Poverty, Culture, and Social Injustice: Determinants of Cancer Disparities

In 1971, President Richard Nixon signed the National Cancer Act and declared a “War Against Cancer. ” In the more than 30 years since this declaration of war, the nation has made extraordinary progress in our understanding of the causes of cancer, especially at the molecular level. We have also witnessed a dramatic evolution in the development of various therapeutic modalities resulting in more effective, more targeted, and less destructive cancer treatments. From a public health perspective, we have a seen a decline in the percentage of adults who smoke cigarettes. Note that tobacco is the cause of more than one third of cancer deaths. Related to this progress, an overall decline in cancer mortality has occurred in the last several years. However, some Americans have not fully benefited from this progress as evidenced by their higher cancer incidence, mortality, and lower survival. Stating this another way, there is a critical disconnect between what we discover and what we deliver, between what we know and what we do for all people (Figure 1). It is critical to accurately define which groups of Americans suffer a heavier burden of cancer, determine the causes, and apply interventions to eliminate the disparities. In this issue of CA, Ward and others highlight disparities in cancer incidence, mortality, and survival in relation to race/ethnicity and socioeconomic status. They conclude that for all cancer sites combined, residents of poorer counties have a higher cancer death rate than residents in more affluent counties. Ward further concludes that even when poverty rates are accounted for, some racial groups (eg, African Americans and American Indians/Alaskan Natives have a lower five-year survival rate than non-Hispanic Whites. Note also that within each racial/ethnic group, looked at separately, those living in poorer counties have the lowest survival rates according to Surveillance, Epidemiology, and End Results (SEER) Program data. For a better understanding of the issues raised by Ward et al., it is important to review the background of our current knowledge of cancer disparities. In 1973, Henschke noted an “alarming increase” in the cancer mortality in African Americans in the preceding 25 years. After the publication of this study, the National Cancer Institute (NCI) increased its focus on racial differences in cancer incidence, mortality, and survival. In 1986, based on a subcommittee’s findings, the American Cancer Society (ACS) issued a “Special Report on Cancer in the Economically Disadvantaged. ” The report concluded that the poorer cancer outcome in African Americans compared with White Americans is primarily related to lower socioeconomic status in African Americans. The study concluded further that poor Americans, irrespective of race, have a 10% to 15% lower five-year survival. A pivotal report by Freeman in 1989 provided an analysis and broad overview of these findings. In 1989, the ACS issued its report “Cancer in the Poor: A Report to the Nation. ” This report was the culmination of a series of fact-finding hearings held throughout the nation in collaboration with the NCI and Centers for Disease Control (CDC). Poor people with cancer of all racial and ethnic groups testified. The key findings were: Y Poor people lack access to quality health care and are more likely than others to die of cancer. Y Poor people endure greater pain and suffering from cancer than most Americans. Y Poor people face substantial obstacles to obtaining and using health insurance and often do not seek needed care if they cannot pay for it. Y Poor people and their families must make extraordinary personal sacrifices to obtain and pay for health care. Y Cancer education and outreach efforts are insensitive and irrelevant to many poor people. Y Fatalism about cancer prevails among the poor and prevents them from gaining quality health care. Dr. Freeman is Director, Center to Reduce Cancer Health Disparities, National Cancer Institute, Rockville, MD.