The 2005 National Health Disparities Report found disparities related to race, ethnicity, and socioeconomic status in the United States health-care system. While varying in magnitude, disparities were observed in almost all aspects of health care including cancer. Disparities were noted across quality and access to health care, levels and types of health care, various health-care settings, and within many subpopulations. In this review, we explore the disparities in cancer care among racial and ethnic minorities. In particular we consider numerous factors that may influence health care for racial and ethnic minority groups including socioeconomic issues, access, cultural beliefs, risk factors, and comorbidities. Although there are extensive confounding factors that vary with each subgroup, trends that may help individual practitioners better understand this complex issue become evident through closer evaluation of available data.
Kolb and colleagues present an overview of a vast and complex subject-the disparities in cancer care among racial and ethnic minorities in the United States. Minority health and health disparities have been of interest in this country due to increasing appreciation of (and concern about) differences in cancer outcome. Indeed, there are distinct racial and ethnic differences in cancer incidence and mortality. A significant reason for these disparities is the fact that there are differences in the amount and quality of both preventive and treatment services that some populations receive.
Comparison of cancer incidence and mortality rates is the most accurate way to measure the burden of cancer and detect population disparities. In general, black Americans have cancer incidence and mortality rates higher than whites, and whites have rates higher than Hispanics. Over time, Hispanic rates are expected to rise. Survival statistics, especially 5-year survival rates, are not good measures of cancer burden disparities between populations. While there are often differences in cancer survival, lead time biases associated with the differences in screening rates and earlier diagnosis skew survival statistics.
Populations can be defined by race or ethnicity; they can also be defined by socioeconomic status. The Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI) has demonstrated that residents of poorer areas of the United States tend to present with more advanced-stage disease and have increased rates of most cancers. Residents of poorer areas also have higher mortality rates from virtually every cancer. Even within racial groups, the poor have worse outcomes compared to the wealthy. Poor whites do worse than wealthier whites, poor blacks do worse than wealthier blacks, and poor Hispanics do worse than wealthier Hispanics. As director of the NCI in the early 1990s, Sam Broder said, "Poverty is a carcinogen." Minorities (both Hispanics and blacks) are disproportionately poor compared to whites. It is worth noting that the absolute number of poor whites is larger than the absolute number of poor blacks and Hispanics combined.
Breast Cancer Data
The authors of this review frequently use breast cancer as an example. This is appropriate, as more is understood about breast cancer disparities than any other disease. Breast cancer is unusual among other cancers in that the incidence among white women is higher than that among black women, yet the black mortality rate is higher than that of whites. Breast cancer incidence among whites may be more than incidence among blacks due to differences in socioeconomic status and behaviors associated with socioeconomic status. Compared to blacks, a larger proportion of whites have certain breast cancer risk factors. An increased proportion of whites have a first live birth after age 30, disproportionately greater use of oral contraceptives, and disproportionately greater use of hormone replacement therapy. These habits or lifestyle choices may increase the risk of less aggressive, more treatable low-grade breast cancers.
On the other hand, dramatic increases in the proportion of black women who have significant weight gain over the past 30 years may mean that an increasing proportion of black women have acquired a greater risk for more aggressive breast cancer. This may be the reason for the rising breast cancer mortality rates among blacks in the late 1980s and early 1990s. The prevalence of black women with higher body mass index outpaced the increase among white women over the past 30 years. Among women, weight gain has been associated with an increased risk for breast cancer and an increased risk for higher grade, more aggressive breast cancer.
Weight gain is also associated with increased risks of diabetes mellitus, hypertension, and cardiac disease. These are significant comorbid disease factors that interfere with the provision of adequate high-quality cancer care. Evidence suggests that weight gain is associated with the development of prostate cancer and other cancers among all races. There is also evidence that increased weight gain is a complicating factor in the care of Hispanic-Americans.
In some cancers, evidence suggests that poverty is correlated with the presentation of more aggressive disease within a given stage. The poor tend to present with more advanced disease, and presentation is delayed after appreciation of symptoms. Of course, higher-grade and more advanced cancer portends disease that is less likely to be effectively treated.
Some have called for increased accrual of minorities to clinical trials and suggested that this might help find treatments for diseases frequently seen in minorities. Reviews have demonstrated that, with few exceptions, equal treatment yields equal outcome among equal patients. Race or ethnicity is not a factor in outcome, although pertinent molecular markers with differing racial/ethnic prevalences can be. Shavers and Brown have published a wonderful review demonstrating that treatment is not equal among the races. Indeed, they cite evidence for significantly disparate treatment patterns in a number of diseases.
The authors correctly point out that cultural differences in the acceptance of therapy and a misunderstanding of cancer biology and principles of medical treatment are common reasons that optimal therapy is refused. We believe that health-care providers do not need to be of the same race as the patient, but do need to be sensitive to the needs, fears, and concerns of the patient (and open to dealing with those needs, fears, and concerns).
Another factor that must be considered beyond the availability of good health care is the lack of convenience of therapy. Even when therapy is available, it may be refused or underutilized if it is inconvenient. We are personally aware of women with limited-stage breast cancer walking out on therapy at an indigent care facility, because they found that obtaining care was unpleasant. They had long waits for surgery and frequent postponements of scheduled procedures.
Several years ago, the federal government initiated a major effort to define the reasons why people are medically underserved. Many of us who worked on that project quickly realized that "the underserved are underserved because they are underserved, and the solution is to get them service." A major effort in minority health and health disparities research must be to determine how we can provide adequate high-quality care to populations that so often have not received it, regardless of race/ethnicity or socioeconomic status.
-Otis W. Brawley, MD
-Mitchell Berger, MD, MMM, CPE
The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
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