This year, doctors from Maimonides Medical Center and SUNY Downstate Health Sciences University collaborated to investigate the ways in which breast diseases are visually represented in educational materials. From SUNY Downstate, Maissa Trabilsy, MD/MPH candidate and from Maimonides, Arielle Roberts, MD, general surgery resident; Charusheela Andaz, MD, Associate Director of the Breast Surgery Division; Donna Marie Manasseh, MD, Director of Breast Surgery; Patrick Borgen, MD, Chair of the Department of Surgery and Head of the Breast Center; and Joshua Feinberg, MD, Director of Research, Division of Breast Surgery, all contributed to the study, titled “Lack of Diversity in Textbook Images Depicting Diseases of the Breast.”
“We reviewed over 500 patient images in 20 breast disease textbooks and evaluated the skin tone of each patient,” said Dr. Feinberg. “An overwhelming majority (96%) were of light skin color, leaving only 4% of figures represented by dark-skinned individuals. Furthermore, our results demonstrate that the dearth of images depicting dark-skinned individuals did not improve during subsequent years of textbook publication.”
The study was awarded the designation of Top Poster at this year’s 40th Annual Miami Breast Conference.
Confronting Medical Biases Can Combat Health Outcome Inequities
This knowledge comes at a critical time, as we know that breast cancer screenings dropped dramatically during the Covid-19 pandemic among people of color. Despite the comparable lifetime risk of developing breast cancer, Black women are nearly 40% more likely than white women to die from the disease.
Some factors behind this are genetic, like a higher predisposition for women of color to develop the more aggressive triple-negative variety of breast cancer. Others can be attributed to the relationship between people of color and the medical field, where historical maltreatment can translate to mistrust and lingering biases today, and perpetuate health inequities.
“Traditionally and historically for good reason, people of color have not been treated well by the medical system,” said Dr. Manasseh. “This mistrust unfortunately continues and percolates today in various other situations. Because of it, they’re less likely to go and get the screening that they need. They’re less likely to try to do some of the therapies that are recommended. And they’re not too far off with respect to mistrusting because, in some situations, there is a reasonable reason for why there is mistrust. We know that, especially when it comes to things like pain, that people of color often aren’t given the appropriate pain medication compared to the white population. So, as a result, some of these fears and concerns get reaffirmed when they encounter a bad situation.”
Medical literature and educational content that features light-skinned individuals almost exclusively can only serve to reinforce these biases. The Breast Center team’s study seeks to change that, and ensure that current and future doctors are able to recognize the different ways disease can present itself on varying skin tones.
“Unequal skin tone representation permeates several areas of medical education and may translate into implicit bias as trainees transition into practice. The addition of images depicting patients of color in future breast textbook editions can help decrease physician bias, alleviate diagnostic inequalities, and contribute to improvement of disparities within breast cancer care,” said Dr. Feinberg.
Breast Center Team’s Study Was Inspired by 2021 Study Led by Maimonides Urologic Surgery Resident
The Maimonides Breast Center team’s research was inspired by the research of another member of the Maimonides team: Karis Buford, MD, former Urologic Surgery resident.
Dr. Buford, along with fellow Urologic Surgery residents Katiana Vazquez Rivera, MD; Andrew Wood, MD; and Arshia Sandozi, DO, and urologic surgeon Ariel Schulman, MD, reviewed photographic depictions of penile pathologies in 9 major urologic textbooks to assess racial representation and diversity in the medical literature. Despite higher stage at presentation and worse oncologic outcomes from penile cancer, images of men with skin of color were more likely depictions of infections rather than malignancy.
The team concluded that the lack of depictions of malignant pathology may contribute to continued disparities in the diagnosis and treatment of penile pathologies in men of color. The article, titled Representation in Figures Depicting Penile Pathology in Urologic Textbooks, was published in a leading Urology journal and presented at the American Urological Association Annual Meeting, 2021. After completing residency at Maimonides in 2023, Dr. Buford is currently a fellow in Female Pelvic Medicine at William Beaumont University in Royal Oak, Michigan.
For more information on research at Maimonides, visit https://maimo.org/research/.
