Stereotypical narratives can harm efforts to address racial disparities in cancer outcomes, say Junaid Nabi and Quoc-Dien Trinh
Routinely, in conversations about the disparities in cancer care between black and white patients, and the fact that black patients continue to experience worse outcomes, the same trite phrase inevitably comes up: “Oh, it’s because of their genes.” This sentiment—that worse outcomes in black patients are a result of their inherent genetic makeup, and not the health systems that serve them—has gained a damaging stronghold in public and private discourse.
According to the American Cancer Society, “African Americans have the highest death rate and shortest survival of any racial and ethnic group in the US for most cancers.” The numbers are indeed grim. Black women are twice more likely to die from breast cancer compared to white women, even after adjusting for age. Black men, also, are at a twofold risk of dying from prostate cancer compared to white men. In the US, against a backdrop of tense race relations and prominent healthcare inequities, the discussion on the complicated relationship between race and cancer has been thrust at the centre of national discourse.
As physician-scientists who investigate health policy and its effect on minority populations, we are dismayed at how this debate has a misplaced understanding of where disparities in cancer outcomes arise from. For far too long, research on race based disparities in cancer outcomes has focused on biological (or genetic) differences between black and white patients—and not our health system. This is a problem; and there is ample empirical evidence to show why.
In order to understand whether a health system is adequately serving a certain population, we need to look at access to care and its quality. For cancer patients who are black or from an ethnic minority, access is (and has almost always been) inadequate. Before the implementation of the Affordable Care Act (ACA), the proportion of uninsured black patients who were aged under 65 was 17% and the equivalent rate for Hispanic patients was 26%; for white patients, the uninsured rate was 12%. These gaps in access persisted after the implementation of the ACA.
What’s more, when black patients—even those with insurance—are not provided the same levels of treatment for cancer, it is not hard to see how worse outcomes could develop. Again and again, studies have found that black patients with cancer, from prostate to breast to colorectal cancer, receive a lower quality of care and are put on different treatment regimens compared to white patients.
Take prostate cancer, one of the most common cancers diagnosed in black men, where studies have shown that black men are more likely to receive lower quality of care than white men. In these investigations, quality of care was judged on metrics such as whether all available treatment options were discussed with patients; whether comprehensive baseline investigations such as Gleason grade classification were conducted; and whether a bone scan was avoided in low risk patients.
The type of cancer treatment received is another quality of care metric where black patients face severe impediments. Black women with breast cancer are less likely to receive definitive therapy (treatment given with a curative intent) and are significantly less likely than white women to be treated at a high quality institution. It is vital that discussions about black patients’ worse outcomes give due consideration to these gaps in quality of care.
For colorectal cancer, it is known that black patients die at a higher rate than white patients, but this has been casually treated as the result of biological differences. This view persists even though studies report that black patients are less likely to undergo diagnostic evaluation for colorectal cancer.
It is possible that patients from different racial backgrounds may have varying personal preferences as to how much medical care they seek. However, these differences cannot explain the ever widening survival gap from cancer between black and white patients over the past two decades.
An empirical way to evaluate whether racial disparities in cancer are a product of genetic differences or inequitable health systems would be to look at what happens to outcomes when impediments (social and economic) are removed. In an equal access setting, such as the US’s Veteran Affairs health system, where access to and quality of care are somewhat equitable, studies have shown no significant difference between black and white patients in terms of the time difference from diagnosis to definitive treatment. A similar analysis from our research group at Harvard also reported that in equal access settings (Medicare, in this case) no racial differences are observed in outcomes such as death from cancer.
Countering negative narratives on minority health, especially in cancer care, is essential—for it is neither based on evidence, nor does it promote the central tenant of treating each patient equally. To focus on the non-modifiable difference of race is, we believe, an abandonment of our overarching responsibilities as healthcare providers.
Millions of dollars are spent on programmes that aim to alleviate and address racial disparities, but stereotypical narratives harm that progress. It is time to focus on improving black patients’ access to care and its quality—because it works.
Junaid Nabi is a senior project manager for research at the Department of Surgery, Brigham and Women’s Hospital, and research associate in surgery at Harvard Medical School, Boston. He is also a New Voices fellow at the Aspen Institute, Washington, D.C. Twitter @JunaidNabiMD
Competing interests: Nothing to declare.
Quoc-Dien Trinh is a urological surgeon at Brigham and Women’s Hospital and an assistant professor of surgery at Harvard Medical School, Boston. He is the core leader for the guidelines and effectiveness research at Harvard’s Center for Surgery and Public Health. Twitter @qdtrinh
Competing interests: Quoc-Dien Trinh reports consulting fees from: Astellas, Bayer, Intuitive, and Janssen.
Acknowledgments for QDT: Quoc-Dien Trinh is supported by: Brigham Research Institute Fund to Sustain Research Excellence; Bruce A. Beal and Robert L. Beal Surgical Fellowship; Genentech Bio-Oncology Career Development Award from the Conquer Cancer Foundation of the American Society of Clinical Oncology (grant # 10202); Health Services Research pilot test grant from the Defense Health Agency; Clay Hamlin Young Investigator Award from the Prostate Cancer Foundation (grant # 16YOUN20); and, an unrestricted educational grant from the Vattikuti Urology Institute, Detroit.
The opinions expressed in this article are solely our own and do not reflect the views and opinions of Brigham and Women’s Hospital.