Breast cancer is the most common cancer affecting women in the UK, with almost 60,000 new invasive cases diagnosed each year. But behind the national figures are significant differences between ethnic groups, including differences in incidence, age at diagnosis and the stage at which the disease is detected.
For British Asian women, the picture is particularly complex. South Asian women generally have lower rates of breast cancer than white women in the UK, but those who develop the disease are, on average, diagnosed at a younger age and are more likely to present with more advanced disease.
“Overall, we know that South Asian women have lower incidence rates of breast cancer compared to white women in the UK,” says Toral Gathani, Associate Professor in the Cancer Epidemiology Unit and Consultant Breast Surgeon at Oxford University Hospitals NHS Foundation Trust, and Senior Research Fellow at Green Templeton College.
“Women from South Asian backgrounds are on average a little younger when diagnosed, and more likely to have more advanced disease at presentation. These differences are more marked in Pakistani women compared to Indian women.”
Lower incidence, but younger diagnosis
However, lower incidence should not be interpreted as lower importance.
A large English study of women diagnosed with invasive breast cancer found substantial differences in incidence between ethnic groups. South Asian women had lower rates overall, while research has also identified differences in age at diagnosis and disease presentation.
Dr Gathani says the differences are particularly important when comparing individual South Asian communities. “Scientifically, it is a challenge to put all these women into one ‘South Asian group’,” she says.
“There are distinct differences between Indian and Pakistani women with respect to, for example, the distribution of some risk factors that may influence being diagnosed with breast cancer and which can also influence the type of breast cancer that is diagnosed.”
One example is alcohol consumption, which varies between communities and can influence breast cancer risk. “By grouping these women together, we may mask differences that are scientifically important,” Dr Gathani adds.
The warning is important because “South Asian” is often used as a convenient umbrella term in health statistics, despite encompassing communities with different migration histories, socioeconomic circumstances, lifestyles, languages, religions and patterns of healthcare use. Bangladeshi, Indian and Pakistani women should not automatically be assumed to have identical risks or experiences.
Is culture really causing women to delay diagnosis?
Breast cancer awareness campaigns have frequently focused on the idea that cultural taboos prevent South Asian women from talking about breast symptoms or seeking medical help. There is evidence that cultural attitudes can play a role, but Dr Gathani says the issue is more complicated than simply blaming “culture”.
“There is evidence to show that women from ethnic backgrounds can find navigating the healthcare system challenging and cultural norms and taboos can influence decisions to seek help for symptoms or attend for screening which can result in delays in diagnosis,” she says.
That can include discomfort discussing breasts, fear of cancer, uncertainty about symptoms or concerns about screening. But focusing exclusively on cultural barriers risks overlooking the wider circumstances that influence whether someone can access healthcare.
Language barriers, health literacy, working patterns, caring responsibilities, transport, familiarity with the NHS and previous experiences of healthcare can all affect engagement with screening and diagnosis.
There can also be differences between generations. A woman born in Britain may have a very different understanding of breast cancer and the NHS from a woman who migrated to the UK as an adult.
The NHS has increasingly focused on health inequalities, with local services developing initiatives aimed at communities that face barriers to accessing screening and early diagnosis.
“In ethnically diverse areas of the country there are many examples of locally delivered initiatives focused on breast cancer, often co-developed and delivered with community partners, to tackle some of these challenges,” Dr Gathani says.
That community involvement can be particularly important because messages about cancer may be more effective when delivered through trusted local organisations and community networks.
Why representation in research matters
Another issue raised by Dr Gathani is the quality of the evidence itself.
If South Asian women are routinely grouped together, researchers may miss important differences between communities. “We need ethnically intelligent approaches to research,” she says.
“But this does mean that we need women from these communities to take part in research studies so that they are sufficiently represented.”
Better representation can help researchers understand not only who develops breast cancer, but why differences occur, how tumours vary between populations and whether prevention, screening and treatment approaches work equally well for everyone.
It can also help healthcare providers move away from broad assumptions about ethnicity.
A British Asian woman is not defined by a single risk profile. Her individual risk can be influenced by age, family history, reproductive history, lifestyle, genetics and other factors, alongside the wider social and healthcare environment in which she lives.
Breaking the stigma
Perhaps the biggest challenge is changing the way breast cancer is discussed.
For some families, cancer can still carry fear and stigma. A diagnosis may be associated with shame, fatalism or the belief that talking about the disease will somehow make it worse.
Dr Gathani believes those attitudes need to change.
“I would like all the stigma that is associated with cancer in general, and breast cancer in particular, to be removed from our South Asian communities,” she says. “By talking about cancer openly and truthfully, some of the myths and misconceptions will be eliminated which will help women to seek help when they need it.”
That conversation needs to happen both inside families and beyond them — in GP surgeries, community centres, workplaces, faith communities and through culturally accessible public-health campaigns.
And it should not be based on fear.
“I would like women from all communities to understand that breast cancer is very treatable if diagnosed early,” Dr Gathani says. “Seeking help for symptoms such as breast lumps and attending for screening when invited is important for all women.”
The statistics show that South Asian women in Britain have historically had lower rates of breast cancer than white women. But the same evidence also points towards differences in age at diagnosis and stage of disease.
The lesson is therefore not that British Asian women should be more frightened of breast cancer. It is that lower incidence does not mean lower importance.
Early diagnosis can save lives, and talking about breast cancer openly is one of the first steps towards making that happen.
