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VOL. 6 • NO. 2
© October 2011
African Americans are suffering from cancer at far greater rates, but the numbers are improving ever so slightly. Researchers say early screenings are part of the reason. Talk about a cultural change. Hawo Adan-Abdi, 51, readily admitted she was not excited about the prospect of regular breast cancer screenings. But the providers at Whittier Street Health Center (WSHC) persisted and when she saw that women emerged from the test unscathed she eventually relented. Adan-Abdi is not alone. Many women share her fears. WSHC personnel found that out firsthand when they conducted focus groups with Somali women to understand their perceptions of the test and the disease. It was an eye-opener. The participants likened the mammogram to a “pancake machine that squeezes your breast.” While all understood its purpose, all commented on its discomfort. “When I hear mammogram I am in pain” was one response. But Adan-Abdi is not complaining. The discomfort of mammograms pales in comparison to fleeing war-torn Mogadishu and the perils of living in a refugee camp with five of her children. There was no such thing as yearly physicals in her native country, much less cancer screenings. “Back home you go to the hospital only if something is wrong,” she explained. And that’s the point of screenings — to detect “something” early enough to increase the odds of survivability. But the reality is pretty grim when it comes to cancer and its impact on African Americans. Blacks have the highest death rate and shortest survival of any racial and ethnic group for most cancers. Nearly 169,000 new cases of cancer are expected in African Americans in 2011 — and roughly 65,500 deaths — according to the American Cancer Society (ACS). It sounds bleak but when one considers the starting point, progress has been made. Since the early 1990s, the incidence rate of most cancers has decreased or stabilized. Death rates have declined as well — by 2.5 percent a year in men and 1.5 percent a year in women. Particularly notable is lung cancer, according to the ACS, where rates of death have decreased faster in African American men than white men. This improvement is significant given the fact that lung cancer is the leading cause of cancer deaths. Despite these improvements, the gap persists between blacks and whites in cancer cases and deaths. Black men have the highest
Cancer, the second leading cause of death in this country, is the uncontrolled growth and spread of abnormal cells. The American Cancer Society estimates 1,596,670 new cases of cancer in 2011 and almost 572,000 deaths. Cancer strikes all races and ethnicities, but African Americans — particularly black males — are disproportionately impacted.
death rates of any group, most notably in prostate cancer where black men die at two to five times the rate of all other races. Black women, on the other hand, pose a different, and often puzzling, picture. While the incidence of cancer overall is highest among white women, blacks have a higher death rate. For instance, while white women are diagnosed more frequently with breast and uterine cancer, the first and fourth most common cancers in women, blacks die of both more often. What researchers have found more troubling is that those rates occur even though black women are regularly screened, and at a rate higher than white women, especially here in Massachusetts. According to the 2010 Behavioral Risk Factor Surveillance System (BRFSS), a survey developed by the Centers for Disease Control and Prevention, more than 94 percent of black females
A disturbing difference Although death rates from cancer are on the decline, the disparity between blacks and whites persists. Between 2003 and 2007, the death rate in blacks was 23 percent higher than whites and more than double the rate in Asians. Black
224.2
White
182.4
Native American
156.7
Hispanic
122.1
Asian
110.8
0
50
100
150
200
Death rates are per 100,000 and age-adjusted to the 2000 U.S. standard population Source: National Center for Health Statistics
250
aged 50 or older in Massachusetts reported that they had received a mammogram within the past two years. This percentage exceeded that of all other women in the state — and in the country, for that matter. Pap smears show similar results. More than 93 percent of black women in Massachusetts — compared to 86 percent nationwide — said they had received the test within the past three years. The numbers begin to recede in regards to colorectal cancer screening, but still are higher than expected. Almost three-fourths of black adults aged 50 or older interviewed in the state said they had received a sigmoidoscopy or colonoscopy. White adults exceeded this number by only 4 percent. Prostate cancer screening is a totally different story altogether — for all races. The BRFSS reports that only 54 Adan-Abdi, continued to page 4
Increasing access key to closing the gap Dr. Christopher Lathan, a thoracic oncologist at Dana-Farber Cancer Institute, has his work cut out for him. As director of the Cancer Care Equity Program at the Institute, his goal is to make sure that minorities have access to and receive the quality of care they need to combat their disease. And that’s not easy. There have been some improvements over the years. “The mortality rates for cancer have decreased overall,” he said. “But the difference between the races remains the same.” And the disparities start from the first step in fighting the disease — screenings. Nationwide minorities are less likely to receive recommended screenings for many reasons. Lack of insurance and transportation and loss of income when away from work are all factors. But it’s that next step that concerns Lathan even more. It’s a challenge to get people to follow up after a positive finding on a screening test. This is often the time when people run scared. Also, other commitments like family or a job might take precedence. More often than not, it’s easier to postpone
treatment when you’re feeling fine. “It means another day off from work,” Lathan explained. Some people might think: “Why should I take a day off work and pay another co-pay when they’re going to tell me something I don’t want to hear?” A recent study published in the Journal of the National Cancer Institute bore that out. Of those referred for additional testing following an abnormal sigmoidoscopy, a screening tool for colon cancer, only 62 percent of blacks compared to 72 percent of whites followed up for additional testing. Lathan places some of the blame on the medical profession. “It’s up to the doctor to make a clear path,” he explained. “The key is to know your community. Then make the system easier by putting in structure [for follow-up]. Have someone call and tell the patient where to go next.” After an initial screening, the next step can be confusing. While the protocol for breast cancer is well devised, it is not as clear cut with other types of cancer, Lathan said. The patient may require another
Lathan, continued to page
Tips to close the gap For women, the top four are breast, lung, colorectal and panHealth disparities are differences in creatic cancers. rates and the effects of diseases between African American men and Jamaican men of African descent are far more vulnerable to prostate cancer than men different populations. When it comes to from any other backgrounds. Breast cancer often gets diagmany kinds of cancer, the American Can- nosed at a more advanced stage in African American women than in white women, which can make it harder to treat. Still, cer Society (ACS) reports that African it’s worth noting that lung cancer causes most cancer deaths in both sexes. Americans experience shorter survival times and higher death rates than people What healthy steps can I take from other racial and ethnic backgrounds. to help prevent cancer? Slightly better news is the fact that this Steps that lower cancer risks often help prevent heart disease, stroke and diabetes, too, and improve all-around health disparity has been shrinking and health tremendously. Smoking plays a major role in cancer the combined cancer death rate has been (see below). And roughly one-third of cancer deaths this year will stem from excess weight or obesity, inactivity or poor declining among African Americans. nutrition, according to the ACS. So healthy steps can make a
So why does this unsettling gap exist?
It’s a complex problem. Some factors at play aren’t easily changed: genes, income, employment, education and access to timely, high-quality health care, for example. “Yet other factors matter, too,” said Dr. Jan Cook, medical director at Blue Cross Blue Shield of Massachusetts. “By seeking preventive health care and making other healthy changes described below, people can lower their risks for many cancers.”
Which cancers are most common in African Americans?
The ACS estimates nearly 169,000 new cases of cancer and 65,400 cancer deaths will occur among African Americans this year. In men, the four most common forms of this varied disease are prostate, lung, colorectal and pancreatic cancers.
big difference:
Talk to your doctor about screening.
Ask your doctor three questions: Which screening tests are important for you to have? When should you start? How often should you have these tests?
Quit tobacco
Tobacco will cause an estimated 171,600 cancer deaths this year. That doesn’t even cover heart disease, stroke, emphysema, asthma and other ailments to which tobacco contributes. See if your employer or community sponsors a free or low-fee program to help you quit. Check with your health plan and doctor,
too. Or try the Somking Quit Line (1-877-448-7848 or www. smokefree.gov) for more information on quitting.
Check the scale
Aim for a healthy weight. Paring off 100 calories a day — that’s a few cookies or two-thirds of a sugar-sweetened soda — by eating less or exercising more can help you lose 10 pounds a year. See the Blue Cross Blue Shield of Massachusetts website (www. ahealthyme.com) for diet and exercise information.
Get moving
Bounding through life lessens the likelihood of obesity and certain cancers, including colon and breast cancer. Encourage children and teens to engage in moderate to vigorous activities an hour a day at least five days a week. Adults should rack up 30-60 minutes a day at least five days a week.
Eat well
The ACS recommends varied, colorful vegetables and fruit (at least five daily servings), whole grains (whole wheat, oatmeal and more), and balancing calories in with calories out to maintain a healthy weight. Limit red or processed meats, such as beef, cold cuts and hot dogs.
Watch alcoholic beverages Overuse of alcohol contributes to liver, breast and oral cancers. Limit alcohol to two drinks or less for men, one drink or less for women, per day.
What is a screening test?
Screening tests check for cancer in people who don’t have obvious symptoms. These tests may use physical exams (for example, skin cancer or oral cancers); imaging technology like mammograms (for example, breast cancer); or laboratory tests on a sample of blood, urine or another substance (for example, prostate cancer). No screening test is 100 percent accurate. Sometimes these tests capture people who do not have cancer (a false positive), and miss people who do have cancer (a false negative). So, if you ever do have a positive screening test result, your doctor will recommend follow-up tests to investigate further. That might mean having more imaging tests like an ultrasound or MRI to get a better look at a worrisome area. Or it might mean having a biopsy. During a biopsy, cells or tissue are removed and checked under a microscope for signs of cancer. Why are screening tests helpful? Catching cancer at an early stage before it has spread to other sites in the body usually makes it easier to treat. Two screening tests — colonoscopy for colorectal cancer and Pap tests for cervical cancer — actually help prevent cancer by allowing doctors to find and remove precancerous growths. Thus far, only screening for breast, cervical and colorectal cancers have proven to lower death rates. Which screening tests are especially important to have and when to start cancer screening varies depending on your age, sex, racial and ethnic background and family history. Your health and lifestyle matter, too. Experts agree, for example, that all women age 50 and older should have an annual mammogram (breast X-ray). Yet some women could benefit from starting breast cancer screening earlier or possibly having additional imaging tests. Talk to your doctor about the best screening schedule for you.
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Questions & Answers
1. Is it necessary for blacks to be checked for skin cancer since its incidence is low in African Americans? Yes. Everyone should check their skin once a month and request a yearly exam by a doctor. Although minorities have a lower incidence of skin cancer, they are not exNadine Jackson McCleary, M.D., M.P.H. empt. In particular, blacks Medical Oncologist need to examine carefully Dana-Farber Cancer Institute their toenails, fingernails, the palms of their hands and soles of their feet — typical locations for a rare but aggressive form of melanoma that occurs more frequently in darker skinned people. 2. If a person has no history of cancer in his or her family, is it still necessary to undergo screening tests? Yes it is. Although some cancers, such as breast and colon, can occur frequently in families, those without a familial history are not necessarily immune. You should follow a screening schedule appropriate for your age and gender established for you by your doctor. 3. Why does healthy eating decrease the risk of cancer? Cells in the body can be damaged by unstable molecules called free radicals. The damage can cause a mutation, which in turn can result in cancer. Plant-based foods, such as fruits, vegetables and whole grains contain antioxidants called phytochemicals, which stabilize the free radicals, thereby reducing the risk of cancer. 4. Since there are differences of opinion in the value of screening for prostate cancer, should black men forgo PSAs, the blood test that can help to detect prostate cancer? To date, according to experts, studies have not substantially proven that prostate-specific antigens, or PSAs, save lives. Some men get prostate cancer, live several years and die from another cause. That is why the current medical advice is to discuss with men the advantages and disadvantages of the test. That being said, black men have the highest incidence and death rates from prostate cancer than any other group. In addition, they get it at a younger age and are often afflicted with more aggressive disease. For these reasons black men aged 40-45 should discuss screening with a doctor.
Myths and misperceptions not only perpetuate poor understanding of cancer, they can often hinder timely or recommended treatment.
Fiction
Fact
Breast cancer is the leading cause of death in women.
Cardiovascular disease kills more women than all cancers combined.
Surgery can cause cancer to spread.
Exposing the tumor to air does not cause cancer to spread. Often surgery reveals a more extensive cancer, which may cause people to think that surgery worsened the disease.
Cancer is contagious.
It is not possible to “catch” cancer from someone. However, through unsafe sex, you can become infected with certain viruses, such as hepatitis C and HPV, which can lead to liver and cervical cancers, respectively.
Living a healthy lifestyle can prevent cancer.
Although exercise, not smoking, a healthy weight and a healthy eating plan can reduce the risk of cancer, they cannot provide an absolute protection against the disease. Other factors, such as genetics and environment may come into play.
5. Does smoking a pipe or cigar instead of cigarettes reduce the risk of cancer? No. Tobacco of any kind can increase the risk of cancer. All tobacco, including snuff or smokeless tobacco contains carcinogens, which are cancer-causing agents. 6. Does a family history of breast or ovarian cancer always come from the mother’s side of the family? A genetic mutation that often results in breast or ovarian cancer can come from your father as well as your mother. The gender of the source of the mutation is not a factor. However, the recipient is. Daughters who inherit the mutation from either parent have an increased risk of either or both types of cancer. 7. Should males as well as females be vaccinated against human papillomavirus (HPV), the virus responsible for cervical cancer and genital warts? Since HPV was found to cause 70 percent of cervical cancers, vaccination against the virus is recommended for females aged 9-26. The Centers for Disease Control and Prevention does not as yet recommend vaccination for boys although it has been found to combat genital warts. With an increase in head and neck cancer as well as anal cancer caused by HPV, however, the organization’s position may change in the future. Until then parents of boys can decide if the vaccine Gardasil is right for their sons by talking with their sons’ health care providers. 8. Why are colonoscopies the preferred screening test for blacks? It has been found that blacks have a higher risk of polyps — predecessors of cancer — on the right side of the colon. Colonoscopy is the only screening test for colon cancer that examines the entire colon. 9. If a person has several risk factors for a particular type of cancer, does that mean that he or she will get the disease? Not necessarily. Having a risk, or even several risk factors for cancer, does not mean you will get it. Likewise, not having the risk is not foolproof protection. Because the incidence of cancers is not predictable, it is wise to follow a screening schedule to find cancers early and follow a healthy lifestyle to reduce its risk. 10. Do only women get breast cancer? No. According to the American Cancer Society, more than 2,000 men will be diagnosed with breast cancer in 2011 and 450 will die from the disease. The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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October is National Breast Cancer Awareness Month
Adan-Abdi, continued from page 1
to quality of health coverage. But it was mostly fear that prevailed. The participants expressed fear that surgery can activate breast cancer, that radiation makes it spread faster and that chemotherapy was ineffective. Perceived discrimination was also a barrier, as reported in a study from Stanford University. People who perceived discrimination from their health care providers were less likely to be screened for breast or colorectal cancer. Some people are just fatalistic and believe that recovery from cancer is not possible. But the health system cannot escape blame as a player in the issue of cancer disparities. Two-thirds of patients who were newly diagnosed with cancer were unable for a variety of reasons to obtain timely appointments with oncologists, according to a recent review by the University of Pennsylvania. Schedulers were not always available, medical records had disappeared or appropriate referrals did not materialize. More disconcerting than scheduling complications is a lesser quality of treatment rendered to black cancer patients. In 2008 the ACS found that over a 10-year period black patients covered by Medicare were less likely than whites to receive the recommended types of care. For instance, African American women with breast cancer who underwent the It took a bit of coaxing to get Hawo Adan-Abdi (right) to breast-conserving lumpecstart screenings for breast cancer when she came to this tomy did not always undergo country from Somalia. Pictured with her is her son, Abdiradiation therapy, although rahman Abdi. (Photo courtesy of Rachel Boillot, Boston the combined treatment is Housing Authority) considered the gold standard. New cases of lung cancer are lowest in a handDespite the obstacles, Adan-Abdi said ful of states, such as Arizona and California, she is a convert now. “I am no longer afraid,” while the highest numbers can be found in she said. Now she gets a yearly physical and Maine and Kentucky. handles her mammograms like a pro. She But more than anything else, experts hasn’t stopped at mammograms. She’s into explain that it is a person’s socioeconomic Pap smears as well. “It’s good to know,” she status (SES) that fuels cancer’s development. said. “The sooner the better.” The National Cancer Institute (NCI) notes that Cancer screening was new to her. And people who are poor and uneducated, lack health scary. So scary she ran from it for a while. She insurance and are medically underserved are admits now that she sometimes did not show up impacted the most. for appointments. One time, she says, she was Health literacy presents another barrier. fasting for Ramadan; other times she just forgot. Those uninformed about screenings or warning But looming over these tests was the concern signs and symptoms of cancer are less likely to that they were causing more harm than good. take action, while language and cultural differHer fears became real when she was ences hinder communication. “recalled” after her first mammogram. Her But misperceptions and attitudes about can- results indicated she had a suspicious lesion that cer, regardless of a person’s status, pose another required additional imaging evaluation. Fortuproblem altogether. nately for Adan-Abdi, further testing proved that Researchers at the University of Chicago the lesion was negative. But at one point, the analyzed perceptions of breast cancer treatdoctors were talking about a biopsy. ment among roughly 450 African American Adan-Abdi’s behavioral change does not residents of Chicago’s South Side. Participants end with her own health care. She makes sure in the focus groups cited mistrust of the medical her kids are healthy too. “It’s best to check for establishment and that quality of care is related something before it gets bad,” she said. percent of men aged 40 and above — most of them white — had had a PSA (a blood test to help detect prostate cancer) within the past two years. Cancer health disparities are not defined by race alone. Differences are noted by gender and age. Females have a higher incidence of breast and thyroid cancer than males. Uterine cancer is more common after the age of 60, while Ewing’s sarcoma, a type of bone cancer, tends to afflict teenagers. And it’s not only blacks that suffer cancer disparities. Latinas have the highest incidence of cervical cancer. Asians are more afflicted with liver and stomach cancer, while Native Americans suffer their share of kidney cancer. Whites are not immune. They have a higher incidence of cancers of the skin and blood, such as leukemia and lymphoma. Even geographical location has an impact.
Take the
first step
Mammograms for breast cancer Date 10/6 10/11 10/13 10/18 10/19 10/21 10/25 10/27
Organization Neponset Health Center Whittier Street Health Center Geiger Gibson Community Health Center Bowdoin Street Health Center Martha Eliot Health Center Fenway Health Bowdoin Street Health Center Mattapan Community Health Center
Location 398 Neponset Avenue, Dorchester 1125 Tremont Street, Roxbury 250 Mount Vernon Street, Dorchester 230 Bowdoin Street, Dorchester 75 Bickford Street, Jamaica Plain 1340 Boylston Street, Boston 230 Bowdoin Street, Dorchester 1425 Blue Hill Avenue, Mattapan
Mammograms provided through Dana-Farber’s Mammography Van. Call 617-632-1974 to schedule an appointment.
PSAs for prostate cancer Date 10/15 10/22
Organization People’s Baptist Church Union United Methodist Church
Location Time 830 Tremont Street, Boston 1 – 4 p.m. 485 Columbus Avenue, Boston 9 a.m. – 1 p.m.
PSAs provided through Dana-Farber’s Blum Van. Call 617-632-6694 for additional information.
BE Healthy • http://behealthy.baystatebanner.com
A life saving timetable
Cancer screenings can help detect cancer in the early stages when treatment is more successful. Some screenings — cervical and colorectal — can actually prevent cancer by removing precancerous lesions. Learn how to examine yourself for skin and head and neck cancers. Early detection can improve survival rates. gender
M
F
Screening Test
Frequency
Starting Age
Cancer Cervical (Pap test)*
21
Every 1 to 3 years
Breast (Mammogram)*
40
Every 1 to 2 years
Prostate (PSA)*
45
Yearly
Colorectal*
45
Every year - fecal occult blood test Every 5 years - sigmoidoscopy and fecal blood test Every 10 years - colonoscopy
Skin
18
Yearly
Head and Neck
18
Yearly
*Screening schedule depends on risk factors. Talk to your doctor to determine the timeline most appropriate for you. Sources: American Congress of Obstetricians and Gynecologists, American Cancer Society, American College of Gastroenterology
Risk Factors
A risk factor is a characteristic that is likely to increase your chance of a particular disease. Having a risk factor does not mean you will get the disease. Likewise, not having one is not a guarantee against it. Some risk factors for cancer are beyond a person’s control, while others can be influenced by behavior and lifestyle.
Factors you
Factors beyond
• Smoking and tobacco use • Inactivity and weight • Unhealthy diet • Alcohol consumption
• Age • Race • Personal or family history of cancer • Genetics/inherited mutations
can control
your control
Lathan, continued from page
increase the risk of colon cancer. test, a visit with a surgeon or a visit with an Physical activity and exercise as well oncologist, a medical doctor who specializes in as weight control are important. Obesity is the treatment of cancer. a strong risk factor for uterine cancer and Lathan acknowledged that there are many breast cancer, especially for postmenobarriers to care that may seem insurmountable pausal women. by minorities. “The single biggest cause of The federal government has even lack of treatment is access,” he said. But he’s weighed in to improve access. The Centers not necessarily referring to the number and for Disease Control and Prevention has location of health facilities. “Some have access established programs that offer free or low but don’t know it,” he cost testing for breast, explained, referring to colon and cervical the state-run insurance cancer (877-414-4447). plan based on income in President Barack Massachusetts. Or people Obama has taken it a may not know where to step further and has go although health facilieliminated co-insurance ties are available. and co-pays for several Lack of education tests, including those about cancer is another for cancer, through the deterrent. Extended famiPatient Protection and lies, which are common Affordable Care Act. in the black community, Additionally, can provide a high level mobile vans, such as of support for a relative Christopher Lathan, M.D. the Mammography with cancer. But they can Director and Blum Vans run by work against you as well. Cancer Care Equity Program Dana-Farber Cancer Incorrect information is Dana-Farber Cancer Institute Institute, offer screenfiltered down. ings throughout the Lathan is a strong advocate of increascommunity for breast and prostate cancers. ing blacks’ participation in clinical trials, but In spite of everything, Lathan is he recognizes that many of these trials are not optimistic and offers a primer to help keep accessible. “You [health providers] must go to cancer at bay. His first advice is to see a the community,” he said. doctor regularly. “You must take care of your Although it is not possible to always health,” he advised, and get the recommendprevent cancer, there are steps a person can ed screenings. His second directive is to take take to reduce its risk. Never smoke or quit if part in your care. Ask questions, he said, and you do, Lathan advised. The majority of lung advocate for yourself. Fight if something does cancers are caused by tobacco use. Lifestyle is not seem right. His last is to demand excelkey. Diet is closely linked to many cancers. For lence of care. “You deserve the best possible instance, high consumption of red meat can treatment,” he said.
Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.