For Most Kinds of Cancer, It Helps If You’re White

The explanation is historical — and scintillating.

FAYETTEVILLE, NC - AUGUST 04: Cancer patient Kimberly Paulson sits with a book as she gets her chemotherapy treatment at the Cape Fear Valley Cancer Center August 4, 2010 in Fayetteville, North Carolina. Health care providers around the country are increasingly specializing their care by creating distinct treatment centers for various disorders and acquiring the latest high-tech medical equipment.
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Janell Ross
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Janell Ross
March 13, 2014, 5 p.m.

Be­fore his hand­lers took back what the act­or had di­vulged, Mi­chael Douglas touched off a me­dia and med­ic­al sen­sa­tion last June when he an­nounced he had con­trac­ted throat can­cer as a res­ult, years earli­er, of or­al sex. In­ad­vert­ently, he in­spired a teach­able mo­ment for a per­sist­ent prob­lem — the some­times highly dis­par­ate rates of can­cer among ra­cial and eth­nic groups. But this dis­par­ity was a mir­ror im­age of the usu­al: Head and neck can­cers rank among the rare can­cers that af­flict white Amer­ic­ans more of­ten than any oth­er demo­graph­ic group.

The ex­plan­a­tion is his­tor­ic­al — and scin­til­lat­ing. This form of can­cer is most of­ten caused by the hu­man papil­lo­mavir­us, or HPV, which is trans­mit­ted by or­al sex. In the wake of the sexu­al re­volu­tion of the 1960s, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, whites took to or­al sex earli­er and more en­thu­si­ast­ic­ally than Amer­ic­ans in oth­er ra­cial and eth­nic groups. That, ex­plains Ot­is Braw­ley, the Amer­ic­an Can­cer So­ci­ety’s chief med­ic­al of­ficer, is why white Amer­ic­ans now in their 50s and 60s are suf­fer­ing dis­pro­por­tion­ately from head and neck can­cers.

But there’s something even more re­veal­ing in Douglas’s tale: His can­cer (at the base of his tongue, as it turned out) is in re­mis­sion, and he ex­pects to sur­vive. While whites ac­count for 85 per­cent of the na­tion’s cases of head and neck can­cer, they die of it no more of­ten than Afric­an-Amer­ic­ans do. The reas­on: earli­er dia­gnos­is and bet­ter med­ic­al care. Head and neck can­cers, par­tic­u­larly those caused by HPV, are highly sur­viv­able when they’re caught in time.

These dis­par­it­ies won’t be easy to erase, in part be­cause they may be be­ha­vi­or­al in ori­gin. In the 1990s, for in­stance, black men were nearly 40 per­cent more likely to die of lung can­cer than white men — and soon­er. The av­er­age black vic­tim had smoked for 30 “pack-years,” com­pared with 50 pack-years for whites. Why the high­er fatal­ity rate? The an­swer was dis­covered in 1998, bur­ied in to­bacco-in­dustry doc­u­ments re­leased as part of the mega-set­tle­ment between state at­tor­neys gen­er­al and ci­gar­ette com­pan­ies: Lower-in­come smokers smoke dif­fer­ently than those with more money. They don’t talk as much while they puff or let their ci­gar­ettes burn as long between drags. Wealth­i­er smokers are less ef­fi­cient, to their med­ic­al be­ne­fit. This re­search find­ing dis­cred­ited the the­ory that the dif­fer­ence was ge­net­ic.

As Mi­chael Douglas has learned, be­ha­vi­or­al and cul­tur­al dif­fer­ences can work in minor­it­ies’ fa­vor. For dec­ades, Lati­nos and Asi­an-Amer­ic­ans have been dia­gnosed far less of­ten with sev­er­al com­mon can­cers, in­clud­ing those of the lung, breast, and pro­state. This has been par­tic­u­larly true for im­mig­rants, re­gard­less of in­come — largely be­cause of diet and ex­er­cise habits, can­cer re­search­ers say. But in sub­sequent, pre­sum­ably more as­sim­il­ated gen­er­a­tions, these ad­vant­ages shrink.

Or con­sider the ad­vant­age that black and Latino wo­men hold in sidestep­ping “es­tro­gen-sens­it­ive” breast can­cer, the most com­mon form of the dis­ease. The can­cer strikes less of­ten among wo­men who don’t smoke, first give birth be­fore age 30, and avoid hor­mone-re­place­ment ther­apy at men­o­pause. White wo­men have been dis­ad­vant­aged on all counts.

Yet white wo­men fare bet­ter with the less com­mon but more ag­gress­ive “triple-neg­at­ive” breast can­cer. Afric­an-Amer­ic­an wo­men de­vel­op this can­cer twice as of­ten as white wo­men do and are 40 per­cent more likely to die of breast can­cer in either form. In­deed, among all cat­egor­ies of Amer­ic­ans, black wo­men are the like­li­est to die of can­cer of any sort — mainly, Braw­ley says, be­cause of whites’ great­er ac­cess to med­ic­al care.

In Chica­go, for ex­ample, all of the mam­mo­graphy ma­chines able to de­tect smal­ler tu­mors and growths in dense, harder-to-ana­lyze breast tis­sue — which is more com­mon among black wo­men — were out­side the city line and hard to reach by pub­lic trans­port­a­tion, ac­cord­ing to a Sinai Urb­an Health In­sti­tute study in 2012. Among wo­men in met­ro­pol­it­an Chica­go dia­gnosed with breast can­cer between 2005 and 2007, 38 per­cent of Afric­an-Amer­ic­ans died with­in five years, com­pared with 23 per­cent of whites.

Lat­i­nas suf­fer the most from cer­vical can­cer, which is or­din­ar­ily linked to HPV. In the United States from 2006 to 2010, 10.9 out of 100,000 Lat­i­nas fell vic­tim, com­pared with 9.6 blacks, 7.9 whites, and 6.6 Asi­an-Amer­ic­ans. The reas­on, re­search­ers say, is that many Lat­i­nas avoid reg­u­lar gyneco­lo­gic­al screen­ing that might de­tect cer­vical can­cer or its pre­curs­ors, partly from em­bar­rass­ment but even more from lack of health care.

How might the United States re­duce these dis­par­it­ies in can­cer? There may be a les­son in the earli­er ex­per­i­ence with measles. In the late 1980s and early 1990s, an out­break caused nearly 200 deaths across the coun­try, mostly among chil­dren who hadn’t been im­mun­ized. The res­ult, in 1994, was the fed­er­al Vac­cines for Chil­dren pro­gram, which man­dates in­ocu­la­tions and cov­ers the vac­cin­a­tion costs for the poor and un­in­sured. Today, vac­cin­a­tion rates for measles among poor chil­dren nearly match those for kids in wealth­i­er house­holds — between 90 per­cent and 93 per­cent in every ra­cial and eth­nic group.

“This may not be what some people want to hear,” said Anna Kirk­land, a Uni­versity of Michigan polit­ic­al sci­ent­ist who is an ex­pert on pub­lic res­ist­ance to vac­cines. “We use the two strongest tools that we have as a so­ci­ety. We man­date vac­cin­a­tion, then we cov­er the cost — and you ba­sic­ally elim­in­ate dis­par­it­ies.”

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