# Presentation: 011881

## Otis W. Brawley M.D.Director, Georgia Cancer CenterAssociate Director, Winship Cancer InstituteProfessor of Hematology, Oncology, and EpidemiologyEmory UniversityAtlanta, Georgia

## “First get your facts, then you can distort them at your leisure.”				-Mark Twain

## Race, Economics and Disparities in Health

- The Meeting of Politics and Science:
- Truth, Lies, and Superstitions

## RACE MEDICINE

- The concept that phenotypic racial differences mean biologic differences in disease.  For example syphilis is a different disease in Negroes versus Whites.

## “Those who do not appreciate history are destined to repeat it.”

- 					Santiana

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## Breast Cancer SurvivalThe DoD Experience

- Wojcik et al. Cancer 1998

## Breast Cancer SurvivalThe DoD Experience

- Suggests a benefit from fixing socially derived issues:
- the ready access to high quality medical care.
- the availability of a full complement of treatments (there was likely not full usage in the DoD studies.
- Wojck et al. Cancer 1998

## Breast Cancer SurvivalThe DoD Experience

**These observations suggest****:**
**The Black breast cancer mortality rate in the U.S. can be reduced.**
**The 5 year mortality for Black women in the U.S. can be reduced by at least 60%.**
**Wojck et al. Cancer 1998**

## Breast CancerThe Reality

- From 1993 to 1997, 561 Black women died of breast cancer in Atlanta.
- If Atlanta’s Black population had the DOD Black rate 330 would have died (231 less)

## Equal Treatment Yields Equal Outcomeamong Equal Patients in several case series

- All show no B/W difference when  adjusted for stage and SES
- The University of Chicago
- Heimann et al., J. Clin. Oncology, 1997
- M.D. Anderson Cancer Center
- Franzini et al., Ann. Surg.Oncol., 1997
- Henry Ford Hospital
- Yood et al., JNCI, 1999

## Equal Treatment Yields Equal Outcome

- In NSABP node negative breast cancer trials:
- The overall 5 year survival rate was 93% for Blacks and 92% for whites.
- 5 year disease free survival rate was 81% for Blacks and 80% for whites.
- Dignam et al, Cancer 1997

## How can we provide adequate high quality care to a population that has so often not received it?

## The Meaning of Race in Science and Medicine

- Differences in patterns of care by race documented in:
- Prostate Cancer
- Colon Cancer
- Breast Cancer
- Lung Cancer
- The full reasons for the differences have yet to be explained

## Equal Treatment Yields Equal OutcomeThere is not Equal Treatment

- Studies suggest that disparities may be due to:
- Cultural differences in acceptance of therapy.
- Disparities in comorbid diseases making aggressive therapy inappropriate.
- Lack of convenient access to therapy.
- Racism and SES discrimination.
- This is still an active area of research.

## Disparities in Breast Cancer Care

**In an analysis of women in the SEER Black-White Study, 1985-1986:**
**36% of women with late stage disease did not receive minimum expected therapy compared to four percent of the patients with early stage disease.**
**21% of Black women did not receive minimum expected therapy compared to 15% of white women**
**Breen et al, Ethnicity and Disease 1999**

## Disparities in Breast Cancer Care

- Older women and women with no usual source of care were significantly less likely to receive minimum expected therapy.

**Breen et al, Ethnicity and Disease 1999**

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## Defining Populations

- What are the influences on population differences in disease causation?
- Extrinsic
-  Social condition
-  Culture
-  Environment
- Intrinsic
- “Biologic” or “genetic”

## Cancer and Population Science

- Migration studies show the effects of  extrinsic influences:
- Migration of Chinese and Japanese to America increase their incidence and mortality rates of colon, breast, and prostate cancer
- Europeans moving from eastern to western Europe increase their mortality rates in several cancers

## Breast Cancer PathologyRacial Issues

- At diagnosis the Black population with breast cancer has disproportionately more:
- Advanced disease
- Higher grade tumors within stage
- Less ER + tumors
- Younger women (age 35 to 44)
- SEER data 1973 to 1997

## Breast Cancer PathologySocioeconomic Issues

- Lower SES white women present with disproportionately more:
- Advanced disease
- Higher grade tumors within stage
- Less ER+ tumors
- Younger women (age 35 to 44)
- Gordon Am.J.Epidemiol., 1995

## Breast Cancer Pathology and Stage

- Social deprivation studies in Europe and U.S. suggest more virulent tumors in the poor.
- Several studies suggest a correlation between higher body mass index and higher stage at presentation (higher BMI can be a cultural phenomenon).

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## Cancer Disparities

- Are we asking the right scientific questions?
- Are we allowing certain questions to allow us to ignore other legitimate questions?

- Conclusion
- Its bad to have cancer
- Its worse to have cancer and be poor
- Important Questions?
- What are the elements of poverty that influence the experience of cancer and cancer biology?
- These are social science and epidemiologic questions and it is crucial that it be addressed if we are to decrease “health disparities”

## How can we provide adequate high quality care to a population that has so often not received it?

## Otis W. Brawley M.D.Director, Georgia Cancer CenterAssociate Director, Winship Cancer InstituteProfessor of Hematology, Oncology, and EpidemiologyEmory UniversityAtlanta, Georgia