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Cancer in America

Standard of Care

Research suggests that black patients, as a whole, aren’t receiving the same level of treatment as white patients. Can building better bonds between doctors and patients help? Story by Charlotte Huff & photos by Doug Sanford

In 2009, Phyllis L. Fouse, a retired teacher's aide who had just been diagnosed with leukemia, was praying hard for strength before meeting with her oncologist about her blood work.

And the spirit of God spoke to me and said, ‘You can make this journey as long as you know I'm on your side.’” she recounts. “And I said, ‘A journey?’” The 72-year-old, who is quick to laugh, cracks up as she shares the memory.​

“I knew that it wasn’t going to be overnight—OK?”
 
Fouse was right: The treatment path for this mother of four from Columbus, Ohio, wouldn’t be short or easy. Her regimen, part of a clinical trial, involved the chemotherapy drug Fludara (fludarabine) and the drug Rituxan (rituximab). At one point, she developed sepsis—a severe bacterial infection—and required intravenous antibiotics. She completed only four of seven prescribed rounds of treatment for her stage IV chronic lymphocytic leukemia (CLL) before signs of toxicity, including worrisome liver-function results, caused her treatment to be cut short.
 
But Fouse experienced “a wonderful response” to even this abbreviated version of the clinical trial regimen, according to William J. Hicks, her oncologist and a professor at Wexner Medical Center at the Ohio State University in Columbus. By late 2010, Fouse was declared in clinical remission, after bone marrow and other tests found no signs of leukemia.
 
The prognosis for Fouse, who is black, is encouraging so far. What’s discouraging is that other black patients don’t share her outcome often enough, according to national data. Part of the problem, says Hicks, is that not all patients are provided the best medical options, including information about clinical trials, and walked through the complexities of each option. A series of recent studies adds to the growing evidence that stubborn survival differences between black patients and white patients stem from more than differences in biology or delays in diagnosis: For reasons that doctors and researchers are still trying to unravel, treatment patterns among the two racial groups don’t match up.
 

Survival and Treatment Differences
The survival gaps among cancer patients of different races can be stark and sometimes substantial, according to an article published in the Journal of the American College of Surgeons in 2010, which reviewed National Cancer Institute survival data, along with research that examined treatment differences between blacks and whites. For 10 common cancers, the five-year survival rates were higher for whites than for black patients, according to the analysis of data spanning 1995 to 2003.

Notably, the biggest racial survival gaps tended to be associated with cancers for which standard treatments most improve patients’ prognoses—suggesting that better care might have made a difference. For uterine, breast and colorectal cancers, the five-year survival rates of white patients exceeded those of black patients by wide margins: by about 25 percentage points for uterine cancer, 13 percentage points for breast cancer and 10 percentage points for colorectal cancer. In comparison, the survival differences were much narrower, 3 percentage points or less, for lung, liver and pancreatic cancers—diseases for which standard treatments have a smaller impact on survival.
 
Some cancers can be more aggressive in blacks, says Arden M. Morris, a colorectal cancer surgeon at the University of Michigan Medical School in Ann Arbor, who led the study. “That partially accounts for the survival disparities,” she says. “But [it] certainly does not account for the majority of the survival disparity between blacks and whites.” Based on their analyses, she and her colleagues believe that larger influences may include the fact that black patients are less likely to receive surgery or chemotherapy, and they are more likely to be treated at lower-quality hospitals. 

Several other recent studies, which focused on specific cancers, have struck a recurring theme: Black patients are less likely than whites to receive recommended treatment.
 
Lung cancer: One analysis, which looked at the surgical rate in early stage non-small cell lung cancer, found that 66 percent of white patients underwent surgery compared with just 55 percent of black patients. Moreover, black patients with two or more significant medical conditions, such as congestive heart failure, were highly unlikely to be rolled into the operating room—just 13 percent had surgery compared with 39 percent of white patients in similar health, according to the 2010 Journal of the American Medical Association (JAMA) study, involving 386 patients.
 
Breast cancer: Older white patients are more likely to receive radiation, the standard treatment, following breast-conserving surgery for invasive breast cancer, according to a study published in 2010 in the journal Cancer. The results, based on an analysis of Medicare data from 2003, found that 74 percent of white patients age 65 or older underwent radiation compared with 65 percent of black women of the same age.

Colorectal cancer: Not only are white individuals more likely to survive longer after a colorectal cancer diagnosis, regardless of their tumor’s stage at diagnosis, but that survival gap has widened over time, according to a 2010 American Journal of Public Health (AJPH) analysis of survival rates from 1960 to 2005. In the 1970s, a 60-year-old white man with localized colorectal cancer would have lived only a year more, on average, than his black counterpart. By the early 2000s, that survival gap had stretched to 2.7 years.
 
Given that screening and treatment for colorectal cancer have improved, more so than for many other cancers, it’s important to understand why those advances have been slow to reach black patients, says Samir Soneji, a statistical demographer based at the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., who led the AJPH study. “The same things that have happened and may happen with disparities in colorectal cancers are going to happen with other cancers,” he adds, “when we start getting more effective screening.”
 
Closing the Gap
Samuel Cykert, who led the JAMA lung cancer study, chose to investigate which patients underwent surgery for early stage tumors because the medical benefit, he says, is clear-cut. “If you don’t have surgery, the odds are that you are going to die sooner,” he says. Interestingly, black patients who said they had a regular primary care physician were more likely to go under the knife. Perhaps, he speculates, that’s because the family physician might intervene if the patient vacillates.

Cykert’s data are just one potential example of the benefits of having a strong connection with your doctor. Yet, developing such a bond may be harder for black patients, who more often sit across a desk from a doctor of a different racial background. Nationally, nearly 13 percent of Americans are black, according to 2010 census data, but among physicians, fewer than 5 percent identify themselves as black, according to the most recent American Medical Association survey data. 
 
Cykert, a physician and professor at the University of North Carolina School of Medicine in Chapel Hill, recommends that physicians be honest with themselves about their own perceptions, whether they are related to race or income or educational status. “As we teach medical students and young physicians,” says Cykert, “we have to almost teach a paranoia that you have to think, ‘Are the decisions I’m making the same no matter where someone comes from?’”

Hicks is on the same page. “We need to make sure that all [doctors] understand that we all have subtle biases that we may not even be aware of or willing to acknowledge,” he says. “We need to do whatever we can to put ourselves in the life or the lifestyle of this other individual.”
 

03/29/2012
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