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Ethnic Minority Disparities in Cancer Treatment:
Why the Unequal Burden?
Testimony by Harold Freeman, M.D.
Director, Center to Reduce Cancer Health Disparities
The National Cancer Institute
National Institutes of Health
Department of Health and Human Services
Hearing before the House Committee on Government
2154 Rayburn House Office Building
Monday, September 25, 2000 at 1:00 pm
Good afternoon, Mr Chairman and distinguished Members. I
am Dr. Harold Freeman, and I am pleased to have the opportunity
to speak with you this afternoon about the disparities in
the diagnosis and treatment of cancer and the unequal burden
of cancer among minorities, poor and underserved. This spring,
Dr. Richard Klausner, Director of the National Institutes
of Cancer (NCI), asked me to consult with him on these issues
and asked if I would consent to become Director of NCI's new
Center to Reduce Cancer Health Disparities. My experience
as director of surgery at Harlem Hospital for twenty-five
years (1974-1999) and as national president of the American
Cancer Society (1988-1989), as well as my continued commitment
to examining health disparities in cancer treatment were deciding
factors in accepting this appointment.
Profound advances in biomedical science have occurred over
the last several decades which for many Americans have contributed
to increased longevity and improved quality of life. Despite
this progress, a heavier burden of disease is borne by some
population groups, particularly the poor and underserved.
The unequal burden of disease in our society is a challenge
to science as well as a moral and ethical dilemma for our
nation. The scientific evidence is compelling - the incidences
of cancer do vary among race and ethnic groups - but the number
of those dying of cancer vary at higher rates among certain
races and ethnic groups. The urgency for action to address
these disparities is critical.
Ten years ago, I co-authored an article in the New England
Journal of Medicine entitled "Excess Mortality in Harlem",
in which we documented that a black male in Harlem had less
chance of surviving to age sixty-five than a male in Third
World Bangladesh. I regret to have to report that too little
has changed during the past ten years for many members of
the minority populations. Poverty, because of its many effects
on resources, environment, behavior and attitude remains to
this day to be a major driving force of excess mortality among
minorities in this country.
In 1997, the President's Cancer Panel convened a meeting
to discuss the meaning of race in science. We invited a number
of nationally recognized scholars across many disciplines
including scientists, philosophers, sociologists and psychologists.
The group confirmed, what many of us had suspected, that race
is a social construct which, as applied to humans, is no longer
acceptable and has no legitimate place in biological science.
Racial distinctions in science can provide us with evidence
of significant variation in health and disease but this evidence
must be interpreted, by examining the social, economic, cultural
, and environmental factors in order to understand the underlying
causes of the unequal burden of disease among groups.
To begin to examine this complex question let us look at
some examples of high quality peer reviewed studies published
over the last two years.
In October, 1999, the New England Journal of Medicine
published the results of a study that examined racial differences
in the treatment of early-stage lung cancer. If discovered
at an early stage, non-small-cell lung cancer is potentially
curable by surgical resection. However, two disparities between
black patients and white patients with this disease were noted
in the study.
First, blacks were found to be less likely to receive surgical
treatment than whites; and second, blacks were likely to die
sooner than whites from this condition. The study further
concluded that those black patients who did receive the surgical
resection had a survival rate similar to white patients.
Subsequent studies published in the Journal indicated
similar treatment disparities with respect to renal transplantation.
Black patients were found to be less likely that whites to
have been evaluated as candidates for transplants that have
been shown to extend survival time and improve quality of
life. Moreover, this past spring, an NCI-supported study published
concluded that both black and Hispanic patients were less
likely than white patients to be able to obtain commonly prescribed
pain medications, because pharmacies in predominately non-white
communities often do not carry adequate stocks of opioids.
Black Americans have a higher overall incidence of cancer,
and a higher rate of death from cancer than any other racial
or ethnic group. The findings of the study lead us to believe
that in addition to these burdens, blacks are also inadequately
treated for pain from cancer.
Dr. Klausner and I expect that the new NCI Center to Reduce
Cancer Health will be at the forefront of our collective efforts
to reduce disparities in health. We are grateful for the generous
support Congress has provided NCI so the Center can move forward
with its work.
Because minority communities carry an unequal burden of cancer-related
health disparities, NCI is working to enhance its research,
education, and training programs that focus on racial and
ethnic populations in need. In my new position, I will have
the unique opportunity to direct the implementation of NCI's
ongoing efforts to reduce cancer-related health disparities,
and find new ways to translate biomedical research discoveries
into practice to reduce these disparities.
Even before I was appointed by Dr. Klausner as Director of
the Center, the President's Cancer Panel began to tackle this
problem. The Panel has undertaken a series of regional meetings
across the country, with representation from every state,
to explore in detail the obstacles which prevent us from getting
the best available, state-of-the-art cancer care to all people,
regardless of their racial or ethnic background.
In 1999, the Panel conducted a series of meetings survey
the history and status of the National Cancer Program. Among
the most important findings arising from that effort was the
discovery that a crucial disconnect existed between the research
and delivery enterprises associated with modern medical care.
Programs of prevention and treatment that are recognized as
effective were not being incorporated consistently into routine
medical practice in all the diverse populations and neighborhoods
of America. Correcting that shortcoming is vital to improve
overall cancer care, access, delivery and quality.
Our Panel's forthcoming regional meetings, each with representatives
from nine to twelve states, will include local community members
with stories to tell; cancer survivors, employers, health
providers, Medicaid officials, and others involved with cancer
care will add immeasurably to our store of knowledge. We believe
that much of what we will learn at the local and regional
level will provide tools for us to address these disparities
at the national level as well.
Among other things, we want to find out just who specifically
are the under-served for cancer prevention and care in particular
areas. Who are the vulnerable populations in each state or
region? What factors are preventing patients with treatable
cancers from receiving the most appropriate and up-to-date
care? Why are people dying from treatable cancers, and who
are they? What do states and communities need to do to provide
proven interventions for cancer prevention and control? What
policy and legislative changes need to be addressed to ensure
that all people get appropriate cancer treatment services?
The unequal burden of health disparities among minorities
will continue to be a vexing problem. We believe that through
the efforts of NCI's Center to Reduce Cancer Health Disparities,
working with all areas of the Institute, the President's Cancer
Panel, and Members of Congress we will be able to focus national
attention on developing policies to address this complex problem.
This concludes my remarks and I will be pleased to take any
questions you might have.
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