FRONTLINE CANCER: Reducing the disparities in cancer care
By Scott M. Lippman, M.D.
Cancer is a worldwide scourge. Every year, there are more than 14 million new cases and 8 million deaths. Heart disease is still the biggest killer in the United States, but cancer is expected to eventually supersede it. Indeed, cancer is already the leading cause of death in San Diego County.
And yet cancer — or rather the spectrum of diseases we collectively call cancer — is not uniform in its affliction. Different types affect different people differently. It’s obvious why women don’t get prostate cancer and breast cancer is comparatively rare among men. It’s less clear why some forms of brain cancer are more common in women or why tonsil and other forms of head and neck cancers are more prevalent among males.
Some reasons likely relate to differences in physiology and biology; others to cultural histories and social behaviors. And yet others to factors associated with poverty, low education and prejudice.
The last group of factors is arguably the most concerning because it is also the most tractable. Reducing cancer disparities is — or should be — as important and compelling as the overall drive to conquer cancer itself. It is part of the mission at the National Cancer Institute-designated UC San Diego Moores Cancer Center, one in which we have invested dedicated researchers, programs and funds.
These men and women are defining the challenge and marking a path to improvement. For example, a team of scientists recently looked at the impact of racial inequalities in the treatment of African-Americans for metastatic colorectal cancer. The team included principal investigator James D. Murphy, M.D., chief of the Gastrointestinal Tumor Service for Radiation Oncology at Moores and first author Daniel R. Simpson, M.D., in the Department of Radiation Medicine and Applied Sciences.
They found that African-Americans with metastatic colorectal cancer were measurably less likely to be seen by cancer specialists or receive advanced forms of treatment, resulting in a 15 percent higher mortality rate. Roughly 140,000 Americans are diagnosed annually with colorectal cancer, according to the American Cancer Society, and more than 50,000 will die this year. It’s the third leading cause of cancer death in the United States.
On the plus side, significant progress has been made in the prevention of colorectal cancer. On the negative, the benefits of screening and early detection have not been evenly distributed. Some populations, such as the uninsured, recent immigrants and some racial/ethnic minority groups, are particularly impacted. For example, the disease disproportionately affects black patients, who experience high incidence rates, more advanced stages at diagnosis and decreased survival rates compared to other ethnic groups.
In their study, published in the Journal of the National Cancer Institute, Murphy and colleagues found that black patients were 10 percent less likely to have primary tumor surgery, 17 percent less likely to receive chemotherapy and 30 percent less likely to receive radiotherapy. Among patients who got chemotherapy, they found white patients typically got it sooner and received more treatments than black patients. Timely chemotherapy reduces the risk of death from colorectal cancer more than 60 percent.
The authors concluded that almost half of the relative difference between the longer survival times of white patients compared to black was due to treatment differences. They did not offer a conclusion about the cause or causes for the racial disparity, but they did suggest possible explanations: conscious or unconscious bias by health providers, patient mistrust, health literacy, patient-
physician communication breakdown, barriers to access to health care and race- based differences in disease biology.
The Murphy study was followed by another JNCI paper by first author Samir Gupta, M.D., a board-certified gastroenterologist and GI cancer specialist in the UCSD Health System, senior study author Maria Elena Martinez, Ph.D., professor of family and preventive medicine and co-director of the Reducing Cancer Disparities program at Moores, and colleagues. They looked at the challenges of colorectal cancer screenings for the underserved and offered some possible solutions. Specifically, they advocate for promoting the message that “the best (screening) test is the one that gets done”; developing and implementing strategies to identify the neediest individuals; creating and implementing new, organized screening efforts and, of course, boosting the programs and funding that address these issues.
These recommendations may seem like obvious or simple solutions. They are not. They require increased and steadfast efforts by scientists, doctors and all others involved in battling cancers of all kinds. They require the will to prevail for the benefit of everyone.
— Scott M. Lippman, M.D., is director of UC San Diego Moores Cancer Center. His column on medical advances from the front lines of cancer research and care appears in the La Jolla Light the fourth Thursday of each month. You can reach Dr. Lippman at email@example.com
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