Health-Care Disparities, Civil Rights, and Human Rights
With regard to cancer management, minority populations do not fare as well as the majority in the US health-care system. There is clear evidence of an increased incidence of cancer in minority populations, in many cases accompanied by reduced survival. Several factors appear to contribute to these differences, and the biomedical community has begun to focus on definining the scope of the problem and possible solutions. This review will address specific areas of disparity in cancer care, including prevention, diagnosis, treatment, and outcomes, and will consider steps toward resolving these issues.
In this issue of ONCOLOGY, Derek Raghavan outlines the reasons for and potential solutions to disparities in cancer outcomes in the United States. His discussion applies to health-care disparities in other diseases as well.
Some of the issues brought forth in this excellent review deserve reiteration. Black Americans have a shorter survival from diagnosis and higher mortality rates for almost all cancers compared to Americans of any other race or ethnicity.[1] It should not be forgotten that a large body of literature demonstrates that the poorincluding blacks, whites, and persons of other racesare less likely to receive optimal medical care, be it preventive, diagnostic, or therapeutic.[2] These "vulnerable populations" are also disproportionately exposed to the causes of disease. The NCI Surveillance, Epidemiology, and End Results (SEER) program has provided data showing that poor Americans have disparate health outcomes (shorter survival and higher mortality) compared to the middle class and well to do.[3]
Socioeconomic Perspective
We must not overemphasize biologic differences between the races as reasons for the disparities. Anthropologists generally agree that race is a sociopolitical categorization that is not rooted in science.[4] There are pharmacogenetic differences among different populations, when populations are defined by area of geographic origin, tribe, or even family. These pharmacogenetic differences rarely mean a particular drug or treatment ought not be administered for a specific disease. In landmark papers, Bach and colleagues[5] have catalogued disease by disease the literature to show that equal treatment yields equal outcome among the races in the treatment of cancer, and Shavers and Brown[2] detailed the data demonstrating that a large proportion of minority and poor patients receive less than optimal care when compared to nonminority patients.
The vulnerable population is large. Of 285 million Americans, 35 million (12%) are classified as poor. More than 44 million Americans have no health insurance. Many, but not all, live in poverty. Americans without health insurance include 20% of all blacks, 32% of all Hispanics, and 11% of all whites.[6] The absolute number of whites who are poor is larger than the black and Hispanic numbers combined. The same can be said for the absolute number of whites without health insurance. It might be more politically palatable and we might be able to persuade more Americans to support efforts to eliminate health disparities, if the problem is defined in socioeconomic terms instead of racial terms.
In many respects, access to America's health-care industry is segregated by socioeconomic status. Data demonstrate that once diagnosed and in the health-care system, these vulnerable populations often do not have access to or do not receive care from the specialists and the specialty institutions they need.[7] Today, many of our uninsured and poor are forced to obtain health care in institutions that cannot provide the highest quality care. Many of these "safety-net hospitals" are in financial extremis.
Medical Gluttony
The United States has the highest health-care expenditure in the world. It is indeed ironic that we live in a country where a large part of the population gets too little medical care and a large part consumes too much. America as a whole consumes substantial amounts of health-care resources that are unnecessary, often not evidence based, and sometimes even harmful. Such medical gluttony contributes to the disparities in health. We so often use new expensive medications when older cheaper ones would suffice. We indulge in unproven screening technologies when many cannot get those proven to save lives. A greater reliance on evidence-based medicine would decrease medical costs and waste.
This is not a call for socialized medicine. The solutions to disparate health care are far more complicated than simply the availability of low-cost high-quality care. Indeed, some of the best literature to show that the poor do not do as well as the wealthy comes from Scotland, a country with socialized medicine and very few nonwhite residents. The Scottish medical literature even demonstrates that poor women with breast cancer tend to present with more aggressive histologies compared to middle class and wealthier women.[8] These data strongly suggest that some of the biologic differences noted among blacks and whites in the US are likely due to extrinsic environmental influences associated with poverty and social deprivation rather than intrinsic differences. Could poverty be the reason that black women have a higher proportion of estrogen-receptor-negative breast cancers compared to whites?[9]
Important Questions
Physicians, health-care providers, and researchers must also ask, "Are we posing the right scientific questions?" Important questions for health-care researchers include:
• What are the elements of poverty that influence the experience of the cancer patient and influence cancer biology?
• How can we provide adequate high-quality care (to include preventive care) to those who so often have not received it?
The solutions are the responsibility of society as a whole to address and not just the medical community. They include educational efforts concerning diet, exercise, and other healthful behaviors.
Over the past decade, we have made tremendous strides in realizing and defining the problem of disparities in health care. It is an unsettling and embarrassing truth that we as a society have made only meager efforts to solve the problem. While disparities in health care are a civil rights issue, the ready availability of adequate health care is a human right.
Otis W. Brawley, MD
Disclosures:
The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article
References:
1. Ries LAG, Harkins D, Krapcho M, et al: SEER Cancer Statistics Review, 1975-2003. Bethesda, Md; National Cancer Institute; 2005. Available at http://seer.cancer.gov/csr/1975-2003. Accessed March 6, 2007.
2. Shavers VL, Brown ML: Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst 94:334-357, 2002
3. Singh GK, Miller BA, Hankey BF, et al: Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975-1999. NCI Cancer Surveillance Monograph Series, no. 4. NIH Publication no. 03-5417. Bethesda, Md; National Cancer Institute; 2006.
4. Brawley OW: Population categorization and cancer statistics. Cancer Metastasis Rev 22:11-19, 2003.
5. Bach PB, Schrag D, Brawley OW, et al: Survival of blacks and whites after a cancer diagnosis. JAMA 287:2106-2113, 2002.
6. Swan J, Breen N, Coates RJ, et al: Progress in cancer screening practices in the United States: Results from the 2000 National Health Interview Survey. Cancer 97:1528-1540, 2003.
7. Bach PB, Pham HH, Schrag D, et al: Primary care physicians who treat blacks and whites. N Engl J Med 351:575-584, 2004.
8. Thomson CS, Hole DJ, Twelves CJ, et al: Prognostic factors in women with breast cancer: Distribution by socioeconomic status and effect on differences in survival. J Epidemiol Community Health 55:308-315, 2001.
9. Gordon NH: Association of education and income with estrogen receptor status in primary breast cancer. Am J Epidemiol 142:796-803, 1995.
