Inflammatory Breast Cancer in Black Women: Signs on Dark Skin

Inflammatory breast cancer is a rare, fast-growing breast cancer that changes the skin of the breast instead of forming a lump. The National Cancer Institute describes the breast becoming swollen, with skin that may look pink, reddish purple or bruised and dimpled like an orange peel, and notes that it is more common and diagnosed at a younger age in Black women than in white women (NCI fact sheet). On dark skin the color change may not look red at all, which is one reason it can be missed. Changes that appear over weeks and do not clear up need a prompt exam, imaging and, if needed, a biopsy.

Most breast cancers start as a lump. IBC starts in the small lymph vessels of the breast skin, which become blocked by cancer cells, and that blockage is what causes the swelling and skin changes (NCI). The NCI lists these signs:

• Swelling, often with the breast getting noticeably larger in a short time.
• Skin that looks pink, reddish purple or bruised.
• Dimpled or pitted skin that looks like an orange peel (doctors call this peau d'orange).
• A feeling of heaviness, burning or tenderness in the breast.
• A nipple that turns inward.
• Swollen lymph nodes under the arm or near the collarbone.

The classic textbook description says the breast turns red. On brown and Black skin, that is often not what you see. A 2022 paper proposing common diagnostic criteria, written by IBC specialists and published in Breast Cancer Research and Treatment, describes the discoloration as anything from faint pink to bright red, bruising or a purplish color, and notes that in some women the skin is obviously changed from normal but does not look red at all. The authors point out that IBC has a higher incidence among women with highly pigmented skin, including women of African descent, "so it is important to broaden the interpretation of 'skin erythema' beyond simply 'redness'" (Jagsi et al., 2022).

In practice, on dark skin look for:

• An area that is darker, duskier or more purple than the rest of the breast, or looks like a bruise you cannot explain.
• Skin that feels thicker, firmer or warmer than the other breast.
• Pores that look bigger and deeper, giving an orange-peel texture, which can be easier to see in side lighting.
• One breast that is suddenly bigger, heavier or sits differently in your bra.

Compare one breast with the other, and both with how they usually look and feel. Change is the signal.

The hallmark of IBC is how fast it appears. The 2022 diagnostic criteria describe sudden onset of signs within a six-month window, and they score symptoms that appeared within three months as the most typical (Jagsi et al.). The American Joint Committee on Cancer, the body that sets cancer staging rules, defines IBC by diffuse discoloration and swelling covering a third or more of the breast once an invasive cancer is confirmed (as summarized by Jagsi et al.).

Because it grows quickly, IBC is always found at stage III or stage IV, depending on whether it has spread beyond the breast and nearby lymph nodes (NCI). Early recognition still matters a great deal, because the stage and how far it has spread drive the outlook. The NCI gives five-year relative survival of about 53% when IBC has spread only to nearby areas and about 22% when it has spread to distant parts of the body (NCI).

The largest national analysis of IBC, using the National Cancer Institute's SEER cancer registries from 1988 to 2000, found incidence was significantly higher in Black women, 3.1 cases per 100,000 woman-years, than in white women, 2.2. It also found that Black women with IBC had poorer survival than white women with IBC, and that Black women were diagnosed younger (Hance et al., 2005). The NCI fact sheet says IBC is more common and diagnosed at a younger age in Black women, and more common in women with obesity (NCI).

That combination, younger age and skin changes that may not read as red, is a setup for delay. A woman in her 30s or 40s who is not yet getting mammograms, and whose breast looks bruised or dark rather than red, may not think of cancer, and neither may a clinician who was taught to look for redness. The specialists who wrote the 2022 criteria say awareness lags, that public campaigns stress lumps and nipple discharge while often failing to mention changes in skin color or texture, and that delays in diagnosis are not uncommon (Jagsi et al.).

Mastitis, an infection of breast tissue, causes swelling, warmth, pain and discoloration too, and it is far more common, especially while breastfeeding. The NCI notes that mastitis has symptoms similar to IBC (NCI). Clinicians often start with antibiotics, which is reasonable. The 2022 criteria explicitly allow IBC to be diagnosed before or after a trial of antibiotics (Jagsi et al.).

What to do: the American Cancer Society says a doctor may suspect infection at first and prescribe antibiotics, and advises telling your doctor if symptoms do not improve within about a week ({a(ACS, 'ACS')}). If the changes have not clearly improved by then, go back and ask directly for breast imaging and a biopsy, and say the words "inflammatory breast cancer" so it is in the chart.

Diagnosis usually starts with a physical exam and imaging. The NCI lists mammogram, breast ultrasound and breast MRI, followed by a biopsy of the breast or skin. If cancer is confirmed, tests check hormone receptor and HER2 status, and a PET or CT scan checks for spread (NCI). The 2022 criteria recommend a skin punch biopsy of the area with the most change, and note that MRI is the most definitive imaging test (Jagsi et al.).

Treatment combines several approaches. For stage III, the American Cancer Society says treatment usually starts with chemotherapy, sometimes with immunotherapy or a targeted drug, followed by a mastectomy with removal of the underarm lymph nodes if the tumor shrinks enough, then radiation, often with more drug treatment; breast-conserving surgery is not a good option (ACS). An international expert panel emphasized this multimodality approach of systemic therapy, surgery and radiation (Dawood et al., 2011). Because IBC grows quickly and is more likely to come back, the NCI notes that people with it may receive more treatment for a longer period than with other breast cancers (NCI). Ask whether a center that treats many IBC patients, or a clinical trial, is an option.

For more on breast cancer in Black women, see our guides to triple-negative breast cancer and the mammogram gap for Black women. If cost is a barrier, our page on free breast cancer screening lists programs by state.

Call your doctor or gynecologist within days, not weeks, if you notice:

• One breast becoming swollen, heavier or noticeably larger over a few weeks.
• Skin that looks darker, purple, bruised or discolored over part of the breast, without an injury.
• Thick, firm or orange-peel textured skin.
• A nipple that newly turns inward or flattens.
• Swollen lymph nodes under the arm or above the collarbone.
• Breast "infection" symptoms that do not clearly improve within about a week of antibiotics.

To see a Black clinician, search our provider directory for obstetrics and gynecology, primary care or oncology near you.