The Impact of Health Disparities on Clinical Outcomes for Patients with Cancer

TON - August 2021 Vol 14, No 4

Over the past 2 decades, the number of cancer deaths per 100,000 blacks has declined approximately 30% in the United States, but black people are still disproportionately dying of cancer. In certain cancers, for example, there is a greater than 2-fold increase in the incidence and rate of deaths of blacks compared with whites in the country. At the 2021 Hematology/Oncology Pharmacy Association conference, 3 experts described existing disparities in cancer care, summarized structural and social factors that perpetuate racism as a risk factor for cancer-­related death, and provided a framework for mitigating racial disparities in cancer care using evidence-based interventions.

Several socioeconomic factors contribute to health disparities in cancer care, according to Maurice Alexander, PharmD, BCOP, CPP, Clinical Pharmacy Manager, Hematology/Oncology Clinical Services, University of North Carolina Medical Center. For example, blacks are 3 times more likely to have a household income below the federal poverty line than whites, twice as likely to be uninsured, and have a lower level of education compared with whites.

“Impoverished and uninsured individuals are more likely to be diagnosed at a later stage, and less likely to receive optimal therapy, and the cancer mortality rate is 3 times higher for non–college educated men,” Dr Alexander explained. “All of these factors contribute to worse cancer outcomes for blacks compared with whites.”

Genetics versus Racism

Benyam Muluneh, PharmD, BCOP, CPP, Assistant Professor, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, emphasized the need to shift from thinking about race as a risk factor to considering either genetics or racism as the root causes for the disparities in cancer outcomes.

Race is a way of grouping people based on what they look like, whereas genetics is a branch of biology that deals with the heredity and variation of organisms. Although there may be some intersection between race and genetics, Dr Muluneh said, these are very different concepts. Racism, by contrast, is based on the belief that race is a fundamental determinant of human traits and capacities, and that racial differences produce an inherent superiority or inferiority of a particular race.

“Instead of race, I propose that we push ourselves to ask, what is the difference [in cancer outcomes] stemming from?” said Dr Muluneh. “Is it stemming from truly genetic differences, or is it stemming from racism?”

Race is a social construct, Dr Muluneh said, and it is often a poor substitute for genetics. It has been documented, for example, that black women with triple-negative breast cancer (TNBC) have worse clinical outcomes than white women with TNBC. According to Dr Muluneh, there are several TNBC-related risk factors that affect black women. Poor access to healthy nutrition contributes to increased risk for obesity, and lack of knowledge, lack of social support, and lower socioeconomic status contribute to reduced breastfeeding rates at 3 months.

“Although black women develop TNBC at higher rates, it’s important to ask ourselves ‘why do these disparities exist in TNBC clinical outcomes?’” said Dr Muluneh. “A lot of the structural racism in society is likely contributing to some of the clinical outcomes that we see.”

Closing the Gap

To mitigate disparities in cancer care, antiracist work must happen on every level of structural inequality, including individual, institutional, and societal/cultural levels, said Britny Rogala Brown, PharmD, BCOP, Clinical Assistant Professor, University of Rhode Island College of Pharmacy, Kingston.

At the individual level, people must take responsibility to deepen their awareness of structural racism and its impact on our patients and communities over time. For individual actions to have their greatest impact, however, institutional support is critical.

Dr Brown listed the following institutional priorities to combat racism in cancer care:

  1. Increase workforce representation and foster and maintain safe spaces for diverse individuals
  2. Create and support Chief Diversity Officer positions, with antiracism as a priority
  3. Review and revise organizational policies and mission statements from a diversity and equity lens
  4. Engage patients and communities in antiracism work
  5. Adjust patient-facing care to counteract racism
  6. Encourage and support research related to antiracism work.

Finally, at the societal/cultural level, Dr Brown underscored the need for continued advocacy for antiracist training. It is also important, she noted, to prepare future pharmacists to engage in the care of underrepresented groups with cultural humility.

“To err is human, but ignorance is not bliss,” Dr Brown said. “We must foster a space where reporting racist acts, systems, and policies is seen as a necessary opportunity for growth,” she emphasized.

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