Preventing lung cancer is easier than curing it, and any barriers that inhibit blacks from full access to care must be removed, emphasize two doctors at the University of California , San Francisco.
In an editorial in the current issue (October 14) of The New England Journal of Medicine, UCSF co-authors Talmadge E. King, Jr., MD, and Paul Brunetta, MD, analyze study findings that suggest racial attitudes may contribute to the fact that blacks have a higher death rate from lung cancer than whites.
Lung cancer is the leading cause of death from cancer in the U.S. and, overall, the five-year survival rate for the disease is 14 percent among whites and 11 percent among blacks.
The title of the editorial is "Racial Disparity in Rates of Surgery for Lung Cancer." The comments by King and Brunetta relate to new research results, reported by a team from Memorial Sloan-Kettering Cancer Center and the National Cancer Institute, that appear in the same NEJM issue.
The study covers surgical treatment and survival of close to 11,000 black patients and white patients age 65 and older with early stage lung cancer. Results showed that blacks were 12.7 percent less likely than whites to undergo surgical resection, and the research team concludes that if blacks were to undergo surgery for the disease at the same rate as whites, the survival rates for the two groups would be almost equal.
Putting these results into perspective, the UCSF co-authors note current clinical evaluation of surgical treatment by stating, "There is agreement that surgical resection saves lives in patients with early-stage, non-small-cell lung cancer."
They state further that any evidence that bias on the part of physicians--either overt prejudice or subconscious perceptions--influences optimum care is "disheartening because we all believe that if our loved ones get cancer, they will receive the best care possible." They also add that they don't know if this bias exists, but "we must strive to remove any barrier" against blacks. The co-authors note that some of the disparity in lung cancer survival among blacks and among whites can be explained through smoking prevalence, how the body metabolizes and excretes carcinogenic and mutagenic agents in tobacco smoke, socioeconomic status, and access to health care. But these factors account for only some of the inequities in morbidity and mortality in the two population groups, emphasize King and Brunetta, both of whom are experts in pulmonary disorders.
A specialist in lung disease, King is professor and vice-chair of the UCSF Department of Medicine and chief of medical services at San Francisco General Hospital Medical Center. Brunetta specializes in lung cancer and is a UCSF assistant clinical professor of medicine. He also is a member of the thoracic oncology and tobacco control programs of the UCSF Cancer Center. In their editorial, the co-authors discuss three key areas that could impact survival rates among blacks and whites.
Racial differences between physicians and patients: This difference is often a barrier to optimal patient-physician communication and partnership. Black patients are more likely than white patients to feel excluded from decisions affecting their health, and this may be an important contributor to miscommunication. Both black patients and white patients appear more likely to feel involved with their own care when their doctors are of the same race, but blacks are far less likely to have a black physician as part of their care team, they write.
Lack of screening tests: There is no regular screening test for lung cancer to enhance early detection and reduce mortality, and many blacks do not undergo preventive screening for cancer because their physicians do not recommend the tests. Should effective lung-cancer screening become available, "we will need large-scale public health initiatives to make black patients, and their physicians, aware of its importance," they write.
Clinical trials : Most of the knowledge about the best lung cancer treatments has and will come from clinical trials. Many blacks are reluctant to enroll in these protocols due to the aftermath of several shameful episodes in U.S. history, such as the Tuskegee study of untreated syphilis in a group of black men in rural Alabama from 1932-72. Thus, physicians making recommendations to patients about research trials should be sensitive to these issues. In addition, they state, agencies that fund cancer research should devote more resources to maintaining adequate representation of racial and ethnic minority groups in clinical studies and to increasing the number of minorities who conduct research and serve on advisory panels.
In summary, the UCSF co-authors write, "If the poor statistics on survival for the leading cause of cancer deaths in the United States are partially due to racial discrimination that results in inadequate emphasis on prevention or insufficiently aggressive care for blacks, then the medical establishment begins to share a portion of the tobacco industry's culpability for the dismal outcome of patients with this disease."
And they add, "Every educational, social, political, and legal effort should be made to ensure that all patients with lung cancer receive high-quality care-appropriate service delivered in a technically competent manner, with good communication, shared decision-making, and cultural sensitivity."
Journal
New England Journal of Medicine