Breast Cancer Characteristics and Socioeconomic Factors Equally Linked to Higher Death Rates Among Black Women
For the last four decades, we’ve known that Black women are about 40% more likely to die from breast cancer than white women. Studies have suggested that a number of factors contribute to this disparity, including structural racism in the healthcare system and the biology of the cancer tumor.
Now, a study has found that the cancer’s characteristics and what researchers call social determinants of health contribute equally to this difference in survival between Black and white women diagnosed with early-stage, hormone receptor-positive breast cancer.
The research was published online on Feb. 16, 2023, by the journal JAMA Oncology. Read the abstract of “Association of Social Determinants and Tumor Biology With Racial Disparity in Survival From Early-Stage, Hormone-Dependent Breast Cancer.”
Listen to Dr. Kent Hoskins on the episode of The Breastcancer.org Podcast: Breast Cancer Survival Differences in Black and White Women.
Social determinants of health are conditions in the environments where people live that affect a number of health, functioning, and quality of life outcomes. Researchers group social determinants of health into five broad categories:
economic stability
education access and quality
healthcare access and quality
neighborhood and built environment
social and community relationships
Examples of social determinants of health include:
safe housing and neighborhoods
affordable, safe transportation
racism, discrimination, and violence
education, job opportunities, and income
access to healthy, nutritious food
safe, accessible opportunities for physical activity and exercise
polluted air and water
language and literacy skills
Social determinants of health have a huge effect on people’s health and well-being. They also contribute to health disparities and inequality. For example, people who lack access to a grocery store that sells healthy food are more likely to have poor nutrition. Poor nutrition raises their risk of conditions such as heart disease, high blood pressure, and diabetes, all of which can lower a person’s life expectancy.
Among women diagnosed with breast cancer, researchers think a number of social determinants of health contribute to the differences in mortality rates between Black and white women, including:
societal conditions
policy decisions
neighborhood disadvantages
economic disadvantages
About the study
In this study, the researchers wanted to better understand the difference in breast cancer outcomes between Black and white women.
The study included 60,137 women diagnosed with stage I or stage II, estrogen receptor-positive, node-negative breast cancer between 2004 and 2015.
All the information came from the Surveillance, Epidemiology, and End Results (SEER) database. The SEER database is a large registry of cancer cases from sources throughout the United States maintained by the National Cancer Institute of the National Institutes of Health.
The researchers also looked at census tract information to determine poverty, income, and education levels for the women, and also recorded the type of health insurance they had and breast cancer treatments they received.
All the women had Oncotype Dx testing.
The Oncotype DX Breast Recurrence Score Test analyzes a group of 21 genes from early-stage, estrogen receptor-positive, HER2-negative invasive breast cancer to figure out:
the risk of the cancer coming back in a part of the body away from the breast, called distant recurrence by doctors
the likelihood that a person diagnosed with this type of early-stage breast cancer might benefit from chemotherapy
The Oncotype DX Breast Recurrence Score Test assigns a Recurrence Score — a number between 0 and 100 — to the breast cancer. Based on your age, you and your doctor can use the following ranges to interpret your results.
For women older than 50:
Recurrence Score of 0-25: The cancer has a low risk of recurrence. The benefits of chemotherapy are not likely to outweigh the risk of side effects.
Recurrence Score of 26-100: The cancer has a high risk of recurrence. The benefits of chemotherapy are likely to be greater than the risk of side effects.
For women age 50 and younger:
Recurrence Score of 0-15: The cancer has a low risk of recurrence. The benefits of chemotherapy are not likely to outweigh the risk of side effects.
Recurrence Score of 16-20: The cancer has a low to medium risk of recurrence. The benefits of chemotherapy are not likely to outweigh the risk of side effects.
Recurrence Score of 21-25: The cancer has a medium risk of recurrence. The benefits of chemotherapy are likely to be greater than the risk of side effects.
Recurrence Score of 26-100: The cancer has a high risk of recurrence. The benefits of chemotherapy are likely to be greater than the risk of side effects.
The women had an average age of 58.1 years and:
54,489 were white (90.6%)
5,648 were Black (9.4%)
White women were more likely than Black women to:
be in the highest income and education groups
be in the lowest poverty group
have health insurance
Black women were more likely than white women to:
be diagnosed with larger and higher-grade breast cancer
have a high-risk Recurrence Score
be diagnosed with stage II breast cancer
receive chemotherapy
The women were followed for 32 to 86 months.
The researchers wanted to see how much each factor contributed to the difference in breast cancer survival rates between Black and white women:
socioeconomic level and health insurance status accounted for 19% of the difference
Recurrence Score and tumor characteristics accounted for 20% of the difference
racial differences in tumor size accounted for 8% of the difference
racial differences in treatments they received accounted for 6% of the difference
When the researchers looked at all the factors together, they accounted for 44% of the difference in breast cancer survival between Black and white women diagnosed with early-stage, hormone receptor-positive, node-negative breast cancer.
“The main findings of this analysis in terms of the role of social determinants of health are consistent with previous studies that showed both individual- and neighborhood-level measures of socioeconomic deprivation drive racial disparities in breast cancer survival,” the researchers wrote. “By focusing our analysis on women with [estrogen receptor]-positive tumors and by including tumor genomics as a mediating variable, we were able to more precisely quantify the relative excess of breast cancer death mediated by aggressive tumor biology in Black women with the most common breast cancer subtype.”
In a statement, lead author Kent Hoskins, MD, the Eileen Lindsay Heidrick Professor of Oncology and associate director of translational research at the University of Illinois Cancer Center at the University of Illinois Chicago, said that the study adds to evidence that he and his colleagues have generated in the past few years showing that the tools used to determine the best treatments for people diagnosed with breast cancer, such as the Oncotype DX test, may not be serving Black women as well as white women.
“The tools we have to aid in decision-making regarding treatments do not take into account potential differences in tumor biology across race and ethnicity, and even worse could be providing misleading information or a false sense of security with treatment decisions for Black women,” Dr. Hoskins said.
What this means for you
Although very concerning, the results of this study give us more insights about why Black women are more likely to die from breast cancer than white women.
Eliminating this survival gap is not easy or quick. The researchers said we need a better understanding of how the multilayered effects of social and economic disadvantage affect cancer care, as well as more research on the biology of breast cancer tumors in Black women to understand why these tumors are more aggressive.
All people — no matter their race, ethnicity, gender identity, sexual orientation, age, economic status, or other health conditions — deserve the best breast cancer care possible. Differences that affect outcomes, such as access to care, and quality and consistency of care, should be eliminated.
— Last updated on July 26, 2025 at 6:27 PM