Poverty and cancer.... Double jeopardy for women

Cancer and Poverty: Double Jeopardy for Women by Jean Hardisty and Ellen Leopold It would be unusual to meet a woman over thirty who has not been touched either directly or indirectly by an episode of cancer or a cancer scare that has been mishandled in some way by the medical profession. Tales are legion of misdiagnosis, misinformation, and carelessness that, at best, have inflicted unnecessary additional suffering and, at worst, have cost women their lives. Even women with comprehensive insurance coverage who are well-informed and assertive have often fared poorly in the hands of the cancer establishment. Their mistreatment, coupled with the relatively higher incidence of breast cancer among educated white women has tended to reinforce our image of cancer as the great leveler. But while it is true that socioeconomic status may not necessarily determine how well a woman faces her cancer, how well she survives it, or how well she understands it, poverty is a powerful predictor of late diagnosis, poor treatment, and high mortality. Women in this country are disproportionately poor; women of color are the most disproportionately poor. The recent mobilization of women against decades of silence and indifference to women's cancers must, therefore, actively incorporate poverty and its interaction with racism and sexism as a primary focus, since poverty so clearly influences women's experience of disease and their expectations of survival. Poverty It is widely acknowledged that health care in the United States is unevenly delivered and inadequate by the standards set by other industrialized countries. Great Britain, Canada and Australia all have national health insurance; in contrast, the United States has 36 million uninsured persons (without private insurance, Medicare, or Medicaid coverage) and another 50 million underinsured. The uninsured in the U.S. include 13 percent of the white population, 30 percent of African Americans, and a combined statistic for Asian Americans and Native Americans of 20 percent. Of all Hispanics, 35 percent are uninsured: one third of Mexican Americans, one fourth of Cuban Americans, and one fifth of the Puerto Rican community (Trevino, Moyer, Valdez & Stroup-Benham, 1991). A disproportionate number of the uninsured are women and many of these women are single heads of households. According to the 1990 Census, almost three of every five female-headed households live below the poverty line. Of course, poverty is associated with lack of health insurance, but even employed women are more likely than men to hold low-income jobs which provide no health insurance. In 1990, 85 percent of the uninsured lived in families headed by employed workers; nearly 50 percent of all uninsured workers were either self-employed or working in firms with fewer than 25 employees (Employee Benefit Research Institute, 1992; Doress-Worters article in this volume). Lack of insurance becomes a health threat in itself when a woman receives a diagnosis of cancer. Uninsured women are more likely to die of breast cancer and less likely to receive appropriate care at the appropriate time, making lack of insurance an important risk factor. A study carried out at the Harvard Medical School and the Brigham and Women's Hospital (Ayanian, Kohler, Abe & Epstein, 1993) demonstrates a clear link between insurance coverage and health outcomes. Using data from the New Jersey State Cancer Registry on women diagnosed with breast cancer between 1985 and 1987, the study brought to light a sharp contrast in patterns of breast cancer between women who were privately insured and those who were either uninsured or covered by Medicaid. The latter group had breast cancers which were significantly more advanced at the time of diagnosis than were those of the group of privately insured women. Women covered by Medicaid were more than twice as likely as privately insured women to be diagnosed with late-stage disease. Equally, survival rates among those lacking private health insurance were much lower than for those who did have private coverage. (1) Significantly, the contrasts that emerged from this study--between those with some form of private health insurance and those without - lumped together women covered by Medicaid with women lacking any form of coverage, public or private. In fact, there was no appreciable difference in the rates of survival between these two groups of women, for any stage of the disease. In other words, the provision of a safety net in the form of guaranteed payment could not, on its own, overcome the more pervasive and persistent consequences of economic disadvantage on the course of the disease. Of these disadvantages, limited education is certainly one of the most significant. It tends to restrict access to information about cancer prevention and warning signs and it often makes interpretation of that information more difficult. These drawbacks often reinforce each other and contribute to delays in diagnosis which, in turn, are directly linked to higher cancer mortality rates (Baquet & Ringen, 1986). There is considerable evidence from research into other diseases (Winkleby, Jatulis, Frank & Fortmann, 1992) to support this correlation. (2) Educational attainment is, in fact, often used as a surrogate for socioeconomic status in epidemiologic studies of health outcomes. (3) One attempt to estimate preventable breast cancer death rates (Farley & Flannery, 1989) concludes that the rate for women with lowest educational attainment is 2.5 times higher than the comparable rate for women with the highest. Another estimates the five-year survival rate among white women who did not finish high school as 64 percent compared with 81 percent among those who graduated from college (Gaiter, 1991). The difficulties thrown up by inadequate education are, of course, compounded by an increase in the use of written patient education materials, such as brochures and handouts. Weiss, Hart & Pust (1991) review a number of studies that conclude that these materials, including consent forms, are written at a reading difficulty level too high for the average American. This problem is compounded for those women who do not speak English as a first language. For poor immigrant women, language barriers that inhibit access to medical care are aggravated by cultural barriers that may subject women with admitted breast cancer to shame or loss of status, by fatalism based on past experiences, by the threat of deportation that may arise during any contact with service providers, by lack of doctors willing to practice in the inner city areas where many poor immigrant women live, and by inexperience in negotiating their way through the complex tangle of public health services. Further, nearly all women living in poverty are increasingly forced to rely on emergency rooms, overtaxed clinics, and underfunded and inadequately equipped public hospitals. This is one result of the withdrawal of Federal funds from urban clinics, which once provided the basic health care that more affluent people get from their family doctors. (New York Times, 5/4/1992; Boston Globe 5/23/1992) In New York City, for instance, a 1990 report released by Elizabeth Holtzman, then New York City Comptroller, revealed that eight of the eleven municipal hospitals offered no programs for the detection of breast cancer, and that 65 percent of breast cancers diagnosed in city hospitals were not picked up until the cancers had reached an advanced stage. This contrasts with a national figure of advanced stage diagnosis of 20 to 25 percent. Further, of those who were diagnosed with possible breast cancer, 30 percent were "lost to follow up." As Elizabeth Holtzman put it, this "means that thousands of poor women will suffer and die from a very treatable disease." (Office of the Comptroller, City of New York, 1990) According to the National Cancer Institute, the five-year breast cancer survival rate for white women earning less that $15,000 is 63 percent compared with 78 percent for white women earning more than $30,000. The corresponding figures for African American women (64 vs. 68 percent) show less of a spread between low and higher income women, perhaps reflecting the overriding influence of racism across socioeconomic status. (Gaiter, 1991) A review of the research on women, socioeconomic status, and cancer confirms our worst suspicions about a health care system in which the social "safety net" has been decimated: low income correlates with late diagnosis and a higher rate of death from cancer. The risk posed by poverty may be even greater for rural poor women, who suffer from the same severe cutbacks in Federal funding of health care services as those in urban areas. The great distances to be traveled to obtain health care in rural areas, the inability of rural hospitals to reap the economies of scale that would allow them to maintain an infrastructure of expensive advanced equipment, and the drastic shortage of either specialists or general practitioners outside urban areas, all make the health care situation of low-income rural women even more precarious than that of poor urban women. (Boston Globe, 3/22/1992) Racism Although the links between poverty and illness are well- established, most of the historical and current studies of these links do not include specific reference to cancers, concentrating instead on conditions such as infant mortality, tuberculosis and heart disease. The disturbing contrast between death rates for rich and poor in these areas are regularly highlighted in the media. Cancer statistics, on the other hand, have traditionally been handled differently. Here, the attempts to break down the global figures have commonly been based more on race than on income, and in particular, on the markedly higher rates of cancer among Blacks when compared with whites. Clayton & Bird (1993), analyzing this comparison, have called the incidence of cancer among Blacks a "contemporary African American cancer crisis" noting that this higher rate among Blacks was documented during the 1970's by medical researchers at Howard University and is even more severe today (p.84). The practice of comparing cancer rates by race rather than by socioeconomic status has often produced the impression that African Americans are genetically predisposed to cancer. According to Dr. Harold Freeman (1989), a past president of the American Cancer Society, this view is untenable; there is "no known genetic basis to explain the major racial differences in cancer incidence and outcome...Within one race, economic status is the major determinant of cancer outcome. Therefore the target for correction is poverty, regardless of race." In fact, cancer statistics for middle class Blacks show a pattern similar to those for middle class whites. And once the raw statistics are adjusted for age and income differences between the two populations, whites show higher incidence rates for some cancers, particularly lung cancer. (Baquet, Horm, Gibbs & Greenwald, 1991) Because Blacks are disproportionately poor, and suffer from housing discrimination, job and wage discrimination, and other effects of racism, Black culture is often used as a proxy for poverty. All those aspects of life that contribute to reduced survival -- lack of education, lack of access to health care, unemployment, substandard living conditions, poor nutrition, an inadequate social support network, etc. - are most accurately described as symptoms of poverty rather than as aspects of Black culture. To confound poverty with Black culture encourages the public to lose sight of the role of racism in creating poverty. With a few exceptions, race itself is not a known cause of cancer. The exclusive comparison of rates of cancer between Blacks and whites can obscure the threat that cancer poses to other minorities who are also disproportionately poor. Native American women, for example, have a higher rate of cervical cancer and a lower survival rate from breast cancer than African Americans or white Americans. Hawaiian- and Japanese-Americans both have higher rates of stomach cancer than whites or African Americans (Freeman, 1989). Hispanic women have higher than average rates of stomach and gallbladder cancer and twice the rate of cancer of the cervix as white, non-Hispanic women. (National Cancer Institute, 1988). Most statistics presented to the general public fail to make any adjustments to accommodate demographic or socioeconomic differences. The results - which show Blacks and other people of color dying more often of all cancers - inevitably carry with them an unstated but nonetheless powerful imputation of blame. This could create the impression that people of color are genetically or behaviorally more prone to cancer. Patterns of behavior that are known to be harmful--such as smoking, diet, and occupational exposure to toxins - are identified as the cause of higher rates of cancer. These practices are viewed as forms of willful self- destruction that characterize the lifestyles of low income people, instead of being viewed as a response to lack of employment options, stress, chronic economic recession, or, in the case of smoking, as the result of relentless campaigns by tobacco advertisers targeting poor communities. Explanations for the restricted educational and job opportunities that are both cause and effect of poverty are rarely sought. Instead, the focus is placed on the individual. The idea of individual responsibility for health through the pursuit of a healthful lifestyle and lowered stress is without doubt a boon to the health of the nation as a whole. However, the positive effects of changes in individual behavior (with the exception of cigarette smoking) on overall health and longevity are often overstated, and the ability to comply with current wisdom on a healthy lifestyle depends on a wide range of external factors, both environmental and social. Responsibility for health can tend, if we are not careful, to be privatized without regard for the unequal ability of people to "follow the rules." Living near toxic dumps, working in chemical plants, coping with job insecurity, low income, poor diet, and inadequate medical insurance - all these factors can easily overwhelm the most valiant efforts of the individual to take charge of her health. It has been known for some time that toxic waste, radioactive materials, and the production of pollutants are related to cancer. Since the 1970's, people of color have become more politically aware that their communities are disproportionately the targets of toxic dumping and the location of the most hazardous industrial operations. Both are harmful to their health and both are indirectly attributable to the consequences of poverty and racism - low political visibility, lack of clout with environmental organizations, and low property values. As early as 1979, studies linking environmental hazards to the race of those exposed to them revealed that all the city-owned landfills built in Houston since the 1920's were located in Black neighborhoods, even though Houston was once an overwhelmingly white city. (New York Times, 1/11/93) A 1987 study found that this pattern was a national one; three out of the five largest commercial hazardous waste landfills in the United States are located in mostly Black or Hispanic communities, accounting for 40 percent of the nation's estimated commercial landfills (Lee, 1987; Alston, 1990, p. 9). This sort of injustice has inspired grassroots organizing within communities of color, notably a national conference in October 1991, the First National People of Color Environmental Leadership Summit. The raised awareness of environmental racism has also led to a dramatic increase in the number of lawsuits and protests against local, state, and federal agencies, often arguing that Blacks and Hispanics are more likely to be found in areas with high concentrations of cancer (cancer clusters) caused by toxic pollutants. The crucial contribution of this new movement is that it integrates an analysis of environmental racism with broader issues of social and racial justice. Thus, environmental degradation is not seen as one "issue area," but is redefined as part of the larger pattern of exploitation and victimization of poor urban and rural communities, especially communities of color and indigenous communities. The concerns of the environmental racism movement overlap with those of the burgeoning women's cancer movement. Within the women's cancer movement, it is the grassroots groups that are most interested in forging a link with similar grassroots groups in communities fighting environmental pollution. Similarly, within the environmental movement, only Greenpeace of the "Big 10" environmental groups has reached out to grassroots groups working on pollution in their communities and worksites. In fact, Greenpeace has played a crucial role in building bridges between the two grassroots movements by co-sponsoring, with the Women's Environmental Development Organization (WEDO), a meeting in Austin, Texas early in 1994. The meeting brought together environmental groups, environmental justice groups, women's groups and women's cancer groups to launch a campaign called "Women, Cancer and the Environment: Action for Prevention." Greenpeace has also published a report (Thornton, 1993) which marshals evidence that organochlorines - chlorine-based synthetic chemicals which are accumulating in the air, water and food chain - may be an important factor in the escalating rate of breast cancer. Pressure from both movements may be required to spur long-overdue research on the relationship among environmental toxins, race, poverty, and cancer. We need to know much more, for instance, about the effect of chemical pesticides on men and women farmworkers, the causes of cancer clustering, and the relationship among workplace hazards, the race and gender of employees, and cancer incidence (Brady, 1991; Arditti & Schreiber, 1993; Hofrichter, 1993). Sexism One of the first issues explored by the contemporary women's movement was sexism within the medical establishment. The patronizing attitude of doctors, the overuse of hysterectomy and mastectomy, the medication of women deemed "nervous" were all practices exposed through feminist activism. Feminists resurrected the practice of midwifery and changed the norms of childbirth. More recently, feminists, many of them lesbians, have taken up the issue of increasing rates of cancer among women, particularly focusing on the marked increase in the rate of breast cancer. According to The American Cancer Society, one in twenty women developed breast cancer in 1940. The incidence of breast cancer has grown by a rate of 1.4% every year since then; now one in every nine women is at risk of getting the disease during her lifetime.(4) In the late 1980's, grassroots groups began to emerge across the country arguing that indifference to these alarming changes is part of the broader sexist neglect of women within the medical establishment (Foley, 1990; Gross, 1991) Writing in Sojourner in 1989, Susan Shapiro, a Boston area writer and feminist activist, analyzed her own and other women's experience of cancer as a feminist issue (Shapiro, 1989) This was the catalyst for the founding of the Boston/Cambridge-based Women's Community Cancer Project. Earlier that same year in Outlook magazine, Jackie Winnow described the founding of the Women's Cancer Resource Center in Berkeley: "I took some of what I learned doing AIDS work and a lot of what I learned from feminist organizing and women's liberation, and with other women, created the Women's Cancer Resource Center" (Winnow, 1989). Both Susan Shapiro and Jackie Winnow have died of breast cancer, but their efforts and similar efforts have now spawned at least a dozen grassroots groups across the country that organize, protest, and research the neglect of women's cancers and angrily demand that more research money be allocated, especially for breast cancer. In 1990, just as this women's cancer movement was emerging, a Government Accounting Office (GAO) report documented continued sexist neglect within medical research at the National Institutes of Health, despite the existence of a 1986 policy intended to correct it. Women, the GAO reported, have been systematically excluded from controlled experiments, long-term studies, and clinical studies of new drugs (Newsweek, 12/17/90; Boston Globe, 6/19/90.) Also in 1990, the Physicians Insurers Association of America chided doctors for not taking women seriously when they report self-discovered breast lumps. The cost of dismissive and/or patronizing medical attention has been high in terms of claims paid in malpractice suits; in 69 percent of cases where malpractice insurance claims were paid in response to charges of unnecessarily delayed diagnosis, the female patient discovered the breast lump herself, but had not been taken seriously by her physician (Physicians Insurers Association of America, 1990). In large part due to the activism of feminist health groups, Congress in 1993 allocated over $400 million to breast cancer. The 1993 allocation to the National Cancer Institute of $197 million represented an increase of $60 million over the previous year's award. An additional $210 million was awarded to the Department of Defense (DOD), raising total new appropriations to $270 million. By early 1994, the DOD funding had already attracted more than 7,000 proposals from prospective researchers across the country. Though this is an extremely impressive beginning for the young and vigorous women's cancer movement, it does not address the practical impacts of cancer on the lives of women, and, more especially, on the lives of poor women. For women who are the caretakers of children, the elderly and the ill, as well as the principle homemakers, a diagnosis of cancer, whatever the woman's income level, imposes enormous practical as well as emotional burdens. Poor women, however, are less likely to find relief from these burdens as they pursue their treatment options. When there are no family members available to help with caretaking, there is rarely money to hire a substitute. The significant commitment of time that must be made to pursue a course of radiation therapy may make such an option prohibitive for a woman without savings or family support who may also be a single parent or the only breadwinner. The debilitating effects of chemotherapy may equally discourage women from submitting to recommended treatment if it takes too much time away from work or from family obligations. For many women in these circumstances, the most immediate threat may be the loss of their ability to care for their children; their own loss of life may appear as a more shadowy terror further down the road. In other words, while the lives of over-burdened women are governed by short term considerations, a proper understanding of cancer and the likely outcomes of available treatments demands a longer perspective. Poverty necessarily imposes a more limited frame of reference and so might be said to dictate the course of treatment even when the consequences of such decisions are understood and appreciated. Women and Health Care Marketplace Racism, sexism, and poverty all conspire to make women more vulnerable as they face the danger of a cancer diagnosis and make their way within the health care system. To counteract these vulnerabilities, women are now being encouraged to apply market principles to their relationship with their doctors. They are urged to become well-informed "consumers" of medical care, to "shop around" for the best treatment - comparing services, surgeons and fees. In this model, women move from being victims (of both the disease and the medical establishment) to the more empowered role of in-charge consumer. In keeping with the axioms of the self- help movement, women are advised to seek information (the market ideal of "perfect information," if possible) about medical facilities and personnel, as well as treatment options. In this model, women become their own case managers, interviewing potential providers and keeping an eye on the bottom line of each fee-for-service medical experience. This well-intended analogy between consuming goods and consuming medical care is, however, at cruel variance with the actual situation of most women. There are many reasons why women cannot possibly obtain perfect information or make the rational choices about value for money suggested by the advice to "shop around." In the case of seeking information, it is nearly always unrealistic to expect a patient to discover all the relevant facts about the treatment options she faces. The newly diagnosed cancer patient is unfamiliar with the medical concepts and jargon she encounters and usually hasn't the resources to make sense of the often conflicting information she uncovers. Here lack of education becomes an even greater burden, effectively eliminating the possibility that women with low education can fully participate in this process. Further, advising women to consider the cost of their treatment and to compare and contrast the cost of various options open to them is sadly congruent with the situation faced by uninsured women in our current health care system. Knowing that their health care will be paid for out of their own savings or future earnings, they are already at the mercy of the marketplace. Increasingly, the marketplace is dictating even the medical decisions of the insured; third party payers, such as insurance companies or HMO's, are applying cost-effectiveness criteria in order to maintain profitability. Surely the ideal is that women with a cancer diagnosis make decisions based on medical rather than economic criteria. To make those decisions most effectively, they must, of course, participate fully in the decision-making process. But this task should be approached with a realistic view of what can be achieved. Women should not be given responsibility for managing their medical care when they do not have the resources to carry out that assignment. That responsibility must of necessity rest with the system that delivers medical care. Health care is increasingly being seen as a basic human right. Whatever the form of health care delivery system - government-owned, single payer, mixed public and private, or free-market, for-profit health care - it must be monitored constantly for inadequacies in its system of delivery. Equitable distribution is a critical social goal which must remain visibly in the forefront of health care policy. To be vigilant in pursuing that goal is the responsibility of all health care advocates, activists and clients, whether well or ill. Addressing the Inequity Frequent stories in print, TV, and radio media tell of families bankrupted by the crushing burden of medical debt. Families in which the parent or parents are unemployed are particularly vulnerable, but 80 percent of children who have no health insurance have at least one parent who is working (Wall Street Journal, 6/5/92). After years of neglect and footdragging by Republican administrations, popular support for major reform of the health care system has forced the issue onto the legislative agenda. It would be comforting to think that, should a system of universal health care be instituted, the problem of unequal access to quality health care according to socioeconomic status would be solved. However, what is needed is an affirmative action health care program for low income people and people of color, especially women. This is necessary because, even when universal health care is provided, obstacles remain to taking full advantage of its services. In Great Britain, which has operated a universal health care service since 1948, cancer incidence rates of those in the lowest socioeconomic group remain consistently and significantly higher than those in the highest income group (Leon, 1988). Four different cancers among women - invasive and in-situ cervical cancers, stomach and lung cancer - showed the greatest difference in rates between rich and poor, with cervical cancer showing the greatest difference. Mortality rates follow the same pattern (Doyal & Epstein, 1983, p. 13). The long-term persistence of these disparities suggests that, even when there is less economic discrimination in treatment after a diagnosis of cancer, late diagnosis of otherwise curable cancers may remain the overriding determinant of long term survival rates. This in turn is a reminder that the repercussions of poverty (through restricted education and employment opportunities) affect the way women approach health care. Even if free and in principle universally available, timely and appropriate health care may nevertheless continue to elude women who are poor. Less likely to be registered with a primary care physician, they are less likely to learn of the benefits of mammography or to be encouraged/reminded to undergo regular screening for cancer of any kind. There is evidence to suggest (Zapka, Stoddard, Costanza & Greene, 1989: Hayward, Bernard, Freeman & Corey, 1991) that having a primary care physician is strongly associated with the use of mammography. But even where some link to primary care has been established, obstacles remain. Many women are simply boxed in, without access to a car or a babysitter or a sympathetic employer. Further, fatalism may complicate a woman's relationship with the medical establishment. Hampered by limited knowledge of the system, or faithful to religious tenets to follow God's will, a woman may see cancer itself as a death sentence, leading to overwhelming fear of the diagnosis and of any possible treatment.(5) Those who do manage to get to the doctor's office often face other hurdles. Health care may be delivered in a way that stereotypes and alienates patients. The physician, who serves as the gateway to treatment, may not be sufficiently qualified to distinguish between patients who should be referred for diagnostic tests and those who should not. He or she may also be unaware of the most recent changes in clinical practice. But even the most conscientious family doctor cannot overcome the shortages of staff and/or equipment at the hospitals to which patients often must be referred; these may simply lack the resources to employ an oncologist or to purchase radiation equipment. Their own "poverty" sets clear limits on the type of treatment they can offer. This web of obstacles facing poor women with cancer does not, of course, minimize the absolute necessity of universal health insurance. However, universal health insurance will not on its own eliminate the consequences of poverty, racism and sexism on either incidence or mortality rates of cancer for women. Cancer education and outreach efforts to those who do not now have access to high quality health care must be systematic, well- funded, culturally informed, and relevant to low-income people to be effective. Many of those who study and advocate for reform of the United States medical system understand this need (Ginzberg & Ostow, 1991; Menken, 1991; Dalen & Santiago, 1991). Even mainstream organizations such as the American Cancer Society see a need for culturally-specific outreach and education in poor communities about the risk factors and warning signs of cancer. More farsighted advocates see additional needs: for people to organize to oppose criminal profiteering by pharmaceutical corporations, governmental indifference to the health needs of all the people, and the poisoning of the environment which leads to increased cancer rates. Universal health insurance without accompanying legislation to end environmental degradation and environmental racism will not bring an end to the rapidly increasing rates of cancer we are now experiencing. Similarly, universal health insurance will not end corruption within the medical system unless accountability to the public in the areas of profit-making and public health care policy are established. Finally, greater access to expensive drugs and medical procedures must be accompanied by a reassertion of the role of primary care and preventive care. The devastation to women's health caused by poverty does not mean that women with money, education, access, and private insurance are never misdiagnosed, or treated carelessly and stupidly, or even that they do not occasionally have cancer at higher rates. It does not mean we should not care about men, who sometimes have cancer at higher rates than women. It does not mean that we advocate decreasing the federal budget allocation to AIDS research and treatment. This must be stressed since the conservative media often stir up discord between groups of activist women and sometimes play off AIDS advocates against cancer advocates. It is not a matter of pitting one against the other, but of recognizing and supporting multiple layers of demands that must be promoted simultaneously. Conclusion Statistical research speaks a painful truth about health care for women with cancer in the United States. To a shocking extent, a woman's health reflects her ability to pay for it. This is a morally unacceptable condition. Adequate health care is a fundamental right. As a movement for women's health, we must refuse to accept inadequate health care for poor women. We must demand not only health care reform that equalizes access to medical care, but also insist on affirmative outreach to those women who have been paying with their health - even their lives - for their race, their socioeconomic status, and their gender. Jean Hardisty and Ellen Leopold are members of the Women's Community Cancer Project, 46 Pleasant St., Cambridge, MA. 02139. They would like to thank the members of WCCP for their assistance Earlier versions of this article were published in Sojourner: The Women's Forum, vol. 18, no. 4, December, 1992, and in Midge Stocker, ed. Confronting Cancer/Constructing Change (Chicago: Third Side Press), 1993, pp. 213-231. Hardisty & Leopold Footnotes 1 The contrast in survival rates may be distorted to some extent by what is called "lead-time bias." The earlier detection of more lethal forms of breast cancer (picked up in routine screening mammograms paid for by insurance) gives the impression that the patient has survived for a longer period of time even though treatment has been completely ineffective. 2) In a pertinent 1992 study of the effect of socioeconomic status on cardiovascular risk factors, level of education is identified as the most important parameter predicting high risk factors (Winkleby et al., 1992). 3) The media, however, prefer to use income and race as surrogates for poverty. This creates distortions, as discussed in the section on racism below. 4) The reasons for the rise in incidence are complex and not well understood. For a start, before the 1980's, less than 15% of American women had regular screening mammograms. Second, because the disease can grow very slowly, a recent rise of breast cancer among women in their sixties may reflect behavioral or environmental changes that first occurred 30 or 40 years ago. Third, although the rise in incidence of very small tumors has been an expected consequence of increased screening, there has been no decrease in the incidence of later-stage, larger tumors or disease. For a fuller discussion of the changing incidence rates, see Harris et. al., 1992. 5) This point was made in the Findings of Regional Hearings conducted by the American Cancer Society in May and June, 1989 in seven states (American Cancer Society, 1989).