Who Dies From Cancer?
Few things are black and white, yet when it comes to determining who will survive cancer, race may be fate. Doubt my words? The American Cancer Society described the situation succinctly: “African Americans are more likely to develop and die from cancer than any other racial or ethnic group.”
We are not talking about subtle differences here. We are talking about staggering variations in outcome based upon race. Death rates for prostate, cervical, and stomach cancers are more than 200 percent greater among African Americans than whites.[i] Furthermore, though breast cancer is less common among African American women, their death rate is markedly higher.[ii]
The Role of Socio-Economic Status in Determining Fate:
Socio-economic status definitely plays a role, though how large of one, no one knows for certain. We do know that “People with lower socioeconomic status (SES) have disproportionately higher cancer death rates than those with higher SES, regardless of demographic factors such as race/ethnicity.”[iii]
Presumably, a lower socio-economic status puts one at risk by: 1) reducing access to health care resources for the prevention, detection, and treatment of cancer – often resulting in patients presenting at more advanced stages; 2) increasing reliance on behaviors that may foster development of cancer, such as smoking, poor dieting, and a sedentary lifestyle; 3) delaying the onset of treatment until late in the development of the disease; 4) exacerbating co-morbid conditions through lack of adequate treatment, thus negatively impacting the person’s health and functional status.
Lower SES also impacts the options available for care, as can be seen in a survey published in the Journal of Clinical Oncology that examined participation in clinical trials:
The study surveyed 5,499 patients who were newly diagnosed with breast, lung, colorectal, or prostate cancer. Regardless of age, lower-income patients were much less likely to participate in clinical trials, and the trend persisted even among patients who were universally covered by Medicare. Patients who reported an annual income less than $50,000 were approximately 30% less likely to participate in clinical trials than those reporting a higher income. Looking at lower income levels, patients who made less than $20,000 per year were 44% less likely to participate in a clinical trial than patients who made more than $20,000.[iv]
We know that a disproportionate share of the lower SES population is African American. Since African Americans have a long history of being the victims of unscrupulous medical experimentation, there may be an understandable cultural apprehension about participating in such trials. But there’s more to story…of that I’m confident.
SES is Only Part of the Story:
The disparity in cancer prevalence and outcomes among African Americans transcends SES. In fact, there are factors completely independent of societal influence, such as genetics, that may help explain some of the disparity. African American women often develop forms of breast cancer that are highly resistant to treatment. This may well result from a defective gene. The same could be true of the more aggressive variants of prostate cancer seen in African American men.
A more insidious reason for a higher mortality rate amongst African American cancer patients is that they simply don’t get comparable care to their white counterparts. The proof seems abundant:
- The February 15, 2008, edition of Cancer featured a study in which the authors examined care received by 143,512 Medicare beneficiaries diagnosed with malignant breast, colorectal, lung, and prostate cancer was analyzed. The investigators concluded that:
- “There were racial disparities for 6 of the 7 cancer therapies investigated.”
- Among women who had undergone a lumpectomy, black women were less likely to have received radiation therapy
- Significant racial disparities were also noted for resection of lung cancer, adjuvant therapy for colon cancer, adjuvant chemotherapy and (neo)adjuvant radiation for individuals with rectal cancer, and definitive therapy for prostate cancer.
- There was substantial variation in the unadjusted magnitude of racial disparities across cancer types. The largest disparity—about 15% difference between black and white patients—was noted among patients with early stage lung cancer, for which 76% of white patients and only 60% of black patients underwent surgical resection.”
- “The length of time between an abnormal screening mammogram and the follow-up diagnostic test to determine whether a woman has breast cancer is more than twice as long in Asian American, black, and Hispanic women as in white women.”[v]
Discrimination in Care:
Discrimination is a blatant problem. The American Cancer Society states: “Discrimination is another factor that contributes to racial/ethnic disparities in cancer mortality. Racial and ethnic minorities tend to receive lower-quality health care than whites even when insurance status, age, severity of disease, and health status are comparable.”
In addition to failing to receive appropriate preventive, diagnostic, and treatment modalities, “Racial/ethnic and socioeconomic disparities also exist in cancer survivorship care. Lack of access to survivor care services is a major barrier to the health and well-being of cancer survivors who lack health insurance or who experience exclusions or restrictions on their policies.,” according to an article appearing in the February 10, 2013, edition of the Journal of Clinical Oncology.
African American not only fail to receive optimal cancer care, but if they are fortunate enough to survive cancer, they likely won’t receive appropriate survivorship care. If they are unfortunate enough to succumb to the cancer, they almost certainly won’t be the beneficiary of hospice services.
A 10X Difference in Hospice Care:
According to data from the National Hospice and Palliative Care Organization, 81.5% of hospice patients were white and 8.6% were African American. That’s nearly a 10X difference! Yet, we know that hospice can make a tremendous difference in quality of life for end-stage cancer patients, as well as potential extend their survival. One could argue that some of the variation may be attributable to cultural differences in end-of-life care…but, again, I’m doubtful that tells the full story.
The facts regarding cancer prevalence and mortality amongst African Americans are black and white. The reasons behind them are shades of gray. If we are committed to an equitable health care system, it is our moral obligation not only to understand the causative factors behind the extraordinary differences in prevalence, care, and outcome, but to work assiduously to improve this situation.
IOM’s Call to Action:
“In 2000, the Institute of Medicine convened a special panel to examine the underlying causes of racial disparities in health. The resulting book, Unequal Treatment (2003), concluded that health and mortality disparities result from many factors, including lower quality of care provided to racial minorities. Other factors include lack of familiarity with racially diverse patients at hospitals and clinics, institutional discrimination based upon health insurance status, conscious and unconscious bias among physicians, lack of cultural competence among health care providers, and mistrust of the health care system as well as language barriers among patients.”[vi]
Stepping Up to the Plate:
What have we done in the intervening 14 years to improve the situation; and what are we doing today to honor our commitment and change the fate of African American cancer victims?
[i]Cancer Facts & Figures for African Americans, available online at cancer.org/statistics.
[ii]Cancer Facts & Figures for African Americans, available online at cancer.org/statistics.
[iv] ASCO Journal of Clinical Oncology. ASCO Special Article. Clinical Cancer Advances 2012: Annual Report on Progress Against Cancer From the American Society of Clinical Oncology. J clin Oncol 31:131-161.
[v] Agency for Healthcare Research and Quality, “Addressing Racial and Ethnic Disparities in Health Care,” last modified April 2013, http://www.ahrq.gov/research/findings/factsheets/minority/disparity/
[vi] Stand Up to Cancer – Racial Disparities in Cancer: Statistics and Solutions. http://www.standup2cancer.org/article_archive/view/racial_disparities_in_cancer_statistics_and_solution