Although progress has been made in reducing the cancer mortality gap, African Americans continue to have the highest death rate and shortest survival of any racial or ethnic group for most cancers, according to a study released Monday by the American Cancer Society.
“[The death rate] is going downward — that’s an important thing to acknowledge,” said Dr. Otis Brawley, the society’s chief medical officer. “But we can do better.”
Deaths among black people for all cancers combined have been decreasing since the early 1990s, translating to more than 300,000 deaths averted, the study found. Cancer death rates for the U.S. population overall fell by 22 percent since peaking in 1991, a drop largely attributed to advances in prevention and basic and clinical research, as well as policy changes such as tobacco-control legislation, workplace protections against carcinogens and insurance reimbursement for cancer screening.
Overall cancer deaths have declined more for black people than for white people, particularly for black men, narrowing the cancer mortality gap to 24 percent higher in black males than while males in 2012, down from 47 percent higher in 1990. The drop was driven by declining deaths from lung and prostate cancers, the first- and second-leading causes of cancer deaths for both white and black males.
The gap narrowed among women, too, although not as dramatically, to 14 percent higher for black women than whites for all cancers in 2012, down from 19 percent in 1991, according to the study, published in CA: A Cancer Journal for Clinicians.
But for two cancers — colorectal cancer in black men and breast cancer in black women — the mortality gap widened. Colorectal cancer death rates remain about 50 percent higher for black than white males. And while breast cancer deaths declined for both black and white women, the drop for whites was so much steeper that the disparity in breast cancer deaths “is actually greater today than it has been at any time in our history,” Brawley said in a video released with the report. Breast cancer death rates are 42 percent higher in black women compared with white women.
For both black and white populations, cancer was the second leading cause of death in 2012 after heart disease, led by lung cancer for both men and women, followed by prostate cancer in men and breast cancer in women. Colorectal cancer was the third leading cancer killer.
The study attributed lingering disparities in cancer outcomes to socioeconomic barriers that limit access to “timely, appropriate and high-quality medical care,” including screening. Because of those barriers, the study pointed out, black populations are more likely to be diagnosed at later stages of disease progression, when treatments are more limited and less effective.
“Until we level that playing field, we’re not going to get rid of health disparities,” said Dr. Beti Thompson, head of Fred Hutch’s Health Disparities Research Center, who was not involved in the study.
One well-recognized source of disparities is cancer screening, said Dr. Amanda Phipps, an epidemiologist with Fred Hutch’s Public Health Services Division, who was also not involved in the study.
“Colonoscopy is not an inexpensive test,” she said. “If you don’t have insurance or access to care, screening doesn’t happen.”
The study drew on data collected through 2012, just as the Affordable Care Act was being implemented. The health care law made insurance more affordable and, for those insured, eliminated out-of-pocket costs for breast, cervical and colorectal cancer screening.
Screening will hopefully be less of a factor moving forward, Phipps said.
But while screening can lead to better outcomes by detecting cancers at an early stage, the study also found that for most cancers, the five-year survival rate is lower in black people than in white people for every stage of diagnosis.
African American women are more likely than white women to be diagnosed with a particularly aggressive form of breast cancer — triple-negative (estrogen receptor-, progesterone receptor- and human epidermal growth factor receptor 2-negative). The study pointed out that such cancers have a poorer prognosis, in part because there are no targeted therapies, underscoring both the need for more research into this type of cancer and the importance of including different races and ethnicities in clinical trials.
There are socioeconomic and cultural disparities in preventive measures as well. One of the key risk factors for triple-negative breast cancer is a lack of breastfeeding in women who have children, and African Americans have lower rates or at least shorter duration of breast feeding, according to Phipps.
“Part of that may be logistical constraints due to a person’s employment,” Phipps said. “I know that from my own experience as a new mother that it can be hard to find a time and place to continue breastfeeding once you return to work. The onus is, in large part, on employers to make that possible.”
Lifestyle factors also influence colorectal cancer risk; one of the primary ones is diet, Phipps said. Obesity increases cancer risk, and black women have the highest obesity rates of any racial-ethnic group.
As for colorectal cancer, “the World Health Organization last year released a message that processed meat is associated with increased risk of colon cancer,” she said. “That is certainly an area that could plausibly differ across ethnic groups, and certainly a modifiable factor.”
For African Americans living in low-income communities, studies have shown that adopting healthier lifestyles can be challenging due to living in “food deserts” without nearby grocery stores.
As for being able to afford treatment, cancer can be financially toxic even for those with middle-class incomes, regardless of race.
“If your employer finds out you are diagnosed with cancer and you don’t have the means to fight for your job, they let you go,” said Bridgette Hempstead, a Seattle African-American breast-cancer survivor. “There’s no true safety measure to stop a bankruptcy, to stop the stress of the disease. And we all know that, when you remove the stress, you have a greater outcome.”
For African Americans, racism can make it even harder to get help, Hempstead said.
“These so-called systems that are supposed to be in place to help an individual that has been diagnosed — when it comes down to the African American community, the disparities continue to grow and the help is not there,” she said. “It is a very daunting reality.”
Hempstead founded a support network called Cierra Sisters to warn and educate other African-American women “that breast cancer is real, but you don’t have to die from it.”
“We as a community need to start focusing on health,” agreed the American Cancer Society’s Brawley, who is African American. “We need to start focusing on preventive health, we need to start focusing on screening, we need to start focusing on getting good treatment. Indeed, one of the things that’s hidden behind these statistics is a substantial number of black Americans who are diagnosed with cancer — be it breast, colon or lung — get less than optimal care. It’s no longer just go to the doctor, it’s go to the doctor, interact with the doctor, ask questions and make sure you’re getting high quality care.”
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Mary Engel is a former staff writer at Fred Hutchinson Cancer Center. Previously, she covered medicine and health policy for the Los Angeles Times, where she was part of a team that won a Pulitzer Prize for Public Service. She was also a fellow at the Knight Science Journalism Program at MIT. Follow her on Twitter @Engel140.