The Color of Cancer: Time for a Change

In New York City, where I live, life-expectancy is 7 years shorter for Black people (73 year life span) than for white people (80 years) and cancer is one of the leading causes of premature death – according to the City’s Vital Statistics records in their most recent summary. Too many Black lives are cut short, in many cases by cancer, documented by me and others over the years in our public health research.

This was not always the case in the past, but as advances in cancer screening and care came out, not everyone benefited equally.

Where are we going wrong?

Some cancer death rates have been decreasing over the years, but a closer look shows they are still higher for Black people all across the country. In NYC, research I did with others showed that Black women lose their lives to breast cancer at significantly higher rates, are diagnosed at younger ages, and at later stages of cancer disease than other women here. We showed the same racial inequalities in colon cancer.

Why does the stage of disease matter so much for people with cancer?

It’s crucial. When diagnosed with early stage breast cancer the 5-year relative survival  of women is 99%, but it is only 30% when diagnosed at a late stage. In my mother’s case, survival was only a few short months. So that makes a world of difference.

Many other types of cancers show the same grim statistics. This was as true a decade earlier as it is now, as a City Health Department report documented.

What have we done to change these injustices here?

Cancer should not have a color, but it does.

The inequities are not a matter of race, but of racism, according to current thinking. When healthcare systems provide equal cancer care, research shows time and again that outcomes are no different for Black patients than for anyone else. But to reach equity here would take changes in healthcare systems and policies driving cancer prevention and care.

New policies here would surely be welcome by the NYC Board of Health – who made a Declaration of Racism as a Public Health Crisis.

In NYC, where 23% of the population are Black, cancer health equity would mean attainment of the highest level of cancer prevention and lowest level of cancer disease and death for all City residents, where no one is disadvantaged because of their social position or other socially determined circumstances.

Can we get to cancer equity from where we are now?

Root causes of cancer inequities are thought to stem from a long history of structural racism in NYC – health policies, healthcare structures, healthcare access, quality of care, and neighborhood disinvestment – which together placed the heaviest cancer burden on people of color.

Revised policies prioritizing improved care for the people most at risk for cancer deaths could relieve that burden.

Because social inequities and racism exacerbate mortality, City policies could consider these effects when evaluating a person’s cancer risk and providing their cancer care. Currently, policies don’t.

Screening for cancer younger saves lives.

Take cancer screening, as a start. Evidence from decades of research has proven cancer screening saves lives – a mainstay of preventive medicine today. Screening recommendations for doctors changed to advise that they start screening patients younger for both colon cancer (now age 45) and lung cancer (now age 50) recently. But the guidelines for cancer screening used by healthcare systems and in health policies do not consider the lethal effects of racism at all. City screening recommendations could.

Screening is vital to detect a person’s cancer at early stages of disease. This increases chances of a person surviving from all of the top 4 cancer killers: lung, breast, prostate, and colorectal cancers. Yet for lung cancer, the #1 leading cause of all cancer deaths, New York healthcare systems and providers have reached only 6% of eligible people who smoke with screening (low-dose CT, which is a free, 30-second scan). So 94% of people don’t get screened.

That leaves out a lot of people.

What’s more, published studies show some healthcare systems refer proportionately less of their Black patients who do actually qualify for screening, than other patients. People who don’t get the referral, can’t get screened.

The City could explicitly prioritize increased screening in neighborhoods that have the highest cancer death rates and among Black New Yorkers. And because they are dying younger, policy could also recommend healthcare providers refer their Black patients for screening at younger ages. These kinds of changes could be made by revising cancer screening policies used at City hospitals and by the City Health Department; based on the current local evidence.

The largest racial disparities known in cancer are in people with prostate cancer.

Increased screening for Black New Yorkers could prevent excess prostate cancer deaths, too. These are the widest cancer racial inequities known, and prostate cancer is the second leading cause of cancer death among men (first among nonsmokers).

Healthcare providers diagnose prostate cancer at later stages of disease in Black men than others, and Black men die from it at twice the rate of white men. This is largely not due to any biological differences, but in lifelong experiences of social determinants of health. Prostate cancer screening with a simple blood test to detect prostate specific antigen (PSA) levels increases survival. The screening does not reach many of the Black men who are most at risk.

Setting Citywide screening policies in Gotham that prioritize PSA screening in neighborhoods with the highest death rates, and among Black men, and screening them at younger ages, could help close the racial mortality gap.

Excess Black lives are lost to cancer each year and people are dying unscreened.

The color of cancer is unlikely to change by telling the general public to “ask your doctor” about screening. As a friend of mine in the nonprofit world recently said to me, it doesn’t help to tell someone to talk to their doctor, if their doctor doesn’t talk back to them. You need the referral in order to get screened.

Equity will more likely require demands for change in healthcare policies and their enforceable regulation.

Policy change takes time.

Meanwhile, all of us, including healthcare providers, public health professionals and community leaders can certainly raise awareness within our families and our organizations of the pressing need for increased screening and cancer health equity.