Challenging Dogma - Fall 2009

Monday, December 21, 2009

More African Americans Dying from Cancer: A Critique and Modification of the Approach to Cancer Prevention in the African American Community

—Brandi Vaughan


Cancer is one of the top ten leading causes of death in the United States and has been for a number of years (4). Many technological advances have been made to assist with early diagnosis for cancer by screening patients in order to detect cancer, prevent further stage progression of the disease and to prolong life. These advances include the mammogram which is used to detect breast cancer, the colonoscopy and fecal occult blood test to detect colorectal cancer, and the PSA test to detect prostate cancer. Even with the uncertainty of the accuracy of the PSA test because of high false-positive rates, all of these screening tests have been successful in reducing the prevalence of cancer cases in this country (4,5). Interestingly enough, these cancers, as well as lung cancer, are the top leading causes of cancer deaths in both African American men and women (4).

The incidence of all sites of cancer in African Americans had substantially increased during the 1990s and significantly decreased between the years of 2000 and 2006 (5,6). This has significantly narrowed the gap between the incidence of cancer in Whites and African Americans. However, the major concern regarding African Americans is based on the mortality and survival rates of this ethnic group compared to Whites. According to the American Cancer Society, the survival rate of African Americans compared to whites in the four cancer types at all stages respectively are: 77% vs. 90% for female breast, 55% vs. 65% for colon and rectum, 12% vs. 16% for lung and bronchus, and 95% vs. 100% for prostate cancers(5,6). The mortality rate of African American men and women with cancer is 313.0 and 186.7 per 100,000 respectively, which is higher compared to those of their white counterparts which is 230.7 and 159.2 per 100,000(5,6).

Some studies indicate that the reason for the high mortality rate in African Americans is due to the lack of taking preventive measures by getting the appropriate screening tests on a regular basis when prompted by their physicians(3,7). In this case, the disease is detected later when the cancer is no longer local and has progressed in stage. This has a direct effect on how responsive a patient will be to treatment, and how likely they are to survive. As a result, interventions were designed to reduce the incidence of cancer in the African American community. These interventions had two main focuses, exposure to information and education.

By using the Health Belief Model in conjunction with other models, they exposed African Americans to information about the mammogram, PSA and colonoscopy tests in hopes of increasing the number of those that understood the importance of these tests.(1,2) For example, The Targeting Cancer in Blacks (TCiB) intervention, conducted as early as 1994 to 1996 in Georgia and Tennessee, intervened by means of Historically Black College and University medical schools (Morehouse School of Medicine and Meharry Medical College) , churches and other institutions. These community institutions were used to spread the message of the importance of regular screenings and living a healthy lifestyle (1). Another intervention that was done from 2001 to 2003 was the randomized prostate cancer intervention conducted by Georgetown University. It was done in conjunction with the National Cancer Institute on the effects of print and video exposure to information on the PSA test to African Americans (2). Both interventions had the same approach which would allow African Americans to take the information and independently decide whether they should get screened regularly in the future (2).

Based on the data provided by the Surveillance Epidemiology End Results (SEER) and the American Cancer Society, the cancer mortality rate and survival rate of the African American population are a cause for concern. These rates not only magnify the problem, but they also reflect the effectiveness of the overall approach to the problem. This paper will critique the approach to cancer prevention in the African American population. It will present the existing problems in the interventions of the past and what changes can be made to future interventions of the approach to eliminate racial disparity of cancer mortality and survival with regards to the African American community.

A Critique on the Approach to Cancer Prevention in African Americans

There are three main setbacks to the previous interventions designed to promote cancer prevention in the African American population that will be discussed. The first one is that these interventions have relied on the Health Belief Model to assure that people will get screened. Secondly, the previous interventions do not significantly take social, cultural and environmental factors with regards to the African American community into account. Lastly, these interventions have not intervened past education nor do they allow the community institutions to get involved past education on the screening tests.

Previous Interventions heavily rely on the Health Belief Model.

The previous interventions that have been designed to reduce the incidence of cancer in African Americans are flawed because they have consciously used the Health Belief Model which implies that human behavior is rational. Furthermore, it assumes that if information is provided to people, they will automatically weigh the perceived benefits and barriers which will prompt them to act accordingly to prevent disease. The TCiB intervention purposely used this model with the assumption that it would help to promote unity and a community effort by promoting self efficacy and developing “cues of action” (1). This was attempted by displaying messages that would cause unity such as, “Get a pap smear once a year” and “Don’t wait too late, check the prostate”(1). This would then prompt intention which would lead to everyone acting as the intervention expected.

When weighing the perceived benefits, The Health Belief Model also takes the perceived susceptibility and perceived severity into account. This indicates that a person will consider how likely they are to get a disease (susceptibility) and how bad it would be if they got the disease (severity) which leads a person to act. Evidently, this model assumes that individuals are able to make a knowledgeable decision to act in order to prevent themselves from getting a disease. This is suggested in the prostate cancer screening intervention. In this intervention African Americans were randomly assigned into three groups (2). Two of the groups were given information about prostate cancer and the PSA test in two forms, one in print and the other as a video. The third group was on a waiting list to set a control (2) The measure of the exposure types was tested based on how many people reported knowing of the information (2).

The complete disregard to test if the exposure had an effect on the number of people that would get screened regularly leads to the assumption that the decision to get screened is dependent on the individual. This interaction is flawed because it only measures the exposure, not the effectiveness of the exposure on the subjects (1,2). Providing people with information suggests that they will weigh the benefits, followed by intention and then acting on preventing disease by getting screened (1,2). However, this will not necessarily cue them to act as expected because it depends on how they perceive their susceptibility to getting prostate cancer and how severe it would be for them. In addition, there are many factors that could have an effect on a person’s action and prevent them from getting screened such as fear of the screening test or potential diagnosis.

Previous interventions have not paid substantial attention to the social, cultural and environmental factors that exclusively affect the African American community.

The main aspect that is observed when studying different cultural groups is the difference between them and their white counterparts. Clearly there is a difference between these groups in terms of their environment, as well as social and cultural standards which are taken into consideration when intervening with other ethnic groups. Earlier interventions that target cancer prevention in African Americans have completely overlooked these differences which have affected their overall approach and have proven why they are flawed.

When intervening with African Americans, previous interventions recognized that there is a necessity for cultural sensitivity (1) and that community involvement has a positive effect on administering information to this ethnic group (1). However, these interventions fail to discuss in detail what other differences exist between African Americans and Whites and how to overcome those differences to intervene effectively in the future. They accounted for educational differences by producing reading material from less than 6th grade to 8th grade levels (1) assuming that some African Americans aren’t on the same educational level as their white counterparts. They also understood the importance of getting community institutions involved and presented visual and culturally accurate print and video material in attempt to gain acceptance of the intervention’s message (2).

The incidence of cancer in African Americans was at its highest in 1993 at 567.6 per 100,000 people compared to 496.6 per 100,000 in Whites (6). During this period, an insufficient amount of attention was paid to social, cultural and environmental factors when promoting screening tests to African Americans. It is only recently, particularly in the past couple of months that researchers are beginning to acknowledge these other factors that have affected the incidence and mortality rate of African Americans with cancer (3,7).

Recent studies have shown that there are social, cultural and environmental factors that have affected the mortality rate of African Americans. One study reveals that there are cultural factors that affect the prevalence of colorectal screening among the African American population such as medical mistrust, perception of group susceptibility and strong traditional cultural orientation (7). Another study that focuses on African American women with breast cancer suggests that there are external social factors that exist such as lack of access to high quality care and the opportunity to participate in clinical trials (3). Other factors include inadequate mammography screening and difference in tumor characteristics in African American women due to late detection of the disease (3). Presently, it is evident that there are strides being taken to tackle these environmental and external social factors, however, the mortality and survival rates of African Americans with cancer proves that there is still progress to be made.

Previous interventions were discontinued after exposure to information and education.

Since it is noted that recent studies have discussed that social, environmental and cultural factors should be considered when studying the mortality rates of African Americans with cancer, it can be predicted that future interventions will be extensive. However, previous interventions were not extensive in nature. These interventions were implemented with the preconceived notion that education and exposure to information were sufficient to increase incidence of appropriate screening in the African American population.

As previously stated, the interventions of the past focused on educating African Americans about the importance of regular screening. They incorporated community institutions to educate them on the importance of getting screened, and they introduced print materials such as flyers, posters and brochures (1), as well as video material (2). Educational lectures and workshops took place at different community events, public health clinics, small businesses and churches (1). The measurement point of exposure to the information by means of educational workshops and different media materials marked the end of these interventions.

Studies suggest that they were unable to determine the effects of education and the community outreach on the mortality rate of African Americans with cancer because their interventions only involved a cross-sectional survey (1,2,3,7) This type of study examines the relationship between the disease of interest and other existing variables that have affected a population at a specific point in time (10). In this case, previous interventions conducted by cross-sectional survey provided substantial information on different exposures which measured knowledge of the screening tests. However, it prevents follow up with subjects over a course of time (10). This did not permit the interventions to study how their efforts affected the African American population because they did not track the incidence over a given time period. Therefore, the approach to this problem is flawed and more appropriate measures need to be taken to assure that the efforts of the intervention are measurable.

“Yes We Can”: the introduction of social sciences to cancer prevention in African Americans

Given the fact that the majority of previous interventions conducted to prevent cancer in African Americans are based on individual health models, the proposed approach will be unique due to implementation of social sciences models. This approach will be explained and will show how the introduction of social science models can positively affect the cancer mortality and survival rates in the African American population.

The Proposed Approach

This approach will maintain the promotion of regular screening and will continue to inform African American men and women of the benefits of getting mammograms, PSA tests and colonoscopies on a regular basis. It is important that screening continues and increases in the African American population in order to decrease the mortality rate (3,7). In addition to the screening promotion, this approach will continue to use community institutions as channels to emit the message (1). Lastly, this approach will implement the advertising theory as well as the psychological reactance theory to motivate people to live a healthy lifestyle by getting screened.

The proposed approach will implement a community effort to increase the incidence of screening tests with the help of community institutions across the nation. Churches, black-owned businesses, hospitals, clinics and Historically Black Colleges and Universities (HBCUs) will be the institutions that will collaborate in order to host weekly community events. These events will provide educational workshops on the four cancers that are the main causes of cancer death in the African American population: breast, prostate, colorectal and lung cancers. They can also provide free screening tests, informational and Q&A sessions with African American physicians who would discuss the issues surrounding the cancer mortality rate among African Americans.

This approach will also implement the psychological reactance theory by including prominent figures in the African American community who can help in the efforts to eliminate the racial disparity. This theory suggests that messages are more accepted when they are given from someone of high similarity (11). The community events present the opportunity for African American politicians, physicians, nutritionists, nurses, community organizers, and Greek social organizations to get involved in the efforts. This would also mark the inclusion of African American celebrities, Colin Powell, Richard Roundtree, Ruby Dee and Marsha Hunt who survived cancer by means of participating in the community events and the advertising theory. In this case, the advertisement will not be selling health. Instead it will sell the core values that are associated with a happy and healthy life such as family, unity and freedom.

Support for the Proposed Approach

The Proposed Approach assumes that others’ opinions can affect human behavior.

The proposed approach does not rely on the Health Belief Model which assumes that human behavior is rational and dependent on the individual. This approach utilizes the psychological reactance theory to demonstrate how a group of people can be motivated to act in response to a message that causes a threat to one’s freedom (11). It administers the message by means of the communicator. The presence of the communicator will determine how the group will act based on similarities between the communicators and the members of the group (11). This assumes that human behavior is irrational and is dependent on other factors.

In this approach, the communicators are the prominent figures of the African American community which include cancer survivors. The male survivors include the former Secretary of the State, Colin Powell, who was treated for prostate cancer in 2003, and the actor Richard Roundtree who was diagnosed with breast cancer in 1993 (8,9). The female survivors include the actress Ruby Dee who was diagnosed with breast cancer in 1974 and former singer Marsha Hunt who was diagnosed with breast cancer in 2004 (8,9) Under the psychological reactance theory, these communicators would be able to present a strong threatening message such as, “you will die unless you get screened”. This threatens the groups’ freedom and self control in which people are either prompted to behave in compliance or to not conform (11). However, since the communicators have physical and cultural similarities with the group, they are more likely to comply to the expected action and get screened regularly.

The Proposed Approach uses the Advertising Theory to reinforce core values

American core values are very important to the people of this country because they are one of the factors that separate the US from the rest of the world. Many of these core values such as love, family, unity, hope, and freedom are universal across the nation. The advertising theory is regularly used to persuade people to like a product or it used to change their attitude about a product in order to make them purchase it.(12) The proposed approach would use this model to persuade African Americans to get screening on a regular basis by showing images that represent these values. This is done through means of printed advertisements and television commercials.

The phrase “Yes We Can” was borrowed from the Barack Obama campaign for the proposed approach for this purpose. The inauguration of the first African American president in this country and the pride that was felt among the African American community was immense. President Obama has been in office since January, and there are still people, including African Americans that continue to proudly wear the “Yes We Can” apparel. If African Americans were shown a commercial that showed the accomplishments that African Americans made in this country that ranged from freedom to President Obama’s inauguration, making a connection to screening methods would persuade African Americans to get screening because they are connected to that experience and screening would be connected to a sense of pride in making a positive difference in the community.

The Proposed Approach accounts for environmental, social and cultural factors that have affected cancer mortality in the African American population.

Aside from the theories and models that are used, the main aspect that separates this approach from the previous approach to reduce cancer mortality in the African American population is the consideration for environmental, social and cultural factors. This approach has accounted for these factors by implementing community efforts by introducing education, access to services and strong clinical and community leaders in the African American community.

This approach takes a few steps ahead of the previous interventions which discontinued after education. In addition, by involving African American celebrities who survived the disease and are currently in remission, it is evident to the community that the disease does not discriminate and it is possible to obtain. However, with getting the proper screening and following up with treatment if diagnosed with the disease, it is possible to live a healthy life and to live longer than anticipated.


The mortality rate in African Americans with cancer is likely to continue to rise if the lack of attention to the different external factors that affect access and quality of care in this population are not taken into account. While I initially found interventions that only focused only on the education factor, it appears that there are upcoming interventions that will begin to take these factors into account. This provides a very promising future for the African American community, and hopefully future interventions will reduce and eventually eliminate the racial disparity that exists.


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2. Kathryn L. Taylor, Jackson L. Davis III, Ralph O. Turner, Lenora Johnson, Marc

D. Schwartz, Jon F. Kerner, and Chikarlo Leak

Educating African American Men about the Prostate Cancer Screening Dilemma: A Randomized Intervention

Cancer Epidemiol Biomarkers Prev November 2006 15:2179-2188; doi:10.1158/1055-9965.EPI-05-0417

3. Gabram, Sheryl G. A., Mary Jo B. Lund, Jessica Gardner, Nadjo Hatchett, Harvey L. Bumpers, Joel Okoli, Monica Rizzo, Barbara J. Johnson, Gina B. Kirkpatrick, and Otis W. Brawley. "Effects of an outreach and internal navigation program on breast cancer diagnosis in an urban cancer center with a large African-American population." Cancer 113.3 (2008): 602-07. Wiely InterScience. Cancer. Web.

4. ACS :: Statistics for 2009." American Cancer Society :: Information and Resources for Cancer: Breast, Colon, Prostate, Lung and Other Forms. Web. 10 Dec. 2009. .

5. "Browse the SEER Cancer Statistics Review 1975-2006." SEER Web Site. Web. 10 Dec. 2009. .

6. "SEER Stat Fact Sheets - Cancer of All Sites." SEER Web Site. Web. 10 Dec. 2009. .

7. Purnell, Jason Q., Mira L. Katz, Barbara L. Andersen, Oxana Palesh, Colmar Figueroa-Moseley, Pascal Jean-Pierre, and Nancy Bennett. "Social and cultural factors are related to perceived colorectal cancer screening benefits and intentions in African Americans." Journal of Behavioral Medicine (2009). SpringerLink. Web.

8. "Touched by Breast Cancer - AOL Black Voices." Black Entertainment and Sports, African American News, Culture, and Community - AOL Black Voices. Web. 10 Dec. 2009. .

9. "Celebrities With Cancer." About Cancer. Web. 10 Dec. 2009. .

10. Aschengrau, Ann, and George R. Essentials of Epidemiology in Public Health. New York: Jones & Bartlett, 2003. Print.

11. Brehm, Jack W. "PSYCHOLOGICAL REACTANCE: THEORY AND APPLICATIONS." Advances in Consumer Research 16 (1989): 72-75. Association for Consumer Research. Web

12. "Advertising theory: How to get people to think, feel and take action." Creative advertising ideas, techniques, example ads and workshops. Web. 10 Dec. 2009. .

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