The year was 1967, and Dr. Harold Freeman had just arrived at Harlem Hospital for his first job. He had learned the latest techniques during his surgery residency at Howard University and Memorial Sloan-Kettering (MSK). But now in Harlem, he was devastated to discover that most of his patients had disease that was too far advanced for surgical cure.
His patients — mostly poor, African American women with breast cancer — had only a 39 percent survival rate, as compared to the usual 75 percent. Freeman recalled, “I was really raring to go out and do what I could … but then I’m facing late-stage cancer that is too late for me to be effective technically.”
Freeman realized that many of his patients were "more worried about the pain of lack of food, clothing, and shelter, and the pain of violent crime than about the painless lump in their breast." He knew that these issues — now called the social determinants of health — had to be addressed. Shocked, he asked, "Should poverty be an offense punishable by death?"
He was determined to find a new approach that ensured that women had help with these life circumstances if they were to be diagnosed earlier, treated more effectively and have a better chance of a cure.
Cancer disparities on the basis of race and socioeconomic status remain stark today. Economic, cultural and social factors too often limit minority patients’ access to the diagnostic tools and treatment modalities that are improving cancer outcomes for other segments of the population.
Overall, minorities and those living in deprived neighborhoods remain more likely to be diagnosed with late-stage cancer and to have worse survival rates. African-Americans have the highest death rates and lowest survival rates of any racial or ethnic group in the U.S. for most types of cancer; for breast cancer, mortality is still about 40 percent higher. And because black women are more likely to have the more deadly "triple negative" form of breast cancer, it is particularly imperative that barriers to early diagnosis and effective treatment be minimized.
A key social determinant of successful cancer intervention, among many, is the quality of the doctor-patient relationship. Cultural and language barriers can deter patients from undergoing timely screening, prevent them from understanding treatment options, and dissuade them from participating in clinical trials. Patients are clearly more responsive and less wary of medical professionals and staff with whom they share a common culture, race, language and life experience.
Access to logistical support can also be decisive in optimizing cancer outcomes for struggling patients. Assistance with burdens like coordinating time off from work, arranging for child care, facilitating transportation, and securing insurance approvals frees patients to adhere to complicated medical regimens.
Put another way, the best outcomes in cancer treatment are directly correlated with a patient’s ability to focus on their health and healing. Support in securing basic requirements for safe housing, nutritious foods, and transportation allows patients to do so.
Addressing these critical social determinants that impact treatment outcomes was the focus of Dr. Freeman’s innovative interventions in the Harlem community. He began by establishing free cancer screening centers that evolved into a patient navigation program for which he received the Mary Woodard Lasker Public Service Award in 2000. His community-based programs helped support the timely movement of patients through the health care continuum — from prevention and detection, to diagnosis and treatment.
By 2003, with the support of Ralph Lauren and Harold Varmus (MSK president and 1982 Lasker Laureate), Dr. Freeman’s work led him to co-found the Ralph Lauren Center for Cancer Care in Harlem.
The center now sees about 12,000 patients annually from underserved communities across New York City and offers diagnostic cancer screenings along with “patient navigators” (including a pro bono legal team) who help with transportation, child care, housing, and insurance approvals. Staff come from similar backgrounds and speak the same language(s) as the communities they serve and are thus more-readily embraced as trustworthy counselors.
Based on Freeman’s successes, Congress passed the Patient Navigator and Chronic Disease Prevention Act in 2005, allocating funding for 20 patient navigation sites across the country. Today, programs using this approach have been established at Dana-Farber Cancer Institute, the National Breast Cancer Foundation, Seattle Children’s Hospital, and others.
Freeman’s patient navigation programs and those inspired by it have been proven effective in addressing social determinants and improving cancer survival. Patients who are supported in this way are almost 2.5 times as likely to undergo lifesaving health screenings. And overall, patient navigation produces higher rates of satisfaction and empowerment, increases adherence to treatment, and is economically beneficial to providers.
Biomedical research has brought tremendous breakthroughs in the ability to diagnose and treat many cancers, and ongoing funding and support for cancer research is more important now than ever. Death rates from certain cancers are on the decline for minorities, and we’re clearly headed in the right direction. However, if we as a society are to effectively close the racial “cancer gap,” we must ensure equitable access to the discoveries that are saving lives.
Dr. Freeman provided an invaluable road map: Addressing the social determinants of health must be a central tenet of successful oncology. Our most vulnerable patients can’t afford any more delays!