"Of all the forms of inequality, injustice in health is the most shocking and the most inhumane….”
—Dr. Martin Luther King, Jr
Progress has been made in expanding access to health care for low-income populations, but the quality of care still lags behind and can result in less successful outcomes for underserved patients. You don’t need a complex study to learn that health disparities and inequalities exist in the United States. Those research studies exist, but you can clearly see those differences in hospitals, clinics, and doctors’ offices every day.
Quyen D. Chu, MD, MBA, FACS
Like many medical providers, I encounter these disparities in my work as a physician in Louisiana, particularly when caring for women with breast cancer. Fortunately, the death rates for this disease declined 40% from 1989 to 2016, largely because of improvements in early detection and targeted therapies. But not all women have benefited equally. Despite similar incidence rates, African American women are 40% more likely to die of breast cancer than white women.1
The Breast Cancer Mortality Gap
This mortality gap exists in almost every state, but the differential rises to 60% or higher in my home state of Louisiana. The fate of a woman with breast cancer, sadly, can rest upon where she resides.
Let me share a recent case that illustrates this reality. A mother of three was diagnosed with advanced breast cancer. It could have been detected earlier—and likely cured—if she had been able to access the health-care system and have a supportive social network.
Instead, she selflessly neglected to care for herself so she could tend to her children, her sick parent, and a debilitated spouse. She finally sought help at her nearby emergency room after the perfume she used no longer masked the stench of her fungating and eroding breast cancer.
Her limited means meant she could barely pay the rent, much less purchase health insurance. Instead of being treated at a nearby private facility, she was referred to a safety-net hospital 100 miles from her home.
Once at the hospital, she was told that she would need up to 6 weeks of radiation and months of chemotherapy followed by a mastectomy. Besides the mortifying news of being diagnosed with cancer, she worried about the welfare of her loved ones. As if these challenges were not enough, she had to contend with navigating the health-care system.
These barriers are not unique to this patient in Louisiana. They also are real for people in metropolitan California, remote Appalachia, or South Texas. If there is any silver lining for this patient, it is that she lives in a state that recently embraced the Patient Protection and Affordable Care Act (ACA). As a result, her medical expenses are covered.
Here is another example of how poverty limits a person’s options for treatment. A woman with early-stage breast cancer may be able to save her breast by having just the cancer removed provided she receives radiation therapy. But if she cannot access a radiation facility in her hometown because she is underinsured or a facility is not available, she will lose her breast through a mastectomy. Writer Eli Khamarov once wrote, “Poverty is like punishment for a crime you didn’t commit.”
I understand why companies do not like mandates. However, would it be an onerous task to require insurance companies to grant sick patrons a grace period while women like this one undergo this treatment?
Formidable Challenges: Focus on Louisiana
These formidable challenges are amplified in a state like Louisiana. The 2017 American’s Health Rankings reported that Louisiana is the second least-healthy state, and according
o the U.S. Census Bureau’s 2017 American Community Survey, Louisiana is the second most-impoverished state, with one of the lowest median incomes. Fortunately, with the expansion of the ACA, the number of adults without health insurance in Louisiana was cut in half, from 22.7% in 2015 to 11.4% in 2017.2
At the same time, about 26% of Louisianans reside in rural areas. Access to insurance coverage, health-care providers, and major cancer centers is an acute problem for those residents. Social isolation, lack of phones, and limited access to transportation further exacerbate their difficulty in obtaining health care. A recent report, “The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey,” found that although 19% of the U.S. population lives in rural areas, only 7% of oncologists practice in these regions.3
A “perfect storm” of poverty, low levels of education, severe socioeconomic challenges, and catastrophic natural disasters make for less-than-ideal outcomes for Louisiana’s most vulnerable patients with cancer. The incidence of breast cancer in Louisiana is 28th in the nation, but the breast cancer mortality rate is the second highest. African-American women in Louisiana present with significantly higher rates of late-stage disease than the national average.4
We confront these realities every day at the Ochsner-Louisiana State University Health Sciences Center in Shreveport. We are a public-private partnership hospital that serves as the safety net for the vast number of uninsured Louisianans. Due to the ravages of the 2005 hurricanes, our Feist-Weiller Cancer Center is, for all practical purposes, the major station—and often the only station—to care for the neediest Louisianans. More than one-third of women with breast cancer must travel over 200 miles to see us for their care. Many of them arrive with the disease in its latest stage.
“A ‘perfect storm’ of poverty, low levels of education, severe socioeconomic challenges, and catastrophic natural disasters make for less-than-ideal outcomes for Louisiana’s most vulnerable patients with cancer.”— Quyen D. Chu, MD, MBA, FACS
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We search for the solution every day. The short answer is we need both the public and private sectors addressing these deadly inequalities.
We had no data to determine whether the work my colleagues and I do has made an impact on breast cancer care, especially on an underserved population. But in 2009, we published a report in Cancer Epidemiology, Biomarkers & Prevention that looked at 786 patients with stage 0 to 3 breast cancer.5 Despite the fact that African American women have higher-grade tumors and more triple-receptor negative tumors than white women, we found that our multidisciplinary practice has mitigated such differences. We were able to achieve this because we had a patient-centric approach. The 5-year overall survival rate for African American women with operable breast cancer was 81%, which was comparable to the 84% in white women.
These results were achieved in a population where 72% of our patients were classified as having either free care or Medicaid. What’s more, 86% of patients resided in a geographic area with a reported median annual income of less than $30,000, and 60% of the patients were African American.
So, this can be done, but not alone. National organizations such as ASCO, the American Cancer Society, the Commission on Cancer of the American College of Surgeons, and the Susan G. Komen Foundation have advocated vigorously for disadvantaged women. They show how the private sector can help share the burden of caring for them.
Physicians, of course, have a unique role to play in championing novel therapies and expanding treatment options. Years ago, when socioeconomic factors forced many women with breast cancer to undergo a mastectomy, our institution initiated a novel program that allows radiation to be given over a 5-day course rather than the traditional 6-week course. As a result, more women who live a distance from our center are now able to save their breasts.
There is no one simple answer for the lack of access to quality health care that some low-income women with breast cancer face. However, there are ways that hospitals, insurance companies, medical providers, and nonprofit organizations can make a difference. It starts with seeing these women as human beings in need of the same health care so many of us enjoy. President John F. Kennedy reminded us that “if a free society cannot help the many who are poor, it cannot save the few who are rich.” ■
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
DISCLOSURE: Dr. Chu reported no conflicts of interest.
1. American Cancer Society Cancer Facts & Figures for African Americans 2019-2021. Available at www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf. Accessed September 10, 2019.
2. Karlin S: Medicaid expansion made Louisiana an outlier in national trend of stalling insurance coverage. The Advocate, June 12, 2019. Available at https://www.theadvocate.com/baton_rouge/news/politics/legislature/article_030ab37c-8c96-11e9-beb5-6b3a1d8d9a62.html. Accessed August 27, 2019.
3. Kirkwood MK, Hanley A, Bruinooge SS, et al: The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey. J Oncol Pract 14:e412-e420, 2018.
4. Louisiana Comprehensive Cancer Control Plan 2017-2021. Available at ftp://ftp.cdc.gov/pub/Publications/Cancer/ccc/louisiana_ccc_plan.pdf. Accessed September 10, 2019.
5. Chu QD, Smith MH, Williams M, et al: Race/ethnicity has no effect on outcome for breast cancer patients treated at an academic center with a public hospital. Cancer Epidemiol Biomarkers Prev 18:2157-2161, 2009.
Dr. Chu is Professor of Surgery, Department of Surgery; Chief, Division of Surgical Oncology at Louisiana State University Health Sciences Center, Shreveport. Dr. Chu was named a Presidential Leadership Scholar in 2018 and was the recipient of the ASCO Humanitarian Award in 2016.
This article originally appeared in the 2018 Winter Edition of The Catalyst: A Journal of Ideas From the Bush Institute.