Breast cancer rates rose by 1 percent per year from 2012-2021 for all U.S. women combined, with steeper increases for women under 50 and Asian American and Pacific Islander women, according to the American Cancer Society, which released its biennial report on the state of the disease in the nation in October.
The results are concerning for numerous reasons. Even though mortality rates have fallen by 44 percent since 1989 because of advances in treatment and earlier detection, breast cancer remains the second leading cause of cancer death in women, second only to lung cancer.
But the new figures also show there remain significant racial and ethnic disparities in breast cancer outcomes. There has been no change in mortality rates for Native American women over the past 30 years, and Black women have a 5 percent lower incidence rate than white women but are 38 percent more likely to die from the disease, a trend of divergence that began after 1980.
Laura Collins, Harvard Medical School professor of pathology at Beth Israel Deaconess Medical Center and physician-researcher specializing in breast disease, discussed the report’s surprising findings, what they mean for young women, physicians and researchers, and what can be done about the persistent racial and ethnic disparities in cancer mortality.
Did anything in the latest report surprise you?
Collins: The piece of the report that caught the headlines was the increasing incidence found for breast cancer in young women. Anecdotally, we’ve been diagnosing breast cancer in younger women in the patient case mix coming through our practice. So, in some ways it wasn’t surprising, but it was a surprise to see it documented in this important paper from the American Cancer Society.
Do we have a sense of why that is?
Collins: People have many thoughts about this. Certainly there are changes in lifestyle that could impact the incidence of breast cancer — things like deferring childbearing to later in life, increasing obesity rates, and people walking and moving about less. We know that exercise is protective for many types of cancers, but certainly for breast cancer.
And then there are other environmental factors that we’re less certain about, and those need to be investigated further. The recent concern that people are thinking about is microplastics. These chemicals are everywhere, and it’s been found that we are ingesting them too. And so, we need to figure out what harm they do and how we can avoid them.
While rates for younger women are on the rise, it looks like the overall rate of increase (1 percent per year) remains fairly stable. Have we made progress, or should we be worried?
Collins: Breast cancer is still one of the leading cancers among women and causes of death from cancer among women. Certainly with the introduction of widespread screening mammography we have increased detection at earlier stages.
We did see a decline in breast cancer rates because of improvements in diagnosis, treatment, and understanding of the different types of breast cancers that women get. We’ve seen a decline in the mortality rate. We were seeing a decline in incidence in the 2000s, but we are now seeing a slow rise again, with that increase more dramatic in younger women.
Are there other demographics of women who are more at risk than others?
Collins: It was outlined in the report the different populations for whom the increases are more marked, with the caveat that the ethnicities may not be as accurately captured as one would like.
There are differences in rates between white, Black, Asian, and Pacific Islander women, attributed in part to ongoing issues of systemic racism and access to care. Black women often present at a higher stage as well. We see biologically more aggressive cancers in that population.
Additionally, where a person lives and their ability to access care can factor into the stage at which their breast cancer is detected. These are challenges that we need to figure out and resolve to create equity of care for all.
For young women who develop breast cancer, what are some additional challenges they face with their diagnoses and care?
Collins: Because we think of breast cancer as a cancer of older women and postmenopausal women, when young women present with a breast mass there’s a tendency to think that it’s something benign and very unlikely to be cancer. And often that is the case — it is much more likely to be a benign rather than malignant tumor.
But what this report tells us is that we can’t ignore these things. We can’t have this assumption that there’s nothing to worry about in younger women. The report should be a consciousness-raising issue, telling us that we need to make sure that if a young woman presents with an abnormality, there is prompt follow-up with necessary steps. Whether it’s with imaging studies or a biopsy, we need pathologic confirmation that it’s either benign or malignant. And if it’s malignant, we need to ensure that the patient is referred promptly for appropriate care. It’s important we don’t delay treatment.
What advice would you give to younger women when it comes to breast cancer awareness and how they might advocate for themselves?
Collins: The U.S. Preventative Services Task Force lowered the age for biennial screening from 50 to 40. If you’re younger than 40, knowing if you have a family history of breast cancer is important because you may have an increased genetic predisposition to cancer. That would be a conversation to have with your health care provider.
And then knowing your other risk factors — such as having children later in life, your exercise levels, weight, things like that — is useful so you and your health care provider can consider them to guide screening.
If you feel an abnormality in your breast, make sure you speak to your health care provider about it. Because we are seeing increased breast cancer in younger women, it is important to advocate for yourself to ensure that further examination or work-up is not delayed.
What gives you hope that we will continue to improve our capacity and ability to detect and reduce occurrences of breast cancer?
Collins: There’s a lot of work going on in the arena of breast cancer research. I know that Harvard-affiliated hospitals have a strong commitment to taking care of young women with breast cancer. I think there’s a big effort to understand the differences in the biology of breast cancers occurring in young women and those occurring in older women. That exploration and research is important for understanding how best to treat women with breast cancer.
Additionally, there are many psychosocial factors that affect young women with breast cancer compared to older women, such as impacts on career, fertility concerns, or coping with cancer treatments while caring for young children. Attending to those issues is important, and there’s lots of work going on in those areas as well.
This interview was edited for length and clarity.
Adapted from an article in the Harvard Gazette.
