NEWS

Racial Gaps in Cancer Survival — Asking the Wrong Questions?

Bob Kuska

A landmark 1973 study showed for the first time an "alarming increase" in the number of American blacks dying from cancer. Today, nearly 30 years later, experts say the alarm bells continue to sound unabated.

One reason the problem persists is its sheer complexity. Black healthcare topics often extend far beyond medicine, intertwining with thorny social issues, such as education, economics, culture, and racism.

Although the lion's share of the biomedical research in this area over the last two decades has focused on identifying inequities among the races within the U.S. healthcare system, future work may begin to ask why these inequities exist.

According to Otis Brawley, M.D., who heads the National Cancer Institute's Office of Special Populations Research, only by determining the source of these barriers can they be removed and the plight of African Americans with cancer be improved.



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Dr. Otis Brawley

 
"I think we've been asking the wrong questions," said Brawley whose editorial on this topic appears in this issue of the Journal (p. 1908). "In the meantime, people continue to die. We need to sit down and finally focus in on what are the critical, truly important questions about African-American and minority health."

Tough Sell

As many people have noted over the years, virtually all races and ethnic groups in America benefit, either directly or indirectly, from the National Institutes of Health's support of the biomedical sciences.

It is the other part of the minority research equation — healthcare delivery — where critics contend the NIH machine bogs down. Some say that grant proposals that touch on issues such as access to treatment often face a tough sell. "They face a horrible sell," said Lovell A. Jones, Ph.D., a scientist at the University of Texas M. D. Anderson Cancer Center in Houston. "You always have the debate about whether this is really research or whether it is a social issue that another government agency should fund."



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Dr. Lovell A. Jones

 
Mack Roach III, M.D., a radiation oncologist at the University of California San Francisco School of Medicine, said the peer-review problem in minority health extends to most medical journals. "A lot of people who are reviewing the papers don't have the background to understand the big picture," he said. "So, how can you expect them to do the right thing? The published literature perpetuates misleading information."

Over the last two decades, Brawley said, scientists have hammered home again and again two general themes: Blacks tend not to have equal access to quality cancer care in the United States; but, when African Americans and whites are afforded the same quality of treatment, mortality rates tend to be roughly the same between the races. The implication being — get rid of the healthcare obstacles, and mortality rates for black cancer patients will plummet.

But, as Brawley noted, where the research runs out of gas is in taking the next logical step: explaining why the obstacles exist. "What we need are surveys of how a population of 1,000 black women diagnosed, say, with breast cancer are treated in their first year," he said. "We need interviews with patients and doctors to determine why the treatments were as they were. No one is doing those types of studies in an organized way."

Full Court Press

To move forward with these more targeted studies, Brawley said he thinks the NIH peer review process needs to be tweaked, not dynamited. "The system as it is currently structured is fine," he said. "It's the attitudes and professional prejudices of the people who populate that system that need to be changed. We need to insert some health services researchers into peer review positions and review groups."

But others have suggested going the next step: launching a special initiative on African-American and minority cancer care. They say the subject is so terribly complex that rather than sprinkling a few research grants here and there, a more coordinated approach might be the most direct route toward improving cancer care for American minorities.

"It is time to document in a systematic way why there are differences in access and what the nature of the differences are," said Claudia Baquet, M.D., associate dean of the University of Maryland School of Medicine in Baltimore.



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Dr. Claudia Baquet

 
Baquet and others are quick to note that many black cancer patients, particularly those who are lower income, face healthcare problems that extend far beyond questions of access. These hurdles include basic issues such as transportation, poverty, and a cultural distrust of doctors.

Another perplexing factor is determining why some doctors often fail to provide prompt or appropriate treatment to black cancer patients, regardless of their socioeconomic status. Brawley said one of many possible explanations is African-American cancer patients also have high rates of hypertension, diabetes, kidney disease, and other chronic conditions. He said it may be that in some cases doctors choose not to aggressively treat black patients because they do not seem to be good candidates for the rigors of surgery or chemotherapy.

False Assumptions

"A lot of people get hung up on access," said Brawley. "They assume that because a person can go to the doctor or a person does get medical treatment that they get good medical care. That is frequently a false assumption."

Another false assumption is that blacks are biologically different from whites. Studies continue to trickle into the medical literature suggesting that being black is a poor prognostic factor in cancer treatment, breathing life into the old notion that therapies that work for one race will not work for the other.

"I think the first thing that we need to do is recognize that the differences in mortality rates among the races is unlikely to be due to genetic causes," said Roach. "I think it needs to be said loud and clear."

Roach's point agrees with the current consensus in genetic epidemiology. "Most human genetic variation antedates the migration of modern humans out of Africa," Kelly Owens, Ph.D., and Mary-Claire King, Ph.D., both of the University of Washington in Seattle, wrote in a recent viewpoint article in Science. "The possibility that human history has been characterized by genetically relatively homogenous groups (‘races'), distinguished by major biological differences, is not consistent with genetic evidence."

Many say that in the future, scientists must stop lumping blacks together as one big genetic family and recognize that the black population in the United States is as ethnically diverse as the majority white population. It is estimated that at least half of African Americans have Native American ancestry and more than three-fourths have a white European relative rooted somewhere in their family tree. In addition, the United States has large and growing Carribean and African-immigrant populations.

Myriad Subpopulations

Jones and others said they look to NIH to move forward and genetically define the myriad African-American subpopulations. He said such studies will be critical to improving cancer care for the race. He noted, for instance, that breast cancer often strikes African-American women earlier than white women, a finding that superficially suggests a biological difference. Jones said, based on the current state of the science, it is impossible to know whether early onset breast cancer affects a large subpopulation of women rather than the entire race.

"We need to solve this problem before we actually get clear and defined data," he said. "Otherwise, we're always going to be out there on a limb talking about who's what and confusing the issue of culture, poverty, and ethnic background."

With a new millennium just around the corner, all experts agree that African-American and minority health should become a greater priority in American healthcare. "That's the key," said Baquet.

As Jones noted, "The population demographics are changing in America. It's like being in a boat and noticing a hole down at the other end and saying, ‘It doesn't affect me.' Well, of course it does."



             
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