CANCER IN THE AFRICAN AMERICAN The Annual William E. Allen, Jr, MD, Memorial Lecture Carl M. Mansfield, MD, ScD Philadelphia, Pennsylvania
I have been asked to speak about African Americans and cancer. In doing so, it is necessary to address the issue of race and socioeconomic status as it relates to cancer. Cancer is a group of diseases characterized by uncontrolled growth. Portions of the tumor can spread to other parts of the body and eventually cause the death of the patient. If cancer is found early, in many instances, cure is possible. Surgery and radiation therapy can cure most cancers when found in an early stage. Chemotherapy and hormonal therapy can be used in some instances to prolong the interval in which the patient is free of disease. It has been estimated that 76 million Americans now living will develop cancer, about one in three. In 1991, 1.1 million people will develop cancer and 514000 will die from cancer. An additional 600 000 will develop skin cancer.1 There are 7 million Americans alive who have had cancer; 3 million of these patients have been alive for more than 5 years. In the 1930s, less than one in five cancer patients survived 5 years. Today, four in 10 cancer patients will survive 5 years. This is an increase from 20% to 40%.' With early detection, it is believed that this number could be increased to approximately 80%. This is why the American Cancer Society emphasizes early detection. From the Department of Radiation Oncology and Nuclear Medicine, Bodine Center for Cancer Treatment, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Dr Carl M. Mansfield, Dept of Radiation Oncology and Nuclear Medicine, Bodine Center for Cancer Treatment, Thomas Jefferson University Hospital, Philadelphia, PA 19107. 638
As a general rule, African Americans die at an earlier age than their white counterparts. The fact that there was a higher cancer death rate in African Americans was brought to our attention in 1973 by Dr Ulrich Henschke et al.2 It was first thought that the African American might be more susceptible to cancer. However, it soon became apparent that poor white Americans had similar high death rates. Thus, it was recognized that this problem was intimately related to economic status.3-7 However, even when the economic status is eliminated, there is evidence that African Americans, in some instances, may receive different treatment.8 In addition, stage for stage, middle and upper income African and white Americans had similar mortality rates.9-13 When these patients were classified by stage of disease, there was no difference in survival.12 When patients with lung and colon cancer had equal access to care through the Veterans Administration system, there was no difference in survival.5 Using the Bureau of Census figures, based on a population of 245 million people, approximately 39 million (16%) live below the poverty level. Approximately 23 million of these individuals are white Americans and 9.6 million are African Americans, with the remaining 6.4 million representing all other racial/ ethnic groups. 14 This shows the concentration of poverty among African Americans, since one fourth of the nation's poor are found to be within only 12% of the
population. 15 In America, approximately 17 million people who live above the poverty level are underinsured. An additional 37 million Americans are uninsured. This means that approximately 54 million Americans are JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
CANCER IN THE AFRICAN AMERICAN
uninsured or underinsured, and thereby have difficulty accessing the health-care system. Regardless of race or color, being poor is usually a continuous downward spiral. The poor are usually undereducated and, therefore, are unable to get jobs that will raise them above the poverty level. In a fee-forservice system, they cannot afford health insurance or private health care. Their ability to choose a healthy diet or healthy lifestyle is extremely limited.6"16 This applies to all poor, but because a large percentage of African Americans are poor, they suffer disproportionately all of the effects of being poor. The poor have less ability to practice good health habits and less access to good health care. Because of poor health habits,6'7'17 the incidence of cancer is high,'7-'9 and because of limited and delayed access to health care, the death rate from cancer is high.5"14'20'2' Even though the cancer incidence and death rate among African Americans is 10% to 15% higher than that among the average population,22-24 30 years ago the death rate in African Americans was almost the same as the general population.25 Since 1960, the cancer death rate for the general population has risen by 17% for men and by 2% for women. However, the death rate from cancer in African Americans has risen by 51% for men and by 10% for women.' These differences are most noticeable for cancers of the lung, prostate, head and neck, stomach, liver, cervix, esophagus, and colon.'5'22'24 The higher cancer incidence for African Americans is felt to be primarly the result of lifestyle.3'4"1516"1922-24 The higher cancer rate in lung, head and neck, stomach, liver, and esophagus cancer in African Americans can be attributed almost exclusively to smoking and drinking. The high cervix, prostate, and colon cancer rates also may be related strongly to lifestyle. The importance of other factors such as heredity is unknown. The role of environment, both at work and in the neighborhood, is also an unknown. The poor tend to have industrial jobs and live in neighborhoods that increase their chances of exposure to toxic products. The increased mortality rate is predominantly the result of delay in diagnosis.'4'18 This delay results from a lack of education as to the signs, symptoms, and dangers of cancer. Another cause of delay is inadequate access to health care.21 An example of this problem is illustrated by the fact that the incidence of breast cancer is lower in African Americans, but their death rate from breast cancer is higher. It is believed that this is solely the result of delay in seeking treatment, and in some cases, the result of limited access to health care. For JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
African Americans in the middle or upper income brackets, their cancer incidence and mortality rates are similar to the general population. Therefore, it becomes apparent that African Americans caught in poverty will have a higher cancer death rate purely because they are
poor.14 Again, I emphasize that all poor suffer from many of the same problems. Therefore, we must address this issue as a problem of the poor regardless of race. However, poor African Americans are doubly burdened because they must operate in a society that in many instances acts along racial standards. Solely because of color, they will have limited access to many job opportunities. They will have almost no access to apprenticeship training in the trade unions. With limited education, they are unable to convey to their children the value of education, the fire of aspiration, the beauty of hope, or the promise of success. Instead, the parent becomes a role model of despair and hopelessness. African Americans see themselves surrounded by a hostile environment in their neighborhood, their city, and their country. Their neighborhood is riddled with drugs and crime that threatens them and their family. It is difficult to bring a message of good health habits to a mother struggling to protect her children, trying to keep them from crime and drugs while struggling to provide food and shelter at the same time. African Americans believe that their city oppresses them in many ways, especially through its failure to provide protection and services. They see the fire bombing of the homes of African Americans, who have moved to other parts of the city, as hostile acts by whites and of the city government. In the last 12 years, during the Reagan and Bush administrations, the federal government has effectively shut the poor off from nearly all self-help or selfenrichment programs. African-American children see opportunities available to them only through sports, music, the military, minimum-wage jobs, unemployment, crime, or drugs. Unfortunately, too many choose the latter three. It is easy to look around and find someone else to blame. The first is always the government, especially when it is known that between 1980 and 1989, the US government spent $7 trillion on defense, while at the same time it was actively destroying social and self-help programs. The US government spent more than a half billion dollars a day to kill people in a country over 4000 miles away, but has been unwilling to spend money on the health and education of its own people. Much of this attitude results from the power of 639
CANCER IN THE AFRICAN AMERICAN
the "military-industrial complex"; we must advocate a "health-industrial complex." We must convince Congress that it is all right to spend some of those trillions of military dollars on the health of the poor. We could blame the news media for their failure to take a more responsible role-news media that would not adequately respond to an article in the New England Journal of Medicine in which Drs McCord and Freeman reported that an African-American male in Harlem had "less of a chance of survival" than a male in Bangladesh, one of the poorest countries in the world.26 It is possible that we should.blame the American public for not caring or our politicians for not acting. We could blame the drug cartels for sapping the strength of our neighborhoods or certain residents in our own neighborhoods whose actions have increased the fear of death so much that ministers have had to go into the streets to beg young African-American males to stop killing each other. African Americans are seven times more likely to be murdered than white Americans. What should we do in the face of these problems? There are no easy answers, but we must look for solutions. We in the medical profession, therefore, must concentrate our efforts toward educating the poor on the signs, symptoms, and dangers of cancer.27 This will require the teaching and advocacy of preventive action and prevention programs.28 We must increase efforts to bring about early detection programs so that treatment can be started at an earlier stage of disease.29'30'3' The goal would be to decrease the delay and increase the number of patients seen in the early stages.32 For example, in 1986 43% of white Americans were diagnosed with cancer in early stages compared with only 35% of African Americans.' Churches have been traditional leaders in the African-American community. Effective prevention programs will need to have a very strong church involvement. It will be necessary to pool efforts with established, credible agencies that are working in the neighborhood. Local radio stations are effective methods to carry the cancer message, and local community printed media can be very useful. Health centers and doctors' offices should be used to present cancer awareness and prevention programs. We must work with political, governmental, and private agencies to improve access to the health-care system so that delays in seeking treatment can be eliminated. One example of how various agencies can work together to improve access to the health-care system is a breast mobile screening project developed by the Philadelphia Division of the American Cancer Society in conjunction with the Philadelphia District Health 640
Centers. The program funds approximately 1000 free mammograms in a 1-year period through contributions from private industry, a hospital, a photographic film company, and the work of a dedicated radiologist. Private funds also enabled the Philadelphia District Health Centers to purchase a flexible sigmoidoscope so that district physicians and family practice physicians who serve the poor can develop their skills in performing colorectal screening examinations. The recent American Cancer Society's "Report to the Nation" identified the following 10 specific
challenges33: 1. Ensure that cancer prevention, detection, treatment, and rehabilitation services are accessible and available to all who need them, regardless of the ability to pay. 2. Improve cancer prevention and early detection among poor Americans to eliminate unnecessary pain, suffering, and death. 3. Undertake aggressive educational efforts to counteract fatalism, overcome fears, and enable poor people to reduce cancer risk. 4. Improve and expand public and private assistance for the poor, including health insurance. 5. Develop cancer education materials and outreach programs that are culturally sensitive, understandable, and relevant to poor people. 6. Establish patient advocate and referral services to help poor patients navigate the health system and manage personal problems that result from cancer treatment. 7. Involve community organizations serving the poor and poor people themselves in cancer education and patient advocacy programs. 8. Train health-care providers to be sensitive to the needs of poor patients and to serve their needs more
effectively. 9. Expand the availability of and accessibility to health services for poor people of rural areas, which are now underserved. 10. Conduct research to further document the scope of the problem and identify effective interventions. For those of you who have the will, you must look at this as a problem that goes beyond cancer and general health care. The health risk to African Americans is only a reflection of a greater problem. African Americans should begin to take control of themselves, their neighborhoods, and their political system. This is an action that applies to all aspects of their lives. As physicians, you must work through local neighborhood groups and agencies to encourage African Americans to JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
CANCER IN THE AFRICAN AMERICAN
become more involved in the political system so that their representatives will know and respond to their wants and needs. Literature Cited 1. Borning CC, Squires TS, Tong T. Cancer statistics, 1991. CA. 1991;41:19-36. 2. Henschke UK, Leffall LD Jr, Mason CH, Reinhold AW, Schneider RL, White JE. Alarming increase of the cancer mortality in the US black population (1950-1967). Cancer 1 973;31 :763-768. 3. Baquet CR, Horm JW, Gibbs T, Greenwald R Socioeconomic factors and cancer incidence among blacks and whites. J Natl Cancer Inst. 1991;83:551-557. 4. McWhorter WP, Schatzkin AG, Horm JW, Brown CC. Contribution of socioeconomic status to black/white differences in cancer incidence. Cancer. 1989;63:982-987. 5. Akerly W, Moritz T, Ryan L, Zacharski L. Effect of race and socioeconomic status (SES) on survival in VA hospital patients with lung and colon cancer. Proceedings of the Annual Meeting of the American Society for Clinical Oncology. 1989;8:A376. Abstract. 6. Roberson NLB. A community cancer control intervention for black Americans in Buffalo, New York: a case study. Dissertation Abstracts International: B-The Sciences and Engineering. 1986;47:1916. 7. Bang KM. Recent cancer patient survival among black Americans. Proceedings of the Annual Meeting of the American Association of Cancer Research. 1986;27:164. Abstract. 8. Diehr P, Yergan J, Chu J, Feigl P, Glaefke G, Moe R, et al. Treatment modality and quality differences for black and white breast cancer patients treated in community hospitals. Med Care. 1989;27:942-958. 9. Funch DR A Report on Cancer in the Economically Disadvantaged. New York, NY: American Cancer Society; 1985. 10. Lerner M. Cancer Mortality Differentials by Income. Baltimore, 1949-1951 to 1979-1981. New York, NY: American Cancer Society; 1986. 11. Ragland KE, Selvin S, Merrill DW. Black-white differences in stage-specific cancer survival: analysis of seven selected sites. Am J Epidemiol. 1991 ;133:672-682. 12. Zelen M, Betensky R, Gelman R. Black vs white cancer survival in clinical trials: the ECOG experience 1976-1985. Proceedings of the Annual Meeting of the American Society for Clinical Oncology. 1990;9:A228. Abstract. 13. Routh A, Hickman BT. Comparison of survival of black and white patients in each stage of Hodgkin's disease during 1970-1980. Radiat Med. 1989;7:28-31. 14. Freeman HP. Cancer in the socioeconomically disadvantaged. CA. 1989;39:266-286. 15. Baquet CR, Clayton LA, Robinson RG. Cancer prevention and control. In: Jones LA, ed. Minorities and Cancer. New York, NY: Springer-Verlag; 1989:67-76.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
16. Hargreaves MK, Baquet C, Gamshadzahi A. Diet, nutritional status, and cancer risk in American blacks. Nutr Cancer 1989;12:1-28. 17. Shankar S, Bonney GE, Kofie VY, Schwartz E, Tuckson R, Rivo M, et al. The need for cancer education among blacks: a survey of wards 7 and 8 in Washington, DC. Proceedings of the Annual Meeting of the American Society for Clinical Oncology. 1989;8:A236. Abstract. 18. Gullatte MM. Cancer prevention and early detection in black Americans: colon and rectum. Joumal of National Black Nurses Association. 1989;3(2):49-56. 19. Bang KM, Wite JE, Gause BL, Leffall LD Jr. Evaluation of recent trends in cancer mortality and incidence among blacks. Cancer 1988;61 :1255-1261. 20. Liff JM, Chow WH, Greenberg RS. Rural-urban differences in stage at diagnosis. Possible relationship to cancer screening. Cancer 1991 ;67: 1454-1459. 21. Lerner M. Access to American health care system. CA. 1989;39:289-295. 22. Horton CP, Smith JC. Health and medical care. In: Statistical Record of Black America. Detroit, Mich: Gale Research Inc; 1990:294-368. 23. Wilson J. Cancer incidence and mortality differences of black and white Americans: a role for biomarkers. In: Jones LA, ed. Minorities and Cancer New York, NY: Springer-Verlag; 1989:5-20. 24. Dimery IW. Introduction: prevention and detection programs: national and regional efforts. In: Jones LA, ed. Minorities and Cancer New York, NY: Springer-Verlag; 1989:57-58. 25. White JE, Enterline JR Cancer in non-white Americans. Curr Probl Cancer 1980;4:1 -34. 26. McCord C, Freeman HR Excess mortality in Harlem. N Engl J Med. 1990;322:173. 27. Chen VW, Craig JF, Fontham ET, Correa P. Excessive cancer rates among blacks in Louisiana: an opportunity for physician intervention. CA. 1990;142(4):18-26. 28. Michielutte R, Beal R Identification of community leadership in the development of public health education programs. J Community Health. 1990; 1 5:59-68. 29. Millon-Underwood S, Sanders E. Factors contributing to health promotion behaviors among African American men. Oncol Nsg Forum. 1990; 17:707-712. 30. Brownson RC, Davis JR, Chang JC. Racial differences in cancer mortality in Missouri. Mo Med. 1990;87:291-294. 31. Austin JP, Aziz H, Potters L, Thelmo W, Chen P, Choi K, et al. Diminished survival of young blacks with adenocarcinoma of the prostate. Am J Clin Oncol. 1990;1 3:465-469. 32. Mandelblatt J, Andrews H, Kerner J, Zauber A, Burnett W. Determinants of late stage diagnosis of breast and cervical cancer: the impact of age, race, social class, and hospital type. Am J Public Health. 1991;81:646-649. 33. A summary of the American Cancer Society Report to the Nation: cancer in the poor-ten challenges for the nation. CA. 1989;39:263-265.
641
I have been asked to speak about African Americans and cancer. In doing so, it is necessary to address the issue of race and socioeconomic status as it relates to cancer. Cancer is a group of diseases characterized by uncontrolled growth. Portions of the tumor can spread to other parts of the body and eventually cause the death of the patient. If cancer is found early, in many instances, cure is possible. Surgery and radiation therapy can cure most cancers when found in an early stage. Chemotherapy and hormonal therapy can be used in some instances to prolong the interval in which the patient is free of disease. It has been estimated that 76 million Americans now living will develop cancer, about one in three. In 1991, 1.1 million people will develop cancer and 514000 will die from cancer. An additional 600 000 will develop skin cancer.1 There are 7 million Americans alive who have had cancer; 3 million of these patients have been alive for more than 5 years. In the 1930s, less than one in five cancer patients survived 5 years. Today, four in 10 cancer patients will survive 5 years. This is an increase from 20% to 40%.' With early detection, it is believed that this number could be increased to approximately 80%. This is why the American Cancer Society emphasizes early detection. From the Department of Radiation Oncology and Nuclear Medicine, Bodine Center for Cancer Treatment, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Dr Carl M. Mansfield, Dept of Radiation Oncology and Nuclear Medicine, Bodine Center for Cancer Treatment, Thomas Jefferson University Hospital, Philadelphia, PA 19107. 638
As a general rule, African Americans die at an earlier age than their white counterparts. The fact that there was a higher cancer death rate in African Americans was brought to our attention in 1973 by Dr Ulrich Henschke et al.2 It was first thought that the African American might be more susceptible to cancer. However, it soon became apparent that poor white Americans had similar high death rates. Thus, it was recognized that this problem was intimately related to economic status.3-7 However, even when the economic status is eliminated, there is evidence that African Americans, in some instances, may receive different treatment.8 In addition, stage for stage, middle and upper income African and white Americans had similar mortality rates.9-13 When these patients were classified by stage of disease, there was no difference in survival.12 When patients with lung and colon cancer had equal access to care through the Veterans Administration system, there was no difference in survival.5 Using the Bureau of Census figures, based on a population of 245 million people, approximately 39 million (16%) live below the poverty level. Approximately 23 million of these individuals are white Americans and 9.6 million are African Americans, with the remaining 6.4 million representing all other racial/ ethnic groups. 14 This shows the concentration of poverty among African Americans, since one fourth of the nation's poor are found to be within only 12% of the
population. 15 In America, approximately 17 million people who live above the poverty level are underinsured. An additional 37 million Americans are uninsured. This means that approximately 54 million Americans are JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
CANCER IN THE AFRICAN AMERICAN
uninsured or underinsured, and thereby have difficulty accessing the health-care system. Regardless of race or color, being poor is usually a continuous downward spiral. The poor are usually undereducated and, therefore, are unable to get jobs that will raise them above the poverty level. In a fee-forservice system, they cannot afford health insurance or private health care. Their ability to choose a healthy diet or healthy lifestyle is extremely limited.6"16 This applies to all poor, but because a large percentage of African Americans are poor, they suffer disproportionately all of the effects of being poor. The poor have less ability to practice good health habits and less access to good health care. Because of poor health habits,6'7'17 the incidence of cancer is high,'7-'9 and because of limited and delayed access to health care, the death rate from cancer is high.5"14'20'2' Even though the cancer incidence and death rate among African Americans is 10% to 15% higher than that among the average population,22-24 30 years ago the death rate in African Americans was almost the same as the general population.25 Since 1960, the cancer death rate for the general population has risen by 17% for men and by 2% for women. However, the death rate from cancer in African Americans has risen by 51% for men and by 10% for women.' These differences are most noticeable for cancers of the lung, prostate, head and neck, stomach, liver, cervix, esophagus, and colon.'5'22'24 The higher cancer incidence for African Americans is felt to be primarly the result of lifestyle.3'4"1516"1922-24 The higher cancer rate in lung, head and neck, stomach, liver, and esophagus cancer in African Americans can be attributed almost exclusively to smoking and drinking. The high cervix, prostate, and colon cancer rates also may be related strongly to lifestyle. The importance of other factors such as heredity is unknown. The role of environment, both at work and in the neighborhood, is also an unknown. The poor tend to have industrial jobs and live in neighborhoods that increase their chances of exposure to toxic products. The increased mortality rate is predominantly the result of delay in diagnosis.'4'18 This delay results from a lack of education as to the signs, symptoms, and dangers of cancer. Another cause of delay is inadequate access to health care.21 An example of this problem is illustrated by the fact that the incidence of breast cancer is lower in African Americans, but their death rate from breast cancer is higher. It is believed that this is solely the result of delay in seeking treatment, and in some cases, the result of limited access to health care. For JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
African Americans in the middle or upper income brackets, their cancer incidence and mortality rates are similar to the general population. Therefore, it becomes apparent that African Americans caught in poverty will have a higher cancer death rate purely because they are
poor.14 Again, I emphasize that all poor suffer from many of the same problems. Therefore, we must address this issue as a problem of the poor regardless of race. However, poor African Americans are doubly burdened because they must operate in a society that in many instances acts along racial standards. Solely because of color, they will have limited access to many job opportunities. They will have almost no access to apprenticeship training in the trade unions. With limited education, they are unable to convey to their children the value of education, the fire of aspiration, the beauty of hope, or the promise of success. Instead, the parent becomes a role model of despair and hopelessness. African Americans see themselves surrounded by a hostile environment in their neighborhood, their city, and their country. Their neighborhood is riddled with drugs and crime that threatens them and their family. It is difficult to bring a message of good health habits to a mother struggling to protect her children, trying to keep them from crime and drugs while struggling to provide food and shelter at the same time. African Americans believe that their city oppresses them in many ways, especially through its failure to provide protection and services. They see the fire bombing of the homes of African Americans, who have moved to other parts of the city, as hostile acts by whites and of the city government. In the last 12 years, during the Reagan and Bush administrations, the federal government has effectively shut the poor off from nearly all self-help or selfenrichment programs. African-American children see opportunities available to them only through sports, music, the military, minimum-wage jobs, unemployment, crime, or drugs. Unfortunately, too many choose the latter three. It is easy to look around and find someone else to blame. The first is always the government, especially when it is known that between 1980 and 1989, the US government spent $7 trillion on defense, while at the same time it was actively destroying social and self-help programs. The US government spent more than a half billion dollars a day to kill people in a country over 4000 miles away, but has been unwilling to spend money on the health and education of its own people. Much of this attitude results from the power of 639
CANCER IN THE AFRICAN AMERICAN
the "military-industrial complex"; we must advocate a "health-industrial complex." We must convince Congress that it is all right to spend some of those trillions of military dollars on the health of the poor. We could blame the news media for their failure to take a more responsible role-news media that would not adequately respond to an article in the New England Journal of Medicine in which Drs McCord and Freeman reported that an African-American male in Harlem had "less of a chance of survival" than a male in Bangladesh, one of the poorest countries in the world.26 It is possible that we should.blame the American public for not caring or our politicians for not acting. We could blame the drug cartels for sapping the strength of our neighborhoods or certain residents in our own neighborhoods whose actions have increased the fear of death so much that ministers have had to go into the streets to beg young African-American males to stop killing each other. African Americans are seven times more likely to be murdered than white Americans. What should we do in the face of these problems? There are no easy answers, but we must look for solutions. We in the medical profession, therefore, must concentrate our efforts toward educating the poor on the signs, symptoms, and dangers of cancer.27 This will require the teaching and advocacy of preventive action and prevention programs.28 We must increase efforts to bring about early detection programs so that treatment can be started at an earlier stage of disease.29'30'3' The goal would be to decrease the delay and increase the number of patients seen in the early stages.32 For example, in 1986 43% of white Americans were diagnosed with cancer in early stages compared with only 35% of African Americans.' Churches have been traditional leaders in the African-American community. Effective prevention programs will need to have a very strong church involvement. It will be necessary to pool efforts with established, credible agencies that are working in the neighborhood. Local radio stations are effective methods to carry the cancer message, and local community printed media can be very useful. Health centers and doctors' offices should be used to present cancer awareness and prevention programs. We must work with political, governmental, and private agencies to improve access to the health-care system so that delays in seeking treatment can be eliminated. One example of how various agencies can work together to improve access to the health-care system is a breast mobile screening project developed by the Philadelphia Division of the American Cancer Society in conjunction with the Philadelphia District Health 640
Centers. The program funds approximately 1000 free mammograms in a 1-year period through contributions from private industry, a hospital, a photographic film company, and the work of a dedicated radiologist. Private funds also enabled the Philadelphia District Health Centers to purchase a flexible sigmoidoscope so that district physicians and family practice physicians who serve the poor can develop their skills in performing colorectal screening examinations. The recent American Cancer Society's "Report to the Nation" identified the following 10 specific
challenges33: 1. Ensure that cancer prevention, detection, treatment, and rehabilitation services are accessible and available to all who need them, regardless of the ability to pay. 2. Improve cancer prevention and early detection among poor Americans to eliminate unnecessary pain, suffering, and death. 3. Undertake aggressive educational efforts to counteract fatalism, overcome fears, and enable poor people to reduce cancer risk. 4. Improve and expand public and private assistance for the poor, including health insurance. 5. Develop cancer education materials and outreach programs that are culturally sensitive, understandable, and relevant to poor people. 6. Establish patient advocate and referral services to help poor patients navigate the health system and manage personal problems that result from cancer treatment. 7. Involve community organizations serving the poor and poor people themselves in cancer education and patient advocacy programs. 8. Train health-care providers to be sensitive to the needs of poor patients and to serve their needs more
effectively. 9. Expand the availability of and accessibility to health services for poor people of rural areas, which are now underserved. 10. Conduct research to further document the scope of the problem and identify effective interventions. For those of you who have the will, you must look at this as a problem that goes beyond cancer and general health care. The health risk to African Americans is only a reflection of a greater problem. African Americans should begin to take control of themselves, their neighborhoods, and their political system. This is an action that applies to all aspects of their lives. As physicians, you must work through local neighborhood groups and agencies to encourage African Americans to JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 7
CANCER IN THE AFRICAN AMERICAN
become more involved in the political system so that their representatives will know and respond to their wants and needs. Literature Cited 1. Borning CC, Squires TS, Tong T. Cancer statistics, 1991. CA. 1991;41:19-36. 2. Henschke UK, Leffall LD Jr, Mason CH, Reinhold AW, Schneider RL, White JE. Alarming increase of the cancer mortality in the US black population (1950-1967). Cancer 1 973;31 :763-768. 3. Baquet CR, Horm JW, Gibbs T, Greenwald R Socioeconomic factors and cancer incidence among blacks and whites. J Natl Cancer Inst. 1991;83:551-557. 4. McWhorter WP, Schatzkin AG, Horm JW, Brown CC. Contribution of socioeconomic status to black/white differences in cancer incidence. Cancer. 1989;63:982-987. 5. Akerly W, Moritz T, Ryan L, Zacharski L. Effect of race and socioeconomic status (SES) on survival in VA hospital patients with lung and colon cancer. Proceedings of the Annual Meeting of the American Society for Clinical Oncology. 1989;8:A376. Abstract. 6. Roberson NLB. A community cancer control intervention for black Americans in Buffalo, New York: a case study. Dissertation Abstracts International: B-The Sciences and Engineering. 1986;47:1916. 7. Bang KM. Recent cancer patient survival among black Americans. Proceedings of the Annual Meeting of the American Association of Cancer Research. 1986;27:164. Abstract. 8. Diehr P, Yergan J, Chu J, Feigl P, Glaefke G, Moe R, et al. Treatment modality and quality differences for black and white breast cancer patients treated in community hospitals. Med Care. 1989;27:942-958. 9. Funch DR A Report on Cancer in the Economically Disadvantaged. New York, NY: American Cancer Society; 1985. 10. Lerner M. Cancer Mortality Differentials by Income. Baltimore, 1949-1951 to 1979-1981. New York, NY: American Cancer Society; 1986. 11. Ragland KE, Selvin S, Merrill DW. Black-white differences in stage-specific cancer survival: analysis of seven selected sites. Am J Epidemiol. 1991 ;133:672-682. 12. Zelen M, Betensky R, Gelman R. Black vs white cancer survival in clinical trials: the ECOG experience 1976-1985. Proceedings of the Annual Meeting of the American Society for Clinical Oncology. 1990;9:A228. Abstract. 13. Routh A, Hickman BT. Comparison of survival of black and white patients in each stage of Hodgkin's disease during 1970-1980. Radiat Med. 1989;7:28-31. 14. Freeman HP. Cancer in the socioeconomically disadvantaged. CA. 1989;39:266-286. 15. Baquet CR, Clayton LA, Robinson RG. Cancer prevention and control. In: Jones LA, ed. Minorities and Cancer. New York, NY: Springer-Verlag; 1989:67-76.
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