Illustration of a neighborhood from a bird eye view
Getting Under the Skin
Why Race (Alone) is not a Cancer Risk Factor
Excerpt from a presentation by
Adana Llanos, PhD, MPH, at
the Herbert Irving Comprehensive Cancer Center's 50th Anniversary Symposium, “New Frontiers in Cancer Research and Care: The Next 50 Years”, held Sept. 15, 2022
Illustration of a neighborhood from a bird eye view
Getting Under the Skin
Why Race (Alone) is not a Cancer Risk Factor
Excerpt from a presentation by Adana Llanos, PhD, MPH, at the Herbert Irving Comprehensive Cancer Center’s 50th Anniversary Symposium, “New Frontiers in Cancer Research and Care: The Next 50 Years”, held Sept. 15, 2022
Recent news headlines that underline inequities in maternal mortality and breast cancer highlight the fact that Black women have worse outcomes than other racial and ethnic groups. The wording in some of these headlines, such as “Breast Cancer Less Common in Black Women, So Why Do More Die,” might suggest that Black race is a risk factor for these outcomes. They may also suggest that Black race is a risk factor for poor health in general. But is it? The short answer is no.
Adana Llanos, PhD, MPH
Tracing the Path from Healthy Cell to Cancer Cell
What each of these news reports and the underlying research they cover tell us is that racial inequities exist in such a way that women racialized as Black experience poorer health outcomes.
But many of these media headlines don’t sufficiently consider the why—the reasons these inequities exist in the first place.
Race—as we know it and as it is most often operationalized in research—is not a biological variable. It is also not a causal factor for any disease or health outcome. After all, race is a socially constructed variable that puts people into categories based on advantage or disadvantage due to how we are perceived based on our skin color. And the construct of race is a surrogate for a multitude of other social determinants of health that are highly predictive of our lived experiences.
“With the unprecedented amount of data and tools available, we are able to identify the genes and mechanisms that drive each patient’s cancer.”
—Nicholas Tatonetti, PhD
Chief of Cancer Data Science at Columbia Cancer
Data for Inclusivity
Over the last decade, bioinformatics has made a remarkable impact on cancer medicine and it has resulted in better outcomes, new treatments and longer survival. But these advances have been unequal in their distribution, says Nicholas Tatonetti, PhD, primarily benefitting white and wealthy patients.
Named Chief of Cancer Data Science at Columbia Cancer in May of 2022, Dr. Tatonetti is committed to using data science methodologies to improve an area of cancer care ripe for change: diversity in clinical trials.
“We don’t want to just operate successful cancer clinical trials, we really want to optimize our ability to enroll a diverse population in clinical trials,” says Dr. Tatonetti, associate professor of biomedical informatics at Columbia University Vagelos College of Physicians and Surgeons.
Along with high quality digital health records from cancer patients, genetic data is now adding to the repository of information, making it even more comprehensive. This represents a new opportunity to think about and evaluate how cancer clinical trials are being conducted, including how trials are being evaluated and how to reach out to and recruit patients into those trials so that scientists can accurately assess the effectiveness and safety in multiple groups and different groups that have traditionally been overlooked or marginalized.



Adana Llanos, PhD, MPH
Associate Professor of Epidemiology at Columbia University Mailman School of Public Health
Member, Cancer Population Science Program, Herbert Irving Comprehensive Cancer Center
Recent news headlines that underline inequities in maternal mortality and breast cancer highlight the fact that Black women have worse outcomes than other racial and ethnic groups.
The wording in some of these headlines, such as “Breast Cancer Less Common in Black Women, So Why Do More Die,” might suggest that Black race is a risk factor for these outcomes. They may also suggest that Black race is a risk factor for poor health in general. But is it? The short answer is no.
What each of these news reports and the underlying research they cover tell us is that racial inequities exist in such a way that women racialized as Black experience poorer health outcomes.
But many of these media headlines don’t sufficiently consider the why—the reasons these inequities exist in the first place.
Race—as we know it and as it is most often operationalized in research—is not a biological variable. It is also not a causal factor for any disease or health outcome. After all, race is a socially constructed variable that puts people into categories based on advantage or disadvantage due to how we are perceived based on our skin color. And the construct of race is a surrogate for a multitude of other social determinants of health that are highly predictive of our lived experiences.
Zip Codes are a Health Matter
Our zip code—where we live, where we work, where we play, and where we pray—predicts our health outcomes. Rather than focusing on the impact of race in cancer research we should be considering the impact of place.
For example, how might where we live affect our cells and biology, or affect epigenetic and other biomarkers in our blood, in our tissues, and the microenvironment within tumors? How does place—not race—affect our cancer risk and survival?
To illustrate this, let’s consider the sometimes stark differences from one neighborhood to the next. The effects of neighborhood disinvestment—graffiti on properties, scattered debris, and abandoned buildings—and neighborhood investment—well-kept buildings, green space, and walkable sidewalks, have an impact on our health.
Using data from the New Jersey State Cancer Registry, we found that increasing physical disorder—a measure of neighborhood disinvestment—is significantly associated with shorter breast cancer survival. Our data showed that 69% of Black and Hispanic women lived in zip codes with the highest levels of neighborhood disinvestment. Increasing neighborhood disinvestment was associated with underinsurance, late-stage diagnosis, higher grade tumors, and triple negative breast cancer, the most aggressive, deadly breast cancer subtype.
Areas with high levels of observable disinvestment are communities that also have lower socioeconomic composition, less primary care physicians per person, greater racial residential segregation, and overall, a higher population density.
Again—place, not race—predicts our health outcomes.
Diversity Problem in Genetics, Genomics Research
Another key hurdle in health inequities, particularly relevant in cancer, is the lack of diversity in genetics and genomics research.
This historical and persistent underrepresentation of Black individuals and individuals from other racial and ethnic minority groups from genomics research also contributes to breast cancer inequities.
Most genomics data have been generated from populations of European ancestry, while the groups suffering disproportionate burden of cancers have been excluded. Because of this, we know a lot about how certain genetic mutations impact breast cancer risk among White women, but less about the impacts of these mutations among Black women.
For example, genomics research has uncovered new insights into breast tumor biology and how pathogenic mutations like those in the BRCA1 and BRCA2 genes can predispose us to breast cancer.
The BRCA1 and BRCA2 mutations were discovered in 1994 in Ashkenazi Jewish population from eastern or central Europe. And it has taken more than 20 years to see an emergence of data relating mutations in these genes to breast cancer in Black women.
Inclusivity is Key
Underrepresentation of diverse study participants in clinical trials research also contributes to breast cancer inequities. Yet it is widely documented that breast cancer clinical trials continue to suffer from a lack of adequate representation of the U.S. population.
A recent review documents that while Black individuals accounted for 12% of breast cancer cases in 2020, they accounted for only 3% of clinical trial participants for FDA approved breast cancer drugs between 2008 and 2018. Policies have been put in place to increase the representation of women in clinical trials and these policies have made a difference. Now we need similar policies to increase trial participant diversity in terms of age, geography, and other sociodemographic characteristics to ensure that the patients who will use the devices, drugs, and other products under study, are included in the initial testing.
Learning From the Past to Improve the Future
The past has shown us that persistent breast cancer inequities, including the incidence of more aggressive breast tumors, poorer survival, and greater mortality among Black women are attributable to a combination of social and biological factors. In thinking about advancing our efforts to understand and address these inequities over the next 50 years, we need to consider what we do to move the needle.
A good starting point is to ensure that studies across the cancer control continuum—starting with studies to understand and elucidate biology and etiology—better represent both the U.S. and global populations, and more importantly the communities we serve.
A greater push towards interdisciplinary research that considers the intersection of social determinants of health—above and beyond just race—with biological determinants of health to uncover sociobiologic mechanisms of cancer is also critical.
And of course, we must consider that these factors and mechanisms act at multiple, intersecting levels of influence.
Racism, not race. Racism is a risk factor for poor health, not race. These three words hold the key to better understanding how to truly address health inequities.
It is only through actions taken to eliminate racism that will we move closer to cancer health equity.
Zip Codes are a Health Matter
Our zip code—where we live, where we work, where we play, and where we pray—predicts our health outcomes. Rather than focusing on the impact of race in cancer research we should be considering the impact of place.
—Adana Llanos, PhD, MPH
Associate Professor of Epidemiology at Columbia University Mailman School of Public Health Member, Cancer Population Science Program, Herbert Irving Comprehensive Cancer Center
For example, how might where we live affect our cells and biology, or affect epigenetic and other biomarkers in our blood, in our tissues, and the microenvironment within tumors? How does place—not race—affect our cancer risk and survival?
To illustrate this, let’s consider the sometimes stark differences from one neighborhood to the next. The effects of neighborhood disinvestment—graffiti on properties, scattered debris, and abandoned buildings—and neighborhood investment—well-kept buildings, green space, and walkable sidewalks, have an impact on our health.
Using data from the New Jersey State Cancer Registry, we found that increasing physical disorder—a measure of neighborhood disinvestment—is significantly associated with shorter breast cancer survival. Our data showed that 69% of Black and Hispanic women lived in zip codes with the highest levels of neighborhood disinvestment. Increasing neighborhood disinvestment was associated with underinsurance, late-stage diagnosis, higher grade tumors, and triple negative breast cancer, the most aggressive, deadly breast cancer subtype.
Areas with high levels of observable disinvestment are communities that also have lower socioeconomic composition, less primary care physicians per person, greater racial residential segregation, and overall, a higher population density.
Again—place, not race—predicts our health outcomes.
Excerpt from a presentation by Adana Llanos, PhD, MPH, at Columbia Cancer’s 50th Anniversary Symposium, “New Frontiers in Cancer Research and Care: The Next 50 years”, held Sept. 15, 2022
Diversity Problem in Genetics,
Genomics Research
Another key hurdle in health inequities, particularly relevant in cancer, is the lack of diversity in genetics and genomics research.
This historical and persistent underrepresentation of Black individuals and individuals from other racial and ethnic minority groups from genomics research also contributes to breast cancer inequities.
Most genomics data have been generated from populations of European ancestry, while the groups suffering disproportionate burden of cancers have been excluded. Because of this, we know a lot about how certain genetic mutations impact breast cancer risk among White women, but less about the impacts of these mutations among Black women.
For example, genomics research has uncovered new insights into breast tumor biology and how pathogenic mutations like those in the BRCA1 and BRCA2 genes can predispose us to breast cancer.
The BRCA1 and BRCA2 mutations were discovered in 1994 in Ashkenazi Jewish population from eastern or central Europe. And it has taken more than 20 years to see an emergence of data relating mutations in these genes to breast cancer in Black women.
Excerpt from a presentation by Adana Llanos, PhD, MPH, at Columbia Cancer’s 50th Anniversary Symposium, “New Frontiers in Cancer Research and Care: The Next 50 years”, held Sept. 15, 2022
Inclusivity is Key
Underrepresentation of diverse study participants in clinical trials research also contributes to breast cancer inequities. Yet it is widely documented that breast cancer clinical trials continue to suffer from a lack of adequate representation of the U.S. population.
A recent review documents that while Black individuals accounted for 12% of breast cancer cases in 2020, they accounted for only 3% of clinical trial participants for FDA approved breast cancer drugs between 2008 and 2018.
Policies have been put in place to increase the representation of women in clinical trials and these policies have made a difference. Now we need similar policies to increase trial participant diversity in terms of age, geography, and other sociodemographic characteristics to ensure that the patients who will use the devices, drugs, and other products under study, are included in the initial testing.
Excerpt from a presentation by Adana Llanos, PhD, MPH, at Columbia Cancer’s 50th Anniversary Symposium, “New Frontiers in Cancer Research and Care: The Next 50 years”, held Sept. 15, 2022
Learning From the Past to Improve the Future
The past has shown us that persistent breast cancer inequities, including the incidence of more aggressive breast tumors, poorer survival, and greater mortality among Black women are attributable to a combination of social and biological factors. In thinking about advancing our efforts to understand and address these inequities over the next 50 years, we need to consider what we do to move the needle.
A good starting point is to ensure that studies across the cancer control continuum—starting with studies to understand and elucidate biology and etiology—better represent both the U.S. and global populations, and more importantly the communities we serve.
A greater push towards interdisciplinary research that considers the intersection of social determinants of health—above and beyond just race—with biological determinants of health to uncover sociobiologic mechanisms of cancer is also critical.
And of course, we must consider that these factors and mechanisms act at multiple, intersecting levels of influence.
Racism, not race. Racism is a risk factor for poor health, not race. These three words hold the key to better understanding how to truly address health inequities.
It is only through actions taken to eliminate racism that will we move closer to cancer health equity.
Excerpt from a presentation by Adana Llanos, PhD, MPH, at Columbia Cancer’s 50th Anniversary Symposium, “New Frontiers in Cancer Research and Care: The Next 50 years”, held Sept. 15, 2022
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