Race And Culture

Race remains a controversial topic in American society. Great strides have been made in eliminating the disparity caused by racism; however, many have argued that the continued use of racial identifiers promotes racism and isolation. In addition, the categories used by the US Census Bureau to define race have been criticized as restrictive because these categories do not take into account the various ethnicities within each category. The use of the term African American or black is broad and does not recognize the diversity within this category such as Caribbean, African and others. In a similar manner, Asian, which has been broadened to include Pacific Islander, encompasses Vietnamese, Chinese, Japanese, Thai, and Indian. Once again it does not show the variety within these groups that has proven to be important in certain instances e.g. the increased incidence of cervical cancer specific to Vietnamese 34

women.

Issues of race in American society also extend to the health care system. In the IOM report there are several studies showing that even when low SES is accounted for, race remains an independent variable in health care delivery disparities. It is difficult to find studies that control for race as an independent factor. Race can be a surrogate for culture, belief systems, social and nutritional habits, and various elements, which are difficult to define and control in studies. Yet in many studies when the data are analyzed using multivariate analysis, certain trends can be seen. There is documented evidence of racial bias noted in several areas of medicine including cancer therapy.

Ayanian et al. demonstrated that among Medicare patients the adjusted odds ratio of receiving a revascularization procedure after coronary angiography was 78% higher for whites than blacks.35 Other studies have demonstrated these racial differences in other kinds of intervention. These findings extend to surgical therapy in cancer. Lathan and colleagues in a study looking at the effect of race on staging and surgery in non-small-cell lung cancer found a similar outcome. This study showed that African Americans were less likely to undergo invasive staging (defined as mediastinoscopy, bronchoscopy, or thoracoscopy) than Caucasians. In addition, once invasive staging had been performed they were less likely to undergo surgical resection. The cohort of patients had access to care via their Medicare eligibility. The reasons for decreased surgical therapy in this study varied.36 Figure 3 depicts the reasons in this study why surgery was not performed among patients who had undergone invasive staging. A similar outcome was noted in the use of prostatectomy for prostate cancer in African American and Caucasian men37 and in nonsurgical areas such as the use of standard chemotherapy in adjuvant therapy for colorectal cancer.38 These studies show that when SES is accounted for, equivalent treatment and outcome is still not attained.

Many studies have documented the role of race in health care disparity. The difficulty when assessing these studies is in determining where this racial bias occurs.

Race and Staging in NSCLC

Srugery not recommended

Contraindicated

Figure 3. Reasons Recorded in Surveillance, Epidemiology, and End Results for Why Surgery Was Not Performed Among Patients Who Had Invasive Staging. (Reprinted with permission from Lathan eiai36)

Srugery not recommended

Contraindicated

Figure 3. Reasons Recorded in Surveillance, Epidemiology, and End Results for Why Surgery Was Not Performed Among Patients Who Had Invasive Staging. (Reprinted with permission from Lathan eiai36)

Refused

There are many areas where it may occur; these include two areas where intervention is possible:;i) treatment facility i.e. teaching versus nonteaching hospital, public versus private hospitals (ii) physician-patient interaction. Individuals bring their life experience, culture, and belief system to all health situations. All these factors influence how the physician and patient interact and what treatments may seem acceptable. These areas should be studied in more detail in order to determine how race and culture impact health disparity. In a retrospective review by Baldwin and colleagues, African American and Caucasian colon cancer patients with Medicare both had an equal opportunity to learn about chemotherapy from a medical oncologist but they did not receive chemotherapy equally.39 The reasons for this disparity are complex however; this disparity lessens with increasing age and social support, and severity of illness. It is interesting to note that in this study African Americans were more likely to refuse chemotherapy despite an equal number of referrals. The level of educational attainment and SES were predictive factors for refusal of chemotherapy.

Race and culture are often intertwined. Despite this, culture remains the most poorly studied of all the factors that affect cancer survival. Cancer is a diagnosis that affects not only the individual but also his or her entire family. How an individual reacts to the diagnosis, the kind of treatment he or she chooses, and the social support he or she receives is in a large part influenced by their culture. Studies have shown that non-Caucasian women are more likely to have strong beliefs about religious intervention in curing disease or to have a more fatalistic view of cancer.35,36 Also, as generations are acculturated do we observe differences in health disparities and outcomes across generations? It would be informative to determine how a patient's culture affects their interpretation of their disease and alters their choice of therapy, and their use of self-management techniques. A person's culture may even change his or her approach to long-term health maintenance. From a health care perspective knowing the subtleties in various cultures can only enhance our ability to provide better care for our patients.

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