Racial Disparity in Lung Cancer Treatment Must Be Overcome, UCSF Specialists Assert

Preventing lung cancer is easier than curing it, and any barriers that inhibit
blacks from full access to care must be removed, emphasize two doctors at the
University of California , San Francisco.

In an editorial in the current issue (October 14) of The New England Journal of
Medicine, UCSF co-authors Talmadge E. King, Jr., MD, and Paul Brunetta, MD,
analyze study findings that suggest racial attitudes may contribute to the fact
that blacks have a higher death rate from lung cancer than whites. 
Lung cancer is the leading cause of death from cancer in the U.S. and,
overall, the five-year survival rate for the disease is 14 percent among whites
and 11 percent among blacks.

The title of the editorial is “Racial Disparity in Rates of Surgery for Lung
Cancer.”  The comments by King and Brunetta relate to new research results,
reported by a team from Memorial Sloan-Kettering Cancer Center and the National
Cancer Institute, that appear in the same NEJM issue.

The study covers surgical treatment and survival of close to 11,000 black
patients and white patients age 65 and older with early stage lung cancer. 
Results showed that blacks were 12.7 percent less likely than whites to undergo
surgical resection, and the research team concludes that if blacks were to
undergo surgery for the disease at the same rate as whites, the survival rates
for the two groups would be almost equal.

Putting these results into perspective, the UCSF co-authors note current
clinical evaluation of surgical treatment by stating, “There is agreement that
surgical resection saves lives in patients with early-stage, non-small-cell
lung cancer.”

They state further that any evidence that bias on the part of
physicians—either overt prejudice or subconscious perceptions—influences
optimum care is “disheartening because we all believe that if our loved ones
get cancer, they will receive the best care possible.”    They also add that
they don’t know if this bias exists, but “we must strive to remove any barrier”
against blacks.

The co-authors note that some of the disparity in lung cancer survival among
blacks and among whites can be explained through smoking prevalence, how the
body metabolizes and excretes carcinogenic and mutagenic agents in tobacco
smoke, socioeconomic status, and access to health care.  But these factors
account for only some of the inequities in morbidity and mortality in the two
population groups,  emphasize King and Brunetta, both of whom are experts in
pulmonary disorders. 

A specialist in lung disease, King is professor and vice-chair of the UCSF
Department of Medicine and chief of medical services at San Francisco General
Hospital Medical Center.  Brunetta specializes in lung cancer and is a UCSF
assistant clinical professor of medicine.  He also is a member of the thoracic
oncology and tobacco control programs of the UCSF Cancer Center.
In their editorial, the co-authors discuss three key areas that could impact
survival rates among blacks and whites.

* Racial differences between physicians and patients:  This difference is often
a barrier to optimal patient-physician communication and partnership.  Black
patients are more likely than white patients to feel excluded from decisions
affecting their health, and this may be an important contributor to
miscommunication.  Both black patients and white patients appear more likely
to feel involved with their own care when their doctors are of the same race,
but blacks are far less likely to have a black physician as part of their care
team, they write.
* Lack of screening tests:  There is no regular screening test for lung cancer
to enhance early detection and reduce mortality, and many blacks do not undergo
preventive screening for cancer because their physicians do not recommend the
tests.  Should effective lung-cancer screening become available, “we will
need large-scale public health initiatives to make black patients, and their
physicians, aware of its importance,” they write.
* Clinical trials:  Most of the knowledge about the best lung cancer treatments
has and will come from clinical trials.  Many blacks are reluctant to enroll in
these protocols due to the aftermath of several shameful episodes in U.S.
history, such as the Tuskegee study of untreated syphilis in a group of black
men in rural Alabama from 1932-72.  Thus, physicians making recommendations to
patients about research trials should be sensitive to these issues.  In
addition, they state,  agencies that fund cancer research should devote more
resources to maintaining adequate representation of racial and ethnic minority
groups in clinical studies and to increasing the number of minorities who
conduct research and serve on advisory panels.

In summary, the UCSF co-authors write, “If the poor statistics on survival for
the leading cause of cancer deaths in the United States are partially due to
racial discrimination that results in inadequate emphasis on prevention or
insufficiently aggressive care for blacks, then the medical establishment
begins to share a portion of the tobacco industry’s culpability for the dismal
outcome of patients with this disease.”

And they add, “Every educational, social, political, and legal effort should be
made to ensure that all patients with lung cancer receive high-quality care-
appropriate service delivered in a technically competent manner, with good
communication, shared decision-making, and cultural sensitivity.”