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RESEARCH 

Breast Cancer Disparities Among American 

Indian Women 

Marilyn A. Roubidoux, MD, Department of Radiology, University of Michigan Health Systems,  

TC 2910, Box 5326, 1500 E. Medical Center Drive, Ann Arbor, Mi 48109-5326,  

Corresponding author email: roubidou@umich.edu 

ABSTRACT 
Health disparities in breast cancer among American Indian women include historically higher stage at 

diagnosis, younger age at diagnosis, higher ratios of rates of mortality vs incidence, geographic 

variability of incidence and mortality rates, more difficult access to breast imaging and cancer treatment, 

and racial misclassification in medical records resulting in underestimation of breast cancer data. This 

population is understudied as well as underserved and more research is needed to reveal specific 

causes and interventions for these breast cancer disparities. Proactive efforts may include improving 

access to regular screening, diagnosis and treatment, identifying high risk women for intervention, and 

continuing community based research and educational programs. After a cancer diagnosis, patient 

navigators and prompt access to up to date breast cancer therapy treatment may improve outcomes. 

KEYWORDS: : Health Disparities, American Indians, Breast Cancer, Screening mammography, Breast 

Cancer Mortality 

Citation: Roubidoux MA (2018) Breast Cancer Disparities Among American Indian Women. Cancer Health 

Disparities 2:e1-e9. doi:10.9777/chd.2018.10003 

 

 



 
 
 
 
 

 

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The relative paucity of information about breast 

cancer in American Indian (AI) women compared 

to larger population racial groups makes 

assessment of this healthcare disparity among AI 

women more difficult. Breast cancer risk and 

outcomes information about this underserved 

population is limited or incomplete (Emerson et al., 

2017; Martin et al., 2016). Studies of racial 

differences in breast cancer often do not include 

information about the AI population (Ahmed AT, 

2017). Furthermore, information regarding breast 

cancer screening, incidence, and mortality rates in 

American Indian and Alaska Native women is 

commonly merged into a single group. However, 

looking at data from this merged single data 

group masks wide and unique variations in 

subgroups and regions. Since American Indian 

subgroups are heterogeneous by tribe, 

geographic location, and urban vs. rural residence, 

merging data into one mean value can obscure 

differences and disparities. As a result, evidence 

based breast cancer control in this population is 

more challenging. To address inequities in breast 

cancer screening, prevention, treatment and 

survivorship, accurate, timely, and specific data is 

needed. Community based participatory research 

among these women is a key method to obtain 

useful insight about breast cancer detection and 

treatment challenges, and from which to guide the 

design of interventions needed to address the 

inequities (Burhansstipanov L, 2010; 

Burhansstipanov et al., 2017). 

Racial or ethnic minority patients are 

underrepresented in cancer registries due to racial 

misclassification occurring from missing or 

incorrect entries in medical records, and 

misclassification of American Indian patients is 

common. This misclassification results in 

underestimation of the breast cancer burden in AI 

women (Haozous EA, 2014; Johnson et al., 2009; 

Roen et al., 2014; White et al., 2014b). Accuracy in 

medical records may be improved by matching 

records from different sources, i.e., linking cancer 

registries to tribal and Indian Health Service 

records. Data linkage changes breast cancer 

incidence rates substantially(Roen et al., 2014). 

Recently, linkages between Indian Health Service 

patient files and the national Death Index have 

improved accuracy in American Indian breast 

cancer mortality and incidence data (Espey DK, 

2014; Roen et al., 2014; White et al., 2014b). In 

addition to problems of misclassification, 71% of 

American Indians reside in urban areas with 

medical care outside of the Indian Health Service 

(Emerson et al., 2017). Therefore Indian Health 

Service records represent only part of the entire 

population and data among urban American 

Indians is only recently emerging(Jacobs-Wingo JL, 

2016). 

 In the United States there are medically 

underserved populations which have higher 

cancer burdens in incidence, mortality and/or 

outcomes. The national breast cancer incidence 

rate had a historic decrease 1998-2007, dropping 

1.7% per year, with about 3% per year decrease 

between 1999-2004; in contrast, the overall 

incidence rates in American Indians and Alaska 

Natives were level during that time period (Krieger 

N, 2010). For American Indian women the overall 

incidence of breast cancer historically has been 

lower than that of the US population, but dramatic 

and persistent geographic differences in incidence 

rates among subgroups have been reported over 

many years (White et al., 2014b). Data from 1999-

2009 demonstrated an overall incidence of breast 

cancer of 100/100,000, compared to 131/100,000 

for white women (White et al., 2014b). However, 

the mean value masks the regional variability in 



 
 
 
 
 

 

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this population. The highest incidence rate was 

141.3 in Alaska Native women, followed by 

136.1/100,000 among women in the Southern 

Plains tribes; the lowest incidence was in AI women 

in the Southwest at 59.6 (White et al., 2014b). This 

regional variability of breast cancer incidence is 

unusual, as it is not found among other ethnicities 

or races (Wingo et al., 2008) and persists even 

when improving the accuracy of records by 

adjusting for racial misclassification (White et al., 

2014b). 

Although the average breast cancer mortality rate 

in American Indian and Alaska Native women 

(22.2/100,000) has been lower than white women 

(24.1/100,000) (White et al., 2014a), it is not as low 

as would be expected when comparing incidence 

rates. Similar to the incidence rates, the mortality 

rates vary regionally, with higher death rates from 

breast cancer among American Indian women 

compared to white women in the Northern Plains, 

Alaska, and the Southern plains (White et al., 

2014b). Since the ratios of mortality to incidence 

were reported higher for the years 1990 to 2009 

among American Indian women than among 

white women, American women had a 

comparatively higher risk of death from breast 

cancer (White et al., 2014b). Breast cancer 

mortality rates nationally decreased 39% after 

screening mammography became commonly 

used, beginning in 1989- to 2015. This 

improvement is attributed to a combination of 

better and earlier detection with screening 

mammography and improved therapies, with 50-

80% of the mortality rate decline due to screening 

mammography (DeSantis et al., 2017; Vervoort 

MM, 2004). The mortality rate decline occurred for 

white women and African American women but 

was comparatively unchanged among AI/AN in 

the years up to 2009 (White et al., 2014b). In more 

recent years, death rates for AI/AN women were 

reported to have decreased although, the decline 

in death rates among AI/AN women began in 

2005, more than a decade later than other racial 

and ethnic groups (DeSantis et al., 2017). 

Additionally that same recent data indicated that 

AI/AN women continue to have a lower 

proportion of localized stage and a higher 

proportion of regional stage disease than white 

women (DeSantis et al., 2017). Survival from breast 

cancer was poorer among urban American Indian 

women who were Northern California Kaiser 

Permanente enrollees compared to non-Hispanic 

white women, with mortality rates from breast 

cancer that were 47% higher (Emerson et al., 

2017). Survival from breast cancer in this study was 

lower even when controlling for income and 

comorbid conditions (Emerson et al., 2017). 

Although not proven, it was presumed in this 

study that these California AI women had 

approximately equal access to cancer care 

services, suggesting that the survival differences 

were not due to differences in cancer screening or 

treatment. Further studies like these are needed to 

study factors that influence breast cancer mortality 

in American Indian women, including cancer stage 

and histology, screening, treatment, and social-

behavioral-cultural factors. For example, 

differences in breast cancer by hormone receptor 

and HER2 status have been reported for American 

Indian/Alaska Native women who were found to 

have had a 3.9 fold higher risk of stage IV triple 

negative breast cancer, an aggressive subtype 

(Chen and Li, 2015). 

Breast cancer incidence varies by age, among all 

races and ethnicities, with many more cancers 

occurring in older women than younger women. 

The older the woman, the more likely she will be 

diagnosed with breast cancer, and although more 



 
 
 
 
 

 

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attention has been given to breast cancer among 

young women, women ages 60 years or older are 

at the highest risk for breast cancer. It has been 

reported that more American Indian woman are 

diagnosed with breast cancer at a younger age, 

mean age of 53.5 years, compared to non-

Hispanic White (NHW) women, who are diagnosed 

at a mean of 63.4 years (Wingo et al., 2008). 

Although the overall average breast cancer 

incidence rate is lower compared to NHW, the 

incidence rate among American Indian women 

less than 50 years of age (2007) is not lower than 

the national incidence rate for this age group 

(National Cancer Institute, 2010). Prior studies 

reported that 30% of AI/AN women with breast 

cancer are diagnosed before they reach 50 years 

of age, a substantially higher proportion than for 

NHW women, of whom only 19% are diagnosed 

before age 50 years (Wingo et al., 2008). Similar 

findings were reported in a Michigan study, with a 

mean age of breast cancer diagnosis for AI 

women younger than that of white women, and a 

greater percentage diagnosed under 50 years 

compared to white women (Roen et al., 2014). 

Younger age of breast cancer diagnosis confers a 

higher mortality because the tumors are larger 

and higher grade cancers than occur in younger 

women. Thus, if screening in American Indian 

women does not occur until age 50 years, a 

substantial proportion of women with breast 

cancer will miss a chance for early detection (Arleo 

et al., 2017). 

Annual screening mammography increases the 

rate of early detection of localized disease and 

improves patient health. Screening mammography 

detects breast cancer several years before the 

cancer is palpable (Rosenberg et al., 2006), 

increases patient survival (Kopans, 2007) and 

allows women the option of breast preservation 

treatments such as lumpectomy and radiation 

therapy. Screening mammography could improve 

the health disparity among American Indians by 

detecting breast cancer at an earlier stage 

(DeSantis et al., 2017). The minimal ‘risks’ of 

mammography, including false positive biopsies 

and anxiety from the need for additional views, are 

minor, far outweighed by a diagnosis of a later 

stage of breast cancer. Mammography is the 

lowest cost, most widely available, standardized, 

and evidence-based method to detect breast 

cancer. There is a strong consensus that 

mammography screening for women 50 to 69 

years of age reduces breast cancer mortality. 

Unfortunately, screening women 40 to 49 years of 

age has been controversial (Arleo et al., 2017). 

However, since 40% of the years of life that are 

lost by women due to breast cancer are among 

women 40 to 49 years of age (Arleo et al., 2017; 

Kopans, 2007; Kopans, 2010; Wingo et al., 2008) 

screening mammography beginning at age 40 

years is recommended by the American Cancer 

Society, and is a definite recommendation by the 

National Comprehensive Cancer Network (NCCN), 

the American College of Obstetrician and 

Gynecologists, and the American College of 

Radiology (Arleo et al., 2017). Results from clinical 

trials suggest that the mortality rate from breast 

cancer can be reduced by 30% when 

recommendations for screening are followed 

(Arleo et al., 2017; de Gelder R1, 2015; Kopans, 

2007; Kopans, 2010). Since the vast majority of 

women who get breast cancer have no family 

history of the disease (Neal CH et al., 2018), it is 

not appropriate to limit mammogram screening to 

high risk women in the 40 to 49 years age group. 

Targeted screening for specific subgroups of 

young women at higher risk is indicated, including 

genetic testing and supplementary screening at an 



 
 
 
 
 

 

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early age with breast MRI examinations (Expert 

Panel on Breast et al., 2017; Samphao et al., 2009). 

In addition to screening high risk women in this 

younger age group, elderly women can also 

benefit from screening mammography, preventing 

breast cancer morbidity and death 5-10 years later 

(Arleo et al., 2017). 

Racial minorities are less likely than white women 

to receive adequate mammogram screening, and 

of all racial minorities, American Indians have 

historically had the least breast cancer 

mammogram screening (Peek and Han, 2004; 

Roen et al., 2013; Smith-Bindman R, 2006). 

Historically, use of screening mammography can 

vary by region, such that the average national 

screening rates for American Indian women can 

obscure regional disparities (Peek and Han, 2004; 

Schumacher et al., 2008). Data regarding the 

prevalence of any method of screening 

(mammography, clinical breast exam, or breast 

self-examination) in minority populations is scarce. 

Self-reported mammography use from the 

Behavioral Risk Factor Surveillance System (BRFSS) 

has typically shown less use of mammography 

among AI/AN than other racial groups (Centers 

for Disease Control and Prevention, 2010). In the 

Northern Plains, an area of elevated breast cancer 

prevalence among AI women, only 51% of women 

reported “ever” having had breast cancer 

screening (Pandhi et al., 2010). The percentage of 

AI women in the Southwest reporting “never” was 

30.1% (Schumacher et al., 2008). Self-reported 

estimates of adherence to screening 

mammography are not accurate and are 

commonly higher than medical records (Peek and 

Han, 2004) , and self-reported mammography use 

among minority and low income women is over 

estimated because of under sampling. Using 

medical records to assess mammogram screening, 

the Indian Health Service GPRA report of 2009 

indicated that only 45% (40-55% by region) of AI 

women had screening mammograms (Service, 

2010). In a study with screening mammogram data 

obtained directly from mobile mammography 

records, the majority (60.14 %) of women in the 

Northern Plains who presented to the mobile 

mammogram unit reported not having had a 

screening mammogram in the previous 2 years, 

which is lower screening adherence than found 

nationally, and screening rates were lowest among 

women ages 41-49 years (Roen et al., 2013). 

The recommendations for the interval between 

screening mammograms vary from one to two 

years. In computer models, more frequent 

mammogram screening dramatically reduces the 

mortality rate of breast cancer (Arleo et al., 2017; 

Michaelson et al., 1999). The likelihood of 

metastatic disease is decreased by 51% when 

mammography is performed annually (Michaelson 

et al., 1999). Increasing the compliance with annual 

screening mammography is the most evidence-

based intervention to decrease the mortality rate 

of American Indian women since adherence to 

recommended screening intervals may reduce 

breast cancer mortality rates (de Gelder R1, 2015; 

Smith-Bindman et al., 2006). Historically, 

adherence to screening intervals has substantial 

variation by race/ethnicity, age, insurance status, 

and family history (Strzelczyk and Dignan, 2002). 

There is minimal data about adherence to 

screening mammography among AI/AN women. 

Wampler et al. found that American Indian women 

in Colorado were less likely than non-Hispanic 

White women to adhere to recommendations for 

screening mammography, both annually and 

biennially, with the chief predictor being economic 

status (Wampler et al., 2006). Among Northern 

Plains AI women presenting to a mobile 



 
 
 
 
 

 

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mammography unit, adherence to screening 

mammography guidelines (defined as a prior 

mammogram within the past two years) occurred 

in 39.86 % of the AI women, lower than adherence 

to screening reported in the same time period 

where 74.34 % of white women complied with 

screening mammography guidelines in a national 

mammography database (Roen et al., 2013). 

Disparities in screening mammography are 

improving among medically underserved 

populations but still persist among racial/ethnic 

minorities and low income women (Peek and Han, 

2004). While regular compliance with screening 

mammography is important for early detection, 

many factors affect compliance such as local 

availability of mammographic facilities, physician 

recommendations, financial issues (insurance, low 

cost programs), and patient attitudes. The EARTH 

study found that predictors for mammography 

compliance included higher educational status, 

higher income, older age, positive family history, 

and urban location (Schumacher et al., 2008). 

Pandhi found that the strongest predictor for 

compliance with cancer screening in the Northern 

Plains was the provider recommendation (Pandhi 

et al., 2010). 

In 1990 the National Breast and Cervical Cancer 

Early Detection Program (NBCCEDP) was initiated 

to improve the access of medically underserved 

women to screening mammography and 

subsequent diagnostic procedures. This program 

provides support to women in all 50 states and to 

12 tribal programs among 6 states. Published data 

from the NBCCEDP indicate that while first round 

screening in AI/AN women yields fewer cancers 

than screenings in white women, subsequent 

round screening detections and positive predictive 

values are similar to that of other racial/ethnic 

groups (Eheman et al., 2006). This indicates that 

mammography is equally effective and accurate in 

AI/AN and NHW women. It is estimated that 

approximately 49% of eligible AI/AN women in 

NBCCDP programs have been screened, which is a 

higher rate than any other racial/ethnic group and 

demonstrates the importance of this CDC program 

to native women (Tangka et al., 2006). 

Difficult access to breast screening and diagnosis 

may contribute to the disparity in American Indian 

women in breast cancer mortality to incidence 

ratios. A recent study of geographic access to 

breast imaging services reported marked 

differences among population subgroups (Onega 

et al., 2014). Travel time to mammography and 

ultrasound for 85% of US women was less than 20 

minutes, with Black and Asian women having the 

shortest median travel times. Travel times greater 

than 30 minutes for mammography and 

ultrasound were found for 39.6% of Native 

American women compared to only 12.6% of 

white women and 6% of black women. Access to 

MR imaging is even worse. Long travel times (>30 

min) for breast MRI were found in 85% of 

American Indian women, as compared to only 

46.5% of white women and 26.1% of black women. 

These disparities in American Indian women 

persisted despite rural or urban locations. The 

authors concluded that American Indian women 

are disadvantaged in geographic access to breast 

imaging as measured by travel times. Potential 

interventions could be designed to reduce these 

transportation inequities, improve racial disparity in 

early breast cancer diagnosis and mortality from 

this malignancy (DeSantis et al., 2017; Onega et al., 

2014) Rural women in general have lower 

screening mammography rates than urban 

women, a finding seen in the EARTH study 

(Schumacher et al., 2008). A contributing factor is 

the lack of convenient mammography facilities. 



 
 
 
 
 

 

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One countermeasure taken to improve 

mammography access in this region, was a mobile 

screening mammography unit taken to 18 rural 

and urban clinics in this rural IHS area in 2006-

2017 (Roen et al., 2013; Roubidoux et al., 2006). 

In addition to mobile mammography, telemedicine 

is another way to encourage screening and to 

assess breast cancer risk among women who live 

in remote areas, for whom regular screening is 

more challenging. Through telemedicine, Alaska 

Native and American Indian women may meet 

with providers or patient navigators to discuss 

their breast cancer risk and to learn life style 

modifications to which can reduce breast cancer 

risk. Using telemedicine, high risk women in 

remote areas can be identified and targeted for 

screening, and for preventive therapy with risk 

reducing strategies and medications. A previous 

pilot study showed that telemedicine risk 

counseling, enabled by technology and a patient 

navigator, is feasible and has high patient 

satisfaction. (Pruthi et al., 2013) 

To effectively advise American Indian patients 

about breast cancer screening, individual risk 

needs to be determined because screening 

recommendations are based upon assessing a 

patient’s risk for breast cancer (Expert Panel on 

Breast et al., 2017). When a woman’s risk is 

determined to be average, screening 

mammography and/or digital breast 

tomosynthesis is recommended beginning at age 

40 years. Thereafter, annual repeat mammogram 

screening confers the greatest years of life saved 

from detecting a breast cancer.(Arleo et al., 2017) 

When a woman has dense breasts, breast 

ultrasound may be an adjunct to mammography 

for incremental cancer detection, although 

ultrasound may result in increased false positive 

results. For women at very high risk due to prior 

mantle irradiation between the ages of 10 to 30 

years, mammography is recommended starting 8 

years after radiation therapy but not before age 25 

years. In these patients, screening with breast MRI 

should also be done. For women with a genetic 

risk, such as women with BRCA gene mutations, or 

a 20% lifetime risk of breast cancer, annual 

screening mammography is recommended 

beginning 10 years earlier than the affected 

relative’s age of onset, but not before age 30. 

Additionally, breast MRI is recommended for this 

group of women because MRI has greater 

sensitivity than screening mammography. (Expert 

Panel on Breast et al., 2017) 

In order to determine patient risk, providers and 

patient navigators may use one of a few available 

breast cancer risk prediction models. Commonly 

used models are The International Breast 

Intervention Study (IBIS), or Tyrer-Cuzick, model 

and the Gail model. (Millstine et al., 2014) The 

Tyrer-Cuzick model is based on data from the 

International Breast Intervention Study (IBIS) from 

the United Kingdom. This model can be employed 

to determine whether a woman is a candidate for 

annual screening MRI in conjunction with annual 

mammograms. The need for screening MRI should 

be based on 2007 American Cancer Society 

Guidelines, which indicate that a lifetime risk of 

greater than 20 percent merits supplemental MRI 

screening. The Gail model, which uses age, race, 

menarche, age at first live birth, history of cancer 

in first degree relatives, history of breast biopsy, 

and history of atypical ductal hyperplasia to 

predict 5-year and lifetime risks is used only in 

women age 35 years or older and cannot be 

applied to those with a history of breast cancer, 

lobular carcinoma in situ, or ductal carcinoma in 

situ. However, it is well suited to determine 



 
 
 
 
 

 

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whether chemoprevention is indicated for breast 

cancer risk reduction. When a woman is identified 

to be at high risk, chemoprevention may also be 

prescribed, using tamoxifen, raloxifene, or 

exemestane, each of which has been shown to 

lower lifetime risk of breast cancer.(Burns et al., 

2016; Millstine et al., 2014; Visvanathan et al., 2013) 

 Historically, racial/ethnic minorities and low 

income women have been less likely to receive 

physician recommendations for mammography, 

and this variability in physician recommendations 

must be addressed (Peek and Han, 2004). Native 

American women are strongly influenced by their 

relationship with their provider, their experiences 

and their degree of trust in the health care system 

(Canales and Geller, 2004). However, lack of 

consistency in provider from one year to the next, 

and frequent moves between urban and 

reservation domiciles undermines a good provider 

relationship (Burhansstipanov L, 2010). Lay health 

advisers in the communities can also be effective 

in improving compliance of Native American 

women to screening mammography, especially 

since barriers to participation can be complex 

(Burhansstipanov L, 2010). 

Although breast cancer is the most common 

malignancy among American Indian women, it is 

second to lung cancer as a cause of death. This is 

because survival of women with breast cancer is 

much higher than survival of women with lung 

cancer. Therefore, breast cancer is less likely to 

threaten the life of a smoker than are smoking 

related diseases such as chronic obstructive 

pulmonary disease and cardiovascular disease. As 

screening mammography becomes better 

established in native American communities, 

mammogram screenings become opportunities 

for teachable moments to encourage other 

healthy behaviors such as smoking cessation and 

colorectal cancer screening (Carlos and Fendrick, 

2004). 

Aside from risk reducing chemoprevention 

medications, American Indian women may 

decrease their risk of breast cancer with exercise, 

minimizing alcohol intake, and practicing breast 

feeding for durations as long as feasible. Other 

actions that may decrease the risk of breast cancer 

include increasing the intake of omega 3 fatty 

acids (fish oil), citrus fruits, and vegetables of the 

cabbage family. Further positive steps include 

reducing dietary omega 6 fatty acid (vegetable 

oils) by substituting extra virgin olive oil, reducing 

the intake of red meat, high fat and hormone 

containing dairy products, and by using vitamin D 

supplements. (Ronco et al., 2010) They may 

decrease their risk of death from breast cancer by 

engaging in annual screening mammography and 

for supplemental screening with magnetic 

resonance imaging when genetic risk is evident. 

Finally, guideline concordant breast cancer care 

and treatment needs to be more universally 

received by this population. (Javid SH, 2014) 

Disparities in breast cancer among American 

Indian women may be addressed through a 

variety of activities. First, the heterogeneity of 

American Indian populations must be recognized 

and health information examined by local group 

rather than being lumped into one large group. 

Furthermore, the accuracy of the information must 

be improved by reducing racial misclassification. In 

addition to analyzing data among geographic 

subgroups, differences between rural and urban 

women must be recognized. Access to breast 

cancer screening and treatment must be improved 

for all Native American women, and continuing 

community needs assessments and educational 



 
 
 
 
 

 

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interventions and needed for this understudied 

population.  

Acknowledgements 

The author is thankful to Judith S. Kaur for inviting 

this article. 

 

Conflict of interest 
The authors declare that no competing or conflict of 

interests exists. The funders had no role in study 

design, writing of the manuscript, or decision to 

publish. 

Authors’ contributions 
MAR designed and conceived the study and wrote 

the manuscript. 

 

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