Cancer kills hundreds of thousands of people in the U.S. each year, disproportionately affecting minorities and the poor. The reasons for this are complicated but often come down to two key issues \u2013 socioeconomic factors and race.<\/p>\n
Cancer is the second largest cause of death in the U.S.,[i]<\/a> killing approximately 609,640 people in 2018 alone. That year, more than 1.7 million new cases were diagnosed.[ii]<\/a> \u00a0This is not simply a problem that affects a small segment of the population; it is one of the most significant causes of premature death in the country, and there are multiple disparities between demographics.<\/p>\n We know that biological diseases \u2013 like cancer \u2013 can be rooted in social causes.[iii]<\/a> It\u2019s important to understand how different social contexts can increase or decrease one\u2019s risk of health problems. To better understand this issue, we often use socioeconomic status (SES) as a way to understand the broader issues that surround poverty. With SES, we go beyond just wealth and examine other measures such as educational level, housing, employment and the social structures that increase or decrease health.[iv]<\/a> It is important to note that the majority of cancers are caused by lifestyle risk factors which are not innate, as opposed to genetic causes.[v]<\/a> Because of this, we need to look at these risk factors and the social patterns behind them in order to understand that inequities are more than just random occurrences or unfixable genetic conditions.<\/p>\n <\/p>\n Poverty and cancer<\/strong><\/p>\n Poverty is directly related to increased incidence rates of cancer,[vi]<\/a> as those with lower levels of education and lower levels of income \u2013 both common measures of SES \u2013 \u00a0experience higher rates of cancer diagnoses.[vii]<\/a> They are also more likely to die from certain cancers \u2013 particularly lung cancer and colorectal cancer.[viii]<\/a> For survivors, income and socioeconomic status are significant predictors of quality of life after cancer.[ix]<\/a> Increased income allows patients to maintain a level of comfort that people with low SES might not be able to afford.[x]<\/a> This means that even if a low income patient survives cancer, their quality of life after will be worse than someone more well off.<\/p>\n People who are diagnosed at earlier stages of cancer are more likely to survive, regardless of ethnicity or SES.[xi]<\/a> Unfortunately, it is often more difficult to detect cancer in certain populations. For example, African American women are less likely to receive a stage I cancer diagnosis compared to white women, reducing their chances of survival.[xii]<\/a> This is because of biological differences between ethnicities that make it more difficult to diagnose cancer at an earlier stage in African American women in comparison to white women.[xiii]<\/a> African American women are also more likely to have triple negative breast cancer, meaning that the three most common receptors that cause breast cancer (and the ones that are primarily tested for) are not present, making it harder to diagnose them at earlier stages.[xiv]<\/a> This partially explains why African American women are often diagnosed later than white women, which leads to poorer cancer outcomes.<\/p>\n However, this is not the only reason for disparities.[xv]<\/a> A study conducted on patients with stage I breast cancer demonstrated no differences in outcome based on ethnicity, when SES was controlled for.[xvi]<\/a> This would imply that if caught early enough, patients across a range of ethnic groups would have more equal health outcomes. Therefore, genetics don\u2019t appear to be the only factor for the higher rates of cancer rates and deaths for minorities.<\/p>\n \u00a0<\/strong><\/p>\n Race and cancer<\/strong><\/p>\n Lower-income patients are more likely to have worse cancer outcomes than higher-income patients and are anywhere between 20 percent and 80 percent more likely to die from the disease.[xvii]<\/a> Therefore, not only are low-income patients more likely to be diagnosed with cancer, but those who are diagnosed are more likely to die from it than higher-income patients. The same is true for ethnicity. For example, white women have an 80 percent chance of surviving cancer, while Hispanic and African American women have a 78 percent and 66 percent chance of surviving up to ten years after treatment, respectively.[xviii]<\/a> For breast cancer, being an African American woman was a predictor of increased chances of death, compared to white counterparts.[xix]<\/a><\/p>\n <\/p>\n Treatment inequities <\/strong><\/p>\n The severity of disease has been found to be directly correlated to a lack of access to necessary health care.[xx]<\/a> Also known as the inverse care law, this means that those who require the most help receive the least.<\/p>\n A study of a number of different cancer types found that higher-income populations had lower cancer mortality rates when compared to lower-income populations.[xxi]<\/a> This can be attributed in part to the fact that higher SES populations have greater access to screening services \u2013 which can detect smaller abnormalities \u2013 as well as greater access to necessary follow-ups to track care and develop treatment plans.[xxii]<\/a> Therefore, there are inequities not only in which populations get cancer, but also in how cancers are detected and treatment options that are available due to certain populations being able to afford better testing, services, etc.<\/p>\n Additionally, African American women receive lower rates of care when it comes to breast cancer treatment, even when studies are adjusted for SES (in the form of equal insurance coverage).[xxiii]<\/a> African American women are also less likely to receive care and more likely to undergo more invasive treatments when they do receive care.[xxiv]<\/a> When it comes to prostate cancer, African American and white men access screening services equally, but Asian and Hispanic men have lower levels of access to these same services.[xxv]<\/a> This highlights that not all ethnic groups face the same barriers or lack of treatment equally.<\/p>\n It is important to note that while studies have found that higher-income populations with cancer live longer than lower-income populations with cancer, this is not necessarily due to increased levels of health care.[xxvi]<\/a> One study found the relationship between mortality rates due to cancer and socioeconomic status isn\u2019t necessarily connected to health care utilization.[xxvii]<\/a> Level of access to cancer treatment might explain the discrepancies in health outcomes, but it doesn\u2019t explain how certain groups of people can experience higher rates of cancer in the first place.<\/p>\n <\/p>\n Barriers to care<\/strong><\/p>\n Based on the fact that lower-income and ethnic minority populations receive cancer treatments at lower levels than their higher-income counterparts, it seems that either: a) care for them does not exist, or b) there are barriers preventing them from accessing it.<\/p>\n Individuals with private medical health insurance are usually more likely to be screened for cancer than those who do not have insurance.[xxviii]<\/a> This shows that those with higher SES have the means to access these services, while those who cannot afford insurance do not have the means. Medicaid was created as an attempt to bridge the gap for low-income Americans, but not all low-income residents in all states are able to access it equally due to differences in state eligibility laws. In some states, all poorer people are covered by Medicaid. In others, you have to first have a significant diagnosis (like cancer) to receive coverage. This creates a bit of a catch-22: you don\u2019t have coverage to receive the screening but that screening is necessary to receive coverage.<\/p>\n Those that are enrolled in Medicaid are more likely to develop late-stage cancer, compared to those with alternative forms of health insurance.[xxix]<\/a> Men who were either uninsured or insured through Medicaid had more developed cancer at the time of screening and diagnosis, compared to men who had private health insurance.[xxx]<\/a> Medicaid coverage reduces some financial barriers to care such as early detection screenings, but it doesn\u2019t remove every barrier. And Medicaid is still marginally better than not having insurance \u2013 but given the differences in how states approach Medicaid (and considering 14 states did not expand eligibility since the passage of the Affordable Care Act), in certain states there are higher rates of those with no insurance as well as lower screening rates.<\/p>\n Screening is critical to cancer survival, as lack of access to screening services has also been associated with increased mortality rates.[xxxi]<\/a> Ethnic minority groups have lower rates of access to screening services, in comparison to the majority white population.[xxxii]<\/a> For example, African American and Hispanic populations were less likely to be screened for colorectal cancer, compared to the white population.[xxxiii]<\/a> There are a number of reasons for this, including lower levels of private health insurance, cultural differences, and lack of trust in the healthcare system due to previous negative experiences.[xxxiv]<\/a><\/p>\n Cancer treatment is time consuming and can be difficult to navigate due to the fact that it often involves multiple providers and appointments.[xxxv]<\/a> One of the barriers is language differences \u2013 Spanish-speaking Hispanics were 24 percent less likely to receive cancer screening services, compared to English-speaking Hispanics.[xxxvi]<\/a> But this barrier alone was not enough to account for the complete differences in ethnic demographics \u2013 rather, it exacerbates already-existing inequalities.<\/p>\n We can clearly see the unequal trends in both rates of cancer and deaths caused by cancer \u2013 but what causes them? There are a number of different factors that should be considered, but it should also be noted that these social trends are complex and interwoven, and there is no single cause of these unequal health outcomes.<\/p>\n To some extent, we can also blame the different mortality rates of cancer on genetic differences between ethnic groups \u2013 something that is innate and cannot be changed. White women are more likely to present with certain types of breast cancer, which are easier to treat and result in better outcomes than other more deadly types.[xxxvii]<\/a> This suggests there is a biological reason for different ethnic outcomes, including why African American women are more likely to die from breast cancer than white women. However, this alone does not explain the disparity between ethnic groups when it comes to incidence and mortality rates, and also does not work as an explanation for all cancers.<\/p>\n There are also certain cancers that are directly related to lifestyle choices, including lung cancer \u2013 which is one of the most common and deadly forms of cancer in the U.S.[xxxviii]<\/a> Lung cancer is primarily caused by smoking, which makes it a choice as opposed to an unchangeable lifestyle factor.[xxxix]<\/a> Lower-income and minority populations are more likely to smoke and have higher rates of lung cancer when compared to white and higher-income populations.[xl]<\/a><\/p>\n <\/p>\n Global trends<\/strong><\/p>\n This phenomenon of cancer inequities is not specific to the U.S., as there are a number of countries that display the same trends in health inequities based on ethnicity and socioeconomic status.\u00a0 Much of the Western world loosely follows the same cancer trends due to the fact that lifestyles are very similar, and cancer trends between socioeconomic groups are relatively similar.[xli]<\/a> Although cancer mortality and inequities are increasing in some developed countries, including South Korea,[xlii]<\/a> overall cancer mortality rates are decreasing in developed nations.[xliii]<\/a><\/p>\n Developing countries show differing cancer mortality trends compared to the U.S. and other developed nations. Developing nations are slightly behind U.S. trends – they are only now starting to increase levels of smoking, consumption of unhealthy fatty foods, and decrease levels of physical activity \u2013 all of which increase cancer.[xliv]<\/a><\/p>\n When looking at cancer from the perspective of race and\/or income, it becomes immediately clear that the problem is complex and multi-faceted, with no one explanation or solution for why different outcomes occur.<\/p>\n In the U.S., it is important to understand that race and income are intrinsically linked. Minorities are more likely to have a lower socioeconomic status, in comparison to the white population. This can compound the risk of cancer and poor health outcomes for minorities, who might also be lower-income. It should still be noted that even after SES is considered, ethnic minorities have worse health outcomes than the ethnic majority in the U.S.<\/p>\n It is also important to note that poverty and poor health are cyclical. Health affects income levels and income affects health. People with poor health are less likely to be able to work full time and retain a steady income. This reduced income then causes further health problems due to a lack of financial access to care. Additionally, having cancer as a child can physically impact an adult survivors\u2019 ability to earn money, even years after they have been declared cancer-free.[xlv]<\/a> Adult survivors of childhood cancers are more likely to receive disability payments because they aren\u2019t able work when compared to the rest of the general population.[xlvi]<\/a><\/p>\n Cancer is a complex health condition that is both caused and worsened by income and race. To even the playing field, we need to first understand how the root causes impact the chance that a certain person will get cancer. The differences in death rates between different socioeconomic groups and races can be partially explained by the different levels of care that these demographics receive, but this does not necessarily fully explain why these differences in care exist in the first place. To some extent, private insurance (or lack thereof) dictates the level of care that patients can access, but this alone does not account for all differences in outcomes that we see. The relationship between ethnicity, poverty\/wealth and cancer is complicated, and we must examine these all together if we are ever able to truly address the issues of inequities in cancer deaths.<\/p>\n <\/p>\n References<\/em><\/p>\n [i]<\/a> Short, Pamela Farley, and Erin L. Mallonee. \u201cIncome Disparities in the Quality of Life of Cancer Survivors:\u201d Medical Care, vol. 44, no. 1, 2006, pp. 16\u201323.<\/p>\n [ii]<\/a> \u201cCancer statistics, National Cancer Institute.\u201d Cancer.gov.<\/p>\n [iii]<\/a> Oakes, J. Michael, and Peter H. Rossi. \u201cThe Measurement of SES in Health Research: Current Practice and Steps toward a New Approach.\u201d Social Science & Medicine, vol. 56, no. 4, Feb. 2003, pp. 769\u201384.<\/p>\n [iv]<\/a> Ibid.<\/p>\n [v]<\/a> Jemal, Ahmedin, et al. \u201cGlobal Patterns of Cancer Incidence and Mortality Rates and Trends.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 8, Aug. 2010, pp. 1893\u2013907.<\/p>\n [vi]<\/a> Aarts, Mieke J., et al. \u201cSocioeconomic Status and Changing Inequalities in Colorectal Cancer? A Review of the Associations with Risk, Treatment and Outcome.\u201d European Journal of Cancer, vol. 46, no. 15, Oct. 2010, pp. 2681\u201395.<\/p>\n [vii]<\/a> Clegg, Limin X., et al. \u201cImpact of Socioeconomic Status on Cancer Incidence and Stage at Diagnosis: Selected Findings from the Surveillance, Epidemiology, and End Results: National Longitudinal Mortality Study.\u201d Cancer Causes & Control, vol. 20, no. 4, May 2009, pp. 417\u201335.<\/p>\n [viii]<\/a> Aarts, Mieke J., et al. \u201cSocioeconomic Status and Changing Inequalities in Colorectal Cancer? A Review of the Associations with Risk, Treatment and Outcome.\u201d European Journal of Cancer, vol. 46, no. 15, Oct. 2010, pp. 2681\u201395.<\/p>\n [ix]<\/a> Short, Pamela Farley, and Erin L. Mallonee. \u201cIncome Disparities in the Quality of Life of Cancer Survivors:\u201d Medical Care, vol. 44, no. 1, 2006, pp. 16\u201323.<\/p>\n [x]<\/a> Ibid.<\/p>\n [xi]<\/a> Iqbal, Javaid, et al. \u201cDifferences in Breast Cancer Stage at Diagnosis and Cancer-Specific Survival by Race and Ethnicity in the United: Breast Cancer Stage at Diagnosis and Survival.\u201d JAMA, vol. 313, no. 2, Jan. 2015, pp. 165\u201373.<\/p>\n [xii]<\/a> Ibid.<\/p>\n [xiii]<\/a> Ibid.<\/p>\n [xiv]<\/a> Ibid.<\/p>\n [xv]<\/a> Ibid.<\/p>\n [xvi]<\/a> Parise, Carol A., and Vincent Caggiano. \u201cThe Influence of Socioeconomic Status on Racial\/Ethnic Disparities among the ER\/PR\/HER2 Breast Cancer Subtypes.\u201d Journal of Cancer Epidemiology, 2015.<\/p>\n [xvii]<\/a> Subramanian, Sujha, and Amy Chen. \u201cTreatment Patterns and Survival Among Low-Income Medicaid Patients with Head and Neck Cancer.\u201d JAMA Otolaryngology\u2013Head & Neck Surgery, vol. 139, no. 5, May 2013, p. 489.<\/p>\n [xviii]<\/a> Iqbal, Javaid, et al. \u201cDifferences in Breast Cancer Stage at Diagnosis and Cancer-Specific Survival by Race and Ethnicity in the United StatesBreast Cancer Stage at Diagnosis and SurvivalBreast Cancer Stage at Diagnosis and Survival.\u201d JAMA, vol. 313, no. 2, Jan. 2015, pp. 165\u201373.<\/p>\n [xix]<\/a> Ibid.<\/p>\n [xx]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n [xxi]<\/a> Welch, H. Gilbert, and Elliott S. Fisher. \u201cIncome and Cancer Overdiagnosis \u2014 When Too Much Care Is Harmful.\u201d New England Journal of Medicine, vol. 376, no. 23, June 2017, pp. 2208\u201309.<\/p>\n [xxii]<\/a> Ibid.<\/p>\n [xxiii]<\/a> Freedman, Rachel A., et al. \u201cThe Association of Race\/Ethnicity, Insurance Status, and Socioeconomic Factors with Breast Cancer Care.\u201d Cancer, vol. 117, no. 1, Jan. 2011, pp. 180\u201389.<\/p>\n [xxiv]<\/a> Ibid.<\/p>\n [xxv]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n [xxvi]<\/a> Welch, H. Gilbert, and Elliott S. Fisher. \u201cIncome and Cancer Overdiagnosis \u2014 When Too Much Care Is Harmful.\u201d New England Journal of Medicine, vol. 376, no. 23, June 2017, pp. 2208\u201309.<\/p>\n [xxvii]<\/a> Yim, Jun, et al. \u201cContribution of Income-Related Inequality and Healthcare Utilisation to Survival in Cancers of the Lung, Liver, Stomach and Colon.\u201d Journal of Epidemiology and Community Health, vol. 66, no. 1, 2012, pp. 37\u201340.<\/p>\n [xxviii]<\/a> Jinjuvadia, Raxitkumar, et al. \u201c1168 Impact of Health Insurance, Education and Income Status on Colorectal Cancer Screening in Minority Populations: 2001 \u2013 2010.\u201d Gastroenterology, vol. 142, no. 5, 2012, p. S-214.<\/p>\n [xxix]<\/a> Subramanian, Sujha, and Amy Chen. \u201cTreatment Patterns and Survival Among Low-Income Medicaid Patients With Head and Neck Cancer.\u201d JAMA Otolaryngology\u2013Head & Neck Surgery, vol. 139, no. 5, May 2013, p. 489.<\/p>\n [xxx]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n [xxxi]<\/a> Choi, Seul Ki, et al. \u201cMedicaid Coverage Expansion and Implications for Cancer Disparities.\u201d American Journal of Public Health, vol. 105, no. S5, Oct. 2015, pp. S706\u201312.<\/p>\n [xxxii]<\/a> Liss, David T., and David W. Baker. \u201cUnderstanding Current Racial\/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care.\u201d American Journal of Preventive Medicine, vol. 46, no. 3, Mar. 2014, pp. 228\u201336.<\/p>\n [xxxiii]<\/a> Ibid.<\/p>\n [xxxiv]<\/a> Fedewa, Stacey A., et al. \u201cAssociation of Insurance and Race\/Ethnicity with Disease Severity among Men Diagnosed with Prostate Cancer, National Cancer Database 2004-2006.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 10, Oct. 2010, pp. 2437\u201344.<\/p>\n [xxxv]<\/a> Freedman, Rachel A., et al. \u201cThe Association of Race\/Ethnicity, Insurance Status, and Socioeconomic Factors with Breast Cancer Care.\u201d Cancer, vol. 117, no. 1, Jan. 2011, pp. 180\u201389.<\/p>\n [xxxvi]<\/a> Liss, David T., and David W. Baker. \u201cUnderstanding Current Racial\/Ethnic Disparities in Colorectal Cancer Screening in the United States: The Contribution of Socioeconomic Status and Access to Care.\u201d American Journal of Preventive Medicine, vol. 46, no. 3, Mar. 2014, pp. 228\u201336.<\/p>\n [xxxvii]<\/a> Parise, Carol A., and Vincent Caggiano. \u201cThe Influence of Socioeconomic Status on Racial\/Ethnic Disparities among the ER\/PR\/HER2 Breast Cancer Subtypes.\u201d Journal of Cancer Epidemiology, 2015.<\/p>\n [xxxviii]<\/a> Torre, Lindsey A., et al. \u201cGlobal Cancer Incidence and Mortality Rates and Trends\u2014An Update.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 25, no. 1, Jan. 2016, pp. 16\u201327.<\/p>\n [xxxix]<\/a> Clegg, Limin X., et al. \u201cImpact of Socioeconomic Status on Cancer Incidence and Stage at Diagnosis: Selected Findings from the Surveillance, Epidemiology, and End Results: National Longitudinal Mortality Study.\u201d Cancer Causes & Control, vol. 20, no. 4, May 2009, pp. 417\u201335.<\/p>\n [xl]<\/a> Ibid.<\/p>\n [xli]<\/a> Wong, Martin C. S., et al. \u201cIncidence and Mortality of Lung Cancer: Global Trends and Association with Socioeconomic Status.\u201d Scientific Reports, vol. 7, no. 1, Oct. 2017, pp. 1\u20139.<\/p>\n [xlii]<\/a> Yim, Jun, et al. \u201cContribution of Income-Related Inequality and Healthcare Utilisation to Survival in Cancers of the Lung, Liver, Stomach and Colon.\u201d Journal of Epidemiology and Community Health, vol. 66, no. 1, 2012, pp. 37\u201340.<\/p>\n [xliii]<\/a> Wong, Martin C. S., et al. \u201cIncidence and Mortality of Lung Cancer: Global Trends and Association with Socioeconomic Status.\u201d Scientific Reports, vol. 7, no. 1, Oct. 2017, pp. 1\u20139.<\/p>\n [xliv]<\/a> Jemal, Ahmedin, et al. \u201cGlobal Patterns of Cancer Incidence and Mortality Rates and Trends.\u201d Cancer Epidemiology and Prevention Biomarkers, vol. 19, no. 8, Aug. 2010, pp. 1893\u2013907.<\/p>\n