October 1, 2026:

When I was 23 years old, I asked my primary care doctor about what steps I could take to prevent breast cancer. 

The provider dismissed my concerns. I was “too young” to be worried about it, I recalled the provider saying, unless someone in my family had died from the disease. 

What she would have known if she had simply asked, was that just one week prior, I held a funeral for my mother, who died of breast cancer. 

My mom was one of the disproportionate number of Black women diagnosed with Stage 4 breast cancer, which is the latest stage and occurs when the disease has spread to organs in other parts of the body. She also died from it, an outcome that is 41 percent more likely for Black women than white women, even though Black women are less likely to have breast cancer in the first place. 

Losing my mom to breast cancer is the worst thing that has happened in my life. And fear about my risk and confusion around how to ensure I’m being adequately monitored by providers have been near-constant struggles in the seven years since her death.

So I spoke with Dr. Demetria Smith-Graziani, who treats patients with breast cancer at the Winship Cancer Institute at Emory Midtown in Atlanta, about why breast cancer mortality is so much higher in Black women, what symptoms patients should look out for, and what screening options are available. 

The following conversation has been edited for length and clarity.

Black women are more likely to be diagnosed with a more advanced or aggressive breast cancer, and are also more likely to die of breast cancer than white women. Why? 

That’s a great question, and something that we are still trying to figure out. But big picture wise, even though white women in the U.S. have a higher incidence of breast cancer compared to Black women, Black women have a higher mortality rate. It’s about 40 percent higher. They are more likely to be diagnosed at a younger age, at a higher stage, and more likely to be diagnosed with triple negative breast cancer and more aggressive forms of breast cancer. 

As we think about the different components, the big categories are the biological contributors, the structural social contributors, and then there’s times when there’s interplay between those two. 

On the biological side of things … the greatest disparity in breast cancer outcomes actually occurs in the hormone receptor positive breast cancer subtype, which is the most common form of breast cancer. … So even in those types, [Black] people are having worse outcomes. Even when you look at Black women and white women diagnosed at the same stage, you see even worse outcomes in Black women compared to white women. …

If you don’t have access to the same quality of care [as white women]—in the primary care and preventative care setting—you’re less likely to get regular screening mammograms, then you’re less likely to detect breast cancer until it is at a higher stage. … Once you have that abnormal mammogram, from the abnormal mammogram, you need to then get a biopsy. 

So what’s the time delay from you getting the mammogram to getting the biopsy? Once you get that biopsy and get those results saying it’s cancer, what’s the delay from you getting from there to actually seeing an oncologist? So now, at all of the different stages, if your access to care is inhibited by your lack of insurance, by socioeconomic status, by living in an area where you are not near a major hospital or clinic, then that all is going to affect the quality of care you receive. 

We also have differences because of all of those factors and structural racism, and in Black women versus white women receiving … care for your cancer that meets the national guidelines that we have agreed on that are based on the most up-to-date information we have about how to best treat your cancer. That’s more likely to happen at an academic center, specifically at a National Cancer Institute-designated comprehensive cancer center. So if you are not receiving your care there, then now you’re less likely to have that guideline-concordant care, and that’s going to affect how well you do, your risk of recurrence, and how long you live. 

Black women are also less likely to receive genetic testing for cancers linked to hereditary gene mutations like BRCA. Why is that? 

One, you need to be aware of the fact that genetic testing exists. … Now there are other things we also test for that we know are associated with increased breast cancer and other cancer risks. But when this testing first came, it was really expensive and insurance wasn’t covering it initially. … Because it was expensive, the initial recommendations were a little bit more restricted [regarding] who should be getting this because it’s a resource that was expensive. …

Now we can run all these tests for much less money, which is better. The criteria has changed over the years about who would benefit from genetic testing. But on top of that, you gotta know that it’s available. So your doctor needs to bring it up to you, your care team needs to bring it up.

The initial boom in BRCA testing that became known in mainstream culture was when Angelina Jolie got tested, and she had both of her breasts removed [in 2013] because she found out she was BRCA positive. And so that became the cultural thing. And there might be certain demographics that are paying more attention to Angelina Jolie.

Similarly, there are certain populations where we’ve identified to have a higher prevalence from the BRCA mutation. One of those populations is the Ashkenazi Jewish population. And so there was a huge push among the Ashkenazi Jewish population to get tested. So you can kind of see where maybe that’s a place where Black women weren’t necessarily included. And so I think part of that is just the awareness. They may think, Oh well that’s not me. That might be other women, but that doesn’t apply to me.

How can we get that to change? 

We want to capture the people before they get their first breast cancer diagnosis. So that means your primary care doctor needs to be aware that you might qualify, ask the right questions to figure that out. To be clear, your primary care doctor is already doing so many things. Your primary care doctor, in a single visit, is checking in on all of your cancer screening, as well as maybe your high blood pressure or your diabetes or everything else, so it can be a lot to ask. 

At [Emory Winship Cancer Center,] we have a high risk program for people who have not had a breast cancer diagnosis, but have an elevated risk of breast cancer because of family history. Or maybe they have already gotten genetic testing and found out that they’re positive for BRCA or another mutation. So then that allows them to be followed in a cancer center where they can get the more intense screening that is recommended in some of these cases.  But again, not everyone lives near a cancer center that can provide that. 

What are some of the signs and symptoms that Black women should be looking for regarding breast cancer? 

If you’re feeling a new lump or mass in your breast or under the arm, that’s definitely a reason to seek some medical attention. That mass does not have to be painful. It could be painless, it could be tender. If you’re having any discharge from the nipple—if it’s bloody discharge or you are having new discharge [if you are not lactating]—that’s a reason to get checked out.

Similarly, if you’re having a change in the appearance of your nipple—[like you have always had nipples that point outwards], but then all of a sudden it’s going in—that’s a reason to get checked out. 

Now some people, unfortunately, by the time they’re diagnosed with breast cancer, they’re at Stage 4. The signs for stage four breast cancer can be more vague. People can just be feeling more fatigued, or have bone pain or unintended weight loss. 

There’s a type of breast cancer called inflammatory breast cancer. And it tends to involve the lymphatic system in the skin of the breast, and it can cause redness or this dimpling of the breast. We have a fancy name for it called “peau d’orange,” which is French for “orange peel,” because it’s like that appearance of an orange peel. 

Right now, the United States Preventive Task Force recommends that breast cancer prevention screenings begin at age 40. There’s been discussion about making that age younger for Black women, but is this a feasible solution? 

Until a few years ago, they were saying to start at 50. They finally did move to 40, but they still are saying [to do screening] every other year. …

If you’re asking me as an oncologist, [I’d say get a screening mammogram starting at] age 40 every year, particularly for Black women. On top of that, if you have a first or second degree family member who was diagnosed with breast cancer, you should start screening at least ten years before they are diagnosed. So whichever comes first—age 40 or ten years before they were diagnosed. 

The other part of this is that we know that when you are younger and you have more dense breast tissue, mammograms are not as helpful at seeing the abnormalities. [Breasts get] less dense as you get older. So for people that are [young and] at higher risk—the youngest we usually start is about age 25 for people that we think are at higher risk—we actually recommend an MRI for screening because it is more helpful. Then when you get to the age where we get more information for a mammogram, that’s when we say do both. 

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