October 5, 2017

Nurse scientist Margaret Quinn Rosenzweig is looking for solutions that will save lives

For any woman, finding out you have breast cancer can cause fear and anxiety. But for Black women, breast cancer can be especially frightening — and deadly. In the U.S., Black women with breast cancer have lower five-year survival rates compared to all other races.

Fortunately, researchers at the University of Pittsburgh School of Nursing may be one step closer to explaining how variation in the experience of breast cancer treatment leads to disparity in survival rates. Research suggests Black women are less likely to complete prescribed chemotherapy. Building on that finding, Margaret Quinn Rosenzweig, PhD, CRNP-BC, is leading a new study to examine the physical, social and emotional reasons why many Black women have a harder time getting through treatment.

This research may lead to new strategies to help Black women receive their full dose of chemotherapy — a crucial factor in overcoming breast cancer.

Early influences shaped a career, sharpened research focus

Before she became a research scientist and professor, Dr. Rosenzweig was a cancer nurse practitioner. Prior to that, she was a young nursing school graduate who served in the Jesuit Volunteer Corps. She spent a year living with and caring for people from poor communities in Louisiana.

Dr. Rosenzweig

“I saw first-hand the impact of poverty on health outcomes, and it launched a lifelong interest in improving disparities,” says Dr. Rosenzweig. “When I finished my PhD in 2001, I began pursuing that same line of inquiry among cancer patients. I’m especially interested in helping women with metastatic breast cancer, and Black women with newly diagnosed breast cancer.”

The survival gap between Black and White breast cancer patients has been well documented for many years. But, the reasons for that gap were not well understood. Sixteen years later, Dr. Rosenzweig and her colleagues have made important discoveries that may impact how we understand the experience of breast cancer for Black women.

The study that started it all

In 2004, Dr. Rosenzweig and her team received a grant from the National Cancer Institute. They began exploring whether race and income level influence how women with metastatic breast cancer live with and manage their symptoms.

The results suggested that during cancer treatment, low-income Black patients disproportionately had worse physical symptoms and social distress, including feelings of isolation. These same women also reported uncertainty about their treatment goals.

“A key takeaway was Black women felt they didn’t understand what type of tumor they had, or why they should use certain palliative treatments like pain medication,” explains Dr. Rosenzweig. “This led to poor management of the side effects caused by chemotherapy. And with that comes the potential for women to delay or stop treatment.”

Dr. Rosenzweig says this was a new insight that needed further examination. That’s because the variation in survival rates has historically been linked to factors such as Black women developing more aggressive tumors at a younger age.

As an example, in August 2017, University of North Carolina researchers published results of their analysis of 1,000 invasive breast tumors. Their study confirmed that young Black women are more likely to have “triple-negative” or “basal-like” breast cancers that usually require more aggressive treatment.

“Research findings regarding biologic differences are very important,” confirms Dr. Rosenzweig. “But there has been limited data showing that variation in treatment, specifically chemotherapy, also contributes to lower survival rates among Black patients.”

Exploring uncharted territory

For the next several years, Dr. Rosenzweig and her team studied chemotherapy adherence among Black patients. Clinicians know that completing a full course of chemotherapy increases breast cancer survival rates (and reduces recurrence). But are Black women aware? If so, what would make them walk away from treatment?

In 2011, they launched a five-year study called the Attitudes, Communication, Treatment and Support (ACTS) Intervention to Reduce Breast Cancer Treatment Disparity. It tested an educational strategy that helps Black women understand and adhere to chemotherapy. It also analyzed factors that may cause a woman to discontinue treatment. These include quality of life, severity of side effects, and overall distress caused by the cancer itself.

Their efforts showed a clear relationship between participants’ worsening symptoms as they progressed through chemotherapy, and their ability to finish treatment.

“About 50 percent of our patients who needed chemotherapy did not receive their full dose on time,” says Dr. Rosenzweig. “In most cases, the toxicity from the treatment prompted dose reductions, delays or early discontinuation. This tells me we need to do a better job managing the pain, nausea, fatigue and other side effects of chemotherapy among our Black patients. If we can ease their side effects with symptom management and effective palliative care, we can help them get through treatment.”

An emphasis on better symptom management is the impetus for the team’s new study. It’s a one-year, grant-funded initiative that will look more intensely at the experience of breast cancer among Black and White women.

The culmination of more than a decade’s work

Building on their collective findings thus far, Dr. Rosenzweig and her colleagues launched their latest effort in July 2017. It aims to enroll 50 Black women and 50 White women with breast cancer.

The study will test the hypothesis that racial disparity in breast cancer treatment is linked to racial variation in the frequency and severity of symptoms. It will examine if (and how) patients report symptoms. And it will assess whether there is disparity in how well clinicians respond to and help manage symptoms, which then leads to worsening distress—and a decision to delay or stop chemotherapy.

The team will gather data to use in several ways, including:

  • Compare chemotherapy prescribed to chemotherapy received.
  • Collect symptom scores (reported side effects and symptom-related distress) at each visit and compare them over time. They’ll also assess how these scores influenced each woman’s ability to receive and complete chemotherapy.
  • Examine how certain social determinants of health (age, income and education levels, zip code and lifetime stress exposure) affect patients’ symptom scores, as well as their ability to complete chemotherapy.
  • Analyze audiotapes of patients’ medical appointments to explore how patients and providers communicate with each other.

Dr. Rosenzweig says there are also questions about biology and drug metabolism that need to be answered. For example, are Black women metabolizing drugs more slowly than White women, leading to more symptom toxicity? Are there racially different biologic markers that cause some symptom management strategies to work more efficiently among women with certain biologic markers?

“The holistic picture of the person is important,” says Dr. Rosenzweig. “It may help us better understand the differences and, most importantly, target interventions that ease disparity between Black and White women as they receive chemotherapy for breast cancer.”

Better symptom management for better outcomes

Long term, the team hopes to secure additional research funding and broaden their efforts. By expanding recruitment throughout Western Pennsylvania and Eastern Ohio, they can increase their sample size and generate more statistically significant data.

“Our goal is to develop symptom management strategies that are personalized,” says Dr. Rosenzweig. “It appears Black women experience chemotherapy symptoms differently. And the distress caused by those symptoms may be exacerbated by social factors that are also unique to Black women. If we can relieve physical symptoms and address other social and economic stresses, we can help women can get through their chemotherapy—and improve their chances of survival.”

To make a donation to this research, or any other area of research at Magee-Womens Research Institute, contact Cara Kassabov at (412) 641-5056 or email at kassabovc@mwri.magee.edu.