Poverty and Race Often Determine Lung Cancer Survival, Study Shows

Disadvantaged Americans are far more likely to die of the mosttreatable form of lung cancer--not because of their health habits,but because they don't receive the proper treatment.

A University of Southern California expert on health-care deliveryhas analyzed more than 5,000 cases of stage I non-small-cell lungcancer in an attempt to explain why mortality is higher amongracial minorities and the socially disadvantaged than among higher-incomeAmericans and whites.

Howard P. Greenwald, PhD, found that surgery may have saved thelives of nearly one in three patients whose cancer was detectedearly enough. But the poorest patients were about a third lesslikely to undergo surgery than the richest patients. Half (50%)of the patients in the bottom 10% of income levels received surgicaltreatment, as compared with nearly three-quarters (72%) of patientsin the top 10% of income levels.

Differences in mortality were even more dramatic: Only 22% ofthe poorest survived for at least 5 years after diagnosis, whereas45% of the richest patients survived for that length of time.

As a subset of the study group, African-American patients faredeven worse. At all economic levels, they had only a one in fourchance of surviving, compared to a one in three chance among whiteAmericans. Whereas 61% of white Americans underwent surgery, only51% of African-Americans received that treatment.

Dr. Greenwald presented his findings at an American Cancer Societyconference in New Orleans. "In the form of lung cancer studied,lack of appropriate care seems to have contributed strongly toexcess mortality among the disadvantaged" he said. "Itexplains about 50% of the excess mortality in poor people andall of the excess mortality in African-Americans."

Conventional wisdom has held that the disadvantaged are more likelyto die of cancer because of health habits. Studies have consistentlyfound that they are less likely to exercise or eat healthy dietsand more likely to smoke cigarettes than the affluent. Discrepanciesin survival rates between African-American and white patientshave been attributed to income differences.

"In the past, we've blamed the victims, but now it lookslike the problem may be that we have not been giving them adequatetreatment," Dr. Greenwald asserted. He contended that differencesin educational levels and access to health care might help explainthe discrepancies in surgery rates between rich and poor patients."The reasons for the race-based discrepancies are more subtleand bear further research, he said. "They may have to dowith communication problems, suspicion, mistreatment or reluctanceto use a system where only about 3% of physicians are African-Americans."

Further study is needed to determine the impact of income andof race on mortality from other cancers, Dr. Greenwald cautioned.However, he does not believe his findings will be isolated tonon-small-cell lung cancer. "I would expect the findingsto be repeated in about 50% of cases, because that's the proportionof cancers that are treatable when detected at early stages,"he said. "These findings should wave a red flag."

Dr. Greenwald looked specifically at non-small-cell cancer becauseit is treated only with surgery, making the effects of medicalintervention easier to track than with some other cancers. Moreover,survival rates are high when surgical treatment is administeredin this cancer's earliest stage.

Dr. Greenwald studied 5,189 cases of non-small-cell lung cancerdiagnosed between 1978 and 1982 and documented by the NationalCancer Institute's Cancer Surveillance System. He ranked the casesaccording to patients' economic levels. For each of 10 economiclevels, he then analyzed the death rates and the treatment thatpatients received. In addition, he identified 855 African-Americansin the study group and separately analyzed their mortality andtreatment.

Dr. Greenwald, who is Professor of Public Administration at theUSC School of Public Administration's Sacramento Center, has writtenextensively about socioeconomic factors and cancer. His currentand recent sources of funding include the US Department of Healthand Human Services, American Cancer Society, California Tobacco-RelatedDisease Research Program, and W.K. Kellogg Foundation.