In the United States, Black American patients with acute myeloid leukemia (AML) have notably worse survival outcomes compared to White patients. In addition, Black patients are less likely to receive intensive chemotherapy and undergo allogeneic stem cell transplants. Many researchers have reported on this phenomenon, but we want to comment on a different aspect of the variation in health-care diagnosis and delivery. We believe that structural racism along with generational poverty and trauma are key contributors to disparities in leukemia deaths.
Since the inception of the United States, racism has been built into our society. Slaves were brought to America to build the very roads and buildings that house key decision-makers. There was very rarely repatriation of these slaves, nor were there any reparations. Generational poverty and trauma persist in descendants of slaves, and this issue has not been addressed at a national level in a significant way. The census tract, a measure by the U.S. Census Bureau, looks at subdivisions of a county. By census tract, Black Americans have a significant disadvantage, with the highest proportion of families with incomes below the poverty line and greatest proportion of unemployed adults.
Furthermore, young adolescents with AML and acute lymphoblastic lymphoma have reduced long-term survival rates with inferior long-term mortality outcomes. Hispanic Americans and Black Americans have lower survival rates at 10 years after diagnosis. Even in the 21st century, we are dealing with earlier childhood and young adult mortality for hematologic disease largely due to race-based differences in infrastructure and access to care.
Accountability for Cancer Through Undoing Racism and Equity (ACCURE) is a program that was launched to narrow the differences in 5-year survival between Black and White patients with breast or lung cancer. This initiative, which began at the University of North Carolina at Chapel Hill, is an important example that can be modeled to narrow the gap in hematologic malignancies, especially for curative-intent therapies.
Patients’ mistrust in medicine due to generational trauma from large-scale experiments, such as the Tuskegee experiment, combined with cultural beliefs, health illiteracy, and language barriers, are often major deterrents to timely concordant medical care. Geographic barriers, insurance issues, and copayments may also be contributing to difficulties in coordinating multiple appointments and tests. The cumulative effect of these factors may ultimately be unsurmountable and may lead to delayed treatment, suboptimal care, or in some cases, no treatment at all. These issues pose life-or-death consequences, and the importance of addressing these disparities is paramount.
We hope this letter will engender further discussion among all in the oncology community to consider our roles in leveling the playing field so that curative treatments can be effectively and safely delivered to all—in particular, to vulnerable populations who have experienced systemic inequality and structural racism.
— Nithya Krishnan, MD, and Amy Kiamos, DO
Dr. Krishnan is Hematology/Oncology PGY-5 at the University of Florida Health Cancer Center in Jacksonville. Dr. Kiamos is Internal Medicine PGY-2 at the University of Florida Health in Jacksonville, interested in Hematology/Oncology for fellowship.
