As a result, the War on Cancer – declared about three decades ago by President Nixon -- cannot be won until this "unequal burden of cancer" is corrected, according to reports by a panel of cancer clinicians and public health officials in the March issue of Cancer Epidemiology, Biomarkers and Prevention, a journal of the American Association for Cancer Research (AACR).
"In our efforts to reduce disparities, we must identify and remove all of the barriers that prevent the benefits of research from reaching all of the people," wrote Harold P. Freeman, M.D., director of the Ralph Lauren Center for Cancer Care and Prevention in New York City and director of the Center to Reduce Cancer Health Disparities at the National Cancer Institute.
"These barriers are a major cause of health disparities," he added. "This is a national issue, a policy issue." Added Frederick P. Li, M.D., of the Dana-Farber Cancer Institute in Boston who assembled the panel for an October 2001: "The burden of cancer is not equally distributed within the U.S. population, but differs by race, ethnicity and, other demographic characteristics."
"Clearly, it is essential that we address this disparity and work to ensure that all Americans have equal access and quality cancer care."
Statistics tell part of the story, particularly for African Americans:
African Americans are 30 percent more likely to die from cancer than white Americans. In 2003, an estimated 132,700 new cancers will be diagnosed among African Americans and 63,100 deaths will be recorded. In 1992-1999, overall age-adjusted U.S. incidence rates for all cancers combined (per 1 million population) were 527 for African Americans and 480 for whites.
When compared with other racial/ethnic groups in the U.S., African-American men have the highest age-adjusted incidence and mortality rates for at least nine forms of cancer, including the lung and bronchus, colon and rectum, oral cavity and pharynx, stomach, non-Hodgkin's lymphoma, urinary bladder, pancreas, kidney, and renal pelvis. African-American women have the highest age-adjusted incidence and mortality rates for cancers of the esophagus, larynx, multiple myeloma, oral cavity, and pancreas.
In 1993, African-American women were twice as likely as white women to be diagnosed with cervical cancer, and were two to three times more likely to die from their disease. Nearly one-half of all African-American women aged 50-64 did not obtain a Pap smear in the previous three years.
African Americans with the same stage of early and highly curable lung cancer (stages I and II) are 12 percent less likely to receive curative surgery, even though they have the same insurance coverage and seem to be on the same economic level.
Other minorities and underserved groups also are facing a disproportionate rate of cancer incidence and mortality in this country. Native Americans, for example, have the poorest five-year cancer survival rate among any group in the U.S., and preventable cancers are among the leading causes of death among Vietnamese Americans.
"A disproportionate number of these people at risk are among our poor and disadvantaged populations," said Dr. Freeman. "To reduce disparities, I believe we must address factors that affect people universally, such as poverty and lack of insurance, and also address social injustice that affects specific populations."
The panel tracked several factors contributing to the disparity in cancer incidence and mortality among African Americans and other medically underserved minorities. The list includes inherent social, psychological, and economic barriers in this country that thwart proven ways to detect and prevent cancer in its early phases.
For example, since the introduction of the Pap smear in 1941, cervical cancer has been a preventable disease. However, in this country, benefits of early detection have not been shared by all segments of society. In the National Breast and Cervical Cancer Early Detection Program study of low-income women, only 60 percent of 312,858 women reported ever having had a Pap smear.
According to Elizabeth I. O. Garner, M.D., with the Brigham and Women's Hospital in Boston, late-stage diagnosis – often identified as the major cause of excess morbidity and mortality in underserved populations -- is "the final result of complex interactions among multiple factors, including disparities in screening, diagnosis, and treatment, as well as other determinants that are not fully understood."
Language and cultural barriers also present hurdles to non-English speaking immigrant women. Modesty and prohibitions against pelvic examination by male practitioners often inhibit women whose culture does not allow such activities.
"Cultural factors can also contribute to mistrust of medical care providers, contributing to low screening rates," wrote Dr. Garner.
The panel pointed to several other hurdles that discourage minority participation in standard diagnostic and treatment modalities for cancer, in addition to access to NCI-sponsored clinical trials. According to federal statistics, about 2,400 African Americans enroll each year in clinical trials, out of a total enrollment of about 30,000.
"Given the scope of NCI-sponsored trials, the fact that only 2,400 black patients and even fewer Hispanics, Asians and other patients enroll annually is extremely disappointing," wrote Michaele C. Christian, M.D., and Edward L. Trimble, M.D. with NCI's Cancer Therapy Evaluation Program.
The panel also pointed to lifestyle factors that result in higher cancer rates among minorities in general, and African Americans in particular. These factors include the targeting of African Americans by tobacco companies, through advertising in magazines, on billboards, and during sporting events and other forms of entertainment; the African-American diet, which tends to be lower in fruits, vegetables, and fibers and higher in saturated fat; higher rates of alcohol consumption among African Americans; and lower physical activity and higher percentages of obesity among African-American men and women.
"The burden of cancer borne by African Americans far exceeds that of other racial groups, due to lifestyle, behavioral and socioeconomic influences, and inadequate access to medical care," wrote Sandra Millon Underwood, Ph.D., the American Cancer Society Harley Davidson Oncology Nursing Professor at the University of Wisconsin, Milwaukee.
She added: "Reducing this cancer burden borne by African Americans and other underserved Americans has often been touted as a national goal. However, there must be political will, public support, and financial resources to accomplish this goal. "The question remains – if not now, then when?"
Founded in 1907, the American Association for Cancer Research (AACR) is a professional society of more than 20,000 laboratory and clinical scientists engaged in cancer research in the United States and more than 60 other countries. AACR's mission is to accelerate the prevention and cure of cancer through research, education, communication and advocacy. Its principal activities include the publication of five major peer-reviewed scientific journals (Cancer Research; Clinical Cancer Research; Molecular Cancer Therapeutics; Molecular Cancer Research; and Cancer Epidemiology, Biomarkers & Prevention). AACR's annual meeting attracts more than 15,000 participants who share new and significant discoveries in the cancer field, and the AACR's specialty meetings throughout the year focus on all the important areas of basic, translational and clinical cancer research.