Over the past decade, extensive research and promotion
efforts have led to increased awareness and utilization of cancer
prevention and screening methods. Many minority groups, however, have
not benefited equally from these advances, and continue to have
elevated cancer incidence or mortality rates compared with whites.

Overall cancer survival is low in many minority groups, with 5-year
survival rates for Native Americans, blacks, and Hispanics at 34%,
38%, and 47%, respectively vs 50% for whites.[1]

Among women, the highest incidence of colorectal and lung cancers is
found in blacks and Alaska Natives, and the highest incidence of
cervical cancer is found among Vietnamese and Hispanics. Mortality
rates for breast, colorectal, and lung cancer are highest in black
women, while black men have the highest rates of prostate,
colorectal, and lung cancers and are more likely to die of these
cancers than any other racial or ethnic group.[2]

One reason for the high cancer incidence and mortality rates among
minorities may be the disproportionately low rates of cancer
screening and prevention in these populations. Blacks, Hispanics,
other ethnic and racial minorities, the poor, and persons with low
literacy have the lowest utilization rates for cancer screening
techniques such as mammography, breast self-examination, digital
rectal exam, fecal occult blood test, flexible sigmoidoscopy, and Pap
smear.[3-14]

Black women have lower rates of mammography even when compared to
white women with similar use of primary care services.[5] Among
members of the same prepaid health care plan, Hispanic women were
more likely to report never having had a mammogram or Pap smear.[9]

Minority groups face many barriers to obtaining equal benefits from
cancer prevention and screening, including lack of health insurance,
low levels of knowledge and awareness about cancer and cancer
screening, cost, inconvenience and lack of time, problems with
transportation, lack of physician recommendation, psychological
factors such as fear and fatalism, and misunderstanding of
recommended screening frequency.[7,15-17]

While many of these factors may also act as barriers to cancer
prevention and screening within high-income, high-literacy, or white
populations, they disproportionately affect minorities, the poor, and
persons with low literacy.

Due at least in part to these barriers, many generalized cancer
screening and prevention interventions have failed to reach
minorities and medically under-served populations, especially when
they have been developed primarily for white, educated
populations.[18]

To reach specific underserved populations, strategies to increase
awareness and use of cancer screening and prevention must take
culture and ethnicity into account, utilizing population-specific,
culturally sensitive interventions.

We report on the research of Susan Scrimshaw, PhD, of the University
of Illinois at Chicago; Deborah Erwin, PhD, of the Arkansas Cancer
Research Center; and Anna Giuliano, PhD, of the Arizona Cancer Center
at the University of Arizona, who addressed these issues at the 1999
Robert H. Lurie Comprehensive Cancer Center’s Health Policy Symposium.

Dr. Susan Scrimshaw’s presentation focused on cultural factors
that play an important role in cancer survivorship, influencing
exposure to carcinogens, prevention, screening, access to screening,
quality and maintenance of treatment, and survivor care.

While current studies disagree about the roles of socioeconomic
status and ethnicity in cancer survival,[19-25] many studies have
documented differences in survival between ethnic groups that persist
after adjustment for variables such as age, tumor stage and size,
comorbid conditions, and socioeconomic status.[22-24]

Table
1 shows a number of factors related to receiving optimal cancer
screening, diagnosis, and treatment that may be influenced by
cultural factors.[26]

Current national estimates comparing cancer incidence and mortality
of various ethnic groups report statistics according to general
categories of ethnicity. Data from the Surveillance, Epidemiology,
and End Results (SEER) database are described according to the
following ethnic categories: Alaska Native, Native American, black,
Chinese, Filipino, Hawaiian, Japanese, Korean, Vietnamese, Hispanic
(total), and white (non-Hispanic).[1]

Broad Categorizations

While these statistics are useful as general guidelines to direct
attention to high-risk populations, such broad categorizations may
mask important correlations between cultural factors and cancer
survival rates. Each of these general populations has multiple
subpopulations with important and differing cultural influences. For
example, the general term “Hispanic” encompasses persons
from Mexico, Cuba, Puerto Rico, and various other South American,
Central American, and European countries, with diverse cultural
influences, genetic backgrounds, and health beliefs.[27-30]

The
black population also consists of many different subpopulations,
including those of varied African and Caribbean origins.[30]
Similarly, the Native American population is made up of diverse
tribes.

Despite existing commonalities between groups, extrapolations of data
from one particular subgroup to others that fall under the same broad
category may not be valid,[27] and pooling of data on varied
subgroups may mask trends or barriers within a specific
subpopulation. Furthermore, cultural factors may vary not only by
ancestry/background but also by current place of residence.[27]

Cultural factors that vary greatly among subpopulations may play an
important role in cancer survivorship, and may be important in
developing interventions targeted to specific subpopulations (Table
2). Further research into the impact of these cultural factors within
subpopulations will help in the development of successful targeted
interventions. See Table 3 for a list of strategies that may be
effective in increasing survivorship.

While there have been relatively few well-controlled studies
exploring the success of interventions within varied cultures or
subcultures, the results of several recent studies indicate that use
of culturally sensitive, targeted interventions may be highly
successful in increasing awareness and utilization of cancer
prevention and screening measures.

Two
of these studies, targeted to specific, high-risk subpopulations in
rural Arkansas and at the Arizona-Mexico border, have succeeded in
raising mammography and breast self-examination (BSE) rates and
increasing knowledge about cancer screening and prevention.[31, 32]