Death Rate for Colorectal Cancer in Poor African-Americans Remains High

A study published in the journal Cancer(94:2327-2332, 2002) suggests that African-Americans who have colon cancer andlive in poverty are at much greater risk of dying from the disease.

Colorectal cancer is the most common cancer in the UnitedStates and the second leading cause of cancer death. Nearly 7% of Americans willdevelop colon cancer at some point in their lives. Although the death rate hasbeen declining since 1985, colon cancer continues to take a higher toll amongAfrican-Americans. The overall 5-year survival for African-Americans in 1992 was52.4%. In impoverished areas such as New York City’s Harlem, where 41% offamilies have incomes below the government’s poverty line, the problem ismagnified.

"The 5-year survival rates [in Harlem] were muchlower," said Harold P. Freeman, MD, and Tarek A. Alshafie, MD, of theHarlem Hospital Center and authors of the study. "Although colorectalcarcinoma mortality continues to decline nationally, in this population of poorblacks the mortality rate remains extremely high and unchanged. We attributethis primarily to late-stage disease at the time of initial treatment."

Symptomatic at Presentation

For the study, the authors reviewed the tumor registryrecords of 615 patients treated for colorectal cancer at Harlem Hospital in NewYork City from 1973 to 1992. African-Americans comprised 97% of patients, andvirtually all were poor. The authors looked at patient age, gender, symptoms,associated illnesses, family history of cancer, the pathologic staging of thetumor, whether the tumor recurred after treatment, and the status of the patientat 5 years.

All those treated presented with symptoms of their disease atthe initial evaluation. These included such signs of serious disease asbleeding, abdominal pain, weight loss, bowel obstruction, jaundice, and anemia.In contrast, the larger trend is toward early diagnosis, with some studiesshowing that nearly 30% of those diagnosed with colorectal cancer do not yethave symptoms. Furthermore, the overall 5-year survival for these patients was19.7%, significantly lower than the national average, which rose from 49.5% in1974 to 61.5% in 1992.

In addition, even though the most common cause of large bowelobstruction is colorectal carcinoma, only 14% of patients nationwide presentwith bowel obstruction when first seen by a doctor. At Harlem Hospital, 21.1% ofpatients had bowel obstruction at diagnosis. The overall prognosis is generallyworse with this presentation because it is associated with a more advanced stageof disease. Previous studies have shown that disease stage at the time ofdiagnosis is the most important prognostic factor for colorectal carcinoma.

Stronger Interventions Required

Although surgery is considered the most effective therapy formanagement of the disease, only 311 study patients (50.6%) underwent surgerywith intent to cure, and 92 patients (15%) received no treatment. This findingreflects late presentation and the poor general condition of patients due toadvanced disease. Ultimately, 70% of patients who were treated for colorectalcancer in this study had incurable disease at presentation.

Colorectal carcinoma patients in Harlem Hospital Center havesimilar age, gender distribution, and location of the tumor as colorectalcarcinoma patients nationwide. They also have similar treatment outcomes whendiagnosed initially with potentially curable disease.

"We concluded that Harlem and other similar areas with largely poorblack populations have mortality rates so high as to justify specialconsideration analogous to that given to natural disaster areas," said Drs.Freeman and Alshafie. "We also have demonstrated that African-Americans,particularly inner-city African-Americans, suffer higher cancer mortality fromvarious causes than mainstream American society."