Disadvantaged Americans are far more likely to die of the most
treatable form of lung cancer--not because of their health habits,
but because they don't receive the proper treatment.
A University of Southern California expert on health-care delivery
has analyzed more than 5,000 cases of stage I non-small-cell lung
cancer in an attempt to explain why mortality is higher among
racial minorities and the socially disadvantaged than among higher-income
Americans and whites.
Howard P. Greenwald, PhD, found that surgery may have saved the
lives of nearly one in three patients whose cancer was detected
early enough. But the poorest patients were about a third less
likely to undergo surgery than the richest patients. Half (50%)
of the patients in the bottom 10% of income levels received surgical
treatment, as compared with nearly three-quarters (72%) of patients
in the top 10% of income levels.
Differences in mortality were even more dramatic: Only 22% of
the poorest survived for at least 5 years after diagnosis, whereas
45% of the richest patients survived for that length of time.
As a subset of the study group, African-American patients fared
even worse. At all economic levels, they had only a one in four
chance of surviving, compared to a one in three chance among white
Americans. Whereas 61% of white Americans underwent surgery, only
51% of African-Americans received that treatment.
Dr. Greenwald presented his findings at an American Cancer Society
conference in New Orleans. "In the form of lung cancer studied,
lack of appropriate care seems to have contributed strongly to
excess mortality among the disadvantaged" he said. "It
explains about 50% of the excess mortality in poor people and
all of the excess mortality in African-Americans."
Conventional wisdom has held that the disadvantaged are more likely
to die of cancer because of health habits. Studies have consistently
found that they are less likely to exercise or eat healthy diets
and more likely to smoke cigarettes than the affluent. Discrepancies
in survival rates between African-American and white patients
have been attributed to income differences.
"In the past, we've blamed the victims, but now it looks
like the problem may be that we have not been giving them adequate
treatment," Dr. Greenwald asserted. He contended that differences
in educational levels and access to health care might help explain
the discrepancies in surgery rates between rich and poor patients.
"The reasons for the race-based discrepancies are more subtle
and bear further research, he said. "They may have to do
with communication problems, suspicion, mistreatment or reluctance
to use a system where only about 3% of physicians are African-Americans."
Further study is needed to determine the impact of income and
of race on mortality from other cancers, Dr. Greenwald cautioned.
However, he does not believe his findings will be isolated to
non-small-cell lung cancer. "I would expect the findings
to be repeated in about 50% of cases, because that's the proportion
of cancers that are treatable when detected at early stages,"
he said. "These findings should wave a red flag."
Dr. Greenwald looked specifically at non-small-cell cancer because
it is treated only with surgery, making the effects of medical
intervention easier to track than with some other cancers. Moreover,
survival rates are high when surgical treatment is administered
in this cancer's earliest stage.
Dr. Greenwald studied 5,189 cases of non-small-cell lung cancer
diagnosed between 1978 and 1982 and documented by the National
Cancer Institute's Cancer Surveillance System. He ranked the cases
according to patients' economic levels. For each of 10 economic
levels, he then analyzed the death rates and the treatment that
patients received. In addition, he identified 855 African-Americans
in the study group and separately analyzed their mortality and
Dr. Greenwald, who is Professor of Public Administration at the
USC School of Public Administration's Sacramento Center, has written
extensively about socioeconomic factors and cancer. His current
and recent sources of funding include the US Department of Health
and Human Services, American Cancer Society, California Tobacco-Related
Disease Research Program, and W.K. Kellogg Foundation.