'Flawed science' may play a role in health disparities
It's not just the provision of healthcare that needs to improve in terms of reducing racial health disparities, the research supporting the care needs improvement as well.
Clinical research recommendations may be biased or inappropriate for selected racial and ethnic minorities if disparities and differences aren't taken into account.
"We as a society have focused a lot of attention on improving cultural competency at the care delivery point," said David Chang, the co-author of a study on the subject and an associate professor of surgery at Massachusetts General Hospital and Harvard Medical School. "But what I am concerned about is,we haven't really paid as much attention to the scientific research process. And so, some of the problems that we are facing may be happening at the scientific research stage."
Chang said a lot of the medical research used for medical guidelines fails to include or consider the impact on minority populations. (The lack of diversity in hospital and health system C-suites isn't helping matters.)
One of the biggest examples can be found in the racial disparities among women diagnosed with breast cancer, which occurs more often in white women but often kills a greater proportion of women of color.
Chang's analysis published Wednesday in JAMA Surgery found that current screening guidelines issued by the U.S. Preventive Services Task Force that recommend women at average risk for breast cancer begin mammography screening at age 50 may delay detection of the disease in women from ethnic and racial minorities, where it is known to occur on average at a younger age compared to white women.
"The basic message of this study is simple: breast screening guidelines that were developed based on the majority population may not be applicable to minority women," Chang said. "But there is a larger message, and the larger message is that flawed science may contribute to healthcare disparity, more so than flawed care."
The average age of white women at the time of their breast cancer diagnosis was 59, according to the study, while the average age was 56 among both Asian and black women, and 55 for Hispanic women.
While 24% of white women were diagnosed with breast cancer before the age of 50, 31% of black women, 35% of Hispanic women, and 33% of Asian women were diagnosed with the disease prior to reaching the recommended age to begin screening.
The findings suggest waiting to begin breast cancer screening at age 50 may not be an effective means of detecting the disease while it is still in its early stages for a significant number of nonwhite women. The study found that in order to reach a similar rate of disease detection for nonwhite women as the current guidelines achieve for white women at age 50, the recommended screening age would need to be 47 for both black and Asian women, and 46 for Hispanic women.
"Since the scientific basis was flawed, and was done without regards to racial differences, we produced a guideline that is ultimately harmful for minority patients," Chang said. "And if people were to follow the USPSTF guidelines and do not screen patients until age 50, then minority patients would be harmed."
Nonwhite women tend to have lower incident rates of breast cancer compared to white women, according to the Centers for Disease Control and Prevention, but they also tend to have lower survival rates.
A 2016 CDC report found the number of women dying from breast cancer overall dropped from 2010 to 2014, but that black women were still 41% more likely to die from the disease compared with white women.
Women from ethnic and racial minority groups are often already in advanced stages of breast cancer by the time their condition is first detected, reducing the chance treatment will be effective.
In that vein, Modern Healthcare in 2017 looked at how task force age guidelines for screening breast cancer might be contributing to racial disparities in health outcomes and found a number of public health and civil-rights advocates who thought the recommendations that women postpone breast cancer screenings until they are age 50 should not apply to black women, because they were more likely to die from the disease. Task force Chair Dr. Kirsten Bibbins-Domingo said at that time the data was not sufficient to conclude that earlier screenings in black women would reduce delays in treatment or improve mortality disparities. "We just don't have enough information, one way or another, to tell us that."
The scientific findings that make up the basis for task force guidelines, as well as for recommendations issued by leading medical and advocacy organizations such as the American Cancer Society, and the American College of Obstetricians and Gynecologists, are mostly derived from research conducted on largely white populations.
Changes made to breast cancer guidelines in recent years have emphasized the importance of women at average risk for breast cancer to make their own decisions about what age they should begin screening after consulting with their physician.
But task force recommendations for preventive tests such as mammograms play a large factor in whether health plans sold under the Affordable Care Act offer such services free of charge as an essential health benefit. Such tests could prove to be cost-prohibitive for many low-income women if health insurers decide not to provide first-dollar coverage because they are not old enough to begin mammography screening under task force guidelines.
Chang said the study's implications go beyond breast cancer screenings and speak to the overall lack of diversity found in science. He said plans were underway to launch a new course at Harvard Medical School, titled Culturally Sensitive Science: Preventing Medicine's Contribution to Social Bias and Disparity" to begin equipping future physicians and physician scientists on detecting hidden biases in current scientific literature.
"If the science was not done in a way as to respect racial differences, then there is little you can do at the care delivery point to improve care," Chang said.
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