While many nations have significantly reduced breast cancer deaths over the last 30 years—by 42 percent in the United States alone—incredible progress has not held true in low-resource countries and even in parts of the U.S. The World Health Organization last year announced that breast cancer became the most common cancer in the world, impacting an estimated 2.3 million people.
Earlier this year, as part of an employee town hall hosted by The Estée Lauder Companies’ Breast Cancer Campaign, BCRF’s Chief Scientific Officer Dr. Dorraya El-Ashry moderated a conversation with two investigators working to reverse breast cancer disparities and improve outcomes worldwide: Drs. Lawrence Shulman and Sonya Reid. Dr. Shulman has helped establish cancer programs in Rwanda, Haiti, and Botswana with BCRF support. Dr. Reid is investigating genomic differences that may contribute to racial survival disparities and is involved in breast cancer research in her home country Jamaica.
Through the company’s Breast Cancer Campaign, Dr. Shulman’s research is supported by The Estée Lauder Companies’ Employee Fundraising Awards, and Dr. Reid’s three-year Conquer Cancer–BCRF grant was made possible by The Estée Lauder Companies’ Charitable Foundation Awards.
The following is an edited excerpt of their discussion with Dr. El-Ashry:
Dr. Shulman: I’m an old guy. I entered Harvard Medical School in September 1971, and three months later, then-President Nixon [declared] the war on cancer. It was exciting. But frankly, I learned very quickly in medical school that we were treating breast cancer patients the same way we were in 1890 when Dr. William Halsted pioneered the mastectomy. Over the last 40 or 50 years, things have radically changed. We learned how to do surgery that is a lot less deforming. Radiation techniques have gotten much better. We learned how to give systemic therapies. Cure rates have skyrocketed. But our work is not done. Still too many people die of breast cancer in the U.S, and even within the U.S., there are people who don’t benefit from these treatments. That’s even more true worldwide—and something we need to be devoted to changing.
Dr. Reid: We know that Black patients, for example, have a 41 percent higher mortality rate compared to white patients if they get breast cancer. And that alone makes you wonder: What is causing this racial disparity? We always think about access and social determinants of health, but also: Is there something else from a biological or genomic standpoint? We know that there are different gene mutations you can be born with that increase your risk of breast cancer. But here in the U.S. and globally, we have such an under-representation of diverse patients in our genomic databases, so it’s hard to truly understand if there are even differences.
Dr. Shulman: Early in my career, I crossed paths with [Partners in Health Founder] Dr. Paul Farmer, who was an infectious disease doctor and a pioneer in global health. He devoted his life to bringing medicine to places where it wasn’t reaching people. He started with HIV, malaria, and tuberculosis and made tremendous progress, but when you start to cure those diseases and people live longer, they get cancer. In the 2000s, he called me up and said, “Listen, we’re seeing a lot of patients with cancer in Rwanda and Haiti. We need to form programs there to offer them what we offer in the U.S.” I remember going to Rwanda with Paul for the first time over a decade ago, and there was not a single cancer doctor in the country. There was no radiation. As patients told you, “If you got cancer, you died.” We established a cancer program there from the ground up. Since then, we’ve seen about 15,000 patients. There are thousands of women who are alive in Rwanda now who had no options 10 years ago.
We’ve learned how to bring so many of the treatments developed here in the U.S. to that environment, as well as to Botswana, Haiti, and other places. That’s our obligation. We live in a global community. BCRF is very prescriptive about us taking a scientific approach to everything we do. We didn’t show up in Rwanda and start doing stuff. We were very methodical. We publish over and over again to give other countries roadmaps. I’ve gotten feedback from other countries that our work has helped them go from A to B and C to D. With BCRF’s help, we’ve helped others beyond Rwanda.
Dr. Reid: Being from Jamaica, you see a lot of unfortunate health outcomes that are tied to access to care. When I was in medical school, I had the opportunity to spend a day in a hospice with a patient who had breast cancer and had not received optimal treatment due to lack of resources. That was life changing. At that point, I really began to wonder, how could this be? We are in a developing country, yes, but a country that is productive in so many ways with talented oncologists. That really inspired me to pursue a career in oncology with the hopes of contributing to the future of oncology globally.
When I came to the U.S., it was also very humbling. At my residency program here in Nashville, I saw some of the exact same issues I saw in Jamaica, where patients were not able to access equitable healthcare due to their socioeconomic status or what insurance they had. There are so many different inequities in how we provide care to our patients that fueled my passion to not only change the face of what access to care looks globally and here in our backyard.
Dr. Reid: The first thing is representation. We need to make sure that our clinical trials and population-based studies are representative of the general population. Researchers need to then take a step back and say, “What is the population? What is the distribution of racial/ethnic groups?” We need to become more intentional about recruiting a diverse population and asking questions that address the root causes of health disparities in order to achieve equitable care for all patients.
Dr. Shulman: In Rwanda, women came in with very advanced breast cancer. But if you talk to some people—I won’t name names—they say, “Oh, it’s a woman’s fault; they didn’t come in.” Well, we studied that with support from BCRF, and it turned out that the major delays were in the health system. Women went to health centers and their cancers were not recognized and they were sent home. We developed a whole education program for health centers in Rwanda with community health workers and nurses. And in only the couple of years we’ve been doing that, we’ve seen a major shift in women coming in with much-earlier-stage disease that’s much more curable.
Here in Philadelphia, during the early stages of the pandemic as was the case everywhere, we started doing a lot of telemedicine. Our hospitals are within walking distance of West Philadelphia, which is where a lot of the city’s Black population lives. We quickly realized that they partook in telemedicine much less often, and even before the pandemic, their screening rates for breast cancer were much lower and their disease was much more advanced when they came in. One of my colleagues copied the model we developed in Rwanda to reach patients in West Philadelphia, and we’re starting to see benefits. We had to develop this in Rwanda before we could figure out that it would be beneficial in Philadelphia. It made us think about things differently here.
Dr. Reid: We now have a lot in our toolkit. We know so much more than we ever did before. And my hope is that even advanced breast cancer will be a treatable disease with more treatment options available to all patients, regardless of race or ethnicity. That is my true hope.
Dr. Shulman: Our understanding of breast cancer is going up astronomically. Every year, we understand things that were unimaginable the year before, and we’ve developed treatments that capitalize on that new knowledge. I’m very, very hopeful that in the next several years, advances will go up as quickly as our biological understanding of breast cancer has. Then we need to figure out how everybody in the U.S. and in countries like Rwanda can access those advances. But I’m more optimistic than ever that we have the tools to leapfrog to a whole new era in how we treat breast cancer, and, frankly, it’s due to BCRF and the support they’ve supplied not only to Sonia and me, but to literally hundreds of breast cancer researchers around the world.
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