How We Do Harm (3 page)

Not quite.
The proportion of women getting mammography screening is roughly the same among whites and blacks.
(I suspect that the proportion getting high-quality mammography is greater among whites than blacks, but this difference has not been adequately studied.)
The delay of pregnancy and childbirth is a more plausible explanation.
White women tend to have children later in life than black women.
Professional women, regardless of their race, go to college, establish their careers, and then have kids.
Delaying childbirth past the age of thirty clearly increases the risk of breast cancer.
To be specific, it increases the risk of estrogen-receptor-positive breast cancer, which has a better prognosis.

Also, white women have been more likely to use postmenopausal hormone-replacement therapy (HRT).
Doctors prescribed HRT because it made sense logically.
Without definitive data on the therapy’s biological effect, doctors were, in effect, staging a decades-long societal experiment.

By 2003, 35 percent of postmenopausal white American women had taken this therapy at some time.
For cultural and socioeconomic reasons, black women tended not to take HRT.
Fewer than 5 percent of postmenopausal black women took HRT.
This is important, because HRT is associated with better prognosis breast cancer.

In 2003, an analysis from the well-designed study called the Women’s Health Initiative showed that HRT was correlated with an increased risk of breast cancer.
It was actually correlated with an increased risk of estrogen-receptor-positive, better prognosis breast cancer.
The societal experiment was over.

The analysis led to a drop in the use of HRT, which likely accounts for the drop in breast cancer in white women from 147 per 100,000 in 1999 to 129 per 100,000 in 2008.

*

A
focus on some geographic areas offers insight into what drives breast cancer in educated white women.

Consider Long Island.
The area has been known to have a higher incidence of breast cancer than among the general United States population.

In the early 1990s, breast cancer advocates petitioned the U.S.
Congress to force the National Cancer Institute to study the “high rates of breast cancer in Nassau and Suffolk Counties on Long Island.”
This led to Public Law 103-43, which prompted a series of studies, called the Long Island Breast Cancer Study Project.

At the beginning of the project, the incidence of breast cancer among Long Island’s white women was 138.7 per 100,000 in Nassau County and 142.7 per 100,000 in Suffolk, compared to 127.8 per 100,000 in the United States as a whole.

Mortality from breast cancer on Long Island wasn’t especially elevated.
Indeed, several areas of New York State and many areas of the United States had higher death rates.
A similarly high incidence was found among white women in the area north of San Francisco Bay.

Could the elevated incidence have been due to electromagnetic fields, hazardous wastes, or some other environmental cause?

After spending at least $20 million, the Long Island study project did not identify any pollutant that could be responsible for the elevated incidence of breast cancer.

However, those who believed that an environmental factor was at play were right.
At least two such factors were driving the disparity between Long Island and the rest of the country: a higher level of education among area women and their choice to delay childbirth.

*

LET’S
return to the disparity in triple-negative breast cancer by race: 30 percent in black breast cancer patients, and 18 percent in white patients.

There is no difference in the proportion of black and white women with progesterone-positive or HER2-positive disease.
So if we are to focus on the 12 percent disparity, we must look exclusively at the racial difference in the prevalence of the estrogen receptor.

Does
this
suggest that skin color stands for some biological difference?

Not really.

Because of dietary differences that are caused by culture and socioeconomic status, a black girl in the United States accumulates weight much faster than a white girl.
In the 1960s, the Centers for Disease Control and Prevention compared the start of menstruation by age.
The study showed that the average age of menarche for white American girls was 12.8 years.
For black American girls, it was 12.4 years.
This is a bigger difference than it might seem.
It means that 53 percent of black girls have started menstruating by their thirteenth birthday, compared to 43 percent of white girls.

Body mass index, a calculation based on weight and height, correlates with early nutrition status, which has a lot to do with age at first menstruation.
Poor Americans have diets higher in calories and reach the weight of one hundred pounds faster.

Just the simple number of uninterrupted menstrual cycles increases the risk of breast cancer later in life.

The reason for this rapid weight gain in black girls has nothing to do with race, but reflects a high caloric intake and a diet rich in carbohydrates, a socioeconomic determinant of health.
It’s not about race.
It’s at least in part about the sort of food that is available in poor areas of inner cities.

The area of Detroit where I grew up and the areas of Atlanta where my patients come from are known as produce deserts.
Grocery stores there carry all the chips, sodas, and mentholated cigarettes you may desire, but if you want a head of lettuce, you are out of luck.

You observe the same problems among poor whites, yet you don’t see them among wealthy, well-educated blacks.

I cite the CDC data from the 1960s because they measure the racial differences that are driving breast cancers we are diagnosing today.
This disparity has since widened, and if we trace it, we can project the differences in breast cancer rates and prevalence of triple-negative disease for decades into the future.

This extrapolation produces a deeply disturbing picture: the black-white gap in the onset of menstruation and body weight has dramatically widened, which means that the disease disparities will widen also.

*

FOR
the sake of argument, let’s set aside everything we know about Grady, Atlanta, and our race-obsessed society.
Perhaps the best way to learn about breast cancer is to look at Scotland.

Scotland, which is virtually all-white, collects data at its every-ten-year census using a unique tool called the deprivation index.
The index measures socioeconomic factors beyond household income.
It asks about indoor plumbing, electricity, even how many servants one might employ.
This index can discern that a college philosophy professor earning $55,000 per year is in a different socioeconomic stratum from a garbage collector earning $70,000 per year.

Using this index, a group of researchers found evidence pointing to a correlation between social deprivation and incidence of breast cancer that lacks estrogen receptors, a characteristic which makes the disease harder to treat.
The deprived or poor who developed breast cancer were more likely to develop this kind of breast cancer.
I find it ironic that one of the most important studies in minority health was an all-white study.

My friend Samuel Broder, when he was the director of the National Cancer Institute, used to say that poverty is a carcinogen.
Skin color can be a marker of some sort, but you have to be careful not to rely on it too heavily.
Wealth is a marker, too, as is education.
Area of geographic origin and family history are also important, and all these factors must be considered.

*

EDNA
has Stage IV breast cancer.
Disease has spread all over her body.
Had she come to see me early in the course of her disease, it would have cost about $30,000 to cure her.
She could have remained a taxpayer.
Her kids could have had a mother.
Now, the cure is not an option.
Still, we’ll fight.
We will give her breast-cancer chemotherapy that will cost more than $150,000, even though the chances are she will still die in less than two years.
If you are a caring doctor, you realize she is just fifty-three, with kids and folks who love her, and your motivation is akin to a philosophy of Wayne Gretzky: “You miss every shot you don’t take.”

Every time I start chemo for metastatic disease I think of a patient named Sandra, a lively, young black woman whom I have treated for six years.
She had brain metastases when I first met her.
She has had active disease ever since, and even the doctor who sent her to me reminds me every time he sees me that he is amazed that she is alive, functional, and enjoying life.

Yes, sometimes cancer drugs give us “long-term survival,” in the dispassionate language of those of us who study outcomes.
But for every Sandra, we get fifty patients with metastatic disease who “don’t do well.”
They live a median eighteen months, which means that half are living and half are dead a year and a half after diagnosis.

We try three treatments and contain Edna’s disease for a while.
She dies at age fifty-five, about twenty months after walking into the ER.

Chapter 2

Brawleyism

MY GREAT-GREAT-GRANDFATHER
Edward McKnight Brawley was a free Negro born in Charleston, South Carolina.
In the 1880s, Edward, who was a Baptist minister and author of a textbook on evangelism, moved his family to Selma, Alabama, to become president of Selma University, an all-black school.

His son Benjamin became one of the premier black intellectuals of his generation.
He was educated at Morehouse College, Harvard University, and—like me—the University of Chicago.

Benjamin was the dean of Morehouse and later the chairman of the English Department at Howard.
He was a literary critic, poet, writer, historian, and sociologist.
A building at Morehouse is called Brawley Hall.
There is a Brawley High School in Scotland Neck, North Carolina.
He was quoted by his peers, including the historian W.
E.
B.
DuBois in his treatise
Black Reconstruction in America.

A biographer describes Benjamin as an intellectual inclined “to move simply as an American citizen in a democratic society.”
Liberal arts education and cultural advancement were his weapons of choice in the struggle for the rights of the Negro people.

In the thirties, the writers and literary critics of the Harlem Renaissance turned my great-uncle’s name into a disparaging political moniker:
Brawleyism.
To a movement fueled by jazz, outrage, and the politics of the left, Benjamin seemed bourgeois.
While his detractors expressed themselves in an unrestrained manner, Benjamin wrote Victorian verse and uplifting biographies of black Americans who were as worthy of admiration as the founding fathers.
Benjamin’s 1937 book,
Negro Builders and Heroes
, for example, profiles Frederick Douglass, Harriet Tubman, Sojourner Truth, and Booker T.
Washington.
A section is also devoted to his father, my great-great-grandfather.

Benjamin fought back, accusing his critics of excessive emphasis on the experience of the underclass and overlooking stories of triumph against the odds.

I admire people on both sides of that debate, and I don’t side with either Benjamin or his detractors.
There is no need to choose.
The experience of the underclass cannot be ignored, yet there is no reason to diminish the achievements of Negro builders and heroes.

I view this half-forgotten schism of the pre-civil-rights era in the broader context of a continuum of human struggle against injustice, which goes beyond race and encompasses basic human rights, including the right to decent health care.
The debate is raging still, and as chief medical officer of the American Cancer Society I list myself among its participants.

In this debate, I consider myself more fortunate than Benjamin Brawley.
My form of Brawleyism plays out in science, which—unlike literary criticism—can produce measurable, reproducible results.

*

THIS
book is a guided tour of the back rooms of American medicine.
When I was fresh out of the University of Chicago medical school and newly admitted behind the curtains of these back rooms, I could dismiss medical horror stories as isolated episodes of the malfunctioning of the system: another person overlooked, another judgment error, another example of bum luck, another case of the frustratingly slow march of progress.

More than a quarter century later, I have seen enough to conclude that no incident of failure in American medicine should be dismissed as an aberration.
Failure
is
the system, and those of us who are not yet its victims are at high risk of being sucked into its turbines.

My friend and colleague Peter Bach is fond of saying, “America does not have a health-care system.
We have a sick-care system.”
Peter, a health-systems researcher and a pulmonologist at Memorial Sloan-Kettering Cancer Center, goes on to say that it’s a stretch to use the word
system
to describe our health care because this word denotes organization.

Too often, helping the patient isn’t the point.
Economic incentives can dictate that the patient be ground up as expensively as possible with the goal of maximizing the cut of every practitioner who gets involved.
When we, doctors, are at our best, we set aside our self-interest and put the patient’s interest first.
When we aren’t at our best, the public pays more in fees, insurance premiums, taxes—and poor outcomes.

I get furious every time I hear politicians and pundits assert that the American health-care system is the best in the world.
I heard this far too often from opponents of the 2010 health-care reform bill.
I can think of several explanations for repeating this falsehood.
Ignorance is the first and most elegant.
Being out of touch with reality would explain it, as would lying, either to ourselves or to others.

America is the greatest place in the world to get care for a complicated but treatable disease if you have the ability to get the care and pay for it.
It’s not a great place to be sick if you are poor and uninsured or want consistent, basic care.