Steven Evans, MD, is a surgical oncologist at UPMC, vice chairman of the Department of Surgery at UPMC Shadyside, and clinical professor of surgery at the University of Pittsburgh School of Medicine. In this Q&A, Dr. Evans discusses how cancer screening can help reduce health inequities.
In cancer outcomes, does race matter?
Cancer affects all populations. Cancer inequities are defined as differences that exist between incidences and number of new cases, prevalence, all existing cases, mortality, death, and survival among ethnic groups.
African Americans have higher death rates than all other racial and ethnic groups for all cancers. Black women are more likely to be diagnosed with triple negative breast cancer, an aggressive form of breast cancer. Black women are 40% more likely to die from breast cancer. African Americans have the highest incidence and mortality rates from colorectal cancer and have the highest incidence of colorectal cancer in ages 45 and below.
In addition, lung cancer is the second most common cancer in Black men and women. Black males have higher lung cancer rates compared to white males, and lung cancer is the leading cause of death in black men.
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I argue that social determinants matter more than race when it comes to inequities in cancer care.
Why is where a person lives a strong determinant of health?
Race defines a group of people with shared characteristics like skin color and facial features that are influenced by genes. We are 99% identical and are genetically the same. It is our genetics that determines the way certain traits or conditions are passed from one generation to another.
People differ due to human genetic variations influenced by a host of factors including natural selection and random genetic mutations. Most cancers occur through random genetic mutations. Inherited mutations such as BRCA1 and BRCA2 cause less than 5% of all breast cancers.
Where a person lives is a stronger determinant of health than their genetic code. Your zip code determines access to healthy foods, safe walking to neighborhoods and parks, access to transportation, and affordable child care. It reflects the socioeconomic status and educational opportunities and access to quality care.
Poverty and a lack of health insurance negatively impact cancer survival. Not all populations have benefited equally, and many have limited access to preventative care cancer screening and early detection.
How does increasing minority representation in health care improve outcomes?
Unfortunately, African Americans only represent 5% of our health care professionals in medicine. We understand that patient and physician concordance improves trust, and the feeling of being heard and seen. I am aware that there is a barrier and lack of trust due to former engagements of African Americans in trials such as the syphilis trial and the Tuskegee events, and others that may cause lack of trust.
We are aware that these are barriers, and it is our goal to bridge these barriers and to build trusting relationships so that individuals will have the best survival possible. Because what we do know is equal treatment provides equal outcomes.
We are making efforts to increase representation of minorities in health care throughout our system. I was recently awarded a Beckwith grant to help build a pipeline of underrepresented minorities by presenting what I do in the field of surgery to high school students within our communities. The goal is to try to encourage young, qualified, and bright minds to consider the field of medicine, allied health, public health, and even surgery.
With this, our patients will have a broader representation in providers and could potentially have a provider who looks like them and who can then engage with them in a culturally confident and compassionate manner.
Are doctors trained in understanding implicit bias?
Doctors are trained to care for all people regardless of their race, ethnicity, gender, religion, or disability. That is our oath. It is our desire that we treat all people equally.
Physicians must be intentional to learn about other cultures and the barriers and concerns that exist within our different cultures and communities that we serve, so that we can give our patients the best care in a timely fashion. Doctors undergo training to help us be able to look inward and consider our own implicit, unconscious biases that may impact the decisions and recommendations that we make to our patients.
How did COVID-19 affect cancer care?
Screening and preventive health care came to a screeching halt during COVID-19. The pandemic magnified existing disparities in health care access and cancer outcomes.
Unemployment rose from 3% in February 2020 to 14% in April 2020. With unemployment comes lack of health care insurance and inability to afford copays. Thirty million U.S. residents lacked health insurance in the first half of 2020.
It is screening and early detection that will help change how the story unfolds when it comes to cancer outcomes. The goal of screening is to identify cancer, identify people at higher risk due to genetic mutations and social behaviors. Screening tests look for cancer before symptoms develop.
Are there any resources for uninsured or under-insured individuals to keep up with preventive screening?
Those uninsured are disproportionately Black, Latinos, and young adults. In Pennsylvania, we are fortunate to have, for example, for breast cancer, the Pennsylvania HealthyWoman program, which allows women to receive screening for breast cancer, colorectal cancer, and cervical cancer through breast mammography and Pap smears. The program also provides women access to FIT tests, which are immunohistochemical tests that identify blood within the stools, so that we can identify early colorectal cancers. Women may qualify for breast cancer screening at no cost beginning at age 40.
For more information, visit UPMC.com/HealthDisparities.
Cancer Care, Closer to Home
Dr. Evans sees patients at UPMC Hillman Cancer Center at UPMC McKeesport and other locations.
With more than 70 locations throughout Pennsylvania, Ohio, New York, and western Maryland, you’ll find advanced cancer care close to home with UPMC Hillman Cancer Center. To schedule an appointment, call 412-647-2811.
When you are facing cancer, you need the best care possible. UPMC Hillman Cancer Center provides world-class cancer care, from diagnosis to treatment, to help you in your cancer battle. We are the only comprehensive cancer center in our region, as designated by the National Cancer Institute. We have more than 70 locations throughout Pennsylvania, Ohio, and New York, with more than 200 oncologists – making it easier for you to find world-class care close to home. Our internationally renowned research team is striving to find new advances in prevention, detection, and treatment. Most of all, we are here for you. Our patient-first approach aims to provide you and your loved ones the care and support you need. To find a provider near you, visit our website.