Minorities, women struggle with unequal access to cancer care

ATLANTA — Advancements in cancer research have enabled better detection and treatment of cancers and even better quality of life for cancer survivors, but is a significant portion of the U.S. public getting left behind?

Even as the Affordable Care Act (ACA) promises to close gaps in health care coverage and make it more accessible, many cancer researchers are unsure how much it can do.

“It’s not only an issue of being able to pay for care, (but) also is the care that’s delivered (provided) in a culturally appropriate way?” said Dr. Christopher I. Li, program head of the translational research program at the Fred Hutchinson Cancer Research Center in Seattle. “Are the barriers with distance taken care of? Issues such as child care or getting off of work, things like that … There are all these other factors that also need to be addressed. It’s not just about paying for it.”

Li was one of the chairs of a conference sponsored by the American Association for Cancer Research, where researchers came together to discuss how to help close the gap between those who are benefiting the most from new advances and those who have not done as well.

There is plenty of evidence of gaps in how different groups of people fare after they contract various diseases.

“Health disparities are really a global problem, and so when we talk about cancer, disparities really impact every type of cancer,” Li said.

Many of the cancers discussed at these meetings, he said, are both common and have higher rates in certain minority groups — in occurrence or mortality rates. For example, prostate cancer, the most common cancer in men, is found in African-American men at the highest rate in the world. Similarly, he said, African-American women have the highest mortality rates from breast cancer, and along with Hispanic women, they tend to have more aggressive forms of the disease when they are diagnosed. Also, Li said, African-American men and women have higher mortality rates from colon cancer.

Jean McDougall, a postdoctoral researcher at Fred Hutchinson, said there are good reasons to doubt the new health care law alone will close gaps in care.

“I think it’s going to improve access to care,” she said, “but whether it makes a difference in terms of the timeliness of treatment, I’m not convinced.”

Women with public health care plans were more likely to get care later than recommended compared to women with private health insurance, according to a study McDougall and her colleagues at Fred Hutchinson and the University of Washington conducted. It looked at a number of factors to determine how well the care patients received matched quality measures for breast cancer treatment from the American Society of Clinical Oncology and the National Comprehensive Cancer Network.

“Really looking at the quality of insurance plans and reimbursement … will be important, not just insuring everybody,” McDougall said.

Dr. Judith Kaur, medical director for the Native American Programs of the Mayo Comprehensive Cancer Center, noted that some of the problems are related to how specific health care systems are set up.

Cancer is just one of a number of health issues in which minorities may lag in care, she said, noting that heart disease and diabetes are also more likely to affect minority groups. When it comes to cancer, other groups — like people in Appalachia or other rural areas — also fall behind when it comes to care, which is an issue researchers hope to address. While Kaur is optimistic the ACA will close gaps in access to preventive care, she sees areas where it may be incomplete.

“There are a lot of pieces of the law that are permissive and aren’t funded,” she said, saying she questions whether palliative care — care given to alleviate suffering associated with a serious illness — which is called for under the ACA, will receive the necessary funding.

“It sets a blueprint, and it sets a bar that’s pretty high,” Kaur said of the ACA, “but it isn’t necessarily complete enough.”

The new law may be able to narrow the gap, in some cases, in access to the newest research and technology.

“In certain cases, technology will be vital in reducing particular disparities. I think in other cases, it will be helpful,” said John Carpten, deputy director of basic science at the Translational Genomics Research Institute in Phoenix and one of the conference chairs.

He noted that some cancer disparities are due to socioeconomics, with one group getting better care than another. But advances in science, such as gene sequencing, have shown ways to improve cancer care for specific groups.

“There are certain genetic factors … that are related to drug metabolism. If you have a particular genotype, you metabolize a drug well. Other genotypes, you don’t metabolize the drug well,” Carpten said. “By having that genetic information, you can determine how to dose the patient, give them higher doses or lower doses.”

He pointed to a study done at St. Jude’s in which children of Native American heritage were doing worse with leukemia, but after gene testing and an increase in medication, that gap was closed.

The ability to bring a similar approach to more cancer patients is something Carpten said he hopes to see coming from the ACA. By doing gene sequencing up front, he said, doctors may be better able to choose therapies and dosing for new cancer patients rather than try regimens that may not be likely to work for them.

“If you pay a little up front to do the genomic profiling, you can prevent the patient from going on several regimens of chemotherapy at 50, 60, 75 thousand dollars,” he said. “Hopefully at the end of the day, we’ll save the insurance company, we’ll save the health care system by providing the best care earlier on in the course of the patient’s disease. I think that’s one way the Affordable Care Act can improve the lives of patients with cancer.”