VOLUME
33
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NUMBER
8
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MARCH
10
2015
JOURNAL OF CLINICAL ONCOLOGY
E
D
I
T
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R
I
A
L
States As the Laboratory for Democracy: Is Anybody Paying Attention, and Does Anybody Care? Blase N. Polite, University of Chicago, Chicago, IL See accompanying article on page 829
It is important to not lose sight of the methodologically simplistic but still powerful take-home points from the report by Jemal et al,1 which accompanies this editorial. Between 2008 and 2010, ⬎ 23,000 deaths resulting from colon cancer (50% of total) could have been prevented if all states had colon cancer death rates equal to the five states with the lowest rates for the most educated whites. An equally important point is the variation among the states; 69% of deaths could have been prevented in Mississippi, compared with only 29% in Utah. An often-repeated concept of our nation, attributed to Justice Louis Brandeis, is that the states are the laboratory for democracy. Implicit in this is that other states and the federal government should be able to learn from and adapt the successful experiments. To achieve this is complicated, and true parity is unlikely in the foreseeable future, but the lessons are out there if policymakers are willing to pay attention. Jemal et al1 obtained mortality data for colorectal cancer from 2008 through 2010 by age, sex, race/ethnicity, educational attainment, and state of residence from the National Vital Statistics System of the National Center for Health Statistics. For the population denominator, the authors used estimates derived from the Annual Social and Economic Supplement to the Current Population Survey. From these data, they calculated age-adjusted colorectal cancer death rates by race/ethnicity and educational level. Within each racial/ethnic category (non-Hispanic black, non-Hispanic white, and Hispanic), they calculated a rate ratio for each state, comparing those with ⱖ 16 years of education with those with ⱕ 12 years of education. States were ranked based on the rate ratio. To determine preventable deaths, the authors took the colorectal cancer death rates for the five states with the lowest rates among the most educated non-Hispanic whites and calculated what would happen if all other groups achieved these lower death rates. Many of the results are predictable and will come as no surprise to those who follow these data. Blacks or those with lower levels of education had higher colorectal cancer death rates than whites. Also nicely highlighted in Figure 1 of the report is that even controlling for education, blacks did worse. For example, the age-adjusted death rate for whites with ⱕ 12 years of education was 11.3 per 100,000, compared with 16.7 per 100,000 for blacks. The potential reasons for all of these findings have been explored by others but include diet, exercise, obesity, lifestyle, vitamin D status, treatment differences, and health care access.2-4 The low colorectal cancer death rates for Hispanics is quite encouraging. However, this category is complicated by limited data, heterogeneity of the country of origin, and differences in immiJournal of Clinical Oncology, Vol 33, No 8 (March 10), 2015: pp 815-816
gration status (ie, new immigrant, first generation, second generation, and so on). The strength of the report is that it highlights that these disparities may not have to be as large as they are, and in fact, there are places in the United States where the differences by race or education are much smaller. For example, among non-Hispanic blacks with the lowest educational level, the neighboring states of New Jersey and New York had death rates of 16.3 versus 12.9. Similarly, Alabama and Texas had death rates of 20.3 and 21.5, respectively, compared with North Carolina, with a death rate of 14.5. Among non-Hispanic whites, Delaware had a colorectal cancer death rate for the lowest education group of 7.2, compared with neighboring Pennsylvania, with death rate of 10.9. It may not be reasonable in the near term for Texas or New Jersey to achieve parity with Utah or Minnesota, but if Texas could achieve parity with North Carolina as a start and New Jersey could achieve parity with New York, then disparities by education and race would be reduced, and lives would be saved. The question is, how can this be achieved? A partial answer lies in focusing on states like New York and Delaware and learning from what they have done. In this study, New York had the lowest death rate among blacks with the lowest level of education; it was below the US average among other education groups. In 2003, the New York City Department of Health and Mental Hygiene launched a multipronged initiative to combat colorectal cancer, including a public education campaign, an open-access colonoscopy referral system, and patient navigation.5 By 2007, New York was able to increase the colonoscopy rate from 40% to 60%, and among blacks from 35% to 64%, thereby eliminating the screening disparity. Similarly, the state of Delaware, which had the lowest death rate among whites with the lowest level of education, embarked on a statewide effort in 2002, with the goal of eliminating colorectal cancer health disparities.6 It also launched a public education effort and used patient navigation services. In addition, it committed to reimbursing for up to 24 months the cost of cancer treatment for the uninsured so that those diagnosed with cancer could actually be treated. By 2009, it was able to eliminate the incidence rate disparities between blacks and whites and had nearly eliminated the mortality disparity. What will it take for other states to take notice and act on this? Simply put, there has to be a commitment at all levels of the state to the public health of all its citizens. Both New York City and Delaware made the elimination of health disparities in colorectal cancer a priority. That was the bold step, and everything else was a detail. I fear that © 2015 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
815
Editorial
this commitment is not shared across the country, and the study by Jemal et al1 brings that into sharp focus. Among the nine states with the highest number of preventable deaths resulting from colorectal cancer, only three (Arkansas, Kentucky, and West Virginia) have chosen to expand Medicaid under the Affordable Care Act. Among the 10 states with the lowest number of preventable deaths, all but two (Utah and Wisconsin) have expanded Medicaid.7 The point is not about Medicaid, because the data from this study predate the Medicaid expansion. The point is about the public health commitment to citizens, for which the decision to expand Medicaid is likely a good surrogate. Jemal et al1 are to be commended on this innovative use of available public health data. We can quibble about the limitations of education as an adequate standalone surrogate for socioeconomic status, the validity of self-reported data, the method used to calculate preventable deaths, and the use of rate ratios, which tend to hide states that do poorly across the board (Mississippi in Table 2 of the report is an example). The major finding of this study, however, remains unaltered: If you are black or have low educational attainment, where you live in the United States determines how likely you are to die as a result of colorectal cancer. That is an experiment that has to end in the 21st-century United States.
AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the author are available with this article at www.jco.org. REFERENCES 1. Jemal A, Siegel R, Ma J, et al: Inequalities in premature death from colorectal cancer by state. J Clin Onco 33:829-835, 2015 2. American Cancer Society: Cancer fact & figures for African Americans 2013-2014. www.cancer.org/acs/groups/content/@epidemiologysurveilance/ documents/document/acspc-036921.pdf 3. Fiscella K, Winters P, Tancredi D, et al: Racial disparity in death from colorectal cancer does vitamin D deficiency contribute? Cancer 117:1061-1069, 2011 4. Baldwin LM, Dobie SA, Billingsley K, et al: Explaining black-white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst 97:1211-1220, 2005 5. Neugut AI, Lebwohl B: Screening for colorectal cancer: The glass is half full. Am J Public Health 99:592-593, 2009 6. Grubbs SS, Polite BN, Carney J Jr, et al: Eliminating racial disparities in colorectal cancer in the real world: It took a village. J Clin Oncol 31:1928-1930, 2013 7. Henry J. Kaiser Family Foundation: State health facts: Status of state action on the Medicaid expansion decision. http://kff.org/health-reform/state-indicator/ state-activity-around-expanding-medicaid-under-the-affordable-care-act/
DOI: 10.1200/JCO.2014.59.4135; published online ahead of print at www.jco.org on January 20, 2015
■ ■ ■
816
© 2015 by American Society of Clinical Oncology
JOURNAL OF CLINICAL ONCOLOGY
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
Editorial
AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
States As the Laboratory for Democracy: Is Anybody Paying Attention, and Does Anybody Care? The following represents disclosure information provided by the author of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Blase N. Polite Honoraria: Sirtex Medical Speakers’ Bureau: Bayer/Onyx Pharmaceuticals Research Funding: Merck Other Relationship: Gerson Lehrman Group
www.jco.org
© 2015 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
33
䡠
NUMBER
8
䡠
MARCH
10
2015
JOURNAL OF CLINICAL ONCOLOGY
E
D
I
T
O
R
I
A
L
States As the Laboratory for Democracy: Is Anybody Paying Attention, and Does Anybody Care? Blase N. Polite, University of Chicago, Chicago, IL See accompanying article on page 829
It is important to not lose sight of the methodologically simplistic but still powerful take-home points from the report by Jemal et al,1 which accompanies this editorial. Between 2008 and 2010, ⬎ 23,000 deaths resulting from colon cancer (50% of total) could have been prevented if all states had colon cancer death rates equal to the five states with the lowest rates for the most educated whites. An equally important point is the variation among the states; 69% of deaths could have been prevented in Mississippi, compared with only 29% in Utah. An often-repeated concept of our nation, attributed to Justice Louis Brandeis, is that the states are the laboratory for democracy. Implicit in this is that other states and the federal government should be able to learn from and adapt the successful experiments. To achieve this is complicated, and true parity is unlikely in the foreseeable future, but the lessons are out there if policymakers are willing to pay attention. Jemal et al1 obtained mortality data for colorectal cancer from 2008 through 2010 by age, sex, race/ethnicity, educational attainment, and state of residence from the National Vital Statistics System of the National Center for Health Statistics. For the population denominator, the authors used estimates derived from the Annual Social and Economic Supplement to the Current Population Survey. From these data, they calculated age-adjusted colorectal cancer death rates by race/ethnicity and educational level. Within each racial/ethnic category (non-Hispanic black, non-Hispanic white, and Hispanic), they calculated a rate ratio for each state, comparing those with ⱖ 16 years of education with those with ⱕ 12 years of education. States were ranked based on the rate ratio. To determine preventable deaths, the authors took the colorectal cancer death rates for the five states with the lowest rates among the most educated non-Hispanic whites and calculated what would happen if all other groups achieved these lower death rates. Many of the results are predictable and will come as no surprise to those who follow these data. Blacks or those with lower levels of education had higher colorectal cancer death rates than whites. Also nicely highlighted in Figure 1 of the report is that even controlling for education, blacks did worse. For example, the age-adjusted death rate for whites with ⱕ 12 years of education was 11.3 per 100,000, compared with 16.7 per 100,000 for blacks. The potential reasons for all of these findings have been explored by others but include diet, exercise, obesity, lifestyle, vitamin D status, treatment differences, and health care access.2-4 The low colorectal cancer death rates for Hispanics is quite encouraging. However, this category is complicated by limited data, heterogeneity of the country of origin, and differences in immiJournal of Clinical Oncology, Vol 33, No 8 (March 10), 2015: pp 815-816
gration status (ie, new immigrant, first generation, second generation, and so on). The strength of the report is that it highlights that these disparities may not have to be as large as they are, and in fact, there are places in the United States where the differences by race or education are much smaller. For example, among non-Hispanic blacks with the lowest educational level, the neighboring states of New Jersey and New York had death rates of 16.3 versus 12.9. Similarly, Alabama and Texas had death rates of 20.3 and 21.5, respectively, compared with North Carolina, with a death rate of 14.5. Among non-Hispanic whites, Delaware had a colorectal cancer death rate for the lowest education group of 7.2, compared with neighboring Pennsylvania, with death rate of 10.9. It may not be reasonable in the near term for Texas or New Jersey to achieve parity with Utah or Minnesota, but if Texas could achieve parity with North Carolina as a start and New Jersey could achieve parity with New York, then disparities by education and race would be reduced, and lives would be saved. The question is, how can this be achieved? A partial answer lies in focusing on states like New York and Delaware and learning from what they have done. In this study, New York had the lowest death rate among blacks with the lowest level of education; it was below the US average among other education groups. In 2003, the New York City Department of Health and Mental Hygiene launched a multipronged initiative to combat colorectal cancer, including a public education campaign, an open-access colonoscopy referral system, and patient navigation.5 By 2007, New York was able to increase the colonoscopy rate from 40% to 60%, and among blacks from 35% to 64%, thereby eliminating the screening disparity. Similarly, the state of Delaware, which had the lowest death rate among whites with the lowest level of education, embarked on a statewide effort in 2002, with the goal of eliminating colorectal cancer health disparities.6 It also launched a public education effort and used patient navigation services. In addition, it committed to reimbursing for up to 24 months the cost of cancer treatment for the uninsured so that those diagnosed with cancer could actually be treated. By 2009, it was able to eliminate the incidence rate disparities between blacks and whites and had nearly eliminated the mortality disparity. What will it take for other states to take notice and act on this? Simply put, there has to be a commitment at all levels of the state to the public health of all its citizens. Both New York City and Delaware made the elimination of health disparities in colorectal cancer a priority. That was the bold step, and everything else was a detail. I fear that © 2015 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
815
Editorial
this commitment is not shared across the country, and the study by Jemal et al1 brings that into sharp focus. Among the nine states with the highest number of preventable deaths resulting from colorectal cancer, only three (Arkansas, Kentucky, and West Virginia) have chosen to expand Medicaid under the Affordable Care Act. Among the 10 states with the lowest number of preventable deaths, all but two (Utah and Wisconsin) have expanded Medicaid.7 The point is not about Medicaid, because the data from this study predate the Medicaid expansion. The point is about the public health commitment to citizens, for which the decision to expand Medicaid is likely a good surrogate. Jemal et al1 are to be commended on this innovative use of available public health data. We can quibble about the limitations of education as an adequate standalone surrogate for socioeconomic status, the validity of self-reported data, the method used to calculate preventable deaths, and the use of rate ratios, which tend to hide states that do poorly across the board (Mississippi in Table 2 of the report is an example). The major finding of this study, however, remains unaltered: If you are black or have low educational attainment, where you live in the United States determines how likely you are to die as a result of colorectal cancer. That is an experiment that has to end in the 21st-century United States.
AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
Disclosures provided by the author are available with this article at www.jco.org. REFERENCES 1. Jemal A, Siegel R, Ma J, et al: Inequalities in premature death from colorectal cancer by state. J Clin Onco 33:829-835, 2015 2. American Cancer Society: Cancer fact & figures for African Americans 2013-2014. www.cancer.org/acs/groups/content/@epidemiologysurveilance/ documents/document/acspc-036921.pdf 3. Fiscella K, Winters P, Tancredi D, et al: Racial disparity in death from colorectal cancer does vitamin D deficiency contribute? Cancer 117:1061-1069, 2011 4. Baldwin LM, Dobie SA, Billingsley K, et al: Explaining black-white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst 97:1211-1220, 2005 5. Neugut AI, Lebwohl B: Screening for colorectal cancer: The glass is half full. Am J Public Health 99:592-593, 2009 6. Grubbs SS, Polite BN, Carney J Jr, et al: Eliminating racial disparities in colorectal cancer in the real world: It took a village. J Clin Oncol 31:1928-1930, 2013 7. Henry J. Kaiser Family Foundation: State health facts: Status of state action on the Medicaid expansion decision. http://kff.org/health-reform/state-indicator/ state-activity-around-expanding-medicaid-under-the-affordable-care-act/
DOI: 10.1200/JCO.2014.59.4135; published online ahead of print at www.jco.org on January 20, 2015
■ ■ ■
816
© 2015 by American Society of Clinical Oncology
JOURNAL OF CLINICAL ONCOLOGY
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
Editorial
AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
States As the Laboratory for Democracy: Is Anybody Paying Attention, and Does Anybody Care? The following represents disclosure information provided by the author of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I ⫽ Immediate Family Member, Inst ⫽ My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or jco.ascopubs.org/site/ifc. Blase N. Polite Honoraria: Sirtex Medical Speakers’ Bureau: Bayer/Onyx Pharmaceuticals Research Funding: Merck Other Relationship: Gerson Lehrman Group
www.jco.org
© 2015 by American Society of Clinical Oncology
Downloaded from jco.ascopubs.org on November 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 American Society of Clinical Oncology. All rights reserved.
