Exploring Factors Contributing To Disparities In Breast Cancer Among Black Women In The UK: A Qualitative Essay.

Breast cancer is the commonly diagnosed cancer in US women and it is identified as the second leading cause of death among women (Jones et al., 2014). Similarly, it is found to be the most common cancer in the UK accounting for around 15% of new cases (Williams, D. R., Mohammed & Shields, 2016). Since the 1980s, the Black women have been found to have low rate of breast cancer incidence but high death rates. One possible reason behind this is the delay in the diagnosis and treatment, thus contributing to negative impact. A UK cancer registry study revealed that despite lower breast cancer incidence rates, black women in UK are more likely to be diagnosed with metastatic disease compared to white British women (Jones et a., 2014). It reflects that a large proportion of black women develop invasive ductal carcinoma. As incidence shows a major trend towards late diagnosis of breast cancer among Black women, evaluating the causal factor behind the same is important.

Research evidence confirm that racial differences exist in the severity, course and treatment of breast cancer. Black women are diagnosed with cancer at a late stage compared to other groups such as White woman. Another major concern is that Black women most often develop subtypes of breast cancer that are more aggressive and resistant to treatment. The risk was found to differ by premenopausal status of women.  These women usually have high prolification rates, larger tumor size and high rate of lymph nodes. The gap found in past literature is that the reason for high prevalence of poor prognosis is not well-understood. Therefore, the aim of this report proposal is to review existing literatures on the topic area and develop a specific research question based on gaps identified in the research literature. The report will give an overview of the research methodology, sampling method and ethical considerations that will be used to address the research question.  

Previous research studies and government reports have described in various ways how black women or African America women are at disproportionate risk of exposure to breast carcinogens (Breast Cancer Prevention Partners, 2021). According to the report by Bowen et al. (2008), African American women have a 31% mortality rate due to breast cancer. It is the highest rate compared to other ethnic group in US. Over the past 20 year, one trend that has been seen is that there is disparity in the mortality rate among white and black women. The mortality rate for Black women is much higher than the mortality rate for white women. A study comparing the clinicopathological features of Black women in UK revealed that black women tend to had high frequency of grade 3 tumours. For the tumor less than 2 cm, the survival rate was poorer in Black woman compared to white. However, the findings cannot be generalized to current time as the research was conducted in the year 2008. Hence, review of more recent studies may help to further evaluate progress in research in this area.  

Existing research in the area

The study by Gathani et al. (2021) evaluated the ethnicity and tumour characteristics of invasive breast cancer among women in England. The data regarding women with invasive breast cancer was taken from the National Cancer Registration and Analysis Service. The findings revealed that all ethnic minority women had a higher proportion of less favourable tumour characteristics compared to other women. The significance was that the incidence of breast tumor was more marked for black Africans and black Caribbeans. The gap in the study was that causal association was not explored in much detail. It leaves behind gap and there ambiguity regarding the reason behind high invasive breast cancer rate in women. A cross-sectional study also characterized clinical symptoms of positive breast cancer among women before chemotherapy. A cross-sectional analysis of symptom burden was done among Black and White woman and the incidence of stage I to III was recorded. Out of a sample size of 1338 women, Black women were found to have a statistically significant rate of worse symptoms compared to white women. Some gaps left in the study are that the difference in symptoms after chemotherapy could be explored. In addition, the role of symptom burden of treatment adherence was not explored (Hu et al., 2021).

Apart from the studies exploring the association between breast cancer risk and symptom burden in Black women, certain research literatures were found that particularly explored the factors that contributed to Black-white disparities in the context of breast. The most relevant study in this regard is the study by Jemal et al. (2018) which reported about the factors leading to such disparities. The excess risk of death in Black women was attributed to presence of comorbidity, tumor characteristics and treatment options. The argument by Hirko et al. (2021) regarding the contributing factor of delayed breast cancer presentation in racial and ethnic group included low awareness of breast cancer symptoms, stigma of cancer diagnosis, mistrust of health care professionals and inaccessibility of health care services. This was concluded based on the findings from a review of 18 studies. However, there was lack of single cross-sectional studies that explored the reason behind the disparity in further details. The findings are not limited to single country too. Hence, there is a need to design a research considering the gaps seen in previous papers.

The significance of the study by Prakash et al. (2020) was that it explored racial disparities in triple-negative breast cancer (TNBC) by the review of biologic and non-biologic factors. TNBC is an aggressive type of breast cancer that lacks expression of the estrogen receptor. Some of the biological factors of disparities identified in the study were population genetics, tumor heterogeneity and increase in expression of AA breast tumor genes. In addition, various types of non-biologic factors such as socioeconomic disparity, lack of healthcare access, patterns of reproductive factors and unsafe neighbourhood was found. The gap in the study was that it did not target Black women, but all racial groups. In addition, the findings were based on review of different papers and no method was provided to assess the quality of those papers. Therefore, the new research area that has been identified is to explore the reason behind disparity in breast cancer among Black women by considering perspectives of clinicians as well as the target population.   The research that has been proposed is as follows:

Research methods

In UK, why is the risk of invasive ductal carcinoma or breast cancer higher in Black women compared to other women group from the perspective of clinicians and Black women?

From the review of research evidence, it has been found that the risk of breast cancer in Black women compared to white group has been already established. However, ambiguity or limitations have been found regarding the factors contributing to such disparities. Various research methods can help to explore risk factors. A case-control study design is a retrospective study which is used to detect risk factors of any disease. It is a type of observational study where participants are selected based on their outcome status. In this study, participants with the outcome of interest and those with no outcome of interest were selected. The researcher then evaluates the exposure in both groups. However, the limitation of this approach is that it is not useful in studying rare exposures (Setia, 2016). In contrast, the second most appropriate method to explore the risk factor is the use of qualitative research method. Various researchers have used qualitative research design to explore factors influencing a clinical problem. For instance, qualitative study has been used to identify factors contributing to drug-related problem in diabetes or factors influencing clinical decision making in influenza. For this research, it has been planned to use qualitative research approach as the aim is to evaluate perspective of clinicians and target population regarding the change in practice. According to Busetto, Wick and Gumbinger (2020), qualitative research is used to collect non-numerical data and evaluate opinion or perspectives of a research participant. It provides in-depth and rich knowledge on the research question. It is useful to discover reasons for observed patterns in a population group. As the research is concerned with assessing why ethnic disparity has been found in Black women, qualitative research approach is suitable for the research question.

Phenomenological approach will be used to explore the research question and identify reasons for ethnic disparity. Use of phenomenological approach is useful to explore the lived experiences of individuals about a research phenomenon (Neubauer, Witkop & Varpio, 2019). It is planned to conduct the study in an oncology referral centre in UK. The advantage of conducting the study in this setting is that it will be possible to collect data from both clinicians as well as Black women.

The sample for the study will include clinicians specializing or having working work experience in oncology and Black women group with a diagnosis of breast cancer. As the research will involve two different population groups, the sampling method will differ. As the research will be done in oncology referral centre, all clinicians will be selected using random sampling method. The participants will be invited to the study by means of distributing fliers and the participants will be randomly selected after taking informed consent from them. The advantage of random sampling method is that there is an equal chance of selection and there is no risk of bias during selection (Berndt, 2020). In contrast, the recruitment of Black women will be done using purposive sampling method. Purposive sampling method involves selecting specific characteristics of sample group based on researcher’s judgment. The focus of this sampling method is to select information rich sample that provides insight better insight about the research topics. The inclusion criteria for selection will be as follows:

• All the participants should be Black women and no other racial group?
• The participants should have breast cancer diagnosis for a minimum of six months
• All women should be aged 18 years and above
• The participants should be undergoing treatment in a clinic

The advantage of purposive sampling method is that it is a flexible method and provides enough flexibility while addressing the research question (Campbell et al., 2020). While selecting the sample size, the type of research methodology and the nature of data collection will be considered. The data saturation aspect will be considered while collecting the data. One challenge that can be seen during selecting black women group is that all women will not be available at the referral centres. It is planned to take contact numbers and direct contact them to invite into the study. The process will be initiated by a culturally competent staff.

The data collection will be done using semi-structured interview method. A total of 14 in-depths interview will be conducted in the oncology referral centre. After obtaining informed consent from the sample group, the duration and appropriate place of interview will be communicated to the experts. In addition, interview will be conducted in a private room and it will be audio recorded. The interview guide will be developed by the review of research literatures. Participants will be mainly asked to give their opinion about the reasons for high rate of breast cancer in Black women group. For the Black women participants, they will be asked to give their opinion on the reasons for their current diagnosis and challenges in managing the disease. Through the use of probing techniques, the participants will be encouraged to identify the reasons for delay in presentation or diagnosis too. The duration of interview will be kept to 30 minutes.

Before starting with the research, the ethical approval will be taken from the Human Research Ethics Committee. In addition, the informed consent process will be completed by allowing all participants to sign a consent form. The privacy and confidentiality requirement will be addressed by ensuring by keeping private data anonymous (Resnik, 2018). The completion of the above process will help to avoid conflict during the situation.

References

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Bowen, R. L., Duffy, S. W., Ryan, D. A., Hart, I. R., & Jones, J. L. (2008). Early onset of breast cancer in a group of British black women. British journal of cancer, 98(2), 277-281.

Breast Cancer Prevention Partners. (2021). African American Women and Breast Cancer. Retrieved from:

https://www.bcpp.org/resource/african-american-women-and-breast-cancer/

Busetto, L., Wick, W., & Gumbinger, C. (2020). How to use and assess qualitative research methods. Neurological Research and practice, 2(1), 1-10.

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Gathani, T., Reeves, G., Broggio, J., & Barnes, I. (2021). Ethnicity and the tumour characteristics of invasive breast cancer in over 116,500 women in England. British Journal of Cancer, 125(4), 611-617.

Hirko, K. A., Rocque, G., Reasor, E., Taye, A., Daly, A., Cutress, R. I., ... & Park, Y. H. (2022). The impact of race and ethnicity in breast cancer—disparities and implications for precision oncology. BMC medicine, 20(1), 1-12.

Hu, X., Chehal, P. K., Kaplan, C., Krukowski, R. A., Lan, R. H., Stepanski, E., ... & Graetz, I. (2021). Characterization of Clinical Symptoms by Race Among Women With Early-Stage, Hormone Receptor–Positive Breast Cancer Before Starting Chemotherapy. JAMA network open, 4(6), e2112076-e2112076.

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Prakash, O., Hossain, F., Danos, D., Lassak, A., Scribner, R., & Miele, L. (2020). Racial disparities in triple negative breast cancer: a review of the role of biologic and non-biologic factors. Frontiers in Public Health, 762.

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