Creating a level playing field in the fight against cancer

Cancer disparities
Disparities in cancer risk, incidences and deaths among Americans span many racial, ethnic and socio-economic lines.

If you’re a black person in America, you are at a greater risk for many cancers than if you’re white. If you’re Hispanic and you were born in the United States, you’re more likely to develop breast, colorectal, prostate, lung or liver cancer than if you’re Hispanic and moved here from another country. If you’re a bisexual woman, you are at significantly higher risk for cancer than heterosexual women. Cancer death rates are also higher in rural areas than in urban areas.

Disparities in cancer risk, incidences and deaths among Americans span many racial, ethnic and socio-economic lines. And researchers are trying to understand the reasons for such cancer disparities and how they can be eliminated or reduced.

While black Americans aren’t the only people affected by cancer disparities, they have the highest death rate and shortest survival period for most cancers of any racial or ethnic group in the United States, Dr. Robert W. Carlson, chief executive officer of the National Comprehensive Cancer Network (NCCN), said in a June 2020 commentary in STAT, which covers health and medical topics.

People from lower socio-economic backgrounds and people of color are more likely to be diagnosed at an advanced stage of cancer and less likely to receive or complete treatment, the American Cancer Society says. Such statistics show that continuing cancer disparities are having a significant, negative impact on people in the affected populations. Poor health outcomes exist in marginalized populations, and they’re exaggerated or exacerbated by either not getting treatment or getting poor-quality treatment.

Examples of cancer disparities

The American Association for Cancer Research’s (AACR) 2020 Cancer Disparities Progress Report offers these examples of disparities at work in America:

  • Black men have a 111 percent higher risk of dying from prostate cancer compared to white men, while black women are 39 percent more likely to die from breast cancer than white women.
  • Hispanic adolescents are 38 percent more likely to develop leukemia than non-Hispanic white adolescents.
  • Bisexual women are 70 percent more likely to be diagnosed with cancer than heterosexual women.
  • Native American and Alaska Native adults are twice as likely to develop liver and bile duct cancers as white adults.
  • Asian and Pacific Islander adults are twice as likely to die from stomach cancer as white adults.
  • Men living in the poorest counties in the United States have a colorectal cancer death rate that’s 35 percent higher than for those living in the wealthiest counties.

Cancer disparity factors

The AACR report lists many factors that may affect disparities. They include:

  • Social, including education and income levels
  • Clinical, including access to health care, involvement in clinical studies and representation in the medical professions
  • Behavioral, including tobacco use, obesity and physical inactivity
  • Cultural, including health beliefs
  • Psychological, including stress and mental health
  • Environmental, including housing and transportation
  • Biological and genetic

As these factors show, an increased risk of cancer in some ethnic and racial groups frequently has nothing to do with genetics. For instance, the higher incidence of stomach cancer (gastric cancer) among Asians may be related more to their diets, especially ingredients that have been linked to the disease.

For Hispanics, cancer rates may increase the longer they stay in the United States, a 2016 study out of the University of Southern California suggests.

“Across the major cancers (breast, colorectal, prostate, lung, and liver) US-born Latinos have higher incidence and worse survival than foreign-born,” the study says. “Overall, the emerging picture is that lifestyle and behavioral factors preserved or fostered among Latino immigrants can lower cancer risk.”

A shortage of minority doctors

A key contributing factor to closing the health care disparity gap and improving treatment outcomes among minorities may be to increase cultural diversity among doctors. A study by the National Bureau of Economic Research suggests that African Americans would be more likely to agree to invasive preventative services if a black doctor recommended it. “Our findings suggest black doctors could reduce the black-white male gap in cardiovascular mortality by 19 percent,” the research paper says.

Another study stresses the need for minority doctors because evidence shows they’re more likely to practice in communities currently underserved by the health care industry.

“We find that minority and women physicians are much more likely to serve minority, poor, and Medicaid populations,” the report says.

African Americans make up 13 percent of the U.S. population, but they account for only about 5 percent of doctors. And while more women are currently enrolled in medicals schools than men, black females make up about 2 percent of the physician workforce.

“There aren’t many of us,” Anita Johnson, MD, Chief of Surgery and Leader of the Women’s Cancer Center at Cancer Treatment Centers of America® (CTCA), Atlanta, says during a recent interview on WABE, the public broadcasting radio station in Atlanta. .

Driven by her mother’s difficult health care challenges, Dr. Johnson says she knew since she was 8 years old that she wanted to be a doctor. And she encourages others to join the profession.

“You don’t want to spend your life not having your dream job,” she says. “I have a dream job. I get quite of bit of joy in my work.”

Not only should more minorities be encouraged to enter the medical profession, she says, but all doctors should be trained on strategies to connect with patients from diverse communities.

“Cultural sensitivity is a key,” she says. “In some cases, all physicians don’t get that training. So, when we are taking care of individuals, whether they are of African-American descent or Asian descent, sometimes the culture issue is significant, and we are challenged by that.” 

Clinical trial participation

A major impediment to eliminating cancer disparities is the low level of minority representation in clinical studies. This means fewer people in the at-risk populations have access to the groundbreaking cancer drugs that are being researched. Individuals with lower incomes also have less access to trials on these potentially life-saving drugs, since Medicaid in most states does not cover participation in clinical trials.

In addition, advances being made in precision medicine are less likely to benefit groups of people who have little or no representation among clinical trial participants, because researchers are not analyzing the differences in their genetic makeup. “It is increasingly clear that we have limited knowledge of the genetic mutations driving cancer in racial and ethnic minorities, which diminishes the potential of precision medicine in these populations,” the 2020 AACR report says.

A study discussed in the January 2021 issue of the Journal of General Internal Medicine concluded that minority patients were more likely to use genetic counseling or testing after they had been diagnosed with cancer, but they were less likely to seek such testing if the referral was based on a family history of cancer. This amounts to a “missed opportunity for mutation detection and cancer prevention,” the report says, adding that early access to genetic testing and guided cancer prevention strategies is needed to eliminate racial and ethnic disparities in cancer diagnosis and treatment.

Ending disparities

Cancer organizations know more work and research needs to be conducted before disparities can be eliminated.

The National Cancer Institute is funding the Breast Cancer Genetic Study in African-Ancestry Populations that’s looking at the genomes of 40,000 black women—half with breast cancer and half without—to identify genetic factors that may contribute to the disease. It will also compare the genomes to those of white women.

The RESPOND study, a joint effort of the National Institute of Health and the Prostate Cancer Foundation, is looking at prostate cancer development in black males to determine whether environmental and genetic factors account for the disease’s aggressive nature in that population.

Besides additional research, studies say it’s important for more physicians and researchers to come from diverse population groups because they’ll be more attuned to the needs in their communities—and more aware when those interests are being overlooked.

More work is also needed to improve access for people who may have difficulty connecting with cancer care providers.

Learn more about risk assessment and genetic testing for breast cancer.