This article is part of Breast Cancer and Black Women, a destination in our Health Divide series.
A diagnosis of breast cancer is life-changing, but it doesn’t have to be life-threatening.
While breast cancer can be deadly for all women if not diagnosed at an early stage, people have remarkable outcomes when diagnosed early. Unfortunately, this does not always happen. Black women are less often diagnosed with stage 1 breast cancer, when it’s highly treatable, than White women. They also more often receive a diagnosis of triple-negative breast cancer, an aggressive form of breast cancer that requires urgent treatment.
Early detection and prevention are the keys to turning these statistics around.
This article will discuss the role of mammograms, self-examinations, ultrasounds, and other tests in the diagnosis of breast cancer and provide insights into the effect of breast cancer on Black women.
Breast self-exam, or regularly examining your breasts on your own, can be an important way to find breast cancer for women at a higher than average risk for developing the disease.
The five steps of a breast self-examination are:
- Look. Make sure that your breasts are their usual size, shape, and color. If there is redness, swelling, puckering, dimpling, changes in skin color, or your nipples are more elevated than usual, contact your healthcare provider.
- Raise your arms and look for any of the same changes.
- Examine your breasts for any discharge, especially in the nipple area. Bloody discharge may be a warning sign of breast cancer.
- Feel your breasts while lying down. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter, examining the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Push hard enough that you are feeling deep into the tissue but not so hard that you injure yourself.
- Repeat step four while standing up. Report any painless lumps or suspected changes in your breasts to your healthcare provider immediately.
No one will know your breasts better than you do, so routine exams may be helpful.
Although regular breast self-exams haven’t been shown to reduce mortality rates and may even cause harm by prompting unnecessary biopsies, healthcare providers still believe that the benefits of this no-cost preventive measure outweigh the risks.
Breast self-exams are a great way to help you to get to know your breasts better and readily identify changes that may be warning signs of breast cancer. If you are experiencing symptoms or noticing changes in your breasts, do not hesitate to call a healthcare provider. Most lumps are noncancerous, but do not assume that they are. Be sure that you confirm this with a healthcare professional.
Your healthcare provider will take a detailed history prior to performing a physical exam. A detailed history is needed to assess your risk for breast cancer prior to ordering potentially invasive tests or labs.
Breast Cancer Risk
Be prepared to answer questions about your family’s history of breast cancer because a history of breast cancer in a first-degree relative—your parents, siblings, and children—is the most widely recognized breast cancer risk factor.
Breast cancer usually shows no symptoms in its earliest stages. Oftentimes, there is no lump, and only 5% of people present with pain or discomfort.
The most common breast problems that prompt people to see a healthcare provider are:
- Breast pain
- Nipple discharge
- Palpable mass
Most women with these complaints have benign breast disease. On physical examination, a healthcare provider will look at the breast, perform a breast examination, and check for associated signs of potential breast cancer.
If the physical examination is normal—that is, it reveals no evidence of a breast mass—then you are free to go home. You should be reassured and instructed in breast self-examination before you leave your appointment.
If there is any uncertainty after your physical exam, an ultrasound may be performed. Oftentimes this can be done immediately, and you will not have to return for a separate visit. If no mass is found, you may be asked to return for a follow-up visit in two to four months. During that time, you may also be asked to have a mammogram unless you are younger than 35 years old. In younger women, mammography is rarely useful.
Labs and Tests
If breast cancer is suspected, you will be asked to get a mammogram and biopsy (the removal of tissue for examination).
If your biopsy detects breast cancer, your oncologist may suggest additional lab tests to assist with prognosis (the likely outcome of the disease).
The two most common lab tests are the:
- Hormone receptor test
- The HER2/neu test
Your healthcare provider will send you to a lab to have blood drawn to check the status of these receptors. By knowing your receptor status, your healthcare provider can suggest certain treatment options and begin to assist you in formulating a treatment plan.
Estrogen, progesterone, and HER/Neu are the three receptors that are being assessed. If any of the three are present, then they can be treated with hormone-modulating chemotherapies. But if they are not present, different treatments besides mastectomy (surgery to remove all or part of the breast) and radiation must be considered to rid the body of cancer.
The latter, called triple-negative breast cancer, is rare but more common in Black women. It is often more aggressive and can be fatal without timely treatment.
Whenever breast cancer is suspected the three steps that are taken are:
- Clinical examination
- Imaging (usually a mammogram, an ultrasound, or both)
- Needle biopsy
Clinical examination and imaging are almost always performed, while needle biopsy is performed if a healthcare provider’s clinical suspicion is confirmed by an exam and the imaging results.
A breast ultrasound uses sound waves to create an image of the breast tissue. Breast ultrasounds are not used to screen for breast cancer because of the higher-than-average possibility of missing cancer, especially early signs like tiny calcium deposits called microcalcifications.
However, ultrasounds play a major role in breast examinations because they can help rule out other causes of breast changes—like fluid-filled cysts—that are harder to identify on mammograms. Ultrasounds can differentiate between fluid-filled cysts that are benign and noncancerous versus solid masses that need to be investigated further.
Black Women and Breast Ultrasounds
Ultrasounds are great at detecting changes in dense breast tissue. They are also used to help guide a needle during a biopsy.
Ultrasounds are widely available for and accessed by Black women. They are an important low-cost option to assess breast health.
A mammogram is a low-dose X-ray that can help find breast cancer.
Mammograms are the premier screening tool used to detect early breast cancer. Cancers show up white on X-rays, but so does dense breast tissue, making it harder to spot cancer.
The U.S. Preventive Services Task Force (USPSTF) recommends delaying screening mammograms until the age of 50, but this puts Black women at a disadvantage. The data collected for the USPSTF recommendations mainly represents White women and does not adequately reflect the higher-risk Black female population.
The American Cancer Society (ACS) recommends annual or biennial mammogram screening as early as age 45 for those who do not have a family history of breast cancer.
Black Women and Mammograms
In Black women with a family history or a known breast cancer gene (BRCA) mutation, mammograms are recommended before the age of 40.
Ultimately, the choice to get a mammogram is up to you, although studies show that women are often happiest with their decisions when they are made with the guidance of a trusted healthcare provider in a process known as shared decision making.
Effect on Black Women
Black women are dying from breast cancer at an alarming rate and the following conclusions from the ACS’s Breast Cancer Facts and Figures 2019–2020 may provide some insight on the crisis at hand:
- Black women are not translating breast health awareness into tangible actions. A recent survey found that 92% of Black women believe that breast health is important, but only 25% say that they have recently discussed breast health with their family, friends, or colleagues. And, only 17% have taken steps to understand their risk for breast cancer.
- Black women are more likely to present with advanced-stage cancer upon detection.
- Black women are less likely to have health insurance and, therefore, are more likely to skip or neglect mammograms.
- Lack of insurance leads to a lack of access to care. Getting a mammogram without insurance is expensive and providers do not offer enough low-cost options. Eliminating the racial wealth gap would solve access to care issues, but that is a long way off. Meanwhile, Black women may struggle to pay for, or stress over the cost of, healthcare services like mammograms and lab work. Some Black women may not follow up on abnormal mammogram results because they can’t afford the diagnostic testing, wish to avoid bad news, or both.
- Black women often go to lower-quality healthcare facilities and receive lower-quality care so they don’t get the same prompt high-quality treatment that others receive.
- Black women are two times more likely than White women to get triple-negative breast cancer, a rare and aggressive subtype that is often fatal due to its treatment-resistant nature. It is the only breast cancer subtype that does not have a therapy to prevent a recurrence.
- Younger Black women sometimes get diagnosed at later stages and are more likely to get a diagnosis of triple-negative breast cancer when they do.
The lack of diversity in breast cancer research means that some of the recommendations, such as the USPSTF’s breast cancer screening guidelines, are not best practices for Black women. This can be a tough pill for Black women to swallow as they often must overcome medical mistrust and systemic problems.
Breast Cancer Deaths in Black Women
Breast cancer is the second leading cause of cancer death in Black women, with nearly 7,000 deaths each year.
More inclusive research is needed on the race-specific differences in the following:
- Tumor biology
- Treatment options
- Environmental factors
Fortunately, including Black women in research studies is a prime focus in the scientific community. As a result, there has been a large increase in the number of personalized treatments that Black women have access to. While cost remains a concern, Black women now, more than ever, have the opportunity to access the individualized care and treatment options that they need to beat breast cancer.
Determining what constitutes a mass can be difficult, particularly in premenopausal women. Ultrasounds, mammograms, and biopsies are used in concert to determine whether or not you have cancer and, if positive, how widespread the cancer is.
Most lumps are noncancerous, but they all should be examined.
The differential diagnosis of a dominant breast mass includes:
- Macrocyst, a fluid-filled cyst
- Prominent areas of fibrocystic change
- Fat necrosis
- Breast lymphoma
- Metastasis to the breast from other primary sites (such as ovarian cancer, neuroendocrine, or extramedullary acute myeloid leukemia)
- Papilloma, a small wart-like growth
- Duct ectasia
Access to Care
Despite getting breast cancer at rates equal to White women and advancements in screening and treatment, Black women have a 40% higher risk of dying. Among women under 50, the disparity is even greater with the mortality rate of young Black women doubling that of young White women.
For this reason, every Black woman should consider getting a screening mammogram at the age of 40 and every year thereafter.
It should also be noted that screening guidelines that recommend delaying screening mammograms until the age of 50, such as the USPSTF’s guidelines, are often based on data from a population that is predominantly White. When Black women follow those guidelines, they are put at a disadvantage and can receive a delayed diagnosis since the highest rates of new breast cancer diagnosis are made in Black women aged 50 and younger.
According to one recent study, the three most commonly reported barriers to mammography are:
- Fear of cost
- Fear of mammogram-associated pain
- Fear of getting bad news
Systemic problems—such as lack of insurance, concerns over the ability to pay, having no primary care healthcare provider, and having biased care—add another level of difficulty for Black women.
Some additional factors associated with lower mammogram completion rates include:
- Being under the age of 60
- Having a health plan membership of less than five years
- Having an annual family income of less than $40,000
- Being obese and fearing “too much pain” from mammograms
- Having recently immigrated to the United States
- Living in a rural area
No woman should go without a mammogram, whether there are concerns about pain, bad news, or cost. Going to an appointment with a friend may ease your fears, and many providers will work with you to offset the cost of your mammogram.
Breast Cancer Doctor Discussion Guide
Get our printable guide for your next doctor’s appointment to help you ask the right questions.
A Word From Get Meds Info
Checking your breasts often, getting a routine mammogram, and knowing your family history are keys to optimal breast health. Early detection means you have a better chance to treat your cancer successfully with affordable options.
Getting a diagnosis of breast cancer is understandably scary and much of your anxiety may result from a fear of the unknown. Remember that most breast cancers are curable and medical advances are helping people to live longer lives.
Frequently Asked Questions
Is it possible to diagnose breast cancer early?
Yes. The most effective way to catch breast cancer while it’s easiest to treat and before it can spread is with regular screening mammograms. For women at average risk of breast cancer, the American Cancer Society (ACS) recommends those who are:
- Between 40 to 45 have optional yearly mammograms
- Between 45 to 54 have yearly mammograms
- 55 and older switch to mammograms every other year or, if they prefer, continue to have them yearly
The ACS recommends women at high risk of breast have a mammogram and, in some cases, a breast MRI every year starting at age 30.
Is there a blood test for breast cancer?
No, but in a 2018 study, an experimental blood test called CancerSEEK that measures levels of certain proteins and genetic material was able to detect several types of cancer, including breast cancer. However, considerably more research will be needed to determine whether such a “liquid biopsy” is a viable way to test for breast cancer.
Does it take a long time to diagnose breast cancer?
It shouldn’t, although waiting for the results of any type of medical test can feel like a lifetime. Sometimes a radiology center will have permission from an oncologist to share the results of a mammogram as soon as it’s completed. Biopsies take longer—typically a week or so—because after a sample of tissue is examined by a pathologist, a healthcare provider then needs to receive and interpret the results.
What does a breast cancer lump feel like?
This can vary widely, but most are irregular in shape (rather than round or smooth) and firm to the touch (not squishy or spongy). Malignant tumors in the breast may or may not be attached to the chest wall. Lumps can appear anywhere in the breast and tend to be detectable once they’re the size of a pea.
How can you know if breast cancer has spread?
A clue is symptoms that reflect where the cancer has spread—for example, a cough or shortness of breath if it has reached the lungs. To confirm a diagnosis of metastatic breast cancer, an oncologist may use a number of tests, such as imaging or blood tests. If the lungs are involved, this might be an X-ray or ultrasound of the chest and/or a bronchoscopy. If the brain is involved, an MRI of the brain may be performed.
How do healthcare providers diagnose male breast cancer?
Diagnosing breast cancer in men essentially is the same as in women: Following a physical exam, imaging tests, a nipple discharge test, and/or some sort of biopsy typically may be performed. Interestingly, mammograms tend to be more accurate for men than for women because male breast tissue is less dense, allowing for clearer images.
Why do Black women have denser breasts than White women?
It is unknown why Black women tend to have denser breast tissue than White women. Dense breast tissue makes it difficult to spot breast cancer on mammograms. Dense tissue shows up white on mammograms, as do cancer cells, increasing the likelihood that a radiologist will miss a tumor. A missed diagnosis can lead to larger tumors and delays in treatment.
Why is the mortality rate of breast cancer higher for Black women?
While Black women and White women get breast cancer at about the same rate, Black women are 40% more likely to die from the disease. There are many factors that contribute to breast cancer disparities, ranging from social determinants to genetics to tumor biology, but one mysterious phenomenon stands out: Black women are twice as likely to have triple-negative breast cancer, a rarer but more aggressive form that does not respond to hormonal treatment, making it difficult to treat.