Talk to those who treat and study cancer, and you hear about progress in research and treatment. But there is a stubborn exception to the good news: the persistently higher cancer rates for African-Americans. In advance of a Zócalo event that examines this disparity, we asked public health experts: What, if anything, do you think would reduce the high cancer fatality rate of African-Americans to that of white Americans?
Michelle A. Gourdine
We need to know much more about this and other disparities, many of which we cannot yet fully explain
African-Americans have higher cancer death rates than whites, and the oft-cited reasons for this disparity—poverty, lack of health insurance, and no regular source of medical care—are less than satisfying.
To be sure, African-Americans are disproportionately poor and uninsured, and are more likely to live in segregated neighborhoods with fewer doctors. This inequality must be rectified. But for the sake of the significant segment of the black population who has a doctor and is neither poor nor uninsured, we must look beyond poverty and access to understand fully why African-Americans get sicker and die younger.
Take breast cancer, for example. Although black and white women get mammograms at equal rates, black women are more likely to be diagnosed in later, less curable stages of the disease and more likely to be diagnosed with triple negative breast tumors (a highly aggressive form of the disease that does not respond well to standard treatment). But we still don’t know why. We also have not fully explained the fact that although black women overall are less likely to be diagnosed with breast cancer, those under the age of 40 are more likely to be diagnosed than white women. It seems unlikely that the new mammography guidelines (which delay a woman’s first mammogram until age 50) took these facts into account. Until African-Americans are proportionately represented in the studies upon which cancer screening and treatment recommendations are based, we will not be certain that they are appropriately tailored to the unique risks of African-Americans.
We must explore more thoroughly the unique biological, emotional, and cultural factors that influence how African-Americans of all socioeconomic levels cope with cancer, interact with the medical system, and respond to treatment. When we assume that the poor health of African-Americans is primarily related to poverty and lack of access to healthcare, we run the risk of ignoring other crucial factors. Once we improve our knowledge base, we can reduce the high cancer fatality rate of African-Americans.
This dilemma requires a multifaceted solution. Why wouldn’t it? The factors that contribute to disparities in cancer deaths are equally complex and variable, differing by cancer type, access to care, and economic status.
Foremost, a strategic plan to control cancer, particularly among low-income and medically underserved minority populations, is the most important part of such a solution. But it’s easier to develop a plan than to follow through on it. As in many states, the District of Columbia has a comprehensive cancer control plan. However, the capital city’s plan has no sustained source of funding to reduce the highest cancer death rate gap between blacks and whites.
While awareness and outreach efforts in black communities must continue, healthcare systems also must apply proven strategies to detect cancerous tumors at earlier stages. Studies presented to members of our D.C. Cancer Consortium clearly indicate blacks are diagnosed at later stages than whites—especially for preventable cancers such as colorectal and tobacco-related cancers.
If we can discourage black youth between the ages of 15 and 21 from starting to smoke, we will likely see a drop in lung and tobacco-related cancers in their cohort over the long run. The Surgeon General’s most recent report emphasized that the most cost-effective smoking cessation strategy is to discourage youth from starting. Colorectal cancer death rates likely will decline as a result of colonoscopies, starting at age 50. Our Consortium’s D.C. Screen for Life grant—which enabled healthcare partners to provide free colonoscopies for under-insured and uninsured D.C. residents who were 50 and older—demonstrated that detection and removal of polyps and adenomas before they become cancerous save lives.
Breast and prostate cancer also take a disproportionate death toll on blacks. In Washington, mammogram rates for low-income black women are high. Yet, breast cancer death rates for black women far outpace those for white women. The same was true for black men regarding prostate cancer screening and treatment.
We must find ways to reduce the time between cancer diagnosis and active treatment for low-income blacks, regardless of cancer type. In many lower-income communities, there are fewer oncologists who treat Medicaid patients, in part, because of low reimbursement rates.
We know the problem and we know the tools needed to address the issues are available. All stakeholders must work together to ease the burden of cancer in black communities.
To reduce disparities in cancer outcomes for African-Americans—indeed to eliminate all health disparities—the healthcare system must improve the quality of healthcare delivered to all populations.
“Finding Answers: Disparities Research for Change,” a national program of the Robert Wood Johnson Foundation based at the University of Chicago, has been working since 2005 to research what works to eliminate racial and ethnic disparities in healthcare. Based on research and systematic reviews of published research, we developed the Roadmap to Reduce Disparities.
The Roadmap is a six-step framework for reducing racial and ethnic disparities in care and fostering health equity. The Roadmap, available online at http://solvingdisparities.org/tools/roadmap/, focuses on concrete steps that doctors and clinics can do to make sure that they deliver high-quality, equitable care. Among them :
1. Linking Quality and Equity;
Recognize equity as a fundamental component of quality. Then integrate efforts to reduce disparities into routine quality improvement efforts.
2. Creating a Culture of Equity;
Foster change in the organizational culture to support the inclusion of equity as an overarching goal.
3. Diagnosing the Disparity;
Identify the root causes of disparities and prioritize which issues to address.
4. Designing the Activity;
Plan disparities-reduction programs that capitalize on the organization’s available resources and are tailored to the needs of a specific patient population.
There are no magic bullets to eliminating disparities, but successful disparities interventions tend to focus on family and community factors, address multiple levels of the healthcare system, are culturally relevant, involve team-based care, and focus on interactive skills-based education.
Prostate cancer remains the most commonly diagnosed cancer among men in America. Even with the recent decline in the overall death rates, African-American men are still three times more likely to die from prostate cancer than their Caucasian counterparts. The numbers are even more striking for men under the age of 65 years.
There is clear evidence that high-risk populations, which include African-American men, benefit from early detection strategies such as PSA testing (despite efforts by the U.S. Preventive Services Task Force to question and limit early detection). Studies show that early detection not only reduces the risk from dying of prostate cancer but also reduces the tragic consequences of incurable, disabling metastatic disease (when the cancer has spread); this metastasis is four times more likely to happen to African-American men. The bottom line is that African-American men over 40 years of age should have a conversation with their healthcare provider to understand the details of the PSA test, its value, and possible limitations.
In the past 20 years, advances in screening and treatments have decreased breast cancer death rates for U.S. women. Nevertheless, black women have the highest death rates of all racial and ethnic groups and are 40 percent more likely to die of breast cancer than white women.
Why? The disparity may be attributed, in part, to black women having more aggressive cancers and fewer social and economic resources. Also, not all women receive adequate follow-up (after abnormal screening tests) and treatment (after diagnosis for breast cancer).
While black and white women reported being screened for breast cancer at the same rates in 2010, more black women are found to have breast cancer that has spread beyond the breast (45 percent) compared with white women (35 percent). Black women get follow-up care later than white women. Waiting longer for follow-up care may lead to cancers that are harder to treat.
After cancer is found, treatment should start as soon as possible. Fewer black women receive the surgery, radiation, and hormone treatments they need compared to white women.
Culturally appropriate, community-driven programs are also critically important to eliminating racial and ethnic disparities in health.
“As I speak to African-American communities about health disparities, I find that the word ‘cancer’ still strikes fear in the hearts of people,” says my CDC colleague Dr. Leandris Liburd, who directs the Office of Minority Health and Health Equity. “We must work with communities to overcome the fear of cancer and the possibility of a cancer diagnosis if we are going to be successful in reducing cancer death rates experienced by African-American women. Fear can lead to the denial of symptoms, late diagnoses, and the need for more aggressive treatment when cancer is found. There is more power in knowing than not knowing!”
More research is needed to determine the best screening and treatment strategies for aggressive breast cancers. Optimal healthcare delivery can be strengthened through performance-based reimbursement, expanded use of information technology, and quality assurance-reporting protocols. More work also is needed to develop, evaluate, and disseminate additional interventions to decrease inequities in follow-up after an abnormal mammogram and receipt of treatment.
Only when every woman receives adequate screening, timely follow-up, and high quality treatment will the full benefit of breast cancer screening be achieved.