As the director of the AVON Foundation Comprehensive Breast Center (AFCBC) at Grady Memorial Hospital and professor of surgery at Emory University since 2005, Sheryl Gabram, MD, MBA, has been a tireless advocate of redressing breast cancer treatment disparities between black women and white women in Atlanta, a disjunction that is representative of much of the country. Combined with her position as principal investigator on Winship Cancer Institute of Emory University's AVON Foundation grant for decreasing disparities in breast cancer care, and in cooperation with various Emory and Grady colleagues, Gabram's work has produced impressive gains in combating this imbalance: the percentage of African American Stage 0 breast cancer patients treated at the AFCBC is now equivalent to the national average; an AFCBC-sponsored community program identifies patients to be sent to Grady for screening and diagnostic mammography, though only 25% follow up; women can receive a screening mammogram at Grady without an appointment; and once patients are in the system, they receive the highest quality care the field has to offer.
However, Gabram's acute awareness that much work remains to be done was confirmed by an AVON-sponsored study e-published by Cancer Epidemiology in October 2016, then regular published in the journal's December edition. Among the sobering facts to be found in "Black:white disparities in breast cancer mortality in the 50 largest cities in the United States, 2005-2014," written by Bijou Hunt, MA, of the Sinai Urban Health Institute in Chicago, and Marc Hulbert, PhD, Breast Cancer Research Foundation, New York, is that black women continue to die from breast cancer at a higher rate than their white counterparts in 24 of the 43 largest U.S. cities, and that the city with the highest disparity level was Atlanta.
"We've made some real progress, but during the past five years or so disparities across the city have increased," says Gabram. "It is clear that African American women are losing ground in this struggle, and we need to define the reasons and respond to them."
Gabram believes the most culpable forces in sustaining and intensifying disparities are concerns about the cost of treatment, particularly in the wake of the economic downturn, a period in which many African American women lost their insurance and Georgia did not expand its Medicaid program; fear of treatment, which often manifests as denial and can cause such populations as single mothers to ignore their symptoms because of their position as sole supporter of the family; and lingering confusion over screening guidelines and when to seek care for breast changes or abnormalities. One of the sum results of these influences is the alarming trend of too many black women being diagnosed late in the disease process.
"If we can get women into our center early, we can save their lives," Gabram says. "In many cases, I suspect that these women are unaware that that there are ways to get financial support for the care they need. We need to find better ways of getting the word out so these women don’t fall through the cracks."
Gabram is taking the immediate measure of forming a collaborative task force with Susan G. Komen Greater Atlanta, the local affiliate of the global organization dedicated to breast cancer education, research, advocacy, health services, and social support programs. The task force will work to connect with key stakeholders in the city—government officials, social services representatives, civic organizations, public health and medical entities, and so forth—to develop a unified effort to identify those areas that need improvement in the health establishment's communication process with certain communities, and to address any additional roadblocks to treatment.
As PI of the AVON grant, Gabram was informed in December that the team had received a $750,000 award for January 1 through December 31, 2017. The grant will maintain and expand the AFCBC's outreach activities, particularly its involvement in the Community Education and Outreach Initiative (CEOI) led by Winnie Thompson, PhD, of Rollins School of Public (RSPH), which consists of providing patient navigation services in all phases of the treatment process to patients in the AFCBC, and efforts by Community Patient Navigators (PNs) to educate black women in communities and regions that appear to be most at risk.
The grant will also support two new research projects. The first, led by Lauren McCullough, PhD, MSPH, of RSPH, will examine the relationship between obesity and breast cancer in African American women, while the second, managed by Emory hematologist and medical oncologist Adam Marcus, PhD, hopes to advance understanding of the causes of Stage IV breast cancer using a combination of molecular and imaging-based approaches.
Two ongoing projects led by Emory surgical oncologists will continue to elevate the quality of care available to breast cancer patients once they get into the Grady system. Preeti Subhedar, MD, is principal investigator of a study that is working to standardize lymph node biopsy in newly diagnosed breast cancer patients, and Cletus Arciero, MD, is leading an effort to identify best practices and make care consistent for patients with metastatic breast cancer across all Emory facilities, including the AFCBC.
"It's all about dispelling the myths and the fears, getting these women to come in to our facilities, and for healthcare providers to be part of a system that properly educates these women about the resources and options available to them," Gabram says.