Volume 3, Issue 1, Summer 2014
SOCIOECONOMIC STATUS AND CANCER CARE:
A COMPLEX SITUATION
By Steve Mason, Ph.D.
Healthcare inequality has had no shortage of coverage in American media lately due to the rollout of the Affordable Care Act (ACA), colloquially known as ‘Obamacare’. As political pundits sound off on both sides about the implementation of the ACA, it’s easy to forget one of the primary underlying reasons for the ACA in the first place: healthcare is expensive, and costs are continuing to rise. As a result, middle- and lower-income families are feeling the pinch of medical costs, particularly in long-term care situations.
Cancer care is no stranger to rising health care costs, with inpatient and outpatient care, radiation therapy, and medications all adding to the bottom line. For those with insurance, even copays can become prohibitive. The interplay between socioeconomic status, treatments, and patient outcomes has been the subject of several recent studies, with the goal of understanding the reasons for population-based differences. From incidence to outcomes, differences between social or ethnic groups can be seen for several different types of cancer.
One of the most recognized areas for this disparity is prostate cancer, which has historically been linked to socioeconomic status (SES), with non-Hispanic White Americans having significantly greater survival trends relative to African Americans [1]. This may be related to treatment decisions; prostate cancer patients in lower SES groups are less likely to undergo radical prostatectomy, which may leave them at greater risk of recurrence [1]. Even this isn’t certain, though, as no clear reasons for disparities in healthcare access and patient quality of life have been identified [2]. Similar trends have been found for breast cancer patients, with women in lower-income regions less likely to undergo mammograms and more likely to die from breast cancer once diagnosed. Additionally, African-American women in particular have a lower 5-year survival rate from breast cancer relative to other ethnic groups [3]. Finally, other studies have also revealed greater incidence of different cancers in people of lower SES [1].
All of this adds up to a challenge with reasons that are still not very well understood. Gorey et al have now sought to further elucidate the complex interactions that can contribute to differences in care and survival for patients of lower SES by examining a population of American colon cancer patients [4]. Previous work by this group has found that social environments can play an important role in cancer diagnosis and care; for example, while Mexican-American women are generally more likely to be diagnosed with later stage breast cancer relative to non-Hispanic white women, Mexican-American women living in high-poverty neighborhoods had the best chance of being diagnosed with early-stage disease (and thus a better prognosis) [5]. This result strongly indicates that social support can help overcome the costs – monetary and otherwise – of healthcare.
In their new study, Gorey and colleagues compared rates of chemotherapy use between African-American and non-Hispanic White American patients with stage II, III, or IV colon cancer [4]. Overall, African-American patients were 25% less likely to receive chemotherapy. Chemotherapy rates were similar for patients with adequate insurance that lived in neighborhoods with lower poverty rates. However, the ethnic discrepancy was magnified when comparing extremely poor and inadequately insured patients – in this group, African-American patients were 60% less likely to receive chemotherapy even though all other factors were similar between the groups. This finding confirms that SES can have a significant impact on healthcare, and, by extension, patient outcomes. The reasons for this difference aren’t clear, but the authors do point to an earlier analysis that found that, even in the poorest American households, non-Hispanic White Americans still held approximately $10,000 of equity while similar African-American households had no equity at all. This difference may exacerbate the hardships of being poor and under-insured, thus potentially driving discrepancies like the one seen in the study by Gorey et al.
In the face of widespread interest in and enthusiasm for healthcare reform, it is important to remember that access to, and utilization of, health care resources are determined by numerous complex interacting factors. Health insurance programs should take into account as many of these factors as possible, especially because medical expenses are a leading cause of personal bankruptcy, even among insured patients. The ideal solution will not be ‘one-size fits all’ but rather something adaptable to the specific situation of the patient(s) being insured. Analyses like the ones highlighted here are vital to understanding just what components need to be factored into the models to produce the best possible solution for the patients that need it most.
Steve Mason is Senior Editor of Biological Sciences at Cancer InCytes Magazine.
References
1. Hellenthal NJ, Bermejo CE: The role of socioeconomic status in renal cell carcinoma. Urologic oncology 2012, 30:89-94.
2. Maliski SL, Connor SE, Oduro C, Litwin MS: Access to health care and quality of life for underserved men with prostate cancer. Seminars in oncology nursing 2011, 27:267-277.
3. DeSantis C, Siegel R, Bandi P, Jemal A: Breast cancer statistics, 2011. CA: a cancer journal for clinicians 2011, 61:409-418.
4. Gorey KM, Haji-Jama S, Bartfay E, Luginaah IN, Wright FC, Kanjeekal SM: Lack of access to chemotherapy for colon cancer: multiplicative disadvantage of being extremely poor, inadequately insured and African American. BMC health services research 2014, 14:133.
5. Haji-Jama S, Gorey KM, Luginaah IN, Balagurusamy MK, Hamm C: Health insurance mediation of the Mexican American non-Hispanic white disparity on early breast cancer diagnosis. SpringerPlus 2013, 2:285.
