In 2008, the National Institute of Health funded a multisite, longitudinal investigation that was designed to better evaluate racial/ethnic disparities in advanced care planning. Such disparities in patterns of end-of-life treatment, particularly between African American and White patients, had been well established in at least two decades of research.
Patients with advanced cancer and a life expectancy of less than 6 months were recruited from 2002 to 2006 throughout multiple centres in New York, New Hampshire, Connecticut, and Texas. Interviews were conducted regarding the patient’s advanced care planning preferences as well as terminal illness acknowledgement, religiosity, and treatment preferences.
The first goal of study was to determine whether race/ethnicity was associated with advanced care planning while controlling for other possible mediating factors such as terminal illness acknowledgement, religiosity, and stated treatment preferences.
The authors found that, in comparing with white patients, African American patients expressed greater preferences for and received more intensive end-of-life care and treatment, even when the mediators examined were controlled for.
The study added to existing literature in that it suggested that attitudes which contribute to disparities in end-of –life treatment among African American versus whites may have a different basis than previously thought. Such attitudes may partially result from other, unmeasured factors such as health literacy, medical mistrust, or physician bias.
As of this writing, the research team is actively the research team is actively following up on the results of this suggestive study.
In 2004, the Institute of Medicine published a comprehensive review of racial and ethnic disparities in health care in the Cancer Journal for Clinicians in 2005. The goal of this review was to better elucidate disparities in cancer outcomes. The data collected on cancer incidence, stage at diagnosis, and survival were derived from the Surveillance, Epidemiology, and End Results (SEER) program Mortality data were derived from the National Centre for Health Statistics.
The paper found that, of all racial or ethnic groups in the United States, African American have the highest death rate from all cancer sites combined. Furthermore, the 5-year survival rate is more than 10% higher for persons who live in affluent census tracts than for persons who live in poorer census tracts.
Concerning primary prevention modifiable cancer risk factors that were found to vary by race/ethnicity and socioeconomic status included cigarette smoking, physical inactivity, and obesity. Regardless of race/ethnicity, men and women whose income is less than twice the poverty level were found to be much more likely to be current smokers than those with higher incomes.
Concerning secondary prevention, women who had immigrated to the United States in the past 10 years, who lacked health insurance coverage, or who self-described as American Indian/Alaskan native had the lowest usage of mammography. Regarding stage at diagnosis, patients who lived in high-poverty areas were more likely to have advanced-stage disease at initial diagnosis.
Furthermore, 5-year survival in African Americans was found to be much lower than for whites for many cancers with the same stage at diagnosis. The authors hypothesize that such differences in outcomes appeared to result more from disparities in access to care and quality of cancer treatment than from biologic differences. The study found that access to high-quality cancer care varies substantially by socioeconomic status and race.
Furthermore, the study found that three main factors influenced the availability and quality of cancer care. The first, and most significant, stems from structural barriers such as lack of health insurance, financial support, geographic distance to facilities, and access to transportation.
The second is that physician recommendations may be influenced by nonclinical factors such as perception of a patient’s willingness or ability to comply with treatment recommendations, personal preferences, and biases.
Finally, patients’ distrust of conventional medical care, inability to navigate the system, or lack of a trusted provider may sway patient decision making. The elimination of disparities in the burden of cancer is one of the overarching themes of the American Cancer Society’s 2015 challenge goals.
It allows us to better understand the areas of our health care system that contribute to disparate outcomes and therefore would benefit from intervention.
