By Jocelyn Rice
Perceived discrimination reduces cancer screening
By Jocelyn Rice
While it has long been known that cancer screening behavior differs among racial and ethnic groups, the causes of this discrepancy have remained unclear. Now, new research is offering some insight: A report published in the August 2008 Cancer Epidemiology, Biomarkers & Prevention suggests that minority women who believe their medical caregivers discriminate against them are substantially less likely to be screened for breast cancer and colorectal cancer.
LaVera M. Crawley, a biomedical ethicist at Stanford University in Stanford, Calif., and her colleagues crunched numbers from telephone surveys of more than 11,000 Californians, including African-Americans, Native Americans, Asians and Latinos. “Women who had perceived medical discrimination within the past five years were two- thirds as likely to be screened for colorectal cancer and more than half as likely to have received a mammogram compared with women who did not perceive medical discrimination,” the researchers report. Among men, perceived medical discrimination was not associated with decreased screening rates—except, surprisingly, for those men who had a consistent source of medical care.
While the study specifically addressed perception of discrimination, Barbara A. Brenner, the executive director of the advocacy group Breast Cancer Action, argues that the distinction between perceived and actual discrimination is irrelevant. “If what you’re looking at is outcomes,” says Brenner, “then it doesn’t matter whether it’s real or perceived. It’s real to the person whose behavior was affected.”
Crawley agrees. What matters, she says, is that women who feel discriminated against seem less likely to adhere to screening guidelines—even if their health care providers mean no harm. For people at average risk of colorectal cancer, the American Cancer Society (ACS) and U.S. Preventive Services Task Force (USPSTF) recommend colorectal cancer screening starting at age 50. To screen women at average risk for breast cancer, the ACS and USPSTF recommend mammography starting at 40. In future studies, Crawley hopes to home in on the precise cues that make a patient feel unfairly treated so that clinicians can strive to eliminate those triggers. “We really need to characterize what exactly people are perceiving,” she says.
While the effect of perceived discrimination was pronounced, it was limited to a relatively small group of patients. Only 9 percent of the surveyed women reported that they felt medically discriminated against during the previous five years. Crawley, who notes that discrimination is usually underreported, suspects the real proportion may be larger. “The problem is bigger than the numbers,” she says.
Beth A. Jones, a cancer epidemiologist at the Yale School of Public Health in New Haven, Conn., agrees that underreporting plagues these types of analyses. But Jones, who studies racial disparities in cancer screening, says that perceived medical discrimination may play a relatively small role in the inequalities associated with cancer screening. “Clearly this is a piece of that puzzle,” she says, “but there are many factors that contribute to the disadvantage.”
And more than screening is responsible for the racial and ethnic disparities in cancer incidence and mortality rates, adds Brenner. Inequalities persist beyond screening, affecting patients’ follow-up for an abnormal result, treatment for a diagnosed tumor, and monitoring for recurrence. “We ought to talk about fundamental health care reform,” she says. “We need to make sure everyone has access to care that is culturally relevant to them.”