In the nation’s poorest counties, the cancer mortality rate is 20 percent higher than in the most affluent counties, and “the difference is much larger for cancers that are the most preventable: cervical, colorectal and lung,” said Rebecca Siegel, strategic director of Surveillance Information Services at the American Cancer Society and an author of the study.

Sujata Srinivasan Photo.

Rosa Quinones of Hartford had to give up her jobs after she was diagnosed with breast cancer in 2017.

Robert Ciemniewski, 57, a longtime smoker from Connecticut, was on the wrong side of the statistical divide when he walked into the emergency room in 2017 with breathing difficulties from what he thought was pneumonia. He did have pneumonia, but he also had advanced lung cancer.

Ciemniewski had not had a health checkup since 2013, when he quit his job as a mailman to care for his ailing mother. After he started working again delivering car parts for $12 an hour—a sharp drop from the $37 an hour he made at his postal job— he couldn’t afford health insurance. “The premium was more than $200 a month and deductibles were over $7,000,” he said. Now, unemployed again, he lives at his brother’s house in Wallingford because he could no longer afford the rent on his Hamden apartment.

Oncologists are all too familiar with the socioeconomics of cancer. “Patients are choosing less than the treatment they need, and the consequence could be that they could die,” said Dr. Kristen Zarfos, breast surgeon at Middlesex Health, in Middletown. Barriers exist even before a diagnosis is made. “A woman who works at a grocery store came to me with an abnormal mammogram but she refused to have a biopsy,” Zarfos said. The woman told Zarfos, “If I take time off for the biopsy I may lose my job. If I had the biopsy and I had cancer, I don’t have the money to treat it. So, what do I do then?”

Rosa Quinones, 47, of Hartford had to give up her jobs at a school cafeteria and an office after she was diagnosed with breast cancer in 2017.

“I could no longer push the cleaning cart and lift the vacuum and big mops at my night job,” she said in Spanish, translated by her patient navigator Ivonne Lopez, who works at the Hispanic Health Council in Hartford.

The loss of $2,400 in monthly earnings has hit Quinones hard. Her 13-year-old daughter, Kenia, had to give up playing her favorite sports, boxing and basketball. “She won when she played against the boys. And now she has to drop out of the boxing academy,” Quinones said.  “My big worry is that I must provide for her.”

Data show that income levels influence survival rates. “Mortality is higher with diminished resources,” said Dr. Anees Chagpar, assistant director of global oncology at the Yale Comprehensive Cancer Center. The biggest barrier is the cost of care, which is projected to reach $173 billion nationally in 2020, up by 39 percent from 2010.

The Hispanic Health Council’s collaboration with Hartford Hospital is among several partnerships statewide to make mammograms free and easy to access in low-income neighborhoods.

Women who lack transportation, or those who are unable to take time off for health checkups during work hours, are scanned at mobile vans fitted with mammogram units. “Losing a day’s wage is not something these women can afford,” Lopez said.

Even though insurers in Connecticut can no longer refuse to cover mammograms, nonprofits say some women are still struggling with their share of out-of-pocket costs. “It’s a covered benefit, but women might be responsible for a co-pay or a deductible,” said Damaris Velez, program coordinator at Project Access-New Haven. The free mobile vans, they say, are essential for early diagnosis.

A 2018 report from the Kaiser Family Foundation shows that Ohio and Kansas had the highest mammogram rates in the U.S. at 81 percent, while Connecticut had the lowest at 61 percent.

Sujata Srinivasan Photo.

Rosa Quinones worries about being able to support her daughter, Kenia.

Nonprofits such as the Wilton-based Circle of Care pay not only the cost of cancer treatment, but for gas and groceries as well. The organization helps families with children who have cancer when parents have had to reduce their work hours or quit their jobs entirely to care for their child.

“With 70 percent of families experiencing a financial crisis during treatment and 50 percent of the families we serve living below the poverty level, we ensure that no parent has to choose between caring for their child and providing for their family,” said Gina Marie Longo, executive director of Circle of Care.

The silver lining is that “social safety nets in Connecticut are more inclusive,” said Fred Carstensen, professor of economics at the University of Connecticut. By expanding policies such as the Earned Income Tax Credit (EITC) and paid sick leave, he said, the state would ensure that its most vulnerable residents don’t fall through the gaps. Under the Connecticut EITC program, working individuals earning a low to moderate income are eligible for a refundable state income tax credit.

These lifelines can determine the odds of survival and the quality of a cancer patient’s life. Ciemniewski receives free treatment at Smilow Cancer Hospital at Yale. Quinones is exempt from paying rent under a government housing initiative for low-income families.

The American Cancer Society study did report several encouraging developments including, racial disparities are slowly narrowing. In the U.S., the cancer death rate was 47 percent higher for blacks than for whites in 1990. That difference shrank to 19 percent in 2016.

The drop is attributed to smoking cessation campaigns initiated among black teens in the 1970s. “So, the narrowing in the racial disparity that we are seeing now is the benefit of those smoking declines,” Siegel said.

That reaction is typical for men – especially African Americans like Hammond — and it plays a role in explaining why they have the highest cancer death rate in the United States and in Connecticut.

“It’s not deemed very macho to actually admit or discuss physical frailties,” said Hammond, chair of the board at Lawrence & Memorial Hospital in New London.

The death rate for African American men and women nationally – 207.7 per 100,000 people – is more than 20 percent higher than the rate for whites, according to 2009 data, the latest from the National Cancer Institute. Connecticut’s rate is 179.3 for blacks and 167.8 for whites.

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The numbers for African American men alone are even more striking. Nationally, their death rate is 274.7, compared to 209.8 for white men. In Connecticut, the rate is 230.9 for blacks and 204.3 for whites.

Narrowing gaps like this is a top priority for health policymakers here and nationally. Early efforts have seen some progress; deaths for many cancers have been falling.

“But we’re still seeing a wide range of disparities in almost every area,” said Elizabeth Krause of the Connecticut Health Foundation, which has invested almost $15 million in health equity since 1999. “We’ve really got to focus our efforts on advancing solutions.”

The motivation is more than altruism. It’s money.

When cancer patients don’t have health coverage, don’t trust physicians or won’t confront their own vulnerability, their diagnosis is late and treatment is expensive. Those delays added $230 billion to U.S. medical costs between 2003 and 2006, according to the Joint Center for Political and Economic Studies. So the payoff for improving care – starting with prevention – could be enormous.

Policymakers, researchers and practitioners are only beginning to come to terms with the complex role that race, culture, education, income level and even biology play in determining whether a person gets cancer, how soon it’s detected and whether he or she will die.

The focus now is on strengthening public health and prevention: collaborating more effectively with community groups to break through cultural barriers, expanding health coverage, encouraging research and better data collection, and showing practitioners how their attitudes about differences affect the care their patients get.

Practitioners are looking for innovative ways to reach out to underserved people – whether it’s African American men who won’t talk about cancer, or transgendered women who don’t get routine screenings because they feel disrespected by their doctors.

“We are finally getting our act together and beginning to understand that we just can’t do things in the absence of bringing the community together at the same table. We need them. They are experts,” said Marie Spivey, vice president for health equity at the Connecticut Hospital Association and chair of the Connecticut Commission on Health Equity.

Disparities are complex. Some follow income lines that drive lifestyle choices, education and access to health care. Others are cultural. People speak different languages, have different attitudes toward health and wellness, and interact with health providers in different ways. And others are biological.

“It’s a very complicated kind of puzzle,” said Anees Chagpar, director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven Hospital. “All of these issues just kind of spin together.”

Why, for example, do African American women have a lower incidence of breast cancer than white women, but a higher death rate? The most recent Connecticut data show that the incidence is 118.9 per 100,000 for African American women and 139.7 for whites. The death rate, though, is 25.9 for African Americans and 21.4 for whites.

“African American women clearly have a history of issues with access to health care,” said Andrew Salner, director of the Helen & Harry Gray Cancer Center at Hartford Hospital and founding chair of the Connecticut Cancer Partnership. But there are also trust and cultural challenges when it comes to reaching African American women, he said. And they might be predisposed to a type of cancer that’s more aggressive.

But one thing is obvious, Chagpar said: insurance is a main driver of disparity. “At the most basic level, if we can provide health care evenly across the board, we have done a great service.”

Health officials say the Affordable Care Act will help by expanding coverage to more people, focusing greater attention on preventive health, and centering care on individual needs.

Health care is already moving in that direction. The William W. Backus Hospital in Norwich, for example, is matching low-income patients with primary care physicians for follow-up after they visit the Emergency Department or the hospital’s mobile care van. Another program with the NAACP brings breast cancer screenings to churches, temples, salons and senior centers.

“These kinds of collaborations and partnerships – getting people connected – those things really make a difference,” said James O’Dea, a vice president at Backus and administrator of the hospital’s cancer services program. “For the first time in my 25 years in health care, we are genuinely talking about a health care system, instead of a sick care system.”

Other examples from around the state include:

• Hartford Hospital is expanding its outreach to African American and West Indian men with a new wellness program this fall. A community leader is using his connections to build a more holistic awareness of what it means to be healthy.
• Yale researchers are analyzing how cancer develops in people of different ethnic backgrounds.
• A new community coalition is drafting a plan to reduce obesity in Bridgeport and Stratford, in part to prevent cancer. Bridgeport Hospital is coordinating the program with municipal and state agencies, community organizations and health care providers.

Despite the strides, progress can be frustratingly slow. For example, Hartford Hospital began an extensive breast cancer outreach program 20 years ago, including free mammograms for women without insurance. Only now are disparities in the stage of diagnosis and survival rate disappearing, Salner said.

Baker Salisbury, chair of the Health Equity Committee of the Connecticut Association of Directors of Health, said equity efforts must compete with discouraging socioeconomic trends. “The growing inequality of our society is hugely evident in Connecticut,” he said.

Hammond has seen the disparity issue as both a patient and health care leader. At L&M, he helped break ground in June for a $35 million cancer center in partnership with Boston’s Dana-Farber Institute. And as a cancer survivor, he’s talking openly about his experience. A vice president at Connecticut College, he opted for surgery after his initial hesitation and is doing well today.

He tries especially to reach out to fellow African Americans and Latinos because of the cultural challenges they face.

“They know that I get it,” he said. “We can communicate.”