No diagnosis is more feared than the diagnosis of cancer. For many patients the word still implies certain and imminent death.
This year brought welcome news to the war on cancer. For the first time in modern medical history the overall age-adjusted death rate for all cancer declined for a sustained period.1 This story made headlines in the Florida Times Union and other news venues throughout the nation. There was a disturbing side story in the Times Union article, however, that may be just as important to Jacksonville. Further back on page 11 or 12 without a headline or any call to attention was another fact: The Age Adjusted Death Rate (AADR) for all cancers in African-Americans has decreased only slightly, and has actually increased for several common cancers. The overall cancer incidence in African-American males has actually increased.1
There is a disturbing, unexplained and widening gap in AADRs for cancer between African Americans and white Americans. This has been the topic of intense debate and there is a commitment at many levels to reduce this gap.2,3,4
In Jacksonville and Northeast Florida this gap in mortality became one important subject of the "Cancer Plan Development Workgroup" of the Health Planning Council of Northeast Florida. While looking at several years of cancer statistics for Northeast Florida, the racial disparity was compelling. The task force was overwhelmed by the statistics that the AADR for cancer is 15% higher in African-American women; the overall cancer AADR for African-American males is 50% higher than white males; and the combined overall cancer AADR (in spite of lower lung cancer death rates) is 27% higher for African-Americans compared to whites (Table 1).4
It was equally obvious that cancers detected in African-Americans are detected by and large at a much later stage. For example, in Duval County the proportion of "Stage III" prostate cancer at the time of diagnosis is double for African-Americans compared to whites. The proportion of "Stage III" breast cancer at the time of diagnosis is two and a half times greater in African-Americans than in whites; the proportion of "Stage III" colon cancer at the time of diagnosis for African-American men is double that for white men. For some reason this disparity in late diagnosis of colon cancer did not occur for women (Table 2).4 These statistics, combined with the fact that African-Americans comprise nearly one third of Jacksonville's population, led the Cancer Committee to an important conclusion: the first priority in our plan to further reduce cancer death rates and morbidity in Northeast Florida must be the priority of addressing racial disparities. The remainder of this paper will address why racial disparities exist and what might be done to eliminate them.
Differences in stage at diagnosis are important. As physicians, we know that death from cancer is not certain and that the difference between life and death is often determined by the stage of diagnosis. Stage at diagnosis is, in turn, often influenced by how the cancer was detected. In general, cancers detected by routine screenings are more likely to be cured than those diagnosed after symptoms develop. Many cancers are in fact "preventable" through early detection of a "precancerous" or "premalignant" lesion.
Tables 1 and 2 demonstrate two things: 1) cancers in African-Americans are diagnosed at a later stage; and 2) the AARDs for African-Americans are much higher. While there is no necessary "cause and effect" relationship between these two facts, it can be reasonably hypothesized that late diagnosis is, in part, responsible for excess mortality. For purposes of impacting the gap in cancer mortality, it is obvious that the first place to implement changes is at the level of the gap in early detection. Early detection means screening.
The medical literature contains no definitive answer to this question. However several facts do serve to illuminate the issue. First of all, African-Americans are screened by mammography in Florida less often than similar aged white Floridians.5 The reasons for the lower rate of screening mammography are not clear, but it is reasonable to suspect that lower rates of mammography are paralleled by lower rates of other screening activities. In fact, there is some evidence to support this.6
Why are screening rates lower? Access, meaning insurance coverage, is part of the answer. African-Americans are more often in socioeconomic groups that lack insurance to cover cancer prevention and screening services. African-Americans are also more likely to be uninsured than white Americans.7
Another potentially important group of factors are cultural barriers to prevention, screening and early treatment of cancer in African-Americans. These include real or perceived lack of culturally sensitive providers, appropriate geographic locations of providers, and attitudes of providers that place less emphasis on aggressive screening and treatment in minority populations.
There may be other individual and social behaviors among African-Americans that lead to differences in stage at diagnosis. For example, the number of visits to primary care providers, frequency of health screening activities, and self-exam activities may differ independently of access. This area needs further research.
Certain risk factors for cancer incidence are known to affect African-Americans disproportionately, such as high animal fat and low fiber diets. Other risk factors such as alcohol consumption and workplace exposures may prove to be disproportionate in distribution among racial groups and needs further research.
The main risk factor for cancer (smoking) is currently lower in African-Americans, particularly women. This tends to mute the overall excess cancer mortality by lowering lung cancer death rates for African-Americans. However, this protection is diminishing as rates of smoking between African-Americans and whites is equalizing.
Additionally, there may be biologic differences in cancer development among racial and ethnic groups. For example, African-American women who develop breast cancer have a higher incidence of tumors that are estrogen-receptor negative.8 Prostate cancer in African-Americans tends to occur earlier and act more aggressively than prostate cancer in white men.9 Again, this area needs extensive research.
The Clinton Administration has vowed to move quickly to close the gap in cancer mortality. The strategy proposed is largely a strategy of mobilizing research dollars to address the differential cancer burdens among racial and ethnic groups.2
We in Northeast Florida have a potentially important role to play in this effort. Besides being one of America's largest cities, we also have a large African-American minority population. These individuals have been directly affected by these striking statistics of disparity. In Jacksonville we are a center for health care excellence. We have major teaching and research institutions and are the home of the headquarters of several of Florida's most prestigious insurance and managed care plans. Our local government has shown leadership in making health care a privilege enjoyed by all Jacksonville citizens through the Indigent Care Contract with University Medical Center. The DCMS has shown a commitment to equity as the sponsor of Florida's most successful charity health care system, the "We Care" program. It seems that we have all the pieces in place to lead the way in addressing the racial disparities in cancer death rates and stage of diagnosis.
However, taking a national leadership role will require a coordinated effort on several fronts, including patient care, delivery systems changes, community programs, research, education, and policy development. We, as Jacksonville's physicians, have several important roles to play in our practices, communities, and medical organizations, and as politically aware and active citizens.
Each individual physician should work to implement prevention practices in his/her daily patient care routines. Each physician should be aware that there are barriers to prevention activities that preponderantly affect the African-Americans that he/she treats. Therefore, efforts should be made to emphasize prevention and screening for these patients.
The Public Health Department and the Health Planning Council have important roles to play in analyzing the local health care system to determine what is and is not working and to communicate that information to patients, health care providers, policy makers, health plans and payers. The Health Planning Council is currently forming a Health Quality Coalition which will be charged to continuously monitor health outcomes. This Coalition will, in effect, become a sounding board for health policy for the health system(s) of Northeast Florida.
Public health and community programs must be developed to raise awareness that early screening and detection of cancer works to increase survival, and to address behaviors that affect cancer risk and likelihood of survival after diagnosis. This educational effort is the responsibility of public health departments, managed care plans, insurance companies, community organizations, and health educators. Community groups, especially churches, can convey this message of hope and responsibility to their congregations.
Managed care plans will have an increasingly important role to play. Managed care plans can enhance screening programs through incentives to providers as well as directly offering screening programs and health education to their members. Policy makers, purchasers of health care, and health departments should encourage health plans to work together through coalitions to provide community based education and screening efforts and use their considerable resources in partnership with public health to research more effective methods of delivering health care and empowering consumers.
Educational institutions must be sure new and practicing health care providers understand the importance of preventive practices including behavioral changes and cancer screening. Research activities should target specific differences in cancer incidences and mortality rates, and search for methods to effectively address the differences.
Policy makers have a responsibility to ensure that public policy addresses the needs for health care of all members of our community. In Jacksonville, in spite of the University Medical Center's City Indigent Contract and the Medical Society's "We Care" system, there are still major barriers to access to health care. These should be addressed as matters of sound public policy. Also, there are legitimate questions regarding quality of and access to systems of care being put into place by managed care plans. It will be up to our policy makers to keep abreast of these issues and implement appropriate policies to address them. However we, as physicians, have a key role in making sure the outcome is best for our patients.
Individual patients have perhaps the greatest responsibility of all. Much of the advance in cancer prevention and early detection depends on patient behavior. Smoking, diet, excess alcohol, and other environmental carcinogens are clearly important factors in cancer mortality reduction. Early detection relies on motivated patients following through with recommended scheduled screening programs. Again, we as physicians are key to keeping patients informed and motivated.
References
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