Physicians face multiple challenges in combating cancer disparities
■ Doctors need to be aware of ethnic and racial health disparities when treating individual patients, experts advise.
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More people are living longer because of early cancer detection, increased access to care and advancements in cancer treatments. But not all Americans are benefiting equally, according to the Centers for Disease Control and Prevention.
Disparities persist in cancer detection and care, posing challenges for physicians as they work to provide the best care for patients.
“This is a national problem,” said Marshall Chin, MD, MPH, the Richard Parrillo Family Professor of Medicine at the University of Chicago Pritzker School of Medicine.
Black men are diagnosed with cancer and die of the disease at higher rates than other racial, ethnic or gender groups, the CDC said. The incidence of cancer is 599.2 per 100,000 black men compared with 523.6 per 100,000 white men. Death rates among black men are 280.1 per 100,000 compared with 213.3 per 100,000 white men, say CDC statistics, updated Aug. 6.
Black women have higher death rates from cancer at 171 per 100,000 compared with 148.2 per 100,000 white women.
Multiple factors contribute to cancer-related disparities, including lifestyle habits, education, income, personal beliefs, attitudes about the health care system and access to care, said Otis Webb Brawley, MD, chief medical and scientific officer at the American Cancer Society.
Studies have shown that blacks often are diagnosed later than other groups, said Dr. Chin, director of the Robert Wood Johnson Foundation’s Finding Answers: Disparities Research for Change National Program Office.
“African-Americans tend to present with later-stage cancer,” he said. “That suggests a problem with access to care that people aren’t presenting until the cancer is advanced.”
Social factors can affect a patient’s access to care and the quality of care they receive, Dr. Chin said. People not only may have trouble affording medications or treatment, they also may not have reliable transportation to get to regular treatments or doctor’s appointments, Dr. Brawley said. They may not be able to afford to pay for day care for their children. Differences in literacy also can influence disparities.
“Quality differs dramatically,” he said. “We have shown that the big driver is not necessarily race. The driver is, most likely, socieoeconomics.”
Among black men, colorectal, lung and prostate cancer are the most common cancers. But studies have shown that they are less likely to be screened for colorectal cancer, he said.
Even when individuals are diagnosed with cancer, the quality of care they receive varies, Dr. Brawley said. For example, black women diagnosed with breast cancer are less likely to get radiation therapy after a lumpectomy.
“Once people are diagnosed, they are not getting the care they need,” Dr. Chin said. “The question is: How do we address these underlying barriers?”
Recognizing the challenges
Physicians can make a difference by focusing on individual patients, experts said.
“There are a lot of things that primary care physicians can do,” Dr. Chin said. “The first is to provide culturally tailored care — treating patients as individuals. For example, with education — it may be hard to change the public school system, but it is possible to change an individual patient’s attitudes.”
It’s important that primary care physicians be tuned into the challenges of health disparities, and they should be cognizant and honest about factors in their practices that might contribute to the problem, Dr. Brawley said.
Social issues should be considered, including a patient’s education level, access to transportation and family or work obligations that can interfere with care, Dr. Brawley said.
Providing team-based care or patient navigators can help by ensuring that there are more people taking responsibility for a patient, Dr. Chin said. A team can have more contact with a patient and ensure that he or she receives follow-up care.
“That way we can help identify what the barriers are to that patient getting to the mammogram,” he said.
Physicians also can encourage patients to get their families involved in their care. That added support system can help patients with the logistics of getting to appointments and ensure they have encouragement through treatments, Dr. Chin said.
Forthcoming changes in the way health care is provided also will help, such as bundled payments and better payment for preventive care, Dr. Chin said.
“A lot of evidence suggests that the system’s interventions have a big impact,” he said.