need that there are a lot of centers that are beginning to incorporate sites from areas where there is a higher population of Black people so that they can enroll more patients on clinical trials. But I think another barrier that comes up, there are some many barriers, but another one that comes up is trust. And historically the United States has not been so great in terms of doing things in an ethical manner when it comes to research. And I think you just point to the Tuskegee Airmen, there is deep-seated concern about whether or not our patients are getting the best care if they go on a clinical trial they don't necessarily believe that they're going to have full, informed consent. And so this requires that we as clinicians give patients extra time in the clinic to explain the trial, to address any concerns relating to whether best available care is going to be given, what type of oversight there is, outcomes for patients enrolled in clinical trials, et cetera. These are very timely conversations but I think it's something that's very, very worthwhile. But outside of clinical research I think there are areas of unmet need as well. I mean there is inherent bias that clinicians and physician extenders, PAs and NPs, may not even be aware of. We've done some recent training at my own institution to try and address this because we all have our own inherent bias and so I think awareness is really important in helping us tackle the assumptions that we're making that are unfounded when we meet a patient who is different from us. And so I think there's a lot to talk about here and I just love that this conversation is being augmented by guidelines like AACR and ASCO coming out, highlighting this as a huge need right now.

Dr. Kalinsky:
Just to tack on to what Dr. Hurvitz was saying, just in terms of the problem, I think that, you know, two bits of sobering data that I think is kind of telling the story, and this is not specific to triple negative breast cancer, but just breast cancer in general, you know, one, there are data in the state that I reside in, Georgia, that one's survival after breast cancer diagnosis is dependent, for non-Hispanic Black women, is dependent on the zip code that they live, right? Just showing that access to care really is an important issue here. And there're also data demonstrating that survival for non-Hispanic Black women who have breast cancer, they are more likely to die from breast cancer than lung cancer. And I just find that, you know, with all of the advances that we have right now, I just find those data upsetting. I think we all find those data upsetting, and as Dr. Hurvitz mentioned, you know, there are different strategies that are being discussed, we have studies also looking at implicit bias, including how we're testing patients, whether it's genetic testing or next-generation sequencing and hopefully part of this is just the increasing awareness so that we can help address the disparities that currently exist.

Dr. Hurvitz:
I have one example that I would just throw out there, a personal example of this that highlights this. I have a patient who is always late to clinic. At least 30 minutes, sometimes an hour. And my front desk came into my nurse and said, "You know, are we able to accommodate this patient, she just showed up, she's late again." And my nurse was like, "Of course not, we're running behind already." And I recall that this particular patient travels by bus over an hour and a half, you know, she has four kids she's trying to get to school, and there are so many social determinants of health that interface with her ability to come to clinic and get the treatment she needs. And so I think there really does need to be, as you said, some awareness of the struggles our patients have outside the clinic, not just their diagnosis and what the best treatment is, but what struggles they're facing that are get in the way of them having the best outcome.

Dr. Bardia:
Yeah, no absolutely, and thanks for sharing the story, it comes back to a point made earlier in terms of participating in clinical trials. Trials often require a number of tests and many patients just find it difficult to get all those tests done and that's why the participation is low. So, thank you so much for addressing the unmet need for highlighting the various barriers, and also strategies to overcome those barriers. It was a difficult but a very important topic, so thanks for sharing your thoughts, Dr. Kalinsky and Dr. Hurvitz.

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