8.2.21
“This is What Dignity Looks Like”
First anniversary of Chadwick Boseman’s death from a disease that is devastating to the African American community
Son of Inequity
August 28, 2021, will mark the one-year anniversary of the tragic death of actor Chadwick Boseman, who died at age 43 from colorectal cancer (CRC): a disease with one of the largest racial disparity gaps—for both incidence and fatalities—in the United States.
Boseman, who starred in many block-buster films—portraying Jackie Robinson in “42”, Thurgood Marshall in “Marshall”, James Brown in “Get On Up,” and, of course, T’Challa in “Black Panther”—was diagnosed with Stage 3 CRC in 2016.
The premature death of this private man and gifted actor caught a nation off guard. Countless fans mourned publicly on social media, along with many celebrities, including Oprah Winfrey who said the following about Boseman’s battle with CRC:
“Showing us all that greatness in between surgeries and chemo, he had the courage, the strength, the Power it takes to do that. This is what Dignity looks like.”
While great disparities exist by race in the diagnosis and outcomes of many cancers, few are as stark as CRC. According to the National Cancer Society, African Americans are about 20% more likely to get CRC and about 40% more likely to die from CRC than most other groups in the U.S.
Colorectal cancer and the high human cost of inequality of care
“Collectively, blacks have the highest death rate and shortest survival of any racial/ethnic group in the U.S. for most cancers. Black men also have the highest cancer incidence rate. The causes of these inequalities are complex and reflect social and economic disparities and culture differences that affect cancer risk as well as differences in access to high-quality health care, more than biological differences. Moreover, black men and women bear a disproportionately high burden of other diseases, which influences cancer survival. In 2016, the death rate in the U.S. was higher for blacks than whites for heart disease, stroke, influenza and pneumonia, diabetes, hypertension, HIV/AIDS, kidney disease and homicide. Consequently, life expectancy is lower for blacks than whites among both men (71.5 versus 76.1 years and women (77.9 versus 81.0 years).”
From the American Cancer Society’s report “Cancer Facts & Figures for African Americans 2019-2021” :
The ACS report documents the following:
African Americans have the highest rates of CRC compared to all other racial groups in the U.S.
CRC is the third most common cancer in the African American community.
When compared to non-Hispanic Whites, the incidence of CRC is 24 percent higher in non-Hispanic Black males and 19 percent higher in non-Hispanic Black females.
CRC death rates are 47 percent higher in non-Hispanic Black men and 34 percent higher in non-Hispanic Black women, when compared to non-Hispanic White men and women.
Studies indicate that 19% of this racial disparity in fatalities from CRC can be attributed to lower screening rates and 36 percent to lower stage-specific survival among African Americans in general.
Like the incidence of CRC, deaths from this malignancy were highest in White patients in the U.S. until 1979 for women and 1984 for men when the fatality rates for White Americans dropped below that for African Americans.
For African Americans, the 5-year survival rate for CRC increased from 45 percent in 1975-1977 to 58 percent in 2008-2014, while the 5-year survival rate grew from 50 percent to 67 percent over the same time period for White Americans.
- There are many of the lifestyle and risk factors that promote CRC:
- Excess body weight
- Physical inactivity
- Long-term smoking
- Diets rich in red meat or processed meats and poor in fresh fruit, vegetables and whole-grain fiber
- Low-calcium diets
- Moderate to heaving alcohol consumption
- Diabetes
- Hypertension
- Several of these risk factors disproportionately affect African Americans, including excess body weight, long-term smoking and the prevalence of diabetes and hypertension.
- While survival rates are increasing, the disparity is believed to be due to the fact that African Americans are diagnosed at a later stage of the disease.
- For African Americans with CRC, 37 percent are initially diagnosed with local-stage disease, which is an early diagnosis with a better prognosis. For White CRC patients, 39 percent are diagnosed at this early stage.
- The disparity in stage-specific survival rates is due to differences in treatment, comorbidities and tumor characteristics.
- African American patients diagnosed with CRC are less likely than White CRC patients to receive recommended surgical, chemotherapeutic and radiation therapies.
- In the setting of a clinical trial where treatments are implemented equally, the Black-White survival disparity shrank dramatically.
- A recent study conducted by ACS researchers found that access to care, which is dictated by insurance status, is to blame for half of the CRC survival gap between African American and White CRC patients under age 65.
- According to the ACS, 26 percent of the survival disparity in patients under the age of 65 is due to something outside the control of equitable diagnosis and care: “unfavorable tumor characteristics.”
- For patients older than 65, nearly 50 percent of the survival disparity is due to unfavorable tumor characteristics.
- To illustrate these characteristics, the ACS states that African American CRC patients are as much as four times more likely than White CRC patients to be diagnosed with proximal (right-sided) tumors.
- CRC tumor side is associated with significant differences in molecular features that make proximal tumors more difficult to treat.
Screening is the key to survival
- Early screening is the key to survival because CRC is very treatable if caught early so it is not surprising to learn that there is a screening disparity between African Americans and White Americans, as well.
- Up until 1989, White males had a higher rate of CRC than African American males, while females had the same rate of this disease at that time.
- But in the ensuing 30 years, rates increased for African Americans and decreased for White Americans.
- This “crossover,” according to the ACS, may reflect racial differences in the trends of risk factors for colorectal cancer and/or greater access to and utilization by White Americans of recommended screening tests that detect and remove precancerous polyps.
- This is incredibly significant because screening tests that allow for the early removal of adenomatous polyps are the best tools and most effective method to prevent polyps from developing into CRC tumors.
- CRC screening increased from 32 percent to 62 percent in African Americans over the age of 50 from 2000 to 2015.
- Screening rates for White Americans the same age and over the same time period increased from 40 percent to 65 percent.
- According to one recent study, 53 percent African Americans were up to date with their CRC screening while 56 percent of White Americans were considered up to date with screening recommendations.
- An ACS study concluded that African Americans were 30 percent more likely than Whites to be diagnosed with an interval cancer following a negative colonoscopy but before the next recommended screening.
- This may be the case because the same study found that African Americans are more likely than White Americans to receive colonoscopies from “less-skilled physicians.”
Advanced CRC being diagnosed in younger patients
While several indicators show that equity in screening and care is narrowing the CRC incidence and fatality gap between African and White Americans, one striking statistic still persists, and it very relevant in the loss of Chadwick Boseman: Younger and younger American patients are being diagnosed with advanced CRC.
“Colorectal cancer is the second deadliest cancer in the country. This disease is ravaging the Black community, and it is as important as ever that everyone has access to and is receiving the recommended screenings. Even during the coronavirus pandemic, necessary screening tests remain available to prevent the disease or find it at an early, more treatable stage.”
Durado Brooks, MD, VP of Prevention and Early Detection, American Cancer Society
One recent research paper, Colorectal Cancer in Young African Americans: Is it time to revisit guidelines and prevention? discusses this ominous trend:
“CRC incidence is increasing among the young in all racial groups under study. This increase in frequency of CRC is true among young African American adults who display highly advanced tumors in comparison to other races. While the present attention to screening seems to have decreased CRC prevalence in individuals older than 50, special attention needs to be addressed to young African American adults as well, to counter the observed trend, as they have the highest incidence of CRC among young population groups by race/ethnicity.“