A Systematic Review of Interpersonal Interactions Related to Racism in Studies Assessing Breast and Gynecological Cancer Health Outcomes among Black Women

Abstract

Objective

To identify how studies measure racism-related variables at the interpersonal level and identify associated breast and gynecological cancer disparities among Black women.

Methods

A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Searches were conducted in PubMed, CINAHL Plus, and Scopus using terms centered on racism and cancer. Inclusion criteria consisted of the study being conducted in the United States with Black or African American women and the study stating an outcome or focus identified as a breast or gynecological cancer health disparity. Two researchers independently screened titles and abstracts, full texts articles, and completed quality assessments of included studies. Data were extracted into a matrix table, and common concepts were identified and synthesized using the Matrix Method. The quality of included studies was assessed using the Joanna Briggs Institute’s critical appraisal tools.

Results

Thirteen studies, that examined the effect of racism-related variables operating at the interpersonal level on breast, cervical, and ovarian cancer outcomes in Black women, were identified for inclusion. Across studies, racism related variables were measured as discrimination, trust, racism, and clinician-patient interactions. Additionally, across studies disparities were identified in cancer screening, treatment received, survivorship quality of life and incidence.

Conclusion

This review highlights the need for valid, reliable and consistent measurement of racism operating at the interpersonal level to first understand its impact on cancer health disparities and to also facilitate the development and evaluation of interventions aimed at mitigating interpersonal level racism.

Due to improvements in cancer prevention, early detection, and treatments, cancer mortality has decreased in the United States; however, racial disparities in cancer outcomes persist[1]. Non-Hispanic Black women experience disproportionately higher mortality rates of breast and gynecological cancers (e.g. cervical, endometrial, and ovarian cancer) than Non-Hispanic White Women[2, 3]. For example, Black Women have a 40% higher risk of dying from breast cancer and a 55% higher risk of dying from endometrial cancer compared to Non-Hispanic White women[4]. Moreover, cervical and endometrial cancer represents the most common cancer diagnosis with the widest Black-White disparities in cancer mortality[5]. Cancer health disparities are preventable public health problems that require immediate action to improve the cancer outcomes of Black women.

According to the National Institute of Minority Health and Health Disparities Framework, health disparities are driven by multiple domains of influences (biological, behavioral, physical & sociocultural environment and healthcare system) and multiple levels of influence (Individual, interpersonal, community, societal) which exists within these domains[6]. For example, racial disparities in cancer outcomes of Black women can be attributed to genetic predisposition to aggressive cancers such as triple-negative breast cancer (biological domain, individual level), coping and health behaviors (behavioral domain, individual level), patient-clinician relationships (healthcare system, interpersonal), access to early cancer screening (healthcare system, community) or receipt of high quality cancer care (healthcare system, societal)[7–11] However, evidence demonstrates that racism underlies each domain and level of influence and contributes to disparate cancer health outcomes in Black women. The National Nursing Commission to Address Racism defines racism as “assaults on the human spirit in the form of actions, biases, prejudices, and an ideology of superiority based on race that persistently causes moral suffering and physical harm of individuals and perpetuates systemic injustices and inequities[12].” For example, racism-related chronic stress has been linked to an increased risk of tumor development in Black women[13]. A study utilizing the Surveillance, Epidemiology, and End Results (SEER) Program found Black women born during in Jim Crow during the racist Jim Crow era laws had a higher risk of the aggressive estrogen-receptor-negative breast tumor compared to White women born during the same era[14]. Another study examining health outcomes in women receiving treatment for cervical or ovarian cancer found that Black women experience significantly higher levels of race-related stress while receiving treatment for cervical or ovarian cancers, compared to Non-Hispanic White women[15]. The study also revealed that race-related stress was associated with treatment delays and interruptions[15]. There is a need for a more robust understanding of racism in healthcare to improve cancer outcomes disparities among Black women.

Racism is a complex multifaced issue that occurs at multi-levels, including the individual, interpersonal, institutional, and societal levels. Racism manifests at the individual level through internalizing racist beliefs and ideologies and at the interpersonal level through interactions with others[16]. Racism also occurs at the institutional level through structures and processes within an institution that facilitates racist ideologies, beliefs, and actions[16, 17]. Structural racism reflects how multiple systems and institutions interact to perpetuate racist ideologies, beliefs, and policies[18]. Racism is a multi-faceted, systemic problem, requiring multiple levels of intervention. Clinicians have a critical role to play in addressing interpersonal- and system-level racism during their numerous interactions with patients. While systems and policy change is ultimately needed to eliminate health disparities, systems are made up of individuals who interact with patients and who must take collective and individual action to create inclusive and equitable health care systems. At the interpersonal level, clinicians can improve their relationships with patients and deliver equitable care to their patients. Previous research suggests that interpersonal racism manifested in patient-clinician interactions (e.g., the clinician-patient) contributes to disparities in cancer care through mechanisms such as implicit bias and mistrust. For example, a study examining the influence of clinician bias on quality of patient-clinician communication indicates that healthcare providers with more substantial implicit bias are more likely to provide poorer communication and care to Black oncology patients[19]. Patients with higher levels of medical mistrust are more likely to experience poorer health behavior or health outcomes (e.g., poor treatment adherence and quality of life [QoL])[20, 21]. However, the mechanisms through which interpersonal interactions induce negative cancer outcomes are poorly understood[20]. Moreover, minimal evidence exists on how to best measure and therefore identify effective interventions to mitigate the effects of racism in clinical interactions. There is a critical need to understand the ways through which racism has been measured at the interpersonal level and what the effects of these interpersonal level concepts are on cancer health outcomes to help reduce health disparities among Black women. Therefore, this systematic review aims to identify: (a) how racism operating in interpersonal interactions has been measured and (b) associated breast and gynecological cancer disparities among Black women. Because disparities exist across the cancer control continuum and because we aimed to identify how racism may be measured and relate to outcomes among Black women diagnosed with cancer, we examine disparities occurring from incidence through survivorship[22].

Methods

Researcher positionality

The research team actively considered their identities and lived experiences as they conducted this research and acknowledged that researcher positionality impacts data interpretation.[23] This team worked from an understanding of their individual identities and the teams ‘collective identity, striving to conduct this research responsibly and respectfully to make a practical contribution to the literature aimed at energizing and empowering clinicians to take personal responsibility in contributing to collective action for anti-racist equitable cancer health care.

Search, Screening, Extraction, and Synthesis

This review was registered in the PROSPERO database of prospectively registered systematic reviews (ID: CRD42023393303). This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses[24]. On October 26, 2022, a health sciences librarian conducted a comprehensive search in the following databases, including all available data up to the present: PubMed, CINAHL Plus with Full-Text (EBSCOhost), and Scopus. The search strategy included subject headings and keywords for two concepts and related synonyms: racism and cancer. The search was limited to peer-reviewed articles published in English. The complete, reproducible search strategy, that includes all search terms, for all databases is listed in the Supplementary Table 1. Search results were placed into EndNote X9[25] to remove duplicate references. Then the remaining records were imported into Covidence systematic review software[26] for screening purposes.

Studies were included in the review if they met the following eligibility criteria: 1) conducted in the United States; 2) involved a sample of Black or African American (AA) females; 3) focused on breast or gynecologic cancer; 4) had an outcome or focus identified as a cancer disparity (e.g. higher cancer incidence or poorer experiences of cancer care); and 5) discussed the effect or association of an interpersonal racism related variable (e.g. trust, bias) with cancer disparities. The term “racism” was not often explicitly used or named directly in the literature. Thus, reviewers discussed concepts (e.g. discrimination and implicit bias) presented in articles to determine inclusion. All reviewers completed racial equity training[27] to inform this process. This training is designed to build understandings of systemic racism, and prepare trainees to identify where they are situated in racist systems and thus how they can work individually and collectively for change. The reviewers drew on their training to identify studies that included variables in which individuals could work on the interpersonal level for change. The title and abstract of each record were screened independently by two reviewers. The full-text articles were also screened independently by two reviewers. Discrepancies at both stages of screening were resolved by group consensus.

Data from the articles included were extracted into an Excel spreadsheet matrix table and the Matrix Method[28] was applied to guide analyses. Extracted data included study purpose, population, racism-related variable, measures of the racism-related variable, cancer disparity outcome, the evidence or main finding of the study, and notes related to implication for practice translation. Data related to racism-related variables and their measures were reviewed across the studies, in the matrices, to identify common concepts. Similarly, data related to cancer disparity outcomes were reviewed across the studies, in the matrices, to identify common concepts.

Study quality assessment was completed independently by two reviewers using the Joanna Briggs Institute (JBI)’s critical appraisal tools for cross-sectional and qualitative studies. Conflicts of assessment results were resolved through discussion of the two reviewers.

Results

After the removal of duplicates (n=607), a total of 1030 published articles were screened for eligibility (Figure 1). The full texts of 74 relevant articles were retrieved and reviewed, in which 13 studies met the eligibility criteria. In the 60 excluded articles, the majority (n=37) were excluded due to the lack of a racism-related variable. Sixteen were not peer-reviewed articles or original research. Four had mixed cancer/sex/race samples in which the findings among the target population of this review could not be identified, two had no outcomes of cancer disparities, and two focused on intersectionality.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of this review

While no date restrictions were set, the included articles were published between 2002 and 2022. Two of these were qualitative studies, and 11 were cross-sectional studies. Sample sizes ranged from 10 to 49161. Seven studies identified the study participants’ race as “African Americans,” and six identified participants’ race as “Black.” Most studies focused on breast cancer only (n=8). Three studies focused on multiple cancers (breast and cervical cancer). The remaining two studies focused on ovarian and cervical cancer separately. Table 1 details an overview of included studies.

Table 1.

Study and Sample Characteristics, Interpersonal Interaction Variables and Measures, and Their Impact on Outcomes Related to Breast, Cervical and Ovarian Cancers

Author (year)	Sample size	Cancer	Percent of study sample reported as Black/African American (AA)	Racism-related variable	Measurement	Impact on breast/cervical/ovarian cancer outcomes
Ibekwe et al. (2022)	405	Breast, cervical	100	Perceived racial discrimination	A modified 9-item version of Experiences of Discrimination (EOD) scale	Perceived discrimination non-significantly associated with lower mammography; not associated with Pap test screening adherence.
Jacobs et al. (2014)	3258	Breast, cervical	28	Everyday discrimination	The 10-item everyday discrimination scale	Everyday discrimination not associated with breast or cervical cancer screening.
Benjamins et al. (2012)	1699	Breast, cervical	44	Perceived discrimination	The 10-item everyday discrimination scale; Experiences of Discrimination (EOD) Scale; A researcher-developed composite measure of discrimination in health care.	Perceived discrimination not significantly associated with breast or cervical cancer screening.
Taylor et al. (2007)	49161	Breast	100	Everyday discrimination, Major discrimination (in job, in housing, or by the police)	An adapted 5-item scale from the Williams everyday discrimination scale; 3-item major discrimination scale	Major discrimination associated with higher breast cancer incidence; everyday discrimination not significant associated with breast cancer incidence.
Adegboyega et al. (2019)	39	Breast	100	Race-related discrimination, Negative health care experiences	In-depth individual interviews	Race-related discrimination and previous negative health care experiences (of self or of trusted sources) decrease likelihood of mammography.
López et al. (2005)	13	Breast	100	Racial discrimination	Photovoice	Racial discrimination influences survivorship and QoL
Mullins et al. (2019)	486	Ovarian	100	Perceived discrimination, Trust in physicians	The 5-question version of the Williams everyday discrimination scale; Trust in Physician Scale	Discrimination associated with prolonged symptom duration; trust in physicians not associated with prolonged symptom
Sutton et al. (2019)	210	Breast	100	Medical mistrust	12-item 5-point Likert Group-Based Medical Mistrust Scale	Mistrust associated with less satisfaction with cancer care, poorer communication and interpersonal behaviors with clinicians.
Maly et al. (2008)	257	Breast	26	Racism/Medical Mistrust (treated as one latent variable)	A 5-point 4-item Likert-type Scale to Measure Racism in Medical Care; A 5-point researcher-modified Likert-type scale to measure general medical mistrust	Racism/Medical mistrust partially mediates the negative indirect effects of AA race/ethnicity on quality of life (QoL).
Bickell et al. (2012)	374	Breast	20	Perceived racism, medical mistrust	A 5-point 4-item Likert-type Scale to Measure Racism in Medical Care; Trust Scale of the Primary Care Assessment Survey; A 5-point researcher-modified Likert-type scale to measure general medical mistrust	Perceived racism predicted poorer perceived quality of care
Hoyo et al. (2005)	144	Cervical	100	Perceived racism	Anticipation of dichotomous responses to perceived racism by healthcare providers	Perceived racism significantly associated non-adherence to cervical cancer screening.
Mandelblatt et al. (2002)	1833	Breast	54	Racism	A 4-item Scale for Racism	Participants with higher reported racism more often received surgery only treatments as compared to surgery and radiation treatment.
Kwan et al. (2013)	1855	Breast	6	Patient-physician interaction	Interpersonal Processes of Care (IPC) 18-item Questionnaire	Physician compassion and elicited concerns positively affect QoL; disrespectful office staff negatively affect QoL.

Study Quality Assessment

All included studies were assessed as low risk of bias (Supplementary Table). Three cross-sectional studies[29–31] had a risk of bias regarding under-identified confounding factors or unclear strategies to deal with confounding factors, while both cohort studies[32, 33] lacked strategies to handle incomplete follow-ups.

Racism related measures

Among the total 13 studies, only four directly used the term racism; one of them combined racism and medical mistrust as one latent variable (n=1). The most common variable used to assess how racism may operate at the interpersonal level to impact cancer outcomes was discrimination (n=7). Additionally, trust in healthcare professionals or medical mistrust (n=3), patient-physician interactions (n=2), and negative health care experiences (n=1) were studied; all variables are detailed in Table 1.

Discrimination

Across the seven studies that included discrimination, it was assessed as everyday discrimination, major discrimination, or discrimination in medical care. All studies that measured everyday discrimination either used the Everyday Discrimination Scale (EDS)[32, 34], which was a tool developed by Williams et al[35] in 1997 to measure chronic perceived racial discrimination in everyday life, or used an adapted version of it[33, 36]. Similarly, major discrimination was also measured using the Experiences of Discrimination (EOD) scale[34], another tool that measured discriminated experiences in multiple chosen situations (e.g. at school, getting a job, getting housing, and from the police or in the courts), or the adapted versions[29, 33]. Two studies specifically measured perceived discrimination in healthcare settings or by healthcare professionals[30, 34]. The perceived discrimination in health care settings was a subscale of the group-based medical mistrust scale in Sutton et al[30] Benjamins measured perceived discrimination by asking participants if they felt they were treated better, worse, or the same compared with people of other races and ethnicities when they were getting health care during the last 6 months and how often they had experienced discrimination while getting medical care[34]. Adegboyega et al[37] and López et al[38] also conducted qualitative interviews or photovoice to gain an in-depth understanding of discriminated experiences of Black women in breast cancer care from screening to post-treatment.

Trust

Trust was included in four studies[30, 31, 36, 39]; in Maly et al[39], it was treated as one latent variable together with racism. Trust in healthcare professionals was measured using the trust section of the Primary Care Assessment Survey[31] or the Trust in Physician Scale[36]. Medical mistrust is either measured by the adapted version of a 5-item general medical mistrust scale[31, 39] or the group-based medical mistrust scale [30]. The 5-item scale tested the mistrust in healthcare system generally[40] while the group-based medical mistrust scale specifically measured the ethnicity-related mistrust with three subscales, suspicion, lack of support, and perceived discrimination and group-based disparities in healthcare settings[41].

Racism

Racism was examined in four studies with diverse researcher-developed or adapted scales[31, 39, 42, 43]; in Maly et al[39] it was treated as one latent variable together with medical mistrust, as explained above. These scales centered on whether respondents felt being treated fairly by physicians/healthcare professionals[31, 39, 42, 43], received equal treatment options[31, 39, 42, 43], and received the care they want[31, 39, 43] across different racial groups.

Interactions and experiences

One study assessed patient-physician interactions in healthcare settings [44]. The 18-item Interpersonal Processes of Care (IPC) questionnaire was used by Kwan et al[44] to comprehensively assess the interactions between patients and physicians regarding compassion, elicited concerns, explained results, shared decision-making, lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff. Adegboyega et al[37] collected negative healthcare experiences and considered their influence on cancer outcomes using in-depth individual interviews.

Effect of Interpersonal Racism on Breast, Cervical, and Ovarian Cancer Outcomes

The impact of the above racism-related variables was identified across three areas of the cancer control continuum, including detection (e.g., cancer screening) (n=6), treatment received (n=3), and survivorship (e.g., quality of life) (n=3). Additionally, one study examined their effects on cancer incidence.

Screening

The effects of discrimination and racism on Black women’s engagement in breast and cervical cancer screenings were examined across several included studies[29, 32, 34, 36, 37, 42]; contradictory findings were identified. Findings related to the impact of discrimination on cancer screening are mixed and findings indicate that racism negatively impacts cancer screening. Specifically, two studies identified no significant associations between discrimination and mammography and Pap Smear tests[32, 34]. Similarly, Ibekwe et al[29] identified that discrimination was not associated with Pap Smear tests. Yet, other study findings did support relationships between discrimination and cancer screenings. For example, Ibekwe et al[29] reported a significant association between major discrimination and mammography. These findings were further supported by Mullins et al[36] who evaluated the effect of interpersonal racism, operationalized with everyday discrimination and trust in physicians, on prolonged symptom duration in Black women diagnosed with ovarian cancer. As reported by Mullins et al[36], participants with increased everyday discrimination had higher odds of prolonged symptom duration (i.e. interval between symptom onset and diagnosis) (OR 1.77, 95% CI [1.25–2.52]; 1.75, [1.23, 2.48]; 1.74, [1.22, 2.49]), after controlling for demographics, socioeconomic status, and access to care. Similarly, another study identified an association between discrimination and decreased likelihood of mammography[37] among Non-Hispanic Black women. In addition to discrimination, the effects of perceived racism and previous negative healthcare experiences were explored and identified to negatively impact cervical cancer screening[42] and mammography[37] separately. Hoyo et al[42] examined racism by asking AA women if they agreed with the following two statements: (1) “Doctor does not want to bother with me” and (2) “White women are given more information during the screening than Black women” and found significant associations between these measures and non-adherence to Pap tests (p=0.003, p=0.018). Through in-depth interviews with AA breast cancer survivors, Adegboyega et al[37] found that women had hesitations about using mobile mammography due to beliefs that they are substandard and discriminatory. For example, one of the survivors stated, “we know that the new equipment goes to the higher paying areas and the older equipment comes to the lower paying areas of the community.” Additionally, participants expressed that they have avoided breast cancer screening due to previous negative experiences with the healthcare system combined with negative mammography stories from their trusted sources[37].

Treatment

The role of racism-related variables on disparities in treatment satisfaction, the type of treatment received, and perceived quality of care were examined in three studies [30, 31, 43]. Sutton et al[30] studied the effects of mistrust on patient satisfaction; three dimensions of mistrust were examined - medical mistrust, suspicion, and perceived discrimination in healthcare. Their effects on patients’ ratings of overall communication related to chemotherapy, hormonal therapy, and radiation therapy were examined as well as patients’ satisfaction with care received for breast cancer across seven domains (e.g. general satisfaction, interpersonal behavior, communication). No significant relationship between mistrust and total satisfaction was noted, yet greater mistrust was associated with less satisfaction in the clinician’s technical and professional ability (p < 0.0001) and lower ratings of radiation communication (p < 0.01). Additionally, higher suspicion was associated with lower ratings of communication about chemotherapy (p < 0.01), less satisfaction with the technical and professional quality of clinicians (p < 0.05), and worse interpersonal behavior from providers (p < 0.01). Interestingly, racial discrimination was associated with greater satisfaction with interpersonal behaviors with clinicians (p < 0.01); indicating a need to understand how general experiences of discrimination may impact how patients interact with clinicians.

Regarding the quality of treatment received, Bickell et al[31] reported that Black women who perceived greater racism were 67% less likely to rate their care as excellent (RR 0.33, 95% CI [0.10, 0.87]). Finally, Mandelblatt et al[43] examined the effects of perceived racism on the type of treatment received for breast cancer. They found that Black women who received breast conservation only or a mastectomy had higher perceived racism in the medical system (9.2 and 8.9) than Blacks who had breast conservation and radiation (7.0). These differences were not statistically significant. Due to sparse data, the interaction effects of race and racism were not tested[43].

Quality of Life

Three studies observed the negative effects of racism, medical mistrust, and discrimination on QoL among Black women with breast cancer[38, 39, 44]. Maly et al[39] identified that racism and medical trust partially mediated negative indirect effects of AA race on QoL (p≤.05). Kwan et al[44] assessed how patient-physician interactions during oncology care impacted QoL, finding that AA patients with higher scores of physician compassion and eliciting concerns reported higher QoL and patients with lower scores for disrespectful office staff reported lower QoL. Additionally, López et al[38] conducted photovoice discussions with AA breast cancer survivors who relayed that racial discrimination negatively impacts their QoL as cancer survivors. They explained that their decision to seek survivorship support was dependent on if they perceived the source as “safe” for them because doing so as an AA woman might put them at risk for stigmatization, discrimination, and rejection. One participant explained that she found a “safe” provider, “He has been real good to me. He don’t slight me because I’m Black.”

Incidence

Only one study examined the associations of perceived discrimination with breast cancer incidence among Black women[33]. Within the total sample of 64,524 women, this study found no significant associations of breast cancer incidence with each item or the summary of everyday discrimination (e.g. the respondent receiving poorer service than other people in restaurants or stores, other people acting as if they think the respondent is dishonest or not intelligent, and other people acting as if they are afraid of or better than the respondent)[33]. However, among three major discrimination situations measured in this study (on the job, in housing, by police), higher breast cancer incidences only resulted from racial discrimination on the job (incidence rate ratio 1.20, 95% CI [1.01, 1.42]), and between Black women who reported racial discrimination in all three situations vs. those who perceived racial discrimination in no situations (incidence rate ratio 1.31, 95% CI [1.00, 1.73]). These associations were stronger among younger women (< 50 years old) (racial discrimination on the job: 1.32, 95% CI [1.03, 1.70], in all three situations: 1.48, 95% CI [1.01, 2.16])[33].

Discussion

Findings from this review indicated that racism, mistrust, and discrimination all had negative impacts on the QoL of Black women at risk of and survivors of breast, cervical and ovarian cancer survivors. Racism has the most significant impact on health outcomes throughout the cancer control continuum – from detection (i.e., adherence to cancer screenings), treatment (i.e. treatment received) to survivorship (i.e., QoL). Everyday discrimination demonstrated great effects on disparate cancer health outcomes for this population, yet it was not shown to be associated with QoL. Further, major discrimination at work was associated with cancer incidence. Finally trust affected both patient satisfaction with treatment and QoL. Taken together, these findings highlight the vital role clinicians have in understanding the lived everyday experiences of Black women, the impact of those experiences on health and ultimately the role of clinicians working to improve cancer outcomes for Black women. For example, clinicians can actively work to earn the trust of patients, encourage patient questions, ensure quality communication, and most importantly educate themselves on racism and its negative effects on Black women. While making system-level changes is greatly needed, interpersonal-level and clinician-level interventions to provide better care and better experiences for patients may improve detection, treatment, and survivorship experiences. While trust and discrimination relate to racism, these are distinct concepts, yet are included in this review because few studies directly named, measured, and studied “racism”. There is a critical need for research focused on measuring multiple levels of racism to ultimately develop interventions that can effectively and measurably mitigate racism and its effects.

This review identifies relationships between racism and cancer outcomes among Black women. To create effective interventions, further research is needed to better understand the mechanisms leading to disparate outcomes. For example, elevated chronic stress and mistreatment may in part mediate the relationship between racism and racial disparities in breast/cervical/ovarian cancer outcomes among Black women. For example, discrimination as a stressor may be linked to poor health directly[45] or reduce the use of preventive health services by decreasing social, emotional, and physical resources[34]. Although chronic stress was not significantly identified in this review, multiple phenomena may explain its mediation of interpersonal racism to disparities in cancer outcomes. Exposure to racial discrimination is associated with over-circulation of stress hormones, which in turn is linked to an uninhibited inflammatory response, resulting in adverse health consequences, such as breast cancer recurrence and mortality[46]. Persistent exposure to stress hormones also indirectly contributes to tumor genesis, reduces the efficacy of chemotherapeutic medications, and results in more aggressive, difficult-to-treat forms of breast cancer such triple negative breast cancer.[45] Similarly, high levels of catecholamines and reactive oxygen species are emitted during periods of psychological stress, which alter immune functioning and are known to be highly toxic and capable of stimulating cancer development[33]. Quach et al[46] conclude that self-reported medical discrimination experiences highlight the need to incorporate both implicit and explicit discrimination experiences in quantitative surveys in order to better characterize the prevalence of discrimination in the medical setting and its impact on breast cancer outcomes.

Our findings align with prior reviews examining links between racism-related variables and health outcomes among women of color[47–49]. For example, in a recent 2023 systematic review of 84 studies examining the influence of racial/ethnic discrimination among women of color, the authors reported consistent negative relationships between perceived racial/ethnic discrimination and health behaviors such as cancer screening[49]. While our review is consistent with prior reviews, our findings differ from a 2016 review of 19 studies examining the influence of perceived racism/discrimination and health outcomes among Black women[48]. Authors of the 2016 review reported consistent evidence for negative relationships between perceived racism/discrimination and cancer incidence/risk. However, we did not identify significant associations between racism-related variables and cancer incidence in our study. Moreover, only one study[33] examining relationships between racism-related variables and cancer risk met our inclusion criteria for our review. Well-designed studies using empirically sound measures and frameworks are needed to further explore these relationships.

Implications for Practice

Interventions to ameliorate discrimination toward Black women in the health care setting should include cultural competence, sensitivity trainings and racial equity training for healthcare professionals. However, it is important to note that cultural sensitivity trainings may not necessarily reduce patients’ overall experience of stigma or lead to better health outcomes. This is because it fails to address the broader societal and systemic factors that contribute to discrimination[50]. Instead, a growing body of literature proposes the need for structural competency training[50–52]. According to Metzl and Hansen[50], structural competency consists of training in five core competencies: (1) recognizing the structures that shape clinical interactions; (2) developing an extra-clinical language of structure; (3) rearticulating “cultural” formulations in structural terms; (4) observing and imagining structural interventions; and (5) developing structural humility. Increasing awareness of these competencies as well as of complex social hierarchies can improve clinicians’ interactions and relationships with patients, laying the foundation for improved patient health outcomes[51]. Similarly, it is important for clinicians to recognize the present-day ramifications of historical trauma within Black communities who continue to collectively experience psychological distress as a result of racism. Ferrera et al[53] argues the “deep-rooted beliefs and perceptions regarding mistrust of the health care system and fear of deficient treatment become personally mediated. In tandem with internalized messages of being devalued and unworthy of quality of care, these beliefs potentially lead to a lack of engagement in treatment and continuity of care” (p. 456)[53]. It is important for clinicians to recognize this collective trauma as well as to consider past encounters and negative medical experiences that may make a Black patient hesitant or apprehensive about their interaction with the healthcare system. Clinicians may take immediate action to build trust with patients and improve patient experiences. These actions will contribute to improved health equity, as the scientific community simultaneously generates knowledge about deconstructing racism and policy makers work to dismantle racism at all levels. While the role of clinicians is important, achieving health equity will ultimately require systems and policy change.

Gaps in Literature and Future Research Opportunities

There remains considerable need and opportunity for additional research on the effects of racism on cancer outcomes in historically marginalized and underserved communities. Several studies highlight the need for further research into how discrimination can impact breast cancer patients[33, 34, 46]. For example, Doll et al[5] argue that the role of modifiable, non-biological contributors to racial disparities is grossly underemphasized in current research, and that there is a glaring lack of follow-up work to address these factors. Similarly, more research regarding the impact of discrimination on healthcare utilization, including cancer screenings, is needed. Understanding these will facilitate the policy and intervention development to achieve equity in health care[54]. This systematic review serves as an important reminder that delivering healthcare involves significantly more than providing insurance, healthcare access, and the services that patients need. The racial and social contexts in which both patients and providers operate also influences the receipt of healthcare. As Jacobs et al[32] state, “if we are serious about providing optimal care to all the women we serve, we must begin to address these [racial and social] issues as well” (p. 143). Finally, due to the small number of papers that met criteria for this review, as well as the fact that racism was directly named and measured in only four studies, there is a significant need for additional research focused on measuring and determining how racism at multiples levels is impacting health.

Conclusion

Racism in all of its forms, including interpersonal, internalized and institutionalized, is a crucial topic that must be studied, measured, and ultimately eradicated. As Shinagawa observes, until we acknowledge and redress racism, “the miscarriage of health justice will be perpetuated while celebrated advances in cancer research leading to declining incidence and mortality rates continue to evade our nation’s [BIPOC] and medically underserved communities.” (p. 1222)[55]