Deadly Delay

On a hot summer day in 2006, an African-American woman walked into the emergency room at Grady Memorial Hospital in Atlanta complaining of a large sore on her breast. Her family had urged her to go to the hospital, she said, because the stench from the infected wound had become intolerable. Doctors discovered a cancerous tumor so large it had burst through her skin.

When Otis Brawley, then medical director of the hospital's cancer center, asked the woman when she had first noticed a lump in her breast, she recalled that her son had been in second grade. He was now a high school junior. Even after the tumor first broke through her skin, she admitted waiting nearly two more years to seek treatment. She had no health insurance, she explained. Apparently she hadn't realized that, as a public hospital, Grady accepts and treats the uninsured. Despite the intense treatment that followed—a mastectomy, along with radiation and chemotherapy—her cancer was already so advanced that she was dead within a year.

Her case might seem extreme, but Brawley says at Grady's cancer center, where the majority of patients are minorities and many are uninsured, "that sort of thing happens several times a year." When he examined hospital records, he found that, on average, about 40 percent of the breast cancer patients treated there have already reached stage IV, for which the five-year survival rate is just 20 percent (versus nearly 100 percent for those diagnosed at stage 1). By comparison, only a small percentage of the patients he saw at Emory University's cancer institute, which serves a largely white, middle-class population, had progressed to a late stage when they were diagnosed.

The situation at Atlanta's public hospital is hardly unique. In a new study, which will be published in the March issue of the journal Lancet Oncology, researchers at the American Cancer Society (ACS)—where Brawley is now chief medical officer—analyzed records of more than 3.7 million cancer patients diagnosed between 1998 and 2004 throughout the country. They found that minority and uninsured cancer patients like the woman at Grady Memorial Hospital have a significantly higher risk than white patients and those with private insurance of having reached an advanced stage of the disease by the time they are diagnosed or seek treatment. That means they are more likely to endure excruciating, and often more expensive, treatments and they are more likely to die from the cancer.

The ACS study is not the first to note racial disparities in cancer diagnoses, but it is the largest to examine the role of both insurance status and race and it confirms for many oncologists the extent of the issues they've observed in their own practices. "For the uninsured, the underinsured and ethnic minorities, early detection of cancer is a major problem," said Dr. Christopher Lathan, a practicing oncologist and instructor at Harvard Medical School.

Solving it has proven difficult, in part because there is no single explanation. While the study found that being uninsured can lead to a later diagnosis, when ACS researchers examined the data more closely, they found that, regardless of their insurance status, black and Hispanic patients still had an increased risk of having an advanced-stage disease—typically, stage III or IV—at diagnosis when compared with white patients. Even if a white patient and an African-American patient were each privately insured, the African-American patient was more likely to be diagnosed at a later stage. "What we don't see directly in the data for this paper is that the proportion of people who are uninsured or covered by Medicare is much higher among black and Hispanic populations. But even when you take insurance into account, race still has an effect," says Elizabeth Ward, one of the study's authors and managing director of surveillance at the ACS. "So we have to look at factors operating at a variety of levels ... whether the facilities that are available are acceptable, whether or not the person can access [specialized] care, whether there have been experiences of discrimination or a feeling that one is not receiving good care at a particular facility, especially if it seems related to race or ethnicity."