While the overall death rate for cancer continues to drop among African Americans, the group continues to have higher death rates and shorter survival of any racial and ethnic group in the U.S. for most cancers. The findings come from Cancer Facts & Figures for African Americans 2011-2012, the latest edition of a report produced every two years by the American Cancer Society.
The higher overall cancer death rate among African Americans is due largely to higher mortality rates from breast and colorectal cancers in women and higher mortality rates from prostate, lung, and colorectal cancers in men. In recent years, death rates for lung and other smoking-related cancers and for prostate cancer have decreased faster in African American men than white men, leading to a narrowing of the gap in overall cancer death rates. Notably, lung cancer death rates for young African Americans and whites have converged in both men and women. In contrast, the racial disparity has continued to increase in recent years for colorectal cancer in both men and women and for breast cancer in women, cancers for which progress has been made through screening and improvements in treatment.
“While the factors behind these racial disparities are multifaceted, there is little doubt socioeconomic status plays a critical role,” said Otis W. Brawley, M.D., American Cancer Society chief medical officer. “African Americans are disproportionately represented in lower socioeconomic groups. For most cancers, the lower the socioeconomic status, the higher the risk. It’s important to note as well that the factors associated with socioeconomic status contribute to substantial differences in cancer incidence and mortality within racial and ethnic groups as well. People with lower socioeconomic status have higher cancer death rates, regardless of demographic factors such as race/ethnicity.”
Highlights from the report include:
- About 168,900 new cancer cases and 65,540 cancer deaths are expected among African Americans in 2011.
- The most commonly diagnosed cancers among African American men are prostate (40% of all cancers), lung (15%), and colon and rectum (9%). Among African American women, the most common cancers are breast (34% of all cancers), lung (13%), and colon and rectum (11%).
- Lung cancer accounts for the largest number of cancer deaths among both men (29% of all cancer deaths) and women (22%), followed by prostate cancer in men (16%) and breast cancer in women (19%). For African American men and women, cancers of the colon and rectum and pancreas are expected to rank third and fourth, respectively, as the leading sites for cancer deaths.
- Although the overall racial disparity in cancer death rates has decreased, in 2007, the death rate for all cancers combined continued to be 32% higher in African American men and 16% higher in African American women than in white men and women, respectively.
- The use of colorectal screening tests among African Americans has continued to increase over the last two decades, but remains lower than whites (49% having reported a recent test compared to 56% in whites).
- About half (52%) of African American women aged 40 and older reported having a mammogram within the past year, slightly less than whites (54%).
- African American women and teen girls have the highest rates of obesity in the US. According to the most recent data (2007-2008) from the National Health and Nutrition Examination Survey, half of African American women and nearly 1 in 3 African American teen girls are obese. Obesity increases the risk of many cancers, including cancers of the breast (in postmenopausal women), colon, endometrium, kidney, and adenocarcinoma of the esophagus.
- According the National Health Interview Survey, in 2008 almost half of African American adults reported no leisure-time physical activity compared to about one in three whites.
- African American boys and girls, among whom smoking rates have been decreasing since the late 1990s, have lower smoking rates than any other racial/ethnic group.
While improvements for some cancers are encouraging, the overall disparity in cancer mortality is a troubling sign. And for breast cancer, in particular, recent trends indicate a growing disparity. Prior to 1980, breast cancer was both more common and more lethal among white women compared to black women. After 1980, breast cancer incidence remained higher among white women, but mortality in this group began to decline. Among black women, the mortality rate did not begin to decline until approximately 1990. While the death rate is now decreasing in both groups, it has fallen faster among white women, resulting in a widening racial gap. A racial difference of 5.0 deaths per 100,000 in 1990 became a difference of 9.5 deaths per 100,000 in 2005.
According to available data, black women diagnosed with breast cancer will die three years sooner than white women who receive a similar diagnosis. And “some research suggests that institutions providing mammograms mainly to black patients miss as many as half of breast cancers compared with the expected detection rates at academic hospitals,” according to a recent article in the New York Times.
Similar gaps exist for non-cancer deaths as well, including those from heart disease, stroke, diabetes, pneumonia, kidney disease, and sepsis. Considering deaths from all causes, blacks have a 30% higher age-adjusted mortality rate than whites.
In 2000, the Institute of Medicine convened a special panel to examine the underlying causes of racial disparities in health. The resulting book, Unequal Treatment (2003), concluded that health and mortality disparities result from many factors, including lower quality of care provided to racial minorities. Other factors include lack of familiarity with racially diverse patients at hospitals and clinics, institutional discrimination based upon health insurance status, conscious and unconscious racial bias among physicians, lack of cultural competence among health care providers, and mistrust of the health care system as well as language barriers among patients.
Physicians and public health advocates working to bridge the racial gap point to longstanding economic disparities that disproportionately impact black women and a legacy of racial discrimination within the American medical establishment as among the most entrenched causes of the disparity in breast cancer mortality. These factors were highlighted in the New York Times article quoted above. Access to affordable healthcare and delayed treatment — often as a result of not being able to take time off work and other barriers to timely medical care — were also a major factor, according to the Times. The article points out that African American women are substantially more likely to be diagnosed with later-stage breast cancer than White women:
Black women often arrive at the hospital with cancers so advanced, they rival the late-stage disease that doctors see among women in developing nations. A study based on Medicare records published in July in JAMA, the Journal of the American Medical Association, found that 20 percent of African-American women with breast cancer did not learn of their disease until it had advanced to Stage 3 or 4. By comparison, only 11 percent of white women learn at late stages.
According to Tara Parker-Pope, the author of the New York Times article, disparities in diagnosis are not all attributable to lower screening rates among African American women — even when they are screened, doctors are more likely to miss cancerous tumors in African American patients.
…[r]esearchers at the Methodist system analyzed their records of breast cancer patients and discovered that even in what is widely viewed as the top hospital system in the region, black patients took on average about a month longer to begin treatment after diagnosis compared with white patients.
As one breast cancer survivor told the Times, it wasn’t until she was diagnosed with cancer that she was finally able to access health insurance. “I had to get cancer to get health insurance,” Mary Singleton told the Times. “I’ve been one of those people waiting for Obamacare, waiting for health insurance. And this is how I finally get it.”
Many African American women are challenging the systemic inequality that leaves their communities vulnerable, as Debra Reid, who was recently diagnosed with stage 3 breast cancer, told the Times.
“I revealed my breast so they could see it,” she said of a recent breast cancer education event at her church. “It was swollen. I made them touch it. It shocked them. Out of 21 people with me that night, 15 have already had mammograms, and others have them scheduled.”
But it’s not just about raising awareness, it’s about changing the system that allows for such disparities to persist, she added. “A lot of us don’t have insurance. And without insurance, a lot of stuff goes undetected.”
Lack of health insurance was by far the most common barrier to timely care discussed by low-income women in the article. This problem could be nearly eradicated with full expansion of Medicaid in all 50 states, but as of today, GOP governors in more than 20 states are refusing to expand the program. If all governors accepted the expansion, an additional 5-6 million low-income Americans would gain insurance coverage immediately. While Americans of all races and ethnicities will suffer from the GOP’s staunch opposition to health care reform, research shows that low-income minorities will get hit the hardest. Even more troubling, most of the states where people struggle the most to afford health care are not expanding Medicaid.
Racial disparities in health are an undoubtedly complex problem to solve — but when we have solutions right in front of us, as we do with the Medicaid expansion, rejecting them is simply incomprehensible.
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