Reducing the Burden of Cancer Borne by African Americans

Introduction

Cancer incidence, mortality, and survival rates differ among racial/ethnic populations in the United States. African Americans have the highest overall cancer mortality rates and the lowest survival rates. Published reports have highlighted challenges faced by African Americans with regard to cancer prevention, early detection, and disparities in treatment outcomes. Past initiatives have been inadequate to substantially reduce the burden of cancer borne by African Americans. To achieve this national goal, efforts must be undertaken to garner the necessary political will, resources, and support.

The United States Department of Commerce report entitled “Race and Ethnic Standards for Federal Statistics and Administrative Reporting” classifies citizens who trace their ancestry of origin to Sub-Saharan Africa as African American (1) . According to the 2000 United States Census, African Americans comprise the second largest racial group in the United States (2) . Most are descendants of African men, women, and children who were forcibly transported from Sub-Saharan Africa to the United States and the Caribbean in the 17th to 19th centuries and sold into slavery. Others are their descendants who voluntarily came to the United States from the Caribbean Islands, Sub-Saharan Africa, or other parts of the world. There are approximately 35.5 million African Americans, 93% of whom were born in the United States. Among those over age 16 years, approximately 43% have at least a high school education, 92% are employed, and 88% reside in metropolitan areas.

Cancer is the second leading cause of death among African Americans. Data from the National Cancer Institute, American Cancer Society, and Centers for Disease Control and Prevention indicate that incidence and mortality rates for all cancers combined have decreased over the last decade (3, 4, 5) . Advances in early detection, screening, and treatment have reduced cancer incidence and mortality, improved life expectancy, and enhanced quality of life for many cancer patients. However, when cancer incidence and mortality rates of African Americans are compared with other ethnic groups, African Americans are significantly more likely to develop cancer and, subsequently, die from their disease.

In 1992–1999, overall age-adjusted cancer incidence rates for all cancers combined (per 1,000,000 in the population) were 527 for African Americans, 480 for whites, 330 for Hispanics, 341 for Asian/Pacific Islanders, and 245 for American Indians/Alaska Natives (Table 1⇓ ; Ref. 5 ). Corresponding cancer mortality rates were 267 (per annum) for African Americans, 205 for whites, 129 for Hispanics, 121 for Asian/Pacific Islanders, and 129 for American Indians/Alaska Natives (Table 2)⇓ . Also, overall 5-year relative cancer survival rates were 53% among African Americans, as compared with 64% among whites and 62% in the total United States population (Table 3)⇓ .

Prostate cancer is the most common form of cancer among African-American men, followed by cancers of the lung and bronchus, cancers of the colon and rectum, non-Hodgkin’s lymphoma, and cancers of the oral cavity (Table 1⇓ ; Refs. 3 and 5 ). When compared with other racial/ethnic groups in the United States, African-American men have the highest age-adjusted incidence and mortality rates for at least nine forms of cancer, including cancers of the lung and bronchus, colon and rectum, oral cavity and pharynx, stomach, urinary bladder, pancreas, kidney, and renal pelvis and non-Hodgkin’s lymphoma. Among African-American women, the most common cancers are cancers of the lung and bronchus, colon and rectum, uterus, ovary, and pancreas (3 , 5) ; African-American women have the highest age-adjusted incidence and mortality rates for cancers of the esophagus, larynx, oral cavity, and pancreas and multiple myeloma. In addition, African Americans have the highest age-adjusted mortality rates for cancers of the breast, stomach, urinary bladder, uterine cervix, and uterine corpus and Hodgkin’s disease. When compared with whites, African Americans of both sexes have poorer 5-year survival rates for many cancers.

Factors Influencing Cancer Morbidity and Mortality among African Americans

The American Cancer Society estimates that in 2003, approximately 132,700 African Americans will develop invasive cancers, and approximately 63,100 will die from cancer (3) . Cancer incidence rates are determined by several factors, including biological, genetic, behavioral, and environmental influences, whereas cancer mortality rates are also determined by factors, such as site-specific cancer incidence, histology, co-morbid conditions (i.e., tobacco use, poor diet/nutrition, physical inactivity, and overweight/obesity), sociodemographic factors, and disparities in medical care. Decisions made by patients and providers regarding cancer screening, treatment, and follow-up can also impact cancer morbidity and mortality among African Americans.

Tobacco Use

Smoking of cigarettes, cigars, and pipes accounts for approximately 1 in 5 deaths in the United States and is the most preventable cause of disease (4 , 6, 7, 8) . Tobacco use is the major cause of 87% of lung cancers, emphysema, and chronic bronchitis combined. Additionally, smoking causes an estimated 430,000 deaths annually in the United States due to cancer and other diseases of the heart, lung, and other organs. Environmental tobacco smoke can also contribute to deaths from coronary heart disease, lung cancer, and other disease among nonsmokers (9, 10, 11, 12, 13) . Additionally, environmental tobacco smoke increases the risk of asthma attacks, pulmonary infections, middle ear infections, and other health problems, particularly among children. Despite warnings regarding the health hazards of tobacco, an estimated 5.7 million African Americans smoke cigarettes or chew, dip, or sniff tobacco products (3 , 14, 15, 16, 17, 18) . Smoking prevalence of African Americans is reported to be higher among males and those ages 35–44 years (Table 4⇓ ; Refs. 3 and 19 ). An association has also been found between tobacco use and discrimination toward African Americans (20, 21, 22, 23, 24) . Tobacco companies target African Americans through advertising in magazines, billboards, sporting events, and other forms of entertainment (14 , 15 , 18 , 21 , 22) . However, African-American college graduates of both sexes smoke less than their counterparts with less education (Table 5)⇓ . The American Legacy Foundation’s National Youth Tobacco Survey reports that 24% of African-American high school students and 14% of African-American middle school students regularly use some form of tobacco, primarily cigarettes and cigars (25) . If these patterns of tobacco use persist, an estimated 1.6 million African Americans currently under the age of 18 years will become regular smokers, and 500,000 of these individuals will die of smoking-related diseases.

Diet and Nutrition

Diet can influence cancer risk. Diets high in fruits and vegetables, particularly green and dark yellow vegetables, cabbages, and legumes, are associated with lower risk of cancers of the lung, colon, oral cavity, esophagus, stomach, and other sites (26 , 27) . Diets high in fats, red meats (i.e., beef, pork, and lamb), and whole milk and other dairy products have been associated with increased risk of cancers of the colon, rectum, prostate, and endometrium (28 , 29) . Cancer risks may be reduced by consuming healthful foods high in fiber (i.e., whole grains, breads, and pastas) and low in red meats, whole-milk dairy products, and other high-fat foods (30, 31, 32) .

Dietary patterns of African Americans are influenced by diverse historical, regional, religious, social, economic, familial, and cultural factors; therefore, generalizations cannot adequately describe their dietary intake. African Americans and whites with similar incomes and education typically consume similar foods. Overall, African-American diets tend to be lower in fruits, vegetables, and fiber and higher in saturated fats (33 , 34) . The United States Department of Agriculture Center for Health Policy and Protection estimates that only 5% of African Americans consume healthy diets (34) . However, the 2001 Youth Risk Factor Survey found that most African-American students consume the recommended five or more daily servings of fruit and vegetables, along with limited amounts of high-fat foods (35) .

Alcohol Consumption

Chronic alcohol consumption is associated with many serious health-related conditions, including hypertension, cirrhosis, gastritis, colitis, depression, accidents, homicide, suicide, and fetal alcohol syndrome in offspring of alcoholic mothers. Excess alcohol consumption is also associated with cancers of the mouth, pharynx, larynx, esophagus, liver, and breast (36, 37, 38) and, in combination with tobacco use, further increases the risk of cancers of the mouth, larynx, and pharynx (39 , 40) . The National Institute on Alcohol Abuse and Alcoholism and the United States Dietary Association recommend that daily alcohol consumption be limited to two drinks for adult men and one drink for adult women. There are individuals who should not drink any alcoholic beverages: pregnant women or women trying to conceive; individuals who plan to drive or engage in activities that require attention or skill; those taking certain medications; and recovering alcoholics (31 , 32) . However, 56% of African Americans and 39% of African American women age 18 years or older are classified by the National Center for Health Statistics as “consumers” of alcohol (19) .

Physical Activity

Increasing evidence suggests that physical activity may decrease the risk for certain cancers, particularly cancers of the colon, breast, pancreas, lung, endometrium, ovary, prostate, and testicle (7 , 41, 42, 43, 44) . Adults are recommended to engage in at least 30 min of moderately intense physical activity on most days per week (42) . Despite the proven benefits of regular exercise, only 25% of adult African-American men and women engage in regular leisure-time physical activity (19) . Benefits of regular exercise include: (a) maintenance of healthy body weight, bones, muscles, and joints; (b) increased endurance and muscular strength; (c) decreased risk for cardiovascular disease, colon and breast cancers, and adult-onset diabetes; (d) blood pressure control; (e) improvement of strength, stamina, and flexibility; (f) increased psychological well-being; and (g) lower frequency of depression and anxiety. Unfortunately, many African-American high school students are not sufficiently active. Children should engage in at least 60 min or more of moderate physical activity on most days per week (42) . However, less than half of African-American high school students engage in daily physical education classes. During an average physical education class, male African-American high school students were more likely than their female counterparts (81% versus 71%, respectively) to exercise for at least 20 min (Table 6)⇓ .

Overweight and Obesity

Being overweight or obese is associated with chronic diseases, including hypertension, dyslipidemia, respiratory disease, cardiovascular disease, non-insulin-dependent diabetes mellitus, glucose intolerance, gout, and osteoarthritis (45) . Obesity is also associated with cancers of the breast (among postmenopausal women), colon, endometrium, esophagus, gallbladder, pancreas, and kidney (46, 47, 48) . National data indicate that obesity (body mass index of 30.0 kg/m² or greater) and being overweight (body mass index of 25–29.99 kg/m²) have reached epidemic proportions among African-American men and women (49) . Recent data show that 57% of adult African-American men and 66% of women are overweight (45) , and similar trends have been reported among African-American children. During the periods of 1963–1970 and 1994–1998, the percentage of African-American children and adolescents who were overweight nearly tripled (19) .

Cancer Screening

Cancer screening of asymptomatic persons can reduce cancer morbidity and mortality. Screening for cancers of the oral pharynx, breast, colon, rectum, cervix, prostate, and other sites can detect lesions that are curable, thereby improving survival (7) . However, cancer screening tests are typically under-used by African Americans for diverse reasons, including lack of accurate information about cancer screening examinations, fear of pain and embarrassment, a lack of understanding that cancer screening procedures are recommended in the absence of problems or symptoms, and cost of screening and concurrent loss of wages due to absence from work (50, 51, 52, 53, 54) . Even when screening occurs, follow-up of abnormal test results may be delayed, resulting in African Americans more frequently being diagnosed with metastatic disease (5 , 55, 56, 57) .

Access to cancer screening and early detection must be made available to at-risk individuals. Unfortunately, many African Americans do not consider cancer screening a priority because other personal, family, financial and social issues typically take precedence (53 , 54 , 58, 59, 60, 61, 62) . Also, cancer often evokes images of pain, mutilation, suffering, and death for many African Americans (50 , 63) , resulting in feelings of fear, hopelessness, pessimism, and fatalism. Additionally, African Americans often lack accurate information regarding screening examination procedures and the availability of early cancer detection programs (54 , 62 , 64, 65, 66) .

Access, Utilization, and Delivery of Cancer Care

Despite efforts to improve availability of health care in the United States, many African Americans do not have access to quality cancer care, particularly the elderly, medically underserved, poor, or uninsured. Additionally, disparities often remain even after adjustments have been made for socioeconomic differences. For example, elderly African Americans are less frequently offered cancer screening and early detection services (Table 7⇓ ; Refs. 67 and 68 ). Among the 12% of African Americans who reside in rural communities, cancer screening programs are even more limited, and an additional 53% reside in densely populated urban communities that typically have a shortage of health care services. In addition, approximately one-fourth of African Americans live in poverty, 19% have no usual source of health care, and 17% do not have the financial means to seek good health care, including cancer screening. These individuals also have limited access to optimal curative and palliative care when cancers develop (19 , 69) .

Opportunities and Challenges

African Americans are approximately 30% more likely to die of cancer than whites and are twice as likely to die from cancer than Asian or Pacific Islanders, American Indians, and Hispanics. The burden of cancer borne by African Americans far exceeds that of other racial groups due to lifestyle, behavioral, and socioeconomic influences and inadequate access to medical care. If current knowledge, medical expertise, and resources were more readily available to African Americans, their cancer morbidity and mortality rates would almost certainly decline. Unfortunately, few such initiatives have actually been designed and launched. Issues and challenges regarding their cancer prevention and surveillance practices have been well documented, and the time has come to eliminate the excess cancer burden faced by African Americans. Reducing this cancer burden borne by African Americans and other underserved Americans has often been touted as a national goal. However, there must be political will, public support, and financial resources to accomplish this goal. The question remains—if not now, then when?