Challenging Dogma


...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

A Failed Public Health Approach To Improve Colorectal Cancer Screening Among African-Americans - Roxane Handel

Colorectal cancer is the third leading cause of cancer-related deaths among African American men and women. Despite the lingering high death toll, early diagnosis has effectively decreased the number of deaths related to colorectal cancer throughout the years by identifying abnormal growths, or polyps, before they turn into cancer. However, post-diagnosis survival rates are lower for African Americans than for white Americans. From 1992 to 1999 African Americans diagnosed with colorectal cancer had a 53 percent five-year survival rate, compared with a 63 percent survival rate in whites (1). Why the discrepancy? Experts pointed at the lack of access to colorectal cancer screenings among the African American population. To address this problem many insurance companies expanded coverage for colorectal cancer screenings (2,3). Some states such as New York, Maryland, and Missouri even offer free or low cost colorectal cancer screening through the CDC-funded screening demonstration program (4, 12). Currently 18 states require coverage of colorectal cancer screening tests, and a few other states demand they be offered through Medicare supplemental policies (12). In addition, because African Americans are more genetically predisposed to developing colorectal cancer than other races, the age guidelines for colorectal cancer screenings were lowered for this population in order to enhance early diagnosis and curb deaths related to this disease (5). However, albeit these medical interventions, African Americans still have lower survival rates than whites due to later diagnosis. Studies suggest that socioeconomic status and poverty are not related to the incidence rate of colorectal cancer in African Americans, and that the problem lies deeper than access (6). Rather, it is the stigma attached to the medical environment, to African Americans, and to the colorectal cancer disease itself that has contributed to a cycle of low self-esteem that has ultimately caused the discrepancy in the colorectal cancer screening participation rates between African Americans and white Americans. Therefore, although well-intentioned, colorectal cancer screening programs fail to reach African Americans because many lack trust in the medical system, perceive cancer as an incurable disease, and resent the discrimination persistent within the medical field.

One of the underlying causes behind the low rate of colorectal cancer screening among African Americans is their mistrust in the medical system. The stigma attached to the medical environment stems mainly from the injustices of the forty year Tuskegee trials, during which blacks were deliberately withheld of medical treatment for syphilis, although a cure existed, in order to monitor the progression of this deadly disease. However, this example is far from unique. While the abuses from the Tuskegee trials commonly stand out, it merely represents one of many stories of medical scientists’ mistreatment of blacks. Harriet Washington elegantly describes such incidents in her book, Medical Apartheid. One of the events Washington describes involves a Virginia doctor, who poured boiling water on naked, enslaved typhoid patients for his "research." She also recalls an event in the early 1950s, where the U.S. Army and the CIA released disease-carrying mosquitoes near an area where predominately African Americans resided in Florida in an attempt to test the feasibility of using biological warfare. Washington claims that many doctors believed that they “did not feel pain or anxiety, which excused painful surgical explorations without anesthesia" (14). Thus, physicians experimented on African Americans without any sense of remorse. Washington explains how these crimes have created a stigma around the medical system as “a place of terror, violence and shame, not of medical care” (7). An African American’s perception of the medical field as a dangerous place where they can be potentially used or lied to overrides their perception of the dangers associated with developing colorectal cancer. Thus, one component of stigma that the medical intervention failed to address was the social psychological processes operating through the stigmatized African American (13). This population may reject the screening because they fear that it may be a research trap, and so, the mere fact that the screening exists does not increase the number of black people who get screened early. The fear of mistreatment and lack of trust in the medical system has serious negative consequences, that is, later diagnosis of colorectal cancer and higher mortality rates among the black population. Consequently, the use of blacks as guinea pigs throughout history thus plays an influential role in the attitudes of blacks toward the medical system, and has discouraged many susceptible individuals from getting screened for colorectal cancer.

Another reason behind the failure of medical interventions to increase the screening rate of colorectal cancer among African Americans is the lack of knowledge among the population that they are more susceptible to colorectal cancer than other races and their view of cancer as an incurable disease. The stigma around colorectal cancer among this population is detrimental because it instills a sense of futility in the colorectal cancer screening. Furthermore, not understanding their elevated risk exacerbates the situation because no sense of urgency exists. In a study that investigated risk perceptions and screening patterns for colorectal cancer among predominately low-income African Americans age 50 or above, 36% of respondents rated their risk as below average and 37% did not know their risk for colon cancer (8). While this study found that more studies need to be done to more accurately determine the perceived risk, it is clear that enough of the population does not understand that they are at greater risk of developing colorectal cancer than whites. This ultimately affects their decisions to get screened and leads to deaths that could have been prevented. Another study conducted with blacks, Hispanics, and whites also suggests that minority groups particularly lack knowledge of cancer, colon cancer screening tests, and screening in general (9). They had difficulty understanding the simplified medical terms and procedures, and although were hopeful about early cancer diagnosis were still reluctant to get tested if they were symptom free. Thus, the intervention has not significantly increased colorectal cancer screening rates among African Americans in part because it does not simultaneously educate this population on their risk of acquiring the disease, the benefits of screening early, and the details of the procedures that need to be done that could help decrease the incidence of colorectal cancer. If African Americans do not perceive that they are at risk to begin with and do not realize that options exist that could prevent and cure the disease, they will not take action. Ofcourse, recognizing that colorectal cancer is curable and understanding ones risk does not guarantee a change in behavior as the health belief model implies. Nevertheless, the problem of perceived risk must be addressed in conjunction with other social and behavioral issues in order for the situation to improve.

Another social element that public health officials must tackle is the discrimination existent among the caregivers. Many African Americans understand their high risk of developing colorectal cancer and have access to care yet do not get screened early enough because of the issue of discrimination. The reason is linked to a stigma created by the caregivers themselves who discriminate against the African American patient. Recent studies have shown that blacks and whites with equal medical insurance and co-morbidities have unequal colorectal cancer survival rates (10). The differences in mortality are not due to biological differences either. Peter Bach, a pulmonologist and epidemiologist at New York's Memorial Sloan-Kettering Cancer Center, has shown that only modest cancer-specific survival differences are seen for blacks and whites who are treated comparatively for similar-stage cancer. He suggests that differences in treatment, stage of the cancer at diagnosis and mortality from other diseases in addition to the cancer should represent the primary focus of interventions designed to reduce disparities in cancer outcomes. In addition, Bach claims that US medical care providers discriminate against racial minorities, a conclusion also made by both the Center for Reducing Cancer Health Disparities and the IOM (15). Clearly, racial discrimination continues to plague medical departments around the nation.

Racial discrimination is reflected through the level of communication and the amount of time spent between the doctor and the African American patient compared to the white American. Physicians often do not communicate with the African Americans in the same manner as they do with their white patients. In addition, African Americans claim that the time they spend with doctors is minimal compared the time the doctors spend with their white patients. Both the lack of communication and the reduced amount of time result in low quality care among the African American population. Studies suggest that African American patients receive low quality care compared to white Americans, and that only high quality healthcare can ensure adequate procedures and screening recommendations (16). Often it is information on prevention, available screenings, and risky behaviors that physicians choose not to discuss with their African American patients during their ten minute appointments. This selectiveness creates a sense of neglect among African Americans and denies them of information that could help them improve their behaviors and attitudes towards colorectal screenings. Why are physicians selective? Perhaps the physicians see African Americans as less of a law-suit threat than white patients, and thus feel the need to be more explicit and detailed with their white patients. Or maybe physicians don’t feel the obligation to delve into details when it comes to their African American patients because they believe that the African American patient simply won’t understand or won’t take action either way? Although the reasoning behind physicians’ discriminatory behavior is unclear, it definitely clear that communication and time spent with the African American patient is hindered because of discrimination. Studies have shown how communication can improve colorectal cancer screening and survival rates (11). Therefore, the lack of communication and low quality care resulting from discrimination was a critical element that the medical intervention failed to target. Consequently, African Americans still forgo colorectal cancer screening and get diagnosed too late.

In all, the stigma attached to the medical environment, the colorectal cancer disease, and the African American race has greatly influenced the distribution of life chances of blacks particularly by decreasing their colon cancer survival rates in comparison to other races. These stigmas all feed into a low self- esteem cycle and a feeling of inferiority among African Americans. The stigmatized individual has a low self-esteem because they the situations in which they find themselves have consistently negative implications on the self (17). The prejudices and stereotypes exemplify situations surrounding African Americans that affect their self-esteem. As a result they do not stand up for themselves nor care for themselves. This has a negative implication on their health which they often neglect along with their school, and later their careers. Consequently, their family members enter the same cycle of poverty and low self-esteem, both factors having repercussions on the African Americans’ health-related behavior. Therefore, the issue of stigma deserves attention not only because stigma directly affects behavior, but also because stigma indirectly affects ones self-esteem, which ultimately influences behaviors.

Interventions designated to improving colorectal cancer screening rates among African Americans must keep in mind the social and behavioral elements that can influence an individual’s behavior. It is precisely the social stigma attached to the medical field, the disease, and the black race that caused the medical intervention to fail to improve the colon cancer screening among African Americans. Just because a screening exists, and there is access to it does not mean that people will actually participate. Many other issues need to be addressed in order to help educate and change the mindset of both African Americans and caregivers in order for a successful outcome to ensue and for less African Americans to die from a preventable disease.

REFERENCES:

1. Payne. J.W. Cancer: Test Blacks Sooner. New Guidelines Advise Colon Screen at 45 to Curb Deaths. Washington post. 2005. http://www.washingtonpost.com/wp-dyn/articles/A8061-2005Mar28.html

2. Preidt. R. Race, Income Barriers to Colon Cancer Screening Medicare study shows big differences by ethnicity and state. Health on the net foundation. 2007. http://www.hon.ch/News/HSN/601837.html

3. Medicare Colon Cancer Screening Misses Many Minorities, Poor, Less Educated. Senior Journal.com. 2007. http://www.seniorjournal.com /NEWS/Health/2007/7-02-13-MedicareColon.htm

4. Some states offer free colon cancer screening. The Associated Press; October 2, 2006. http://www.msnbc.msn.com/id/14014494/

5. Payne. J. W. Cancer: Test Blacks Sooner. Washington Post. March 29, 2005.

http://www.washingtonpost.com/wp-dyn/articles/A8061-2005Mar28.html

6. Chen et al. Aggressiveness of colon carcinoma in blacks and whites National Cancer Institute Black/White Cancer Survival Study Group. Cancer Epidemiology Biomarkers & Prevention. Vol 6: 12. 1997; 1087-1093. http://cebp.aacrjournals.org/cgi/content/abstract/6/12/1087

7. Williams. B. The History Of Black Men As Medical Guinea Pigs . Courant. Com. 2007 http://www.courant.com/features/booksmags/hc-medapartheid0204.artfeb04,0,2059493.story?coll=hc-headlines-books

8. Lipkus et al. Colorectal screening patterns and perceptions of risk among African-American users of a community health center. Journal of Community Health.Vol 21:6. 1996; 409-427. www.springerlink.com/index/X561J64671421619.pdf

9. Shokar. N. K .Cancer and Colorectal Cancer: Knowledge, Beliefs, and Screening Preferences of a Diverse Patient Population. 2005.

http://www.stfm.org/fmhub/fm2005/May/Navrikan341.pdf

10. Phend. C. Racial Disparities in Colorectal Screening and Treatment Despite Insurance. 2006 http://www.medpagetoday.com/Gastroenterology/ColonCancer/tb/4755

11. Huggins. C. E. Better Info Key To Improving Black Cancer Screening Rates. Charnicia E. Huggins. 2004 http://www.cancerpage.com/news/article.asp?id=7846;

12. Colorectal Cancer Screening: What are states doing? 2007. http://www.ncsl.org/programs/health/colonrectal.htm

13. Link. B. G and Jo C. Phelan. On Stigma and Its Public Health Implications. Columbia University and New York state Psychiatric Institute.

14. Washington, Harriet. Medical Apartheid. New York. NY: Doubleday, 2006.

15. Brower. V. Is Health only skin deep? Embo Reports. Vol 3 : 2. 2002; 712-714. http://www.nature.com/embor/journal/v3/n8/full/embor090.html

16. Myers. D. African Americans and Colon Cancer. 2007

http://coloncancer.about.com/od/ethnicityandsocialstatus/a/BlackPeopleCC.htm

17. Heatherton. T. F et al. The Social Psychology of Stigma. New York. NY: The Guilford Press, 2000.

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