News Analysis: Is Cancer a Disease of Economics?

cancer-se-illustrationStill the second leading cause of death in the United States, cancer is evolving to become a disease of socio-economic status, according to a major report published Jan 8 by researchers at the American Cancer Society. Cervical cancer, which is highly preventable by HPV vaccination, is about twice as likely to kill women in poor counties than women in affluent counties. Lung cancer and liver cancer, which are highly preventable by avoiding smoking and drinking, are about 40% more likely to kill men in poor counties than men in affluent counties. Why?

Smoking

Tobacco use has become very much a marker of low socio-economic class, and it is the main reason why there is a substantial divergence in lung cancer rates. This is somewhat masked because there are two opposing trends: from about 1971 to 1991, the increasing proportion of women who smoked accounted for worsening lung cancer rates overall, but since 1991 the proportion of both men and women who smoke has been declining along with lung cancer rates. Now what we see is a lag in the declining trend for poorer people who are coming to dominate the smoking population.

According to the Centers for Disease Control (CDC) about 15.5% of Americans smoke, but prevalence increases sharply with decreased educational attainment: Only 4.5% of those with graduate degrees and only 7.7% of those with bachelors degrees smoke, but 19.7% of those with high school diplomas and 40.6% of those with GEDs smoke. People below the poverty line are 76.9% more likely to smoke than people above the poverty line. And, the CDC notes, “People living in poverty smoke cigarettes for a duration of nearly twice as many years as people with a family income of three times the poverty rate. People with a high school education smoke cigarettes for a duration of more than twice as many years as people with at least a bachelor’s degree.”

Access to Health Care

Regular access to good health care is a huge problem for poor people. The Affordable Care Act does not magically make good medical facilities appear overnight in Mississippi and West Virginia, especially if the state opted out of Medicaid expansion for political reasons. These kinds of problems take a generation to improve, because the availability of funds through insurance reimbursement takes many years to make it possible to open new facilities and then many more years to staff them with doctors and nurses who will be motivated to make educational choices by the increased pool of jobs. There are serious market imbalances that mess this up, such as that a primary care physician (what used to be called a general practitioner) can expect to earn a fraction of what a specialist might earn, and the urban-rural divide makes this even worse.

There are also contravening forces, such as immigration policy: Before Trump, alien graduates of US medical schools could agree to work for five years in underserved areas in exchange for a Green Card (and therefore eventual citizenship), and this was how many rural parts of the country were able to get doctors at all. The Association of American Medical Colleges predicts a shortage of 90,000 doctors by 2025, in part due to Congress limiting the number of doctors who can be trained per year because Medicare pays $40,000 of the cost of training each doctor, estimated to be $152,000 per year.

Better early detection, which requires regular access to good health care, accounts for improved survival rates for most cancers, especially three of the big four: lung, breast, prostate and colorectal. Lung cancer is still generally not detected early, although (as explained above) this is significantly a consequence of it being more likely in exactly those least likely to have access to health care.

Diet

Diet is much worse for poorer people because cheap food tends to be bad food, and many do not have the resources or knowledge to fight against the trends that push them toward exactly the kind of heavily processed convenience foods that contribute to obesity and attendant increased risk for cancer (as well as heart disease and diabetes). It costs more money and requires more expertise to eat better, and sophisticated commercial consumer messaging, right down to shelf placement in supermarkets, works against it. Even something as simple as transportation issues if poor people do not have cars can force them to shop at small, local markets that are essentially convenience stores rather than supermarkets, especially in parts of the country where even the nearest Walmart may be over an hour away by car.

At about half of farmers markets in RI, there is a “Bonus Bucks” program that gives people on SNAP (food stamps) a 100% bonus at farmers markets for fruits and vegetables: That is, if you charge $10 against your EBT card then you get $10 worth of tokens good for anything at the farmers market plus $10 worth of tokens good for fruit and vegetables, making this a much more affordable and healthier choice for poor people. About 30% of Providence residents are below the poverty line, according to census data.

Interestingly, colorectal cancer, which is significantly correlated with diet, decades ago was more likely among the affluent but now is more likely among the poor.

Conclusion

As these trends reach a confluence, will cancer victims be perceived as less deserving of sympathy? People have been killed by heroin overdose for the better part of a century, but the opioid epidemic only came to consciousness as an urgent public health crisis when middle-class white people started dying. In five or 10 years, will we see “cancer shaming?”

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