Combatting Cancer Health Disparities

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by Mona S. Jhaveri

Cancer is the leading cause of death worldwide. The World Health Organization reported nearly 10 million cancer deaths in 2020. Cancer statistics say the most common cancers that lead to fatal outcomes:

  • Colorectal cancer

  • Lung cancer

  • Stomach cancer

  • Liver cancer

  • Breast cancer

The connection between socioeconomic status (SES) and cancer remains a vital public health issue. Differences in survival rates of cancer treatment have been observed across the globe; studies have established that patients of lower socioeconomic status have a higher cancer mortality rate (higher risk of death from cancer).

“The connection between socioeconomic status (SES) and cancer remains a vital public health issue.”

Low SES is connected to lower screening rates, poor access to high-quality care, lower treatment adherence, and delays in treatment after diagnosis.

This blog post will further explore how SES can impact cancer survival times and what can be done to improve this.

People with low incomes are more likely to encounter obstacles on their path to obtaining quality health care. The variables for this are multifold and cannot be universally applied to all low-income individuals:

  • Lack of health insurance

  • Long travel distances to screening sites or medical facilities

  • Lack of transportation to a medical facility

  • No paid medical leave

  • Lack of clean water or air potentially increasing cancerogenic accumulation

There is a strong inverse association between household income levels and life expectancy after battling cancer. There are many reasons to explain this. For example, households with low-income levels are likely located in neighborhoods that lack safe areas for exercise, affordable healthy food options, and safe infrastructure. So too, access to clinics and state-of-the-art cancer screening tools are likely underrepresented in low-income areas. As a result, residents of these disadvantaged neighborhoods are more likely to lead inactive lifestyles, have poor diets, and not get routinely screened for major cancers, such as breast cancer, colon cancer, and testicular cancer, where early detection could improve survival outcomes.

Unfortunately, too many individuals of low-income circumstances present at a later stage at diagnosis, when it is too late to treat it effectively. This late stage disease diagnosis drastically increases their risk of mortality which could have been averted if their cancer had been discovered earlier.

There is an inverse relationship between cancer mortality rates and level of education. This correlation is the most pronounced between those with 12 or fewer years of school education compared to those with more than 12 years of schooling. Therefore it is not surprising that less schooling too often leads to worse outcomes in cancer cancer and treatment.

The main reasons for that are the following:

Lower education is often associated with lack of awareness on the importance of cancer prevention and screening. Low education levels are too often associated with a lack of awareness of known cancer risk factors. Area-based studies have shown that individuals with higher levels of education are more likely to reduce or avoid cancer risk factors such as lack of physical inactivity, smoking, high fat and calorie diets.

Interestingly, breast cancer patients are the exception to this trend in the United States and Europe. Experts found that European women and American women with higher educational levels (or of a higher SES in general) have a higher risk of developing and dying from breast cancer than women of lower SES and levels of education. This positive correlation between breast cancer incidence and mortality and higher education and SES has been attributed to reproductive behaviors. Women of higher education and SES tend to give birth to their first child later in life than women of lower SES. Later births (or no childbirth) are considered to be risk factors for breast cancer.

That said, this correlation between later births and a higher incidence of breast cancer has been diminishing in recent years, especially in the United States, Finland, and France. More frequent breast cancer screening, earlier detection, and high-quality treatments have contributed to increased breast cancer survival rates in women of higher SES.

Race is not considered a socioeconomic characteristic. That said, in the United States, race can greatly impact the socioeconomic status of an individual. It has been well established in the United States that compared to non-Hispanic Whites, ethnic and racial minorities have lower educational status, higher rates of poverty, and less access to proper healthcare coverage. African Americans and Hispanics/Latinos are more likely to live in low-income areas and be exposed to lower quality air and water that may ultimately lead to poor health and disease.

“Out of all racial and ethnic groups in the United States, careful analysis has shown that African Americans have the highest mortality rate from all types of cancer combined.”

Out of all racial and ethnic groups in the United States, careful analysis has shown that African Americans have the highest mortality rate from all types of cancer combined. Even when poverty level is accounted for, African American individuals have a lower 5-year survival rate compared to non-Hispanic Whites.

The correlation between racial and ethnic disparities as a function of life expectancy may stem from a variety of social issues including:

  • Institutional racism in the US healthcare system

  • The conscious or unconscious bias of healthcare providers

  • Mistrust of the health care system by the patients of ethnic/minority descent

The impact of socioeconomic status on cancer care and survival of patients has been categorized into three groups: structural barriers, healthcare provider bias, and patient hesitancy.

Structural barriers can influence the quality and availability of cancer care. These include large geographical distances to a treatment or medical facility, no health insurance or other type of financial support for health services, and poor access to transportation.

Physicians are normally trained to provide patients with sound recommendations according to the severity of the patient’s disease. However, too often physicians offer treatment advice based on non-clinical care factors that have nothing to do with the stage of the disease, comorbidities, or other prognostic factors. Physicians, for example, may offer inadequate advice to patients if they believe that patients will not comply or will not pay for their service, or if physicians are simply influenced solely by the patient’s race, ethnicity, or socioeconomic status.

Patient characteristics such as hesitancy can contribute to poor survival rates of patients battling cancer. The source of hesitancy from patients is often due to their:

  • Inability to navigate the medical system

  • Distrust of conventional health care

  • Narrative of fatalism

  • Lack of a trusted provider due to negative interactions with previous physicians

Addressing all of these socioeconomic disparities is not a simple task. The first step in the right direction is raising awareness of inequalities in both care and mortality rates in patients of lower socioeconomic groups. The second one is strengthening federal programs and public health strategies to reduce these differences in cancer care and survival outcomes.

In 1991, CDC introduced the National Breast and Cervical Cancer Early Detection Program aimed explicitly at uninsured, low-income women. In 1999, the same organization founded the Racial and Ethnic Approaches to Community Health (REACH) program to reduce health disparity in six crucial segments, including breast and cervical cancer screening.

While these initiatives are bold, they unfortunately only reach a fraction of their target audience.

More needs to be done to address the disparities in survival rates that occur due to socioeconomic differences. This requires policy changes initiated by nonprofit organizations, governments, and private individuals in an effort to overcome racial, social, and institutional inequalities in cancer care. It is vitally important to expand programs on cancer awareness tailored for different cultures and languages and promote change in health behaviors in groups that are high at risk.

Overall, patients have disproportionately large odds of receiving poor treatment or no treatment if they endure multiple risk factors due to poor SES, regardless of the type of cancer diagnosis. Sadly, it is well documented that patients with five or more SES-influenced risk factors have a significant chance of not receiving the same treatment in cancer care as a patient from an upper SES, such as those who live in an urban residence with private insurance, and higher income. Even patients with one SES-related risk factor are more likely to survive cancer than patients who are disadvantaged with five or more SES-related factors.

Cancer disparities are too often the source of inadequate physician recommendations, patient hesitancy, and structural barriers due to living in neighborhoods that offer poor infrastructure and lack of access to key healthcare needs. Multidisciplinary policy changes and efforts to raise awareness of different types of cancer and their risk factors in low SES populations will be key to reversing the trend of socioeconomic status as an influencer of cancer treatment and cancer outcomes.

Find out how you can contribute to the still ongoing war against cancer. Here is a list of cancer research campaigns you can donate to ensure a better future for all.

Mona S. Jhaveri, Ph.D. is Founder and Executive Director of Music Beats Cancer, where this article first appeared.