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Black women were dying of breast cancer at higher rates compared with white women in Chicago, despite a county program that had been put in place to improve their access to mammography screening.

After examining multiple variables, the reason for this was not genetic, found David Ansell, MD, MPH, and colleagues, as many at the time believed. Black women biologically do not have a different type of breast cancer, nor are they likely to die earlier or at a faster rate than white women.

During this week's virtual Society to Improve Diagnosis in Medicine conference, Ansell, of Rush University in Chicago, explained that it was not just about a lack of access to mammography -- it was lack of access to quality mammography.

In many centers located in parts of the city where Black women were more likely to receive care, breast cancers were being diagnosed at a rate of two per 1,000 instead of the expected rate of five to seven per 1,000.

He called the healthcare systems in the nation's cities with the largest Black populations "apartheid healthcare systems in which institutions where Black people go are deprived of the assets that they need to provide good care, and therefore, systemically worse care is provided."

In a nutshell, large-volume screening centers had higher-quality scores than lower-volume centers, which are more likely to be "safety-net hospitals in Black and Brown communities," Ansell noted. Many of these hospitals were missing cancers already developing in Black women far more often than they were missed in white women. The researchers confirmed this by going back to the patients' prior mammograms, and actually documenting those cancers that were missed in the images.

Structural Racism at Work

"Wait a second, we put the screening units in these places. How could people be missing breast cancer?" Ansell asked. "We assumed wrongly that putting the technology in and putting programs together would make a difference, but we never considered that this could be a quality issue." It was, he said, a classic example of structural racism at work.

A higher-quality screening center should expect to find half of breast cancers when they are at an early stage, and they should have a rapid recall rate that enables women with abnormal screens to return for further diagnostic evaluation within 30 days. The centers also should be sure to perform biopsies as needed within 60 days of that abnormal screen, so appropriate treatment can begin promptly.

But in the screening centers where Black women were more likely to get their mammograms, "you were about one-third less likely to have your mammogram read by a specialist" who is trained and has the ability to detect more cancers than generalists. Women were also about 50% less likely to receive screening with the latest technology, and less likely to have a face-to-face conversation with the provider on the day of her mammogram, meaning that Black women were less likely to get their results that day.

In one dramatic example of structural racism that existed in Chicago, Ansell showed a photo of the poor working conditions at Cook County's Provident Hospital. In the area where mammogram studies were developed, the photo showed a radiology tech covering her nose with a mask.

"Look on the floor. Here is a sewer underneath the floor with a smell of feces coming through. Imagine sending your mother or sister to get a mammogram at a place like this," he said.

This hospital had a low detection rate of only two cancers per 1,000 women, he added.

"This is what structural racism looks like, and it was clearly tolerated," he continued. He noted that Provident Hospital now has new screening areas where there is no smell from sewers coming up from the floor.

Ansell said that after the variation in detection rates was discovered, a task force was created, which implemented "rapid cycle improvements, including teaching the techs how to do mammography." They instituted patient tracking systems, mammography and treatment quality reporting systems, training "boot camps," and other improvements.

There is still a breast cancer mortality gap, but in a case study in 2019, Ansell and co-authors pointed out that since the task force's inception, "racial disparity in breast cancer mortality in Chicago has decreased by 20% -- a result not observed in the nine other U.S. cities with the largest Black populations."

"It was very critical that we had to change this narrative from being a biological narrative or genetic narrative into being a narrative of systemic and structural and institutional racism, which if you can imagine in 2006, pretty much fell on deaf ears," Ansell said.

However, racial disparities still persist in breast cancer. According to a study presented at this year's American Society of Clinical Oncology meeting, Black women diagnosed with breast cancer have a poorer prognosis, regardless of disease subtype.

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