Read Advisory Board's take: How providers can fight the racial gap in cancer care

Disparities in cancer incidence and mortality between blacks and whites have significantly narrowed since 1990, according to a report by the American Cancer Society (ACS) published Thursday in CA: A Cancer Journal for Clinicians.

The major drivers and consequences of health disparities

But despite improvement in the disparities, blacks continue to "bear a disproportionate share of the cancer burden, having the highest death rate and the lowest survival rate of any racial or ethnic group for most cancers," according to the report.

Report details

For the report, ACS examined disparities in cancer incidence and mortality from 1990 to 2016 by analyzing data from the National Cancer Institute, the North American Association of Central Cancer Registries, and the National Center for Health Statistics (NCHS). The researchers looked at data on cancer incidence, mortality, risk factors, survival, and screening. 

Findings                                                              

ACS found disparities in cancer incidence and death rates narrowed from 1990 to 2016.

Cancer incidence rates

In particular, researchers found the overall cancer incidence rate declined faster among black men than among white men from 2006 to 2015. The cancer incidence rate fell by 2.4% annually among black men from 2006 to 2015 and by 1.7% annually among white men, according to the report. In comparison, the researchers found the overall cancer incidence rate remained "relatively stable" among black women, but increased by an annual rate of 0.2% among white women, according to the report.

The researchers attributed the drops in cancer incidence rates among black and white men to declines in colorectal, lung, and prostate cancer—which are three of the four most-common cancers, the Washington Post reports. The researchers said the decline in lung cancer incidence rates over the past four years, which is the result of a decrease in smoking, has contributed the most to the narrowing of disparities in cancer incidence rates between blacks and whites.

Cancer death rates

The researchers noted that the cancer death rate was 47% higher among black men when compared with white men in 1990, but found that disparity declined over time, falling to 19% in 2016. The researchers found the disparity in cancer death rates between black women and white women also declined, falling from 19% in 1990 to 13% in 2016.

The researchers wrote, "25 years of continuous declines in the cancer death rate among black individuals translates to more than 462,000 fewer cancer deaths."

'Progress made, but still a long way to go'

Len Lichtenfeld, ACS' interim CMO, said the report's "message is progress has been made, but we still have a long way to go." Lichtenfeld said while racial disparities in cancer incidence rates are important to address, a number of factors—including an individual's address, socioeconomic, and educational status—have an effect on cancer rates.

Lichtenfeld noted that early evidence suggests gains in health coverage made under the Affordable Care Act (ACA) "made a difference" and helped narrow disparities in cancer incidence and death rates. However, Lichtenfeld said it is too early to know whether some recent changes to the U.S. health insurance market will have any effects on cancer rates (Baker, "Vitals," Axios, 2/15; McGinley, Washington Post, 2/14; Neighmond, "Shots," NPR, 2/14; DeSantis et al., CA: A Cancer Journal for Clinicians, 2/14).

Advisory Board's take

Deirdre Saulet, Practice Manager, Oncology Roundtable

While this report shows that we've made laudable progress in closing the racial gap in cancer treatment and mortality, we can't become complacent about the issue. For instance, while the mortality gap is 28% smaller today than in 1990, we're still facing a health system in which black men are 19% more likely to die of cancer than white men.

This shouldn't be the status quo. Rather, it reflects the persistence of deep systemic inequities in care that providers must proactively address. Because, while this gap is not just based on race alone (but other socioeconomic and geographic factors tied to racial inequities), studies have still found that racial disparities in outcomes persist after accounting for socioeconomic factors and access to care. And that's not to mention the racial disparities in outcomes for other races, like Hispanics, who are 1.4 times more likely to die from cervical cancer than white women.

Organizations can meaningfully help to address the issue by rethinking their staffing and training practices. Here are three steps to take:

1. First, leaders must gather data on their market's cultural makeup and understand which populations are underserved. For example, analyze the stage of diagnosis across your patient population and look for trends, such as black women presenting with later stage breast cancer compared to white women.
2. Second, they must proactively seek to employ a workforce representative of the communities they serve. Given the shortage of candidates for specific positions (for example, only 2.3% of oncologists in the US are African American), this may require providing education and getting the community excited about careers in oncology.
3. Third, they should seek to provide all staff with cultural competency training on a regular basis. For instance, implicit racial bias impacts the amount of time and quality of the visit between oncologists and minority patients.

This is not just about doing what's right for patients. Rather, as providers become increasingly accountable for total costs and quality, addressing these systemic inequities will become imperative for every program's success.

Cone Health, a six-hospital health network based in North Carolina, is a prime example of an organization stepping up to this task. Cone crated a program called Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) which aimed to reduce racial disparities in early-stage lung cancer. Their program included four main components:

1. Embedding missed appointment alerts into the EHR to notify providers when a patient misses an appointment or treatment milestone;
2. Training nurse navigators on how to deal with race-related barriers to care;
3. Presenting race-specific feedback to care teams; and
4. Conducting health equity training sessions every three months for staff.

The program had a tremendous impact. Compared to a baseline control, the program closed a 12% black-white treatment gap for patients receiving resection plus stereotactic body radiation therapy (SBTR) and almost completely closed a 6% gap in those just getting resections. Not to mention, it increased overall treatment rates for both races as a whole—a win-win for the entire program.

Other providers have found success going out into the community to reach underserved populations. For instance, researchers at NYU Langone recruited men from predominately black barbershops in New York City into a patient navigation program aimed at increasing colorectal cancer screenings. They found that men who received patient navigation by community health workers were twice as likely to get screened as those who received motivational interviewing alone. Their success showed that patient navigation programs initiated in the community, rather than clinical settings, can be far more effective (especially among hard-to-reach populations).

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