Otis W. Brawley M.D.Otis W. Brawley M.D.

Director, Georgia Cancer CenterDirector, Georgia Cancer CenterAssociate Director, Winship Cancer InstituteAssociate Director, Winship Cancer Institute

Professor of Hematology, Oncology, and Professor of Hematology, Oncology, and EpidemiologyEpidemiology

Emory UniversityEmory UniversityAtlanta, GeorgiaAtlanta, Georgia

““First get your facts, then you can First get your facts, then you can distort them at your leisure.”distort them at your leisure.”

-Mark Twain-Mark Twain

Race, Economics and Race, Economics and Disparities in HealthDisparities in Health

The Meeting of Politics and Science:The Meeting of Politics and Science:

Truth, Lies, and SuperstitionsTruth, Lies, and Superstitions

RACE MEDICINERACE MEDICINE

The concept that phenotypic racial The concept that phenotypic racial differences mean biologic differences in differences mean biologic differences in

disease. For example syphilis is a different disease. For example syphilis is a different disease in Negroes versus Whites.disease in Negroes versus Whites.

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

SantianaSantiana

Colon Cancer Mortality 1973 to 1999

0.05.0

10.015.020.0

25.030.035.040.0

1973

1977

1981

1985

1989

1993

1997

rate

pe

r 1

00

,00

0

Black Males

White Males

Black Females

White Females

Breast Cancer Mortality 1973 to 1999

0.05.0

10.015.020.025.030.035.040.045.0

1973

1976

1979

1982

1985

1988

1991

1994

1997

pe

r 1

00

,00

0

Black

White

Breast Cancer SurvivalBreast Cancer SurvivalThe DoD ExperienceThe DoD Experience

Blacks Whites

DoD 5 yearMortality

24.8% 18.1%

SEER 5 yearMortality

34.2% 18.4%

Wojcik et al. Cancer 1998

Breast Cancer SurvivalBreast Cancer SurvivalThe DoD ExperienceThe DoD Experience

Suggests a benefit from fixing socially derived Suggests a benefit from fixing socially derived issues:issues:

– the ready access to high quality medical care.the ready access to high quality medical care.

– the availability of a full complement of treatments the availability of a full complement of treatments (there was likely not full usage in the DoD studies.(there was likely not full usage in the DoD studies.

Wojck et al. Cancer 1998Wojck et al. Cancer 1998

Breast Cancer SurvivalBreast Cancer SurvivalThe DoD ExperienceThe DoD Experience

These observations suggestThese observations suggest::

– The Black breast cancer mortality rate in the U.S. The Black breast cancer mortality rate in the U.S. can be reduced.can be reduced.

– The 5 year mortality for Black women in the U.S. The 5 year mortality for Black women in the U.S. can be reduced by at least 60%.can be reduced by at least 60%.

Wojck et al. Cancer 1998Wojck et al. Cancer 1998

Breast CancerBreast CancerThe RealityThe Reality

From 1993 to 1997, 561 Black women died of From 1993 to 1997, 561 Black women died of breast cancer in Atlanta.breast cancer in Atlanta.

If Atlanta’s Black population had the DOD Black If Atlanta’s Black population had the DOD Black rate 330 would have died (231 less)rate 330 would have died (231 less)

Equal Treatment Yields Equal OutcomeEqual Treatment Yields Equal Outcomeamong Equal Patients in several case seriesamong Equal Patients in several case series

All show no B/W difference when adjusted for All show no B/W difference when adjusted for stage and SESstage and SES– The University of ChicagoThe University of Chicago

Heimann et al., J. Clin. Oncology, 1997Heimann et al., J. Clin. Oncology, 1997

– M.D. Anderson Cancer CenterM.D. Anderson Cancer CenterFranzini et al., Ann. Surg.Oncol., 1997Franzini et al., Ann. Surg.Oncol., 1997

– Henry Ford HospitalHenry Ford HospitalYood et al., JNCI, 1999Yood et al., JNCI, 1999

Equal Treatment Yields Equal Equal Treatment Yields Equal OutcomeOutcome

In NSABP node negative breast cancer trials:In NSABP node negative breast cancer trials:

– The overall 5 year survival rate was 93% for The overall 5 year survival rate was 93% for Blacks and 92% for whites.Blacks and 92% for whites.

– 5 year disease free survival rate was 81% for 5 year disease free survival rate was 81% for Blacks and 80% for whites.Blacks and 80% for whites.

Dignam et al, Cancer 1997Dignam et al, Cancer 1997

How can we provide How can we provide adequate high quality care to adequate high quality care to a population that has so often a population that has so often

not received it?not received it?

The Meaning of Race in Science The Meaning of Race in Science and Medicineand Medicine

Differences in patterns of care by race documented in:Differences in patterns of care by race documented in:– Prostate CancerProstate Cancer– Colon CancerColon Cancer– Breast CancerBreast Cancer– Lung CancerLung Cancer

The full reasons for the differences have yet to be The full reasons for the differences have yet to be explainedexplained

Equal Treatment Yields Equal OutcomeEqual Treatment Yields Equal OutcomeThere is not Equal TreatmentThere is not Equal Treatment

Studies suggest that disparities may be due to:Studies suggest that disparities may be due to:

– Cultural differences in acceptance of therapy.Cultural differences in acceptance of therapy.

– Disparities in comorbid diseases making aggressive Disparities in comorbid diseases making aggressive therapy inappropriate.therapy inappropriate.

– Lack of convenient access to therapy.Lack of convenient access to therapy.

– Racism and SES discrimination.Racism and SES discrimination.

This is still an active area of research.This is still an active area of research.

Disparities in Breast Cancer CareDisparities in Breast Cancer Care

In an analysis of women in the SEER Black-In an analysis of women in the SEER Black-White Study, 1985-1986:White Study, 1985-1986:

– 36% of women with late stage disease did not 36% of women with late stage disease did not receive minimum expected therapy compared to receive minimum expected therapy compared to four percent of the patients with early stage disease.four percent of the patients with early stage disease.

– 21% of Black women did not receive minimum 21% of Black women did not receive minimum expected therapy compared to 15% of white womenexpected therapy compared to 15% of white women

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

Disparities in Breast Cancer CareDisparities in Breast Cancer Care

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

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

Defining PopulationsDefining Populations

What are the influences on population What are the influences on population differences in disease causation?differences in disease causation?

– Extrinsic Extrinsic Social conditionSocial condition CultureCulture EnvironmentEnvironment

– Intrinsic Intrinsic ““Biologic” or “genetic”Biologic” or “genetic”

Cancer and Population ScienceCancer and Population Science

Migration studies show the effects of Migration studies show the effects of extrinsic influences:extrinsic influences:

– Migration of Chinese and Japanese to America Migration of Chinese and Japanese to America increase their incidence and mortality rates of increase their incidence and mortality rates of colon, breast, and prostate cancercolon, breast, and prostate cancer

– Europeans moving from eastern to western Europeans moving from eastern to western Europe increase their mortality rates in several Europe increase their mortality rates in several cancerscancers

Breast Cancer PathologyBreast Cancer PathologyRacial IssuesRacial Issues

At diagnosis the Black population with breast At diagnosis the Black population with breast cancer has disproportionately more:cancer has disproportionately more:– Advanced diseaseAdvanced disease– Higher grade tumors within stageHigher grade tumors within stage– Less ER + tumorsLess ER + tumors– Younger women (age 35 to 44)Younger women (age 35 to 44)

SEER data 1973 to 1997SEER data 1973 to 1997

Breast Cancer PathologyBreast Cancer PathologySocioeconomic IssuesSocioeconomic Issues

Lower SES white women present with Lower SES white women present with disproportionately more:disproportionately more:– Advanced diseaseAdvanced disease– Higher grade tumors within stageHigher grade tumors within stage– Less ER+ tumorsLess ER+ tumors– Younger women (age 35 to 44)Younger women (age 35 to 44)

Gordon Am.J.Epidemiol., 1995Gordon Am.J.Epidemiol., 1995

Breast Cancer Breast Cancer Pathology and StagePathology and Stage

Social deprivation studies in Europe and U.S. Social deprivation studies in Europe and U.S. suggest more virulent tumors in the poor.suggest more virulent tumors in the poor.

Several studies suggest a correlation between Several studies suggest a correlation between higher body mass index and higher stage at higher body mass index and higher stage at presentation presentation (higher BMI can be a cultural (higher BMI can be a cultural phenomenonphenomenon).).

Cancer DisparitiesCancer Disparities

Are we asking the right scientific questions?Are we asking the right scientific questions?

Are we allowing certain questions to allow us to Are we allowing certain questions to allow us to ignore other legitimate questions?ignore other legitimate questions?

ConclusionConclusion– Its bad to have cancerIts bad to have cancer– Its worse to have cancer and be poorIts worse to have cancer and be poor

Important Questions?Important Questions?– What are the elements of poverty that What are the elements of poverty that

influence the experience of cancer and cancer influence the experience of cancer and cancer biology?biology?

– These are social science and epidemiologic These are social science and epidemiologic questions and it is crucial that it be addressed questions and it is crucial that it be addressed if we are to decrease “health disparities”if we are to decrease “health disparities”

How can we provide How can we provide adequate high quality care to adequate high quality care to a population that has so often a population that has so often

not received it?not received it?

Otis W. Brawley M.D.Otis W. Brawley M.D.

Director, Georgia Cancer CenterDirector, Georgia Cancer CenterAssociate Director, Winship Cancer InstituteAssociate Director, Winship Cancer Institute

Professor of Hematology, Oncology, and Professor of Hematology, Oncology, and EpidemiologyEpidemiology

Emory UniversityEmory UniversityAtlanta, GeorgiaAtlanta, Georgia