Cancer and Inequality
The #2 killer in the country is devastating Black Americans and citizens in the Rust Belt
Cancer killed 600,000 people in America last year. Low-income communities and racial minorities have much higher cancer mortality rates than wealthier, Whiter individuals.
Virginia has 4 of the 6 worst counties for rates of cancer death in the country. Galax City, Virginia has the worst cancer rates at 1 out of 50 deaths, nearly 4x the US cancer average. The median household income is $35,000, 2x the national poverty rate. The county was home to the Vaughan-Bassett Furniture Co for 91 years, the largest employer in the region, before it closed its doors in 2014. Research from FiveThirtyEight explains that a lack of treatment options in Virginia leads to higher death rates. While higher rates of smoking and obesity may account for some disparities, economic and social factors are largely the cause.
Summit County, Colorado has the lowest cancer rate in the US. Unsurprisingly, Summit also has the highest life expectancy of any county in the country.
Poor access to care and delayed treatment create race-based differences in cancer survival
A cancer diagnosis in America is not just a medical issue, but a financial one as well. Cancer can bankrupt even the most well-resourced and insured families, taking individuals out of the workforce and forcing them to pay high copayments. But for families with fewer socioeconomic resources who have a higher likelihood of being uninsured or underinsured, financial strain from a cancer diagnosis is almost certain. In addition, low-income Americans often have poor access to high-quality care and experience lower screening rates, delays in treatment, and lower treatment adherence.
On average, counties with persistent poverty - defined as those with 20% or more of the population living below the federal poverty level since 1980 - suffer from mortality rates that are 12% higher than counties not experiencing persistent poverty. But even when controlling for socioeconomic levels, Black, Latinx, and American Indian/Alaskan Natives die 5-years sooner than White Americans with similar diagnoses.
Structural racism is a brute force in influencing health outcomes, especially cancer. Disparities persist across the cancer continuum from prevention to screening, treatment, and long-term survivorship for racial minorities and low-income groups. In addition, BIPOC individuals are more likely to live in areas exposed to higher levels of environmental pollution and food insecurity than non-Hispanic whites, thereby increasing their risk of cancer. Structural and interpersonal racism may also lead to higher risk of stressors that contribute to higher cancer risk.
For breast cancer in particular - the most common cancer affecting women - Black women are 40% more likely to die than White women, despite White women being diagnosed at a higher rate. In fact, Black, Latinx, and American Indian/Alaska Natives all suffer from a higher mortality rate than their White counterparts. This disparity is due to a variety of factors: women of color are often diagnosed at a more advanced stage of their disease, have limited access to high quality care, and have a higher risk of developing more aggressive subtypes of breast cancer.
Tamiko Byrd was diagnosed with Stage 4 breast cancer in 2015 at the age of 43 after recently moving to Houston. As a Black woman with little financial means living in a new city, she didn’t know how she would survive, both financially and literally. “I was in a new city. I had no savings. I wondered how can I afford this? How am I going to take care of my young children? How am I going to live? Am I going to live?”, asked Byrd.
Tamiko survived her diagnosis against all odds. But even after finishing treatment, she wasn’t well enough to go to work, causing her to lose her job and health insurance. Tamiko then missed a year of medical appointments until she was eligible for Medicaid in 2018.
Sadly, stories like this are all too common. In a recent study from UNC-Chapel Hill, researchers found that more Black women delay their treatment after being diagnosed with breast cancer which can cause horrific consequences for disease outcomes. The researchers identified three specific issues associated with prolonged or delayed breast cancer treatment: lack of insurance, transportation challenges, and financial strain. Coupled with America’s Black-white wealth gap and the fact that Black Americans are twice as likely to not have health insurance than white individuals, Black women are at a significant risk of complications, both financial and medical, from a breast cancer diagnosis.
The Path Forward
The solutions to eliminating disparities in cancer mortality are varied and consist of improvements to access, quality of care, and financial feasibility for low-income groups and communities of color.
Increase community health workers in low-income areas - Given the barriers to cancer prevention, screening, and care that low-income areas and communities of color face, community health worker (CHWs) and patient navigator (PN) programs can help cancer patients navigate better quality care and improve community access to screening. As experts in the communities they serve, CHWs and PNs help connect community members to health and social services. For cancer patients in particular, CHWs/PNs may connect patients to better care, provide transportation to treatment, educate the community on screening and prevention strategies, and support survivors. Expanding these networks of patient advocates in impoverished and hard-to-reach areas is a proven method to improve treatment adherence and overall disease outcomes.
Improve quality of care for communities of color - For cancer and various other diseases, Black Americans consistently receive worse quality care than White individuals, due in part to the undertreatment of Black patients’ pain, longer wait times for Black patients, failure of hospitals to hire racially diverse faculty and staff, and worse treatment for Black patients diagnosed with the same diseases at the same institutions as White patients. As established in “An Antiracist Agenda for Medicine”, mitigating racial health inequities demands that colorblind solutions be left in the past and race-explicit interventions be adopted at hospitals and clinics across the country. Brigham and Women’s Hospital in Boston has already developed a pilot for heart failure patients titled “Healing ARC” based on the reparations framework of acknowledgement, redress, and closure that places marginalized patients at the center of institutional change.
Expand Medicaid access in non-expansion states - Beginning in 2014, under the Affordable Care Act, states were able to expand their Medicaid coverage to all residents under 65 who had incomes below 138% of the Federal Poverty Level (FPL), ultimately filling the major gaps of insurance coverage for low-income Americans. To this day, 12 states have yet to expand Medicaid - Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. If these states were to expand access, more than 4 million Americans would gain coverage, providing more people with financial security in the case of a future cancer diagnosis. Increasing insurance coverage also improves access to primary care for lower-income populations, ultimately building a more equitable health system from the ground up and working to reduce cancer inequities downstream.
If we want to reduce the inequality that exists in cancer diagnoses and cancer deaths, we need to address serious structural challenges in America. Income, location, education, race, healthcare, and community support are all deeply correlated with who lives and who dies from cancer. We can follow a path forward to make a change to cancer and inequality, but we also need to disrupt the disparities that marginalized groups face even before a cancer diagnosis.