By Sue Rochman
What does skin color have to do with cancer?
By Sue Rochman
When Farrah Fawcett was diagnosed with cancer last September, she became the third of television’s original three Charlie’s Angels to confront the disease. Fawcett is reportedly battling anal cancer; her former Angels
co-stars Kate Jackson and Jaclyn Smith have each had breast cancer, Jackson twice. Is this just an odd coincidence, or could it be that there’s something about having been a Charlie’s Angel that influences cancer risk? Virtually no one would take that question seriously. But what if you were asked whether the fact that all three women were white might be a factor. That’s a question that seems to make much more sense. But does it?
RACE AS A SOCIAL CONSTRUCT
The United States is, in many ways, obsessed with race. Race is synonymous with the U.S. Census. It is used to establish voting districts. It is used to determine if schools have met government mandates for integration. It has become widely used in medical research, in many important ways. If research studies didn’t classify people by race, we wouldn’t know that black women are less likely than white women to get—but are more likely to die of—breast cancer; that Hispanics are more likely to get stomach cancer than whites; that Asian and Pacific Islander men are more likely to die of liver cancer than white men. And if we didn’t have this information, we wouldn’t be able to direct limited funds at the groups who appear to be most in need of educational programs or cancer screening.
But it’s one thing to use racial categories to look for disparities. It is another to use race as a variable to account for them. Using race in this fashion requires that race—like cancer—be rooted in biology. And that’s not the case. Race is not a biological category. It’s a social construct. There is no gene that makes someone a certain race. There is no blood cell tied to race. Someone’s skin tone isn’t an accurate indication of his or her racial identity. Based on his color, many people have assumed that golf sensation Tiger Woods is black. But he’s not. He’s one-eighth white, one-fourth black, one-eighth Native American, one-fourth Thai and one-fourth Chinese. What could Woods’ race possibly tell us about any cancer he might develop?
Few people have spent as much time thinking about how race can both contribute to and confound medical research studies as Harold Freeman. A cancer surgeon, Freeman is the former director of the National Cancer Institute’s Center to Reduce Cancer Health Disparities. He has served as president of the American Cancer Society. He has chaired the President’s Cancer Panel. He knows the statistics on race and ethnicity and cancer inside out. But for Freeman, the elusiveness and instability of racial categories and categorization mean that using race as a way to explain cancer disparities is as useful as, well, categorizing people by their appearance on a TV show.
To illustrate this, Freeman points to the history of racial classifications in this country. “In the 1700s,” says Freeman, “the Virginia state legislature decided that you were black if you were one-quarter black; less than that, you were white. Then, a hundred years later, the South Carolina state legislature determined that a person was black if they were one-eighth black.” (This means that a person who was considered white in Virginia in the 1700s might have been considered black in South Carolina in the 1800s.) And categorizations continued to change and evolve. For the past 30 years, the racial and ethnic categories the federal government uses have been determined by Directive 15, which is issued by the federal Office of Management and Budget (OMB). The last OMB update, in October 1997, mandated that government researchers use at least five categories for data on race: American Indian or Alaska native; Asian; black or African-American; native Hawaiian or other Pacific Islander; and white. (Previously, there were only four categories, since Asian and Pacific Islander were combined.) The single ethnicity listed by the OMB didn’t change, but what it was called did. Someone could now be “Hispanic or Latino,” not just Hispanic. (Ethnicity differs from race in that it addresses the language, cultural practices and traditions that distinguish one group from another. For example, a person from the Dominican Republic might be both black and Latino.)
None of these re-categorizations had any basis in biology. No one’s genes had suddenly changed. Rather, sociopolitical developments had affected how people viewed themselves and how the government viewed them. And while taking these changes into account might be fine for the U.S. Census, it has different implications for medical research. “What’s happening,” says Freeman, “is that we are doing biological studies on groups of people that have been assigned to categories that have no biological basis.”
A RACIAL OR GENETIC PARADOX?
Or do they? Some scientists believe that there is some sort of biology to race that we are now only beginning to understand. Relatively recent technological advances have allowed scientists to home in on a tumor’s biology and specific genetic mutations. And the more that is learned about cancer, the more it appears, some researchers say, that even though race is not a biological category, it is responsible in some biological way for certain disparities found in cancer studies.
If this sounds like a contradiction, you’re right. “There is seemingly a paradox,” says Dan Bustillos, the Intercultural Cancer Council postdoctoral fellow at Baylor College of Medicine in Houston. “But I don’t think it’s an irreconcilable one.” As Bustillos explains, it’s clear that “there is more genetic diversity within a racial category than between any two racial categories.” But it’s also true that “there are some genetic differences or traits that are very much still linked to our genetic lineage.” Although these genetic differences are actually a very small part of the human genome, they can alter proteins in ways that make drugs act differently in different people. Because these genetic differences are influenced by a person’s genetic lineage, it’s possible for a high percentage of people of a certain race or ethnicity to have the same genetic profile. When that occurs, Bustillos explains, “race or ethnicity becomes a salient, scientific factor” when the safety and effectiveness of new drugs are investigated. And that means that saying race is both a social construct and a category necessary for medical research is not really a paradox at all, he says.
Maybe not. But it can still be hard to wrap your brain around. So it probably won’t come as a surprise to learn that even scientists who are conducting this type of cancer research are grappling with how to interpret and then speak about their findings when they find racial or ethnic differences.