IV. Who are these cancer treatments for?
“Social inequalities in health care, as in other aspects of social life, are structurally inherent to the capitalist economy” — M. Norman Oliver
Time and time again, it has been shown that non-white racial/ethnic groups, especially African Americans, suffer disproportionately from various cancers compared to non-Hispanic whites in the US, in terms of both incidence and mortality rates. African-Americans have the highest mortality rates across all races/ethnicities from lung, breast, prostate, colorectal, and cervical cancers. The incidence rates of these cancers remain disproportionately high in African-Americans compared to non-Hispanic whites, as well. Hispanics/Latinos, Asians/Pacific Islanders and indigenous populations suffer from higher stomach cancer incidence and mortality rates compared to their white counterparts. Overall breast cancer mortality rates for Native Hawaiians are the highest among all racial/ethnic groups.
It has “officially” been known since the 1980s that racial and ethnic disparities exist in the cancer burden. Such findings were supported by a 2003 followup report by the Institute of Medicine (IOM) that described health care disparities to emerge from complex interplay between economic, social and cultural factors. In the meantime, multiple government initiatives were launched to reduce such disparities — the Centers for Disease Control & Prevention (CDC) formed REACH and NBCCEDP in the 1990s, the NCI established the Center to Reduce Cancer Health Disparities in 2001, and the NIH created the National Center for Minority Health and Health Disparities (NCMHD) in 2000. Both public (Dept of Health & Human Services 2010 People Health Initiative) and private (American Cancer Society Challenge Goals 2015) programs made reducing these disparities primary priorities.
These disparities were originally attributed to a more advance stage at diagnosis and lack of screening in these non-white populations. However, adjustment for stage of cancer at diagnosis did not solve the discrepancies observed. Even as mammography screening for breast cancer became equivalent nationally among black and white women of all ages, these disparities persisted. This has been supported by epidemiology studies that suggest that disparities in outcome by race/ethnicity have not improved over time. In fact, between 1975–2000, disparity in death rates from all cancers combined between black and white, men and women, increased. While much of the blame was put on the differences in biology between races/ethnicities (e.g. — black women have a higher risk of developing a more aggressive form of breast cancer), it appeared that the racial gap in outcomes was prominent among breast cancers with good prognosis (hormone-receptor positive, multiple treatments available). This essentially led to the conclusion that “biological factors cannot explain all of the racial disparity in morbidity and mortality.”
Socioeconomic status (SES) has been used to explain such disparities in outcome since it influences risk factors such as tobacco use, poor dietary habits, sedentary lifestyles and obesity. Factors such as poverty, inadequate education, health insurance, access to healthcare, etc., were blamed as culprits for such disparities. Income determines health insurance coverage that influences access to appropriate early detection, treatment & palliative care. While these factors are important for explaining differences in morbidity, SES glosses over the racial component in disparities observed in cancer outcome since it focuses only on income and status — as MN Oliver describes “SES is not just a confounder of racial differences in health, but part of the causal pathway by which race affects health”. In fact, as the prominent scholar David R. Williams states, “race is an antecedent to and determinant of SES”, the fact that non-white populations experience greater poverty just shows the success of discriminatory policies in the US. The 2010 U.S. Census found that black populations are living in poorer quality housing, have higher exposures to toxins and pollutants in residential and occupational settings, and have less access to healthy food and quality healthcare — conditions that are cancer risk factors, or as more eloquently put by Dr. Sameul Brodar, NCI Director (1991), “poverty is a carcinogen”.
Consider this — racial/ethnic minorities consistently receive proper cancer treatment less frequently, such as surgical resection for lung and colorectal cancers, radiation therapy after breast conservation surgery for breast cancer. Black women are 4–5x more likely to experience treatment delays and less likely to receive cancer-directed therapy for breast cancer, even when they have similar tumors to those in white women. Black and Hispanic women suffer more often from inadequate pain management; between 90–91, data from outpatient centers that treated predominantly minority patients show that these patients were 3x more likely to have inadequate pain management compared to patients seen elsewhere. Minority patients face discrimination in the clinic in the form of physician bias, whether it is intentional or unconscious. Black women were not given proper referrals or recommendations for mammograms, black men diagnosed with prostate cancer are more likely to be treated by inexperienced surgeons, black patients with rectal cancers are less likely to receive adjuvant (early stage) therapy. All this evidence points to the fact that structural racism is pervasive in health care today, or else how does one explain the recent finding that 50% white medical students and residents have misconceptions about the biology of black people? Or the findings that patients across race/ethnicity, when treated equally regardless of SES, have equal outcomes?
