Does Race Matter?
The numbers relating to prostate cancer are staggering on their own: 230,000 new cases in the United States in 2004; nearly 30,000 deaths from prostate cancer in 2004; 82 men die every day from this disease, and we are seeing a steady rise in these rates. Yet when we look at our minority populations, the numbers show an even more sobering picture:
The issue of racial health disparity is one of paramount importance to Government agencies, medical centers and advocacy groups such as Malecare and The Prostate Net; but are we focused on the correct criteria. Is it really “race” that’s the key factor or is it something else?
At the Prostate Cancer Symposium, sponsored by the American Society of Clinical Oncology (ASCO), two leading clinicians and cancer researchers engaged in a point / counterpoint discussion that proved to be illuminating and directional in moving the focus. Though the discussion was themed to create positions of pro versus con, the reality of their arguments really showed more agreement than not.
Dr. Otis Brawley of Emory University and current Medical Director of the American Cancer Society lead the discussion by creating a historical perspective of “race” and its position, or lack of it, in cancer research and treatment. The concept of “race medicine” was one that held strength in the first three decades of the 20th Century and saw its nadir in practice with the infamous Tuskegee experiments that permitted over 300 men with syphilis to go untreated on the belief that the disease was different in African-Americans versus Caucasians.
However, to dismiss that concept, he illustrated that geographic origin was more relevant to certain disease prevalence than “race”. Sickle Cell Disease is normally viewed as a “black” disease, yet the primary areas of geographic origin of the disease are the Mediterranean Basin and Central Africa, regions that are primarily “white”.
Race in America Dr. Brawley posited is really more of a social construct than a true biological reality. Further to the point, in an analysis of all-cancer mortality among U.S. men, those who were in the lowest socio-economic categories, regardless of their race, had the highest mortality percents.
The reality of cancer in America is that poor people die more from the disease than those
designated solely by race. In looking at the “new” factors of racial health disparity, those with the greater relevance, and more scientific correlation, than race are:
* Socio-economic status
* Diet
* Body mass index (BMI)
* Access to care
Given that black people and poor people suffer disproportionately, we must expand our focus past race and address the question posed by Dr. Brawley, “how can we provide adequate high quality care to a population that has so often not received it?”
Taking the not-really-opposing point of view was Dr. Mack Roach III of the University of California at San Francisco, who supported many of Dr. Brawley’s points that race does matter but “why”.
Dr. Roach related several other examples of healthcare disparity: greater utilization of coronary revascularization procedures among Medicare Part A enrollees was higher for whites; Blacks were 33% to 54% less likely to receive enhanced cardiac therapies than whites in Veterans Administration hospitals; and living in a disadvantaged neighborhood is associated with increased coronary heart disease. All of the above examples have been reported in the Journal of the American Medical Association and the New England Journal of Medicine.
In trying to understand the differentials based on genetic factors, studies of the polymorphism Cyp3A4, which is important in androgen metabolism in prostate cancer, would have suggested that the presence of this polymorphism is a factor; however, the reality is that there wasn’t correlation with disease outcomes. In reality, the preponderance of all data suggests that there are no differences in outcomes based on race.
The fact is African-American men have the 2nd highest five-year survival rate in the world, after U.S. white men. If race then does not matter, then why do Blacks still have a higher incidence and mortality from prostate cancer? We can break the factors into categories related to incidence and/or mortality:
Incidence Mortality
–
| Dietary Factors | Lack of access to care |
| Food types | |
| Lower utilization of services | |
| Quality of food | |
| Lower quality of care | |
| Obesity | |
| Patient related | |
| Environmental | |
| Insurance related | |
| Employment | |
| Physician related | |
| Inner City | |
| Less screening | |
| Pollution |
While mortality among minorities and the poor remains the highest, declines have been noted based on advances in screening and treatment; but we must insure that equality in treatment exists to provide for equality of outcomes.