Evidence brief: Social disparities in the frequency and severity of triple-negative breast cancer at diagnosis in a university hospital in Paris, France: confronting race and ethnic blindness

Abstract

Triple-negative breast cancer (TNBC), an aggressive subtype with poor prognosis, is of higher frequency in African American women and women of Sub-Saharan African origin. In France, legal constraints on obtaining health data on race, ethnicity, or nationality in cancer registries and medical records make it difficult to estimate the frequency of TNBC according to women’s origins. These constraints result from a historical “universalist” approach to French citizenship which prohibits the routine collection of ethnoracial data. An anonymous, statistical survey we conducted from a single-hospital case series of 780 women with breast cancer followed in a university hospital in Paris showed that TNBCs were at least 3 times more common in patients born in Sub-Saharan Africa than in patients born in France. The former consulted at a more advanced stage of the disease than the latter. The results of an ethnographic study of African women in the Paris region with breast cancer, conducted for several years, highlighted some explanatory factors: low breast cancer awareness, perceived causes distinct from biomedical etiology, the weight of shame and secrecy, prior recourse to local healing, difficulties in communicating with health professionals and navigating the healthcare system. Although considered a public health priority, TNBCs are an emblematic example of the limits produced by French race and ethnicity blindness in public health, epidemiology, prevention and health care.

Introduction

Triple-negative breast cancers (TNBC), characterized by the absence of receptors for estrogen, progesterone and the HER2 protein, form a subtype of breast cancer that is usually more aggressive than the others, responding less well to available treatments, and with poorer prognosis [1]. In mainland France, it is the least common subtype of breast cancer but highly significant in clinical and social terms: it represents 15% of cases and mainly concerns women under 40, pre-menopausal, too young to be part of the target population of the national organized screening program (which in France concerns women aged 50–75) and tested at an often advanced stage [2,3]. Accordingly, in this supplement to the scholarly literature, ethnoracial differences in TNBC frequency as well as cross-cultural questions of how breast cancer is distributed within and among social communities merit further examination.

This article presents epidemiological and social anthropological research findings on ethnoracial disparities in the causes and distribution of TNBC in particular populations, with special attention to France. We explore TNBC among Sub-Saharan immigrants in Greater Paris and their apparent vulnerability to this high-risk form of breast cancer. We frame this analysis in the context of contested constructs of race and ethnicity in various countries and how these play out in the recognition of breast cancer risk in certain populations. France is a unique case to center our discussion because of the historical and contemporary dissension about race as an individual and collective category of identification. We will discuss state regulations regarding data collection on race and ethnicity and the implications of these policies for understanding breast cancer risk, diagnosis, and treatment.