Disparities in health care: The black population
Disparities in health care: The black population
Racial and ethnic disparities can be multifactorial, encompassing socioeconomic factors (eg, education, income, and employment), lifestyle behaviors (eg, physical activity and alcohol intake), social conditions (eg, neighborhoods and work conditions), and access to preventive health care services (eg, cancer screenings and vaccinations).1 Leading health indicators of progress toward national health objectives for 2020 continue to reflect racial and ethnic disparities.1 Eliminating disparities requires culturally appropriate health initiatives and community support, in addition to equal access to health care.1 Furthermore, disparities are not equal among all racial and ethnic populations, and prevalence and incidence of various diseases are also different across the different populations.
As we continue to make strides in oncology care (eg, prevention, screenings, and treatment outcomes from diagnosis through end of life), we must make an effort to include all racial and ethnic groups in this progression. Health care disparities for black persons in the United States can mean loss of economic opportunities, lower quality of life, perceptions of injustice, and earlier death.1 From a societal perspective, health care disparities for the black population translate into less than optimal productivity, higher health care costs, and social inequities.1
The literature suggests the heritage and history of black persons dating as far back as 1619-1860 had an impact on the black experience in America, thus making their life stories markedly different from that of other immigrants.2 Elimination of disparities for this group is intertwined with knowledge and awareness that focuses on integration of health-related cultural values and practices, disease incidence and prevalence, and treatment efficacy.2 This article focuses on the disparities in oncology care that exist for black and non-Hispanic black persons in the United States, and the interventions that may reduce such disparities.
The black population is estimated to be 61 million people by 2050 and will account for 15% of the total US population.1 The 2000 Census indicated 36.4 million persons, approximately 12.9% of the population, identified themselves as Black or African American, 35.4 million of whom identified themselves as non-Hispanic.1 Cancer is the second leading cause of death in both non-Hispanic blacks and non-Hispanic whites.1 In 2001, the age-adjusted incidence per 100,000 population for various cancers, including colorectal cancer (CRC), was substantially higher in black females than in white females.1,3 Disaggregation studies are examining the relationship between black-white cancer health disparities.3
Recent studies disaggregating the US population based on region showed foreign-born people have better general health outcomes than US-born people; but as the number of years living in the United States increases, health status mirrors that of the US-born population.3 Approximately 6% of persons who identified themselves as Black in the 2000 Census were foreign born.1 What ultimately has emerged from these studies is that despite the limited studies among US black people, specific subgroups of the black population remain at risk. Health promotion efforts need to overcome the barriers facing these specific groups.3
CANCER IN THE BLACK POPULATION
A variety of demographic and sociocultural factors are commonly reported barriers to adherence to suggested cancer screenings. These factors include lack of knowledge or awareness of cancer screenings, lack of access to general preventive health care services, institutional or system barriers, socioeconomic status, language barriers, immigrant status, and cultural beliefs.2-4 Related specifically to the black population, researchers believe social isolation leads to a lack of social support.4 This lack of support has a negative impact on worries and concerns often encountered by patients with cancer.4
Black persons experience higher overall cancer incidence and mortality rates, excessive burden of disease, and lower 5-year survival rates compared with non-Hispanic white, Native American, Hispanic, Alaskan Native, Asian American, and Pacific Islander populations.2,5 Approximately 168,900 new cases of cancer were diagnosed among black persons in 2011.6 The most commonly diagnosed cancers in the black population are prostate (40%), lung (15%), and colorectal (9%).6 In 2010, 142,570 new cases of colorectal cancer were diagnosed and an estimated 51,370 patients died from their disease; in 2011, colorectal cancer lead to 7,050 deaths.5,6 Lung cancer is the leading malignancy among both black men and black women, attributing to 65,540 deaths in black persons.6
Colorectal cancer is the third leading type of cancer and cause of cancer-related deaths in the black population.7 A 20% higher incidence and a 40% higher overall mortality are attributed to disparities in access, high-quality screening, and treatment, as well as later stage disease at diagnosis, in this group.3,5,6
Incidence of cervical cancer in black women is 11.1 cases per 100,000 population compared to 8.7 cases per 100,000 population for white women. Mortality rate for cervical cancer in black women is more than twice that of white women.8 The 5-year survival rate is 66% for black women compared with 74% for their white counterpart; in addition, advanced stage disease at diagnosis occurs more frequently in black women.5,6,8 In 2011, 860 deaths in black women were reported as a result of cervical cancer.6
As recently as 5 years ago, a review of studies yielded an increased incidence of oral cancers among black men. Oral cancers are ranked as the 10th leading cause of death among black males.7 Age-adjusted incidence of oral cancer in black males was more than 20% higher than that of white males from 1998 to 2002.7
Breast cancer is one of the most commonly diagnosed malignancies in black women, with an estimated 26,840 new cases diagnosed in 2011.6 Breast cancer incidence increased rapidly among black women during the 1980s largely due to higher detection rates as the use of mammography screening increased.6 Incidence stabilized among black women 50 years and older from 1994 to 2007, while rates decreased by 0.6% per year from 1991 to 2007 among women younger than 50 years.4,6 However, among women younger than 45 years, incidence rates are higher for African American women compared with white women.6 Breast cancers in black women are more likely to be associated with poor prognosis, such as higher grade, distal stage, and negative hormone receptor status.6 Risk for basal-like breast cancer (ie, triple-negative cancers), an aggressive subtype of breast cancer associated with shorter survival in premenopausal black women, is even more prevalent.6
Lung cancer kills black persons more than any other malignancy.6 In 2011, 23,220 new cases of lung cancer were reported, and an estimated 16,790 deaths occurred. The convergence of lung cancer death rates between young black persons and white adults is the result of faster progression of disease in black persons, likely reflecting a greater reduction in smoking initiation among blacks since the late 1970s.6 Also, as with most of the malignancies diagnosed in blacks, increased mortality is also associated with advanced stage at time of diagnosis.6