Moving from theory to practice: A call to action on cancer disparities

Abstract

Cancer disparities among black individuals in the United States have been well described, and well known, since Congress commissioned a report on cancer incidence by race in 1950. 1 Blacks were thought to be more susceptible to infectious disease or trauma, and therefore not prone to the development of cancer, which was considered a disease of culture and civilization. To the surprise of the establishment, black individuals did develop cancer, and at disproportionate rates for certain malignancies such as cervical and prostate cancers. Since that time, multiple population-level studies have demonstrated persistent disparities between black and white individuals with regard to incidence and mortality for most cancers. Colorectal cancer (CRC) fits squarely in this space, because blacks have the highest incidence of CRC of any ethnic group in the United States, and death rates are reported to be 47% higher in black men and 34% higher in black women. 2 There are several factors that play a role in the disparities noted in CRC, including differences in screening rates, risk factors for the development of cancer, and receipt of treatment. In an analysis of the National Health Interview Study, Ahmed et al found that black individuals were 26% less likely to receive a recommendation for CRC screening, and Hispanics were 34% less likely. 3 Black women were at the highest risk of not receiving a screening recommendation, and were found to be approximately one-half as likely as black men to receive a recommendation. Importantly, only adjustment for educational attainment, not insurance status or access to usual source of care, was found to reduce the disparity to a nonsignificant difference. This highlights the importance of literacy-based interventions for improving screening behaviors.The disparity in CRC is not unusual because the literature reflects a similar trend in other screen-detected cancers. For example, black men have the highest mortality rate for prostate cancer of any racial or ethnic group in the United States at a rate that is 2.3 times higher than that reported in white men. 2 Despite this high-risk status, black men continue to be screened less often than white men, and are less likely to receive treatment after being diagnosed, regardless of disease risk stratification. 4,5 Similarly, black women have a 39% higher mortality rate from breast cancer compared with white women, with excess deaths on a state-to-state basis ranging from 20% in Nevada to 66% in Louisiana. 6 Despite screening mammography rates having improved over the past 2 decades, black women and uninsured women continue to have lower rates of use of mammography services. 7 Screening guidelines are quite clear (prostate cancer notwithstanding) with regard to whom screening should be offered. However, to my knowledge, nowhere in any guideline is there a provision for offering differential care based on race, insurance status, sex, or income. Yet in nearly every type of cancer, this is the case. This fact represents an abject failure of the med...