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Insurance Doesn't Cure Health-Care Disparities

Blacks with colon cancer still have worse outcomes, study finds

THURSDAY, Dec. 21, 2006 (HealthDay News) -- Having health insurance does not eliminate the poor outcomes that blacks with colon cancer experience, researchers report.

Instead, differences in screening tests and surgical treatment may be part of the reason blacks have lower survival rates than whites, Hispanics and Asians, according to the report in the Dec. 21 online issue of Cancer.

"Whether you're black or white matters in how you get treated, even with the same access -- that's the bottom line," said Dr. Harold Freeman, a senior advisor to the director of the National Cancer Institute and former director of the Center to Reduce Cancer Health Disparities at the National Cancer Institute.

The disparities for those with health insurance are less than they are in the general population, said study author Dr. Chyke A. Doubeni, of the University of Massachusetts Medical School and the Meyers Primary Care Institute. "But just having health insurance alone does not eliminate disparities," he said. "There need to be systems in place that make sure that everyone is getting services."

Doubeni noted that when blacks and whites with colorectal cancer are treated the same, they have similar outcomes.

In the study, Doubeni and colleagues collected data on 10,585 non-Hispanic whites, 1,479 non-Hispanic blacks, 985 Hispanics and 909 Asians/Pacific Islanders who were diagnosed with colorectal cancer from 1993 to 1998. All the patients had health insurance.

The researchers found that compared with whites, blacks were 17 percent more likely to die from colon cancer, Hispanics had a similar risk of death to whites, and Asians had the lowest risk of death from the disease.

In addition, blacks were less likely to undergo surgery, compared with whites. Moreover, earlier detection and greater use of surgery would each, independently, improve mortality risk, the researchers found.

In fact, Doubeni's team found that surgery to treat the cancer significantly reduced the risk of death among blacks, to around 6 percent.

Doubeni thinks that the reasons these disparities exist are complex. Among these are doctors who don't recommend certain treatments, and patients, especially minority patients, who are distrustful of medical care, he said.

In addition, Doubeni said that racism plays a role. "Racism and discrimination is still at play," he said. "Most of this occurs at an unconscious level. But there are preconceived ideas and prejudices about patients."

Disparity in medical care is a reflection of racism in our society, Doubeni said. "These disparities appear to come about as a result of societal issues in terms of discrimination, and they play out in the health-care setting," he said. "But we don't have to wait for society to fix this problem before we fix this problem in health care."

Freeman also thinks that patient bias and physician bias plays a role in the difference in treatment between blacks and whites. On the doctor's side, sometimes decisions are made based on whether the doctor thinks the patient will comply with the treatment, he said.

"On the patient's side, there may be patient bias, where patients don't trust the medical care system," Freeman said. "Patients can also have belief systems that lead them not to accept treatment. There are studies that show that there are patients who believe that if anyone touches cancer, the cancer will spread, and black Americans have a higher percentage of having that false belief compared with whites."

Being insured doesn't guarantee proper care, Freeman said. "It depends on the type of insurance you have," he said. "There are people who are insured, but underinsured for the particular things they need," he said. "There are 46 million people who have no insurance, and an additional 35 million who are underinsured."

Freeman thinks that having universal health insurance will go a long way toward eliminating disparities in health care, but it's not the sole cure. "It doesn't eliminate the problems of other barriers," he said.

Race prejudice in society also plays a part in health-care disparity, Freeman said. "In our nation, we tend to see people through the lens of race," he said. "We make decisions through a very powerful lens of race, which helps determine what assumptions we make about each other, whether we are doctors or not."

Another expert isn't sure whether the onus for different treatment falls on the doctor or the patient, or a combination of both.

"Treatment differences are playing a significant role in outcomes," said Dr. Durado Brooks, director of colorectal cancer at the American Cancer Society. "But are those treatment differences the result of patient choice, patient inaction, or are they system or provider barriers?" he asked. "If you provide equal levels of treatment, you can go a long way to decreasing these barriers," he said.

Brooks noted that blacks tend not to undergo colonoscopy to screen for colorectal cancer. But he isn't sure why. "Colorectal cancer is a preventable disease," Brooks said. "Proper screening and lifestyle changes can help avoid colorectal cancer," he said.

More information

The U.S. National Cancer Institute can tell you more about disparities in cancer care.

SOURCES: Chyke A. Doubeni, M.D., M.P.H., professor, University of Massachusetts Medical School and the Meyers Primary Care Institute, Worcester; Harold Freeman, M.D., senior advisor to the director, National Cancer Institute, New York City; Durado Brooks, M.D., director, colorectal cancer, American Cancer Society, Atlanta; Dec. 21, 2006, Cancer online
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