Blacks “have the highest death rate and shortest survival of any racial/ethnic group in the U.S. for most cancers,” according to the 2019-2021 American Cancer Society’s Cancer Facts & Figures for African Americans. Recognition of racial disparities in cancer is not new, and the many questions about disparities have not gone unexamined. After decades of professional discussion for the need for greater African American participation in research the results continue to disappoint.
A PubMed search of “racial disparity cancer” brings up 1,906 results for just the past five years. A similar keyword search of the abstracts presented at the 2020 meeting of the American Society of Clinical Oncology (ASCO) in May brought up 22 abstracts. The National Cancer Institute has a Center to Reduce Cancer Health Disparities, and its Surveillance, Epidemiology and End Results database is easily searchable by race. The cancer society has been publishing its biannual facts and figures reports about African Americans’ health for at least 15 years.
The Underrepresentation of African Americans
As part of a virtual meeting in late June, the American Association for Cancer Research held a panel discussion titled “Racism and Racial Inequities in Cancer Research,” led by the organization’s president, Antoni Ribas, M.D., Ph.D., FAACR. When the discussion turned to the underrepresentation of African Americans in cancer clinical trials, Ken Frazier, CEO of Merck, acknowledged that “too often we go to the usual suspects — the academic medical centers that we are very used to using.” Frazier promised to work with the FDA and others “to make sure that this isn’t just something that has enormous rhetorical appeal but happens in reality.”
That Mr. Frazier, one of the more impressive Big Pharma CEOs is engaged is a good and healthy thing. But it will take far more than pharmaceutical executives, FDA and academic medical centers to materially move this dial. Rather deep into health systems, from regional to the community, must be understood and embraced and then from there a leap to the social determinants of health and social providers in the community that represent the forefront of actual health care in America in 2020 and beyond.
Battle of The Sexes
At 13%, the difference in the death rate between black and white women is narrower but still sizable. The death rate for some of the most common cancers, including breast and colorectal, is higher among black women than it is among white women.
For men, the incidence patterns, by and large, fit the death rate patterns, with black men more likely to receive cancer diagnoses than white men (22% vs. 9%). But cancer incidence among black women is actually lower by 7% than it is among white women.
The reasons for racial disparities in cancer data hinge on how race is defined. Increasingly, investigators are viewing race primarily as a sociopolitical category.Viewing race as a sociopolitical grouping doesn’t mean there aren’t noteworthy genetic and biologic differences among those groupings. For example, black women are twice as likely to have triple-negative breast cancer (lacking estrogen and progesterone receptors and excess HER2 protein) as white women, and women who have this type of cancer tend to have worse outcomes.
A perhaps more manageable problem for organized oncology is the one that Frazier said Merck is working on: improving the representation of African Americansin clinical trials.
Samer Al Hadidi, a postdoctoral fellow at Baylor College of Medicine in Houston, and his colleagues reported findings in the Annals of Internal Medicine in June that showed how underrepresented African Americans are in trials. They calculated a participation-to-prevalence ratio of the clinical trials related to 75 FDA-approved cancer drugs. A 1.0 ratio would mean that the number of African Americans in the trials matched the number of African Americans in the patient population. Instead, Al Hadidi found a 0.31 ratio for all cancers combined; for prostate and multiple myeloma, 0.18 and 0.04, respectively.
Call to Action: One of the reasons investigators believe it is important to solve the underrepresentation problem in clinical trials is to discover early on whether African Americans respond differently to a drug. Follow TrialSite News’ Daily Newsletter for updates on this issue. Check out TrialSite’s African American research disparity survey for southeast Texas.