This essay critiques the below-cited publication:
Language matters. In the scientific community, publication is king. Members of the health science community are vocal about making health betterment a priority; however, their efforts fall short when the urge to get published takes center stage. What does that mean? When a study sets out to describe minority group health disparities, their language has an impact on future interpretations of the data. Scientists must be mindful about the greater context of a health disparity in order to avoid unintentionally perpetuating the very structure that led to it. As a case study, this essay will be critiquing the language used to describe disparities in black women’s breast cancer outcomes in the above-mentioned publication.
Sturtz et. al. describes a higher burden of breast cancer mortality among black women in comparison to their white counterparts. Black women display “earlier onset, less favorable clinical outcomes, and an aggressive tumor phenotype.” Triple negative breast cancer (TNBC), defined as tumors that display no vulnerabilities to hormone treatments, is a severe form that leads to significantly worse outcomes. The purpose of the study was to determine if the higher burden of breast cancer in black women could be explained by TNBC being a different and more severe disease. The data in the study showed that the disease is the same between the races. Additionally, black and white women had similar outcomes, although the proportion of TNBC was higher among black women with breast cancer.
The article discusses possible reasons for the observation of a higher proportion of triple negative tumors among black women. Further data analysis showed that TNBC was associated with higher BMI, greater waist-to-hip ratio, and less breast feeding. Almost half of the black women enrolled in this study had BMI greater than 30. While there was no significant difference in breastfeeding duration between black and white parous women, the overall proportion of black women who ever breastfed was significantly lower than. The authors discuss these associations from within the context of a need to reduce breast cancer mortality disparities by addressing “modifiable lifestyle factors” associated with a greater likelihood of TNBC in the community. Black women are more likely to have obesity, and they are less likely to breastfeed their infants. The article concludes by advocating for weight loss and breast feeding as a way to reduce black women’s risk of developing the more lethal form of breast cancer.
This study failed to show evidence for the hypothesis that TNBC is a more severe disease in women with “African ancestry.” The results of the molecular aspect of the study showed that TNBC tumors from black women were almost indistinguishable from tumors from white women. Many health disparity studies attempt to use genetic differences between races to explain differing health outcomes. This biological stratification is fallacious and causes harm – self-reported race is widely considered to be a poor method of describing ancestry (Borrell, 2021). Explaining health inequities as ancestral genetic differences fails to consider upstream factors contributing to those inequities. Those same upstream factors may also lead to the observed genetic differences themselves, by way of epigenetic change.
An epigenetic change occurs when an individual’s environment changes their gene expression. The expression changes are genetically passed on generationally (Crews, 2006, Salas, 2021). For instance, the level of infant nurturing a woman displays can be influenced by her great-grandmother’s experiences of famine and stress. Epigenetic inheritance is one way that trauma is passed on intergenerationally. When the scientific community seeks to explain differences in health outcomes by racial stratification and genetic etiologies, it fails to consider the real causative racial injustices. It also contributes to the invisibility of those injustices. Sturtz et. al. demonstrated that TNBC is the same disease in black and white women because there is no meaningful biologic difference between them. Of course it’s the same disease, and of course it has similarly severe outcomes.
Discussions about modifiable risk factors associated with increased TNBC incidence also do a disservice to the black community. Advocating for black women to lose weight and to breastfeed covertly implies causative links between those factors and TNBC. Black women are more likely to have obesity, yes. Obesity and TNBC could – and very likely do – share common etiological factors. Black women are also less likely to breastfeed. Why? Do they have the resources to take time off work? Can they make time to breastfeed? Are they too stressed to maintain a milk supply? These are important questions.
Health betterment is not effectively served when it’s focused on downstream, individual level factors. The social-ecological model of health describes the individual as one of many factors that contribute to overall health. Environmental factors play a much larger role in health outcomes – it could be postulated that individual factors are almost meaningless in the scope of community health (CDC, n.d.). Higher obesity rates and lower rates of breastfeeding in black women are easily recontextualized as symptoms of the same condition that leads to more severe forms of breast cancer.
That condition is racism.
The authors of the study formulated a hypothesis that TNBC is a different and more severe disease in black women. When their studies failed to produce positive data in support of the hypothesis, further analysis was done in order to describe the why of the higher incidence of TNBC in black women. One could speculate that in the pursuit of the production of some kind of publishable positive data, the authors missed the original point of their research. The lethality burden of breast cancer on black women needs to be addressed. It’s best addressed by considering the factor that also contributes to “modifiable lifestyle factors” associated with TNBC. It’s best addressed by confronting institutionalized racism – defined in Ford & Griffith (2019) as the “differential access to the goods, services, and opportunities of society by race. Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage.”
The article is neatly concluded with an assertion that black women can reduce their risk by losing weight and breastfeeding more. While solution proposals for the systemic and structural racism leading to TNBC, obesity, etc., is outside the scope of the study, their point could have been better served if the discussions were within the context of health equity and social justice. Further studies regarding upstream, systemic factors leading to poorer health outcomes in black women warrant recommendation and discussion.
As research into health disparities continues, it would behoove all researchers to remain cognizant of the social-ecological model of health. While ‘modifiable’ individual level interventions are certainly important, oppressed groups’ health will not improve until upstream factors are continually and reliably included in every health-related conversation. Avoidance of the active perpetuation of racist systems is not enough. Silence/ignorance is not enough. We must all actively push against racism. By ignoring racist institutional impacts on generations of black women, this study covertly endorses a victim-blaming mindset regarding TNBC in the community. “Well, if she doesn’t want to lose weight then she’ll just remain at a higher risk.” The attitude of personal responsibility is lazy, and harmful. It’s an injustice to the group of people the study is meant to serve. I propose rewriting the background and the conclusions in the abstract of the study as follows:
Black women are diagnosed with breast cancer at a lower rate than their white counterparts. When diagnosed, black women carry a heavier burden of severe characteristics, including earlier onset, less favorable clinical outcome, and an aggressive tumor phenotype. These inequities may be associated with other inequities like differences in access to health care, increased prevalence of obesity, and increased frequency of triple negative breast cancer in young black women. Improved understanding of the molecular characteristics of TNBC, as well as common etiological factors, is critical to describing how TNBC contributes to the inequitable increased mortality and morbidity from breast cancer in the black community.
The molecular results affirm no genetic difference in breast cancer pathology between black and white women. Black women’s higher frequency of TNBC is associated with other inequities the community faces. These results may inform individual level risk reducing interventions. Disparate health outcomes are continually linked to other injustices the community faces and as such merit more research into systems level interventions to decrease the impact of systemic and generational discrimination on health.
Publication pressure disserves the scientific community in numerous ways. There’s this idea that a study must have a goal, and then show positive data serving the goal. The original goal of the study was to determine if TNBC in black women was a different disease leading to higher mortality than in white women. When data showed that the disease was the same in both instances, the authors sought to use other indicators of injustice done to the black community as etiological placeholders for TNBC. Inequities associated with being black, and therefore with a higher burden of severe breast cancer, are described as “lifestyle choices” that are modifiable. An illusion of control and personal responsibility is inadvertently created from the proposal of individual level interventions meant to decrease TNBC in the community.
Considering systems level factors leading to poor health outcomes is hard. The etiological factors are multi-faceted and complex. The true causes don’t lend themselves to a simple open-and-shut publishable data analysis. Truly effective solutions aren’t usually neat and tidy ways to conclude an academic paper. Addressing these problems requires more than a singular scientific team changing its language surrounding health inequities and disparities. Similar to how a truly efficacious solution for poor health outcomes in oppressed communities requires systems level interventions, the scientific community as a whole must take a higher dimensional approach to anti-racist method improvements. ‘Publication above all’ must be replaced instead with a priority for contributions to an overall scientific understanding of social determinants of health. Scientists must work cooperatively on systemic intervention development. Advancements in public health will continue to stall until the lens is shifted in this manner.
Borrell, L. N., Elhawary, J. R., Fuentes-Afflick, E., Witonsky, J., Bhakta, N., Wu, A. H. B., Bibbins-Domingo, K., Rodríguez-Santana, J. R., Lenoir, M. A., Gavin, J. R., Kittles, R. A., Zaitlen, N. A., Wilkes, D. S., Powe, N. R., Ziv, E., & Burchard, E. G. (2021). Race and genetic ancestry in medicine — a time for reckoning with racism. New England Journal of Medicine, 384(5), 474–480. https://doi.org/10.1056/nejmms2029562
Centers for Disease Control and Prevention. (n.d.). The Social-Ecological Model: A Framework for Prevention. Retrieved 3/6/2022, from https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Crews, D., McLachlan, J., A. (2006). Epigenetics, Evolution, Endocrine Disrupt ion, Health, and Disease. Endocrinology, 147:6, s4-s10. https://doi.org/10.1210/en.2005-1122
Ford, C. L., Griffith, D. M., Bruce, M. A., & Gilbert, K. L. (2019). Racism: Science & tools for the Public Health Professional. American Public Health Association.
Salas, L., A., Peres, L., C., Thayer, Z., M., Smith, R., W., A., Guo, W., Si, J., & Liang, L. (2021). A transdisciplinary approach to understand the epigenetic basis of race/ethnicity health disparities. Epigenomics, 13:21. https://doi-org.proxy1.cl.msu.edu/10.2217/epi-2020-0080
Sturtz, L.A., Melley, J., Mamula, K. et al. (2014). Outcome disparities in African American women with triple negative breast cancer: a comparison of epidemiological and molecular factors between African American and Caucasian women with triple negative breast cancer. BMC Cancer 14, 62. https://doi-org.proxy1.cl.msu.edu/10.1186/1471-2407-14-62