Cancer study sees cultural factors in racial disparities

Staff WriterJune 16, 2010 

  • Years of efforts to close gaps in health outcomes between whites and racial minorities have not ended disparities.

    Breast cancer: Although deaths caused by breast cancer have decreased among white women, African-American women continue to have higher rates of mortality.

    Heart disease: Overall, minority and low-income populations have a disproportionate burden of death and disability from cardiovascular disease. Blacks have the highest rate of high blood pressure of all groups and tend to develop it younger than others.

    Diabetes: Compared to whites, African-Americans and Hispanics are more than twice as likely to have diabetes.

Despite a high likelihood of death, black patients are much less inclined to have surgery for early stage lung cancer than whites, often because of a communication gulf between them and their doctors, scientists at UNC-Chapel Hill report today.

In a study published in the Journal of the American Medical Association, UNC-CH researchers surveyed nearly 400 patients newly diagnosed with lung cancer to determine what factors influenced their treatment decisions.

For black patients, who have long had worse outcomes for lung cancer than whites, just 55 percent chose surgery to remove the tumor - the only lifesaving option when cancer is diagnosed early. Sixty-six percent of white patients chose surgery.

The UNC-CH team found that many black patients misunderstood their prognosis, or didn't connect well enough with their doctors to feel comfortable discussing the options.

Such insights, while specifically addressing a decision about lung cancer treatment, may help explain persistent differences between racial minorities and whites in disease interventions and outcomes.

"It's a frustrating problem," said Dr. Samuel Cykert of the of the Cecil G. Sheps Center for Health Services Research at UNC-CH and lead author of the study. "It's not just lung cancer," he said. "It's everything from using tooth floss to knee replacement surgeries. There are hundreds of categories where disparities systematically exist."

Doctor-patient gulf

Cykert said many black patients reported they didn't connect with their doctors, and as result, didn't ask questions or initiate a dialogue about treatment options and their potential outcomes.

"Black perceptions of physicians as uninterested and less engaging lead to fewer adherences to physician recommendations and inadequate understanding of treatment problems," the authors reported.

Patients often opted against surgery if they interpreted pessimistic spin in a doctor's explanation about the difficulties of the procedure and post-operative rehabilitation.

For the doctor, that pessimism may stem from a subtle bias. Among the study participants who declined surgery, black patients tended to be older and single, and have more health problems in addition to their cancer - factors doctors might see as impediments to a strong recovery.

Cykert said one solution to the problem is training doctors to be hypersensitive to this tendency, and make sure "every decision they make is justified and it would be the same for another person."

Shirley Lawton, 65, of Raleigh, was diagnosed with lung cancer in 2007. Although she was not part of the study, she said one of the biggest impediments to a trusting relationship with doctors is how much time they spend with patients. An African-American woman, Lawton said she trusts her doctors at the N.C. Cancer Hospital in Chapel Hill, but understands how a hasty exchange might erode that relationship.

"Doctors are so busy," said Lawton, who was ineligible for surgery. "They try to help, but they don't spend the time with you they should."

Would 'navigators' help?

To address that problem, Cykert's group suggested doctors and hospitals add a sort of navigator to the care team to spend the time doctors may not have for lengthy sessions with patients about various treatment options.

Such solutions could be easily incorporated, said Dr. Richard Payne, director of the Institute on Care at the End of Life at Duke University, who has studied racial disparities in medicine.

Payne said the reason health disparities have been an intractable problem is they are so complex, fed by culture, wealth, education levels, religion and other social factors.

"There are so many social determinants and potential barriers to improving disparities," he said. "There is no one thing that can be done."

But he said the UNC-CH study offers some immediate strategies.

"These authors really focused on potential factors that could be modifiable, like the negative perceptions of patient-physician communications," Payne said. "We can work on improving that."

sarah.avery@newsobserver.com or 919-829-4882

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