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Cancer Disparity Among Black Women Unresolved


I'm Michel Martin and this is TELL ME MORE from NPR News. Now we turn to one of those uncomfortable questions that many people, particularly in health, have asked themselves and know all too well.

The question is about cancer. Why are white women more likely to get breast cancer, but black women are more likely to die from it? In fact, black Americans have a higher death rate from cancer than any other racial or ethnic group. Dr. Harold P. Freeman saw this for himself as a cancer surgeon in New York's Harlem Hospital and later as leader of the American Cancer Society. He recently wrote about this issue in an essay for the New York Times titled "Why Black Women Die of Cancer." And Dr. Freeman is with us now. Welcome. Thank you so much for joining us.

HAROLD P. FREEMAN: I'm very glad to be with you. Thank you for inviting me.

MARTIN: You know, your piece is hopeful in parts - and we'll get to the hopeful part of it - but it also is very sad. You point out in the piece that this has been known since the '70s...


MARTIN: ...That there was this disparity. So why are we still talking about it?

FREEMAN: We're still talking about it because we haven't solved it. Everyone, black and white, have improved in outcome over 40 years. But the relative disparity has remained the same. And I think the reason for the black and white difference is primarily related to economic status and lack of insurance on part of black women. But also, we have a health care system that doesn't treat everyone equally.

MARTIN: Some people think that it's one of two things. They think it's either genetics, that for some reason black women are genetically more likely to get a more aggressive form of breast cancer. So let's take that question first. Is that true?

FREEMAN: That is true. Among young black women, there's a higher incidence of what is called triple-negative breast cancer, which is more aggressive. The problem is beyond that small group of black women who have aggressive cancer. The point is that at the same stage of disease and diagnosis, black women don't get treated the same as white women do. I think that's...

MARTIN: How do we know this? You're saying that even if you have the same circumstances, you don't get treated the same. Is that because of insurance, because of money?

FREEMAN: It has to be partly because of insurance and money. But there's a small part of it, too, that has been shown by the Institute of Medicine, a respected group of scientists, that race matters as a determinant of what is recommended for people. For example, in lung cancer, there's a difference in who was recommended for curative surgery. For early stages of lung cancer, race matters. And that's true for who gets worked up for cardiac disease, how people are treated for renal failure, across the board.

MARTIN: Well, let me read a quote from your piece. You write that black women experience significant delays in diagnosis and treatment. According to the CDC - that's the Centers for Disease Control - even when they have similar insurance coverage, 20 percent of black women with abnormal mammograms wait more than 60 days for a diagnosis compared with 12 percent of white women.

According - also from your piece, the Institute of Medicine reported in 2003 that black Americans with health insurance similar to that of white Americans are at times less likely to be recommended by physicians to receive curative cancer care. Now you say you don't think that's because doctors are racist. Why - what - if they're not, then what's the issue then?

FREEMAN: The matter of race and racism is very complicated. But I don't believe that doctors intend to hurt anyone. That's what I mean. I think doctors sometimes make assumptions related to race that hurt people.

For example, if a poor black woman has breast cancer and she needs to have complex therapy, maybe doctors will assume that she won't be compliant or she won't follow through. And sometimes recommendations follow that pattern, so they don't get recommended the highest quality of care. This actually has been shown scientifically.

MARTIN: If this is something that is known and that has been studied by reputable people, isn't this a problem of medical education? Is this a problem with how doctors are trained and supervised?

FREEMAN: I think it's a deeper problem than doctors. I think we're in a society where we see each other through the lens of race, and we make assumptions through that lens that sometimes can be harmful to people. So I don't think doctors should be separated off as people who are different from other American people. On the other hand, I want to emphasize the point - the main reason for the disparity of black and white women in breast cancer is economic status and lack of insurance.

MARTIN: If you're just joining us, I'm speaking with Dr. Harold P. Freeman. He's a former cancer surgeon at Harlem Hospital. We're speaking about a recent essay he wrote the New York Times titled "Why Black Women Die of Cancer."

It's interesting that we're talking now. The Affordable Care Act sign-up deadline has just passed, as we are speaking. The White House has declared that more than 7 million Americans have sought coverage through the program. Do you feel that - I mean - I don't mean for this to be an advertisement for the Affordable Care Act - but do you feel that this is going to make a difference?

FREEMAN: If we had universal insurance for everybody, it certainly would have a positive effect. However, having insurance does not necessarily assure that you will get good quality and timely care. And the combination, in my experience, of having people insured but also giving them personal assistance to get through the health care system - we call it patient navigation - seems to work.

MARTIN: And that's what you are doing now. Let's kind of loop this around. As we mentioned, that you had started working in Harlem as a cancer surgeon back in 1967, and then you subsequently became president of the American Cancer Society. What are you doing now?

FREEMAN: Well, right now I have what is called the Harold P. Freeman Patient Navigation Institute in New York City, and we're training people from all over America and other parts of the world to be patient navigators. What navigators do is go one-on-one with patients. Patients come in to a doctor, for example, they have a lump in their breast, doctor recommends biopsy and then that's it.

The navigators take the patient to a different room and say, did you understand what the doctor said? There are communication issues, for example. Do you have insurance? Maybe not. We have to fix that. Patients may be afraid. Fear and distress is very prevalent. So navigators can solve many problems and concentrate on the timely movement of patients through the system from diagnosis to treatment and through treatment and through survivorship. We changed the five-year survival rate in Harlem in breast cancer from 39 percent to 70 percent by using a screening - free of charge if they could not pay - along with navigation.

MARTIN: You're saying that only 39 percent of people at Harlem Hospital used to survive breast cancer.

FREEMAN: By actual study and publication, over a 22-year period ending in 1986, there was a five-year survival rate for black poor women was 39 percent when it should've been 75 percent.

MARTIN: And now you're saying what? You've been able to bring it almost to parity...

FREEMAN: We changed the...

MARTIN: ...With the navigation.

FREEMAN: ...Through assuring that the women could get the tests they needed, which was the mammogram, and also assuring if they had a finding on the mammogram, we navigated them to a diagnosis rapidly and through treatment. We changed the five-year survival in Harlem by actual study from 39 percent to 70 percent.

MARTIN: What would you most want people to draw from your piece?

FREEMAN: Universal insurance is very important, but for poor communities, we have to add to that personal assistance for people who have findings and diagnoses of cancer. And a combination then of screening and navigation seems to be the answer to this problem.

MARTIN: Dr. Harold P. Freeman is a former cancer surgeon at Harlem Hospital. That's in New York City. He's a former president of the American Cancer Society, and now he's founder and president of the Harold P. Freeman Patient Navigation Institute in New York City. The piece that we were talking about was called "Why Black Women Die of Cancer." And it appeared in the New York Times. Thank you so much for speaking with us, Dr. Freeman.

FREEMAN: Thank you very much, Michel. Transcript provided by NPR, Copyright NPR.

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