The Socioeconomics of Cancer
Pop Quiz: Which is a bigger determinant of cancer mortality in America, being poor or being black?
According to Dr. Harold Freeman of the National Cancer Institute, poverty is the bigger factor today, but it hasn’t always been so:
During 250 years of slavery (1619-1865) and to a lesser extent during the ensuing 100 years of legalized segregation (ending in the mid 1960’s), I suggest that being black in America was a greater determinant of health disparities (including those related to cancer). For example, a slave’s poverty was overwhelmingly related to being a slave. But, in my opinion, as racial discrimination gradually diminished over this 400 year time period (particularly in the last 40 years since the Civil Rights Act) race has diminished as a relative determinant of health disparities compared to poverty.
Here are the principle distinctions I am making:
- In overview, health disparities are principally due to relatively lower economic status (which also co-relates to level of education).
- In the past American racist society (slavery and legalized segregation) race — being black — was the principal determinant of who was poor. There are still some residual effects of this history with respect to the demographics of who is poor.
- However, in the past 40 years, as our society has moved toward a post overt racist society, poverty has now exceeded race as a determinant of cancer mortality.
- Even so, race still matters. But it is my view that today “unintended bias” is the principal form of “racialism”. Poverty as a universal force affecting all who are poor predominates as the dominant cause of health disparities.
- Therefore the diminishment of the effects of poverty — providing resources to all, while in particular addressing disproportionate poverty in blacks — becomes the target for correction.
Comparing blacks and whites with respect to cancer, Freeman continues:
- Black Americans have an overall higher cancer death rate compared to whites. Also blacks have an overall 10-15% lower 5 year cancer survival compared to whites.
- Correcting for socioeconomic status (SES) factors (between white and black Americans) nearly eliminates the white and black differences in overall cancer survival. This suggests that most overall black and white cancer outcome differences are related to SES. (Blacks are disproportionately poor and uninsured compared to whites).
- Some reports have shown that blacks have a higher cancer mortality compared to whites even at the same stage of cancer diagnosis (breast, colon).
- However the weight of evidence indicates that when black and white patients receive the same treatment at the same stage of disease (breast, colon, cervix) the results are the same. This is an important conclusion.
- The Insititute of Medicine (IOM) concluded that race is a determinant of poorer cancer outcome in blacks, even at the same SES and insurance status. This suggests that there is some degree of racial bias on the part of some cancer care providers. This is born out by other studies such as: Blacks at the same SES and insurance as whites are less likely to receive renal transplantation, less likely to receive curative lung cancer surgery in early lung cancer, less likely to be completely worked up diagnostically for chest pain, less likely to be treated for severe pain.
In summary, most evidence suggests that racial differences in cancer outcome are primarily associated with SES and not innate racial factors. In addition there is significant evidence indicating that race in and of itself is to some extent a determinant of the quality and timeliness of receiving health care. Disproportionate poverty and uninsurance are the principal factors. To the extent that blacks disproportionately smoke cigarettes, have less healthy diets or are obese, these are factors that may cause racial disparities in cancer outcome.
Racial classifications are socially and politically determined, not based on biology. But to the extent that race is a lens through which people see, value and behave toward one another, race is an important factor.
For more information check out the following references:
- “Racial Injustice in Health Care” New England Journal of Medicine (2000)
- “Race, Poverty and Cancer” Journal of the National Cancer Institute (1991)
- “Cancer in the Socioeconomically Disadvantaged” CA: A Cancer Journal for Clinicians (1989)
- “Commentary on the Meaning of Race in Science and Society” Cancer Epidemiology, Biomarkers & Prevention (1998)