Disparities in cancer detection, treatment cost lives -- June 2002 -- FP Report

June 2002 • Volume 8 • Number 6

• Cancer & the FP •

Disparities in cancer detection, treatment cost lives

BY CINDY McCANSE & SHERI PORTER

" Life's not fair!" You've heard that expression so often that it just seems trite. But when it comes to health, no other truism says it better. For if you're born into life with brown skin or almond-shaped eyes -- or any of a number of other gene complements -- you might be more likely to suffer from certain diseases. And you might get less effective care.

Study after study has demonstrated that health disparities exist among specific patient groups. The phenomenon is twofold: Certain diseases occur more often in certain racial and ethnic populations, as well as in people in the lower socioeconomic tiers. And disparate levels of care are accorded these different groups.

EXTENT OF THE PROBLEM

These disparities involve numerous chronic and acute health conditions, including many types of cancer. A few statistics help illuminate the extent of the problem:

The Agency for Healthcare Research and Quality reports that Vietnamese women develop cervical cancer at nearly five times the rate white women do, yet according to 2001 data from the Common-wealth Fund, Asian-American women were the least likely to have had a Pap test in the past year.
National Cancer Institute data reveal that although the overall incidence of breast cancer in African-American women is lower than in white women, age-adjusted mortality from breast cancer is higher in African-Americans because the disease is often not detected in these patients until it is advanced.

NO EASY FIX

Unfortunately, there's no easy fix, said M. Norman Oliver, M.D., of Charlottesville, Va. Oliver, assistant professor of family medicine and director of the Center for Improving Minority Health at the University of Virginia, Charlottesville, recently presented "Racism and Racialism: The Impact on Cancer Disparities in America" at a conference on reducing health disparities. He advocates a systemic approach to the problem.

"Those cancers that you could directly relate to some sort of genetic difference actually make up only a small portion" of the overall cancer picture, said Oliver. "It's more than the genetics; it's more than the individual practices. It goes well beyond what the individual physician can do. It's changing policy. When you look at racial and ethnic disparities, you'll find that although some of these cancers do occur more frequently in certain groups, it's much more likely that they're related to social factors."

Lack of access to care, suboptimal nutrition and exercise practices, and difficulty in establishing rapport with health professionals are some of the factors Oliver cited.

LONG-TERM SOLUTIONS

Some physicians feel that one way out of the disparity-of-care quagmire is to get more minority physicians into practice.

Diego Osuna, M.D., M.P.H., agrees with this viewpoint. He's medical director of Latino services at Colorado Kaiser Permanente and a senior instructor at the University of Colorado Health Sciences Center in Denver, and is a frequent participant in AAFP's e-mail discussion group on minority health issues. In a recent interview, he cited these reasons:

Research from the Robert Graham Center in Washington indicates that minority physicians are more likely to practice in settings with higher rates of minority patients. (To request the Robert Graham Center research paper, "Hispanic Versus White, Non-Hispanic Physician Medical Practices in Colorado," e-mail policy@aafp.org and supply the article title and your address.)
Many minority physicians speak a second language, such as Spanish -- and when physician and patient speak the same language, communication is improved.
Minority physicians understand cultural nuances they share with their patients. In his own Hispanic culture, Osuna said, the concept of time is relational rather than linear: "When I ask a patient how long she's had abdominal pain, she might answer, 'since my child went away to college.'" Osuna knows it's important that he acknowledge how the pain is related to that event in the patient's life. "But then I go one step further by saying, 'I need to know how many months or days,'" he said.

"When a Hispanic patient sees a Hispanic doctor, there's a certain amount of inherent trust," said Osuna. The shared background means the patient is more likely to share critical health information.

Osuna said he'll soon be serving on the admissions committee for the University of Colorado School of Medicine, Denver. He encouraged other minority physicians to do the same. "Often, they (admissions committees) are seeking input from practicing physicians who recognize the worth of minority applicants," he said.

But Joshua Freeman, M.D., chair of the family medicine department at the University of Kansas Medical Center in Kansas City and another participant in the e-mail discussion on health care disparities, wrote that the problem goes deeper. "The committee can only admit who applies," he said. When Freeman served on the admissions committee for the College of Medicine at the University of Illinois at Chicago, he saw a shortage of qualified minority applicants. "That's where pipeline programs in colleges, high schools and middle schools become critically important," he said.

(For more on recruiting minorities, see "The Color of Medicine: Strategies for Increasing Diversity in the Workforce" at http://www.commmunitycatalyst.org/index.php3?fldID=143.)

CONTINUITY COUNTS

Another tool for lessening disparities is continuity of care. "Screening for cancers is greatly improved when patients have a usual source of care," Oliver said. It's not so much a matter of looking for particular conditions in particular patients. Instead, continuity of care facilitates detection of cancer at an early, more treatable stage. "You'll see patterns when you're doing the family history. Patients who have a significant history -- like having four relatives with breast cancer -- those are the ones you really want to discuss this with," he said.

"Practices vary in their racial and ethnic makeup, and the evidence shows that FPs are quite good at providing screening for their racially and ethnically diverse patients," said Oliver. "We have to continue to emphasize this general clinical attitude of doing thorough preventive screening in all patients."

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