Black and White: A Disturbing Look at Racial Disparities in Cancer Prevalence, Outcome and Care

By in Cancer, Healthcare, Healthcare reform 1 Comment Tags: , ,

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Who Dies From Cancer?

Few things are black and white, yet when it comes to determining who will survive cancer, race may be fate. Doubt my words?  The American Cancer Society described the situation succinctly:  “African Americans are more likely to develop and die from cancer than any other racial or ethnic group.”

We are not talking about subtle differences here. We are talking about staggering variations in outcome based upon race. Death rates for prostate, cervical, and stomach cancers are more than 200 percent greater among African Americans than whites.[i] Furthermore, though breast cancer is less common among African American women, their death rate is markedly higher.[ii]

The Role of Socio-Economic Status in Determining Fate:

Socio-economic status definitely plays a role, though how large of one, no one knows for certain. We do know that “People with lower socioeconomic status (SES) have dispropor­tionately higher cancer death rates than those with higher SES, regardless of demographic factors such as race/ethnicity.”[iii]

 Presumably, a lower socio-economic status puts one at risk by: 1) reducing access to health care resources for the prevention, detection, and treatment of cancer – often resulting in patients presenting at more advanced stages; 2) increasing reliance on behaviors that may foster development of cancer, such as smoking, poor dieting, and a sedentary lifestyle; 3) delaying the onset of treatment until late in the development of the disease; 4) exacerbating co-morbid conditions through lack of adequate treatment, thus negatively impacting the person’s health and functional status.

 Lower SES also impacts the options available for care, as can be seen in a survey published in the Journal of Clinical Oncology that examined participation in clinical trials:

 The study surveyed 5,499 patients who were newly diagnosed with breast, lung, colorectal, or prostate cancer. Regardless of age, lower-income patients were much less likely to participate in clinical trials, and the trend persisted even among patients who were universally covered by Medicare. Patients who reported an annual income less than $50,000 were approximately 30% less likely to participate in clinical trials than those reporting a higher income. Looking at lower income levels, patients who made less than $20,000 per year were 44% less likely to participate in a clinical trial than patients who made more than $20,000.[iv]

We know that a disproportionate share of the lower SES population is African American. Since African Americans have a long history of being the victims of unscrupulous medical experimentation, there may be an understandable cultural apprehension about participating in such trials. But there’s more to story…of that I’m confident.

SES is Only Part of the Story:

The disparity in cancer prevalence and outcomes among African Americans transcends SES. In fact, there are factors completely independent of societal influence, such as genetics, that may help explain some of the disparity. African American women often develop forms of breast cancer that are highly resistant to treatment. This may well result from a defective gene. The same could be true of the more aggressive variants of prostate cancer seen in African American men.

 A more insidious reason for a higher mortality rate amongst African American cancer patients is that they simply don’t get comparable care to their white counterparts. The proof seems abundant:

  •  The February 15, 2008, edition of Cancer featured a study in which the authors examined care received by 143,512 Medicare beneficiaries diagnosed with malignant breast, colorectal, lung, and prostate cancer was analyzed. The investigators concluded that:
    • “There were racial disparities for 6 of the 7 cancer therapies investigated.”
    • Among women who had undergone a lumpectomy, black women were less likely to have received radiation therapy
    • Significant racial disparities were also noted for resection of lung cancer, adjuvant therapy for colon cancer, adjuvant chemotherapy and (neo)adjuvant radiation for individuals with rectal cancer, and definitive therapy for prostate cancer.
    • There was substantial variation in the unadjusted magnitude of racial disparities across cancer types. The largest disparity—about 15% difference between black and white patients—was noted among patients with early stage lung cancer, for which 76% of white patients and only 60% of black patients underwent surgical resection.”
  • “The length of time between an abnormal screening mammogram and the follow-up diagnostic test to determine whether a woman has breast cancer is more than twice as long in Asian American, black, and Hispanic women as in white women.”[v]

Discrimination in Care:

Discrimination is a blatant problem. The American Cancer Society states: “Discrimination is another factor that contributes to racial/eth­nic disparities in cancer mortality. Racial and ethnic minorities tend to receive lower-quality health care than whites even when insurance status, age, severity of disease, and health status are comparable.”

 In addition to failing to receive appropriate preventive, diagnostic, and treatment modalities, “Racial/ethnic and socioeconomic disparities also exist in cancer survivorship care. Lack of access to survivor care services is a major barrier to the health and well-being of cancer survivors who lack health insurance or who experience exclusions or restrictions on their policies.,” according to an article appearing in the February 10, 2013, edition of the Journal of  Clinical Oncology.

 African American not only fail to receive optimal cancer care, but if they are fortunate enough to survive cancer, they likely won’t receive appropriate survivorship care. If they are unfortunate enough to succumb to the cancer, they almost certainly won’t be the beneficiary of hospice services.

A 10X Difference in Hospice Care:

According to data from the National Hospice and Palliative Care Organization, 81.5% of hospice patients were white and 8.6% were African American. That’s nearly a 10X difference!  Yet, we know that hospice can make a tremendous difference in quality of life for end-stage cancer patients, as well as potential extend their survival. One could argue that some of the variation may be attributable to cultural differences in end-of-life care…but, again, I’m doubtful that tells the full story.

The facts regarding cancer prevalence and mortality amongst African Americans are black and white. The reasons behind them are shades of gray. If we are committed to an equitable health care system, it is our moral obligation not only to understand the causative factors behind the extraordinary differences in prevalence, care, and outcome, but to work assiduously to improve this situation.

 IOM’s Call to Action:

“In 2000, the Institute of Medicine convened a special panel to examine the underlying causes of racial disparities in health. The resulting book, Unequal Treatment (2003), concluded that health and mortality disparities result from many factors, including lower quality of care provided to racial minorities. Other factors include lack of familiarity with racially diverse patients at hospitals and clinics, institutional discrimination based upon health insurance status, conscious and unconscious bias among physicians, lack of cultural competence among health care providers, and mistrust of the health care system as well as language barriers among patients.”[vi]

Stepping Up to the Plate:

What have we done in the intervening 14 years to improve the situation; and what are we doing today to honor our commitment and change the fate of African American cancer victims?

 


[i]Cancer Facts & Figures for Afri­can Americans, available online at cancer.org/statistics.

 

[ii]Cancer Facts & Figures for Afri­can Americans, available online at cancer.org/statistics.

 

[iii] ACS

 

[iv] ASCO Journal of Clinical Oncology. ASCO Special Article. Clinical Cancer Advances 2012: Annual Report on Progress Against Cancer From the American Society of Clinical Oncology. J clin Oncol 31:131-161.

 

[v] Agency for Healthcare Research and Quality, “Addressing Racial and Ethnic Disparities in Health Care,” last modified April 2013, http://www.ahrq.gov/research/findings/factsheets/minority/disparity/

 

[vi] Stand Up to Cancer – Racial Disparities in Cancer: Statistics and Solutions. http://www.standup2cancer.org/article_archive/view/racial_disparities_in_cancer_statistics_and_solution

We’ve Made Great Strides in Treating Cancer, But Not Its Survivors

By in Cancer, Healthcare 2 Comments Tags: , , , ,

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From Death Sentence to Chronic Disease:

Few words are more emotionally-laden than “cancer.” It does not merely connote disease, but rather suffering and death. Fortunately, not only the perception of cancer but the reality of the disease are changing rapidly thanks to early detection and advancements in treatment that render many cancers, at worst, a chronic illness, and at best curable. Proof can be readily seen in statistics from the American Cancer Society: “The 5-year relative survival rate for all cancers diagnosed between 2003 and 2009 is 68%, up from 49% in 1975-1977.”

Of course, not all cancers have yielded to the advancements of medicine. Pancreatic cancer, metastatic melanoma, certain types of brain tumors, and other difficult diagnoses remain devastatingly difficult to treat. For some of these diseases, the differentiating variable is the stage at which they are diagnosed. Whereas there are excellent screening modalities for common cancers, such as breast and colon, other cancers, including ovarian, are often detected after they have metastasized to vital organs.

Nonetheless, the scales are tipping in favor of survivorship: “While cancer incidence is projected to almost double over the next two decades to 21.4 million new cases annually, the number of people living with a history of cancer (i.e., ‘survivors’) is expected to triple to 75 million worldwide by 2030.”

The Challenges of Survivorship:

Cancer survivors face a plethora of challenges – challenges that were unimaginable when they were originally diagnosed, and the focus was purely on ridding their bodies of the invading disease. Most patients have endured regimens in which their disease was cut-out, burned-out (with radiation), or “poisoned” (with chemotherapy). Depending upon the extent of their treatment, there may be lingering or permanent side-effects– ranging from peripheral neuropathy to heart damage. Some patients are cognitively impaired from whole-brain radiation, and many others bear deep, but invisible emotionally scars from the journey.

McCabe et al. described the medical challenge facing cancer patients as follows: “Cancer survivors are at increased risk for long-term morbidity and premature mortality, related directly to the cancer itself, to preexisting comorbidities, and to exposure to therapy.” As a result, cancer survivors need ongoing medical supervision by physicians who understand: 1) the specific treatment regimens that a patient received; 2) the outcome of these regimens; 3) the sequela of post-treatment side-effects that the patient is or may experience; 4) the patient’s prognosis; 5) the recommended screening or monitoring activities to ensure that the cancer remains in check.

Who is My Doctor?

But exactly who provides such care in today’ health system remains ambiguous, causing patients to fall through the proverbial “cracks” and not receive the care they need.  The Institute of Medicine stated that, “For patients, it can be a time of confusion both about what follow-up care involves and about which physician is responsible for follow-up care.” The IOM also proffered a solution:  “Patients completing primary treatment should be provided with a comprehensive care summary and follow-up plan that is clearly and effectively explained.” The report terms this as the “Survivorship Care Plan.”

Sounds simple and logical – the patient receives a roadmap providing “a summary of treatment and a specific detailed plan for surveillance follow-up and symptom management.” However, there appear to be four impediments preventing this vitally important step from happening: 1) oncologists are not compensated for creating such plans; 2) the short supply of oncologists limits their ability to take time away from the active treatment of patients for the construction of such plans; 3) most cancer patients receive multi-modality treatment that occurs across disparate treatment sites – necessitating consensus on the part of the multiple specialists regarding the patients’ care management plans; 4) oncologists are reluctant to facilitate transition of their patients to primary care physicians because they are less than convinced that PCPs have the clinical knowledge to properly manage cancer patients.

PCPs in Need of Respect:

In a study published in the Journal of Family Medicine, researchers found, “that a majority of PCPs perceive themselves as having an active role in the cancer-related follow-up care of survivors, most often in a co-management capacity with an oncologist. In contrast, most oncologists perceive that they directly provide cancer-related follow-up care themselves without much involvement from PCPs or other providers, a finding that parallels recent work documenting medical oncologists’ limited engagement in co-managing breast cancer care.”

A Call to Action:

Professional squabbles aside, the reality is that in fifteen years, there may be an additional 50 million cancer survivors. Just as medicine has made great strides in the early detection and treatment of cancer, now it must make comparable strides in addressing the profound needs of survivors. These hurdles to proper, ongoing care of cancer survivors must be overcome. Physicians need to be compensated for the time required to assemble detailed care plans, and primary care physicians must be appropriately educated to care for cancer survivors.

 

A Panacea for the Ills of Health Care

By in Healthcare, Healthcare reform 11 Comments Tags: , , , , ,

iStock_000026356944LargeWhat if I told you that there was a panacea to our nation’s health care crisis? Would you burst into laughter, stop reading, or simply conclude that I could not possibly understand the complexity of issues underlying our health system’s dysfunction?  After all, everyone knows that there are no silver bullets in real life.

Yet, that’s exactly what I am going to propose – there is a panacea, we are simply choosing not embrace it. Before describing the cure, let’s define the illness.

In the most basic of terms, the U.S. spends far more than any other nation on health care services, yet “enjoys” some of the worst health outcomes. We live shorter lives, have ridiculously high rates of infant mortality, and succumb to a plethora of chronic, yet preventable diseases. Here are a few, quick stats:

“In 2005, nearly half of all adults – 133 million – had at least one chronic illness. In 2009-2010, more than one third (35.7%) of U.S. adults were obese, and 8.3% had diabetes. In 2005-2008, over 30 percent had high blood pressure.”

“Health care spending represented 17.9% of our gross domestic product (GDP) in 2010, and is expected to reach 20 percent by 2020. Three quarters of these costs go to treat chronic diseases, which in many cases are preventable.”

“According to the IOM’s 2012 report…an estimated 80 percent of cases of heart disease and of type-2 diabetes, and 40 percent of cases of cancer, could be prevented by implementing public health interventions that increase physical activity and healthy eating and help reduce tobacco-use and excessive alcohol use.”

We Stand to Save as much as $1.1 trillion annually:

According to a research published by the American Public Health Association, “By investing in prevention and treatment of the most common chronic diseases, the U.S. could decrease treatment costs by $218 billion per year and reduce the economic impact of disease by $1.1 trillion annually.”

Jim Fries’ Contribution:

These are not stunning, new revelations. The July 17, 1980, issue of the New England Journal of Medicine featured a landmark article by Jim Fries, a professor of medicine at Stanford University. The article became one of the most frequently cited scientific references in the emerging field of wellness. Fries focused on the impact of chronic disease, which he described as follows: “Chronic illness now is responsible for more than 80 percent of all deaths and for an even higher fraction of cases of total disability.”

The power of Fries’ article, however, lies in his conclusion: “Disability and lowered quality of life due to the most prevalent chronic diseases are thus inescapably linked with eventual mortality. These chronic diseases are approached most effectively with a strategy of “postponement” rather than cure. If the rate of progression is decreased, then the date of passage through the clinical threshold is postponed; if sufficiently postponed, the symptomatic threshold may not be crossed during a lifetime, and the disease is “prevented.”

Fries is stating that, while we cannot escape the human condition, by taking care of ourselves, we can stay vital, active, and healthy until the very twilight of our life. We can “compress morbidity” – thus reducing the disease burden, costs, and impact on our quality of life.

A Pittance of an Investment in Wellness:

So what level of investment are we making in prevention/wellness? “In 2009, U.S. public health pending amounted to $76.2 billion – only 3.1 percent of the nation’s overall healthcare expenditures of $2.5 trillion.” Granted, the Affordable Care Act (ACA) provides additional funding for prevention/public health initiatives– but a few more billion dollars, though significant, pales by comparison to our burgeoning health care tab that now exceeds $2.8 trillion.

Perhaps even more significantly, ACA may have stifled many embryonic efforts by providers to implement more robust wellness offerings. Like deer in headlights, most providers are responding to ACA by trying to eviscerate costs – not expand wellness programs for which there is little to no direct reimbursement.

Hospitals and the Wellness Sham:

Furthermore, while hospitals and health systems may preach wellness, few offer comprehensive services designed to improve your health and well-being. Rather, they pay lip-service to this essential component of health care – viewing wellness more as a marketing opportunity than a true effort to do everything in their power to minimize unnecessary and costly utilization of their medical services.

There’s no surprise here, since the dominant reimbursement mechanism, fee for service, rewards the provision of medical services – not maximization of the health of a defined population. As a result, we pay a very dear price.

From Sick-care System to a Positive Health System:

It is possible to shift from a sick-care system that doles out interventions to manage the burden of chronic illness to a positive health system, focused on wellness/well-being system, that minimizes unnecessary utilization by focusing on population health. However, it would require tremendous will on the part of numerous constituents to achieve such a powerful transformation. 

Far short of transformational change, there are nonetheless small seeds of hope in the form of new, evolving reimbursement and delivery models, such as ACOs and medical homes that stress population health management. Unfortunately,  the pace of adoption is glacial. For providers who have been burned in the past by assuming risk for a defined population, there’s little enthusiasm for doing so again.

Our Role in Changing the System:

More than three decades ago, Jim Fries gave us one of the keys to healing American health care…a silver bullet. The question is whether we have the fortitude to change the health care paradigm, as well as accept the personal, stewardship responsibility for our health that is essential to success. If so, there’s a role for each of us to play:

Consumers/patients:  We need to understand what it means to be prudent stewards of our health, and the health of our families. It is essential that we understand the role lifestyle choices make in determining our health, and how we might combat risk-factors that imperil our future. For many of us, we will need to have access to resources that will aid in this journey – particularly if we are socio-economically challenged, and thus find lifestyle change all the more difficult. As has been well-demonstrated, the social determinants of health play a profound role in wellness and well-being.

Providers: Health care executives need to take the moral high-ground and do the right things for the communities they serve. One place to begin is with the development of a strategic wellness plan illustrating how wellness initiatives can be integrated into the very fabric of your hospital or health system’s care model. Once developed and implemented, you can then reasonably assert that you do everything possible to minimize unnecessary consumption of health care resources while maximizing the health and well-being of your patients.  

Insurers/Payers: There needs to be an unremitting pressure to partner more fully with providers on the assumption of risk for the health and well-being of a defined population…thus accelerating the demise of fee-for-service medicine, and its replacement with a reimbursement mechanism that rewards wellness.

Employers:  There needs to be broader adoption and implementation of wellness programs that incorporate proven mechanisms for elevating the health and well-being of an employed population. Such programs will likely involve potent incentives for lifestyle modification by those employees at risk. Expect the providers within your network to make two promises: 1) They will do everything in their power to help keep your employees healthy and out of their health system; 2) when medical care is needed, they will provide the highest value care as measured by agreed upon standards of quality, safety, and costs.

Government:  There needs to be dramatically increased spending on proven prevention programs that can be administered at a local, state, or federal level. Furthermore, there need to be greater rewards under governmental reimbursement programs for those providers who embrace risk and demonstrate their ability to reduce the morbidity of a defined population.

Out on a Limb:

Panacea, silver bullet, and transformational change – these are powerful, almost Pollyanna-ish words to use in a serious article about health system change. Yet I’m convinced that this change represents our path to salvation, if we are willing to make the arduous journey.

A blog will never do justice to a proper articulation of the wellness argument, but hopefully it is a start. I welcome your thoughts!

 

Obamacare Distracts From the Real Issues Plaguing Healthcare

By in Healthcare, Healthcare reform 1 Comment Tags: , ,

Caduceus Medical Symbol chromeThe calamitous launch of the Obamacare web-site has been an embarrassment to the administration, and a rallying cry for Republican opposition to the landmark legislation.  Yet, within short-order, even detractors acknowledge that the web-site will be fixed, the vitriolic rhetoric will subside, and Obamacare, however flawed, will become part of the national healthcare landscape.

The real danger of Obamacare is not so much what it does, but what it fails to do.  After all, improving access to care for millions of Americans would seem to be a good thing in a wealthy, developed nation…unless that access is to a fundamentally dysfunctional system desperately in need of meaningful reformation.

Our system is terribly broken, and Obamacare, despite its 2,000+ pages of text, fails to address the core issue plaguing American healthcare – the issue of insatiable greed. While pundits pontificate on Obamacare’s failure to launch, our nation is spending more than $7 billion per day to fund a bloated, dysfunctional system that, at times, seems to exist more to line the pockets of the few, than to meet the health care needs of the many.

Greed has driven our nation’s healthcare bill from a paltry $12.7 billion in 1950 to $2.7 trillion in 2013. It has catapulted healthcare to the top of the hit parade relative to GDP expenditures…accounting for approximately 18 percent of our nation’s gross domestic product.

 Greed versus Value

Yet despite the escalating costs of care, we pale by comparison to other nations in the value our system delivers.  Just ask Arnold Relman, M.D., Editor Emeritus of The New England Journal of Medicine, who opined::  “Considering that we spend so much more on medical care than any other advanced country, we ought to expect health outcomes to be at least as good, and our citizens ought to be at least as satisfied with the system. But we can claim neither.”

After spending thirty years working within the healthcare system, I can attest to the fact that the American healthcare system is without peer when it comes to creating wealth for certain stakeholders.  You need look no further than the profits of the pharmaceutical, biotech, and medical device manufacturers for proof.

The real question we should be asking is: Why does our society allow an unparalleled level of profiteering to occur within the healthcare industry? Why should we pay $10 for an aspirin and $500 for a bottle of saline (saltwater) when we are hospitalized?  Part of the answer can be found by looking at the strength of the medical-industrial complex.

The Medical-Industrial Complex

The first reference to the medical-industrial complex was made more than 30 years ago by Barbara Ehrenreich. Ehrenreich borrowed a potent phrase from Eisenhower’s 1961 farewell address to the American people, in which he warned of the dangers of the growing “military-industrial complex:”

This conjunction of an immense military establishment and a large arms industry is new in the American experience. The total influence — economic, political, even spiritual — is felt in every city, every State house, every office of the Federal government. We recognize the imperative need for this development. Yet we must not fail to comprehend its grave implications. Our toil, resources and livelihood are all involved; so is the very structure of our society.

In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.

As is evident from this quote, Ike did not merely coin the term, but also admonished the American people to be wary of the growing clout of the military-industrial complex.

The very abuses that Eisenhower envisioned occurring within the military-industrial complex are today rampant within the medical-industrial complex. Such abuses drive-up costs of our care at the expense of quality and accessibility.  Proof is rampant. Here’s a teaser:  According to a report published by OpenSecrets.org: “Total annual lobbying in 2012 for pharmaceuticals and health products, which includes: medical products, dietary and nutritional supplements, etc. = $234,104,389.” What kind of influence does $234 million buy one?

When will we take off our blinders and redirect our focus from the red herring that currently taunts our highly divisive politicians, and instead focus on an issue desperately in need of a solution – the issue of rampant greed?

Until then, we will continue to be mired in political rhetoric regarding our current attempt at healthcare reform that has little to do with true reformation of the delivery system.

 

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