Despite one of the highest health-care expenditures in the world, the United States is currently facing several crises in health care. One of the most important of these crises is inequity in health services: Our increasingly diverse nation is characterized by the fact that our minority populations do not fare as well as the majority in our health-care system.[1-3] This applies particularly to cancer management, where it is clear that prevention, diagnosis, treatment, and research are inferior for these populations, culminating in substantially impaired survival among minority groups.[2,3]
Several factors appear to contribute to these differences, including minority community suspicion of the health-care system and of physicians drawn from other cultures (reflecting past unsatisfactory experience), poverty, lack of access to care, lack of health insurance, stigmas associated with cancer and death, linguistic and literacy barriers, and poor expectations of cancer treatment outcomes. This lack of equity in the health-care system can collectively be termed "disparity of care," and the phenomenon is not unique to minority populations in the United States. Although there are many relevant definitions, the US Department of Health and Human Services defines health disparities as "differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups."
Scope of the Problem
The biomedical community has increasingly recognized the existence of these issues in recent years, and has begun to focus on defining the extent of the problem(s) and possible solutions. For example, the recent position paper from the American College of Physicians addressed the following key items:
• Health insurance coverage is inadequate for minority populations, especially the economically disadvantaged, for whom it is often economically not affordable.
• There is an important need for health-care providers to recognize and address extant cultural differences in minority populations, including the limitations imposed by language barriers, and to develop skills related to cultural competency.
• The health-care industry is not adequately addressing minority community needs, nor involving their leadership in addressing these problems.
• The medical workforce is not sufficiently diverse to deal with minority needs, and this should be addressed at the level of the health-care industry and medical training institutions, as well as at the level of community support, for appropriate training of minorities for the health-care professions.
• There is a need for public policies to improve public education on prevention strategies and to reduce targeting of minority populations by the tobacco industry, firearms manufacturers, and other providers of potentially harmful products.
• There is a deficit of research on disparities in care, including demography, causes, and outcomes, which must be urgently addressed to allow the definition of the extent and impact of these problems, as well as strategies for their resolution.
In addition to the factors enumerated above, it should be noted that evidence suggests there are real differences in the biology of cancer and of response to treatment in different populations, based on differential gene expression, as discussed below.
Disparities in Cancer Care
These problems, as they relate to cancer, are somewhat unique. Before one even considers the specific problems pertaining to minority communities, cure for many advanced cancers remains elusive for the general population. This is an area of clinical practice and research in which change is evolving rapidly, and where optimal treatment often involves clinical research or the early implementation of its products. This, in turn, may require involvement in early-phase or randomized clinical trials, exposure to incompletely defined levels of hazard, and the necessity of dealing with detailed informed consent documentation, nonroutine patterns of care, and consequently higher levels of uncertainty. Furthermore, overextended local medical practitioners in minority communities may not be up to date with the latest developments in cancer care and technology, and are thus unable or unwilling to encourage their minority patients to gain the benefits of all available advances. These factors combine to make cancer care a particularly difficult issue for minority populations.
One of the most fundamental issues in any discussion of disparities in medical care that are based on race or ethnicity is the definition of these terms. Self-identified race or ethnicity (SIRE) is widely used as an index. However, this is subject to the vagaries of family legend, and it has been suggested that this parameter is more useful as a sociocultural index rather than for serious biomedical research, and that specific genetic studies are more informative in this context. The alternative view is that, for whatever reason, there are genetic variations that are associated with SIRE, and that this index should not be dismissed. Rebbeck et al propose that, with the paucity of extant information, SIRE and genetic information should be integrated and applied to disparities research to the extent possible—a view that seems pragmatic and sensible.
On an international basis, disparities in health care are predominantly associated with poverty, advanced age, and geographic isolation,[3,4] whereas in the United States, there appears to be an added factor—race/ethnicity—even if this is based on self-identification. Although not clearly documented, it is likely that similar situations exist throughout the world, and perhaps most dramatically in Third World countries. Of course, this situation may be confounded by economic status.
Notwithstanding the fact that national cancer statistics are predominantly based on SIRE, there is clear evidence of an increased incidence of cancer in minority populations, in many cases accompanied by reduced survival.[1,2,9] The total incidence of cancer is higher in African-Americans than in Caucasians, with particular differentials in cancers of the prostate, lung, breast, and colon. Even when the stage of the disease is considered, survival figures are inferior in African-Americans and Latinos, although these data may be confounded by socioeconomic status, social habits, attitudes toward treatment, and comorbidities. It is clear that the perceivable gap in incidence and mortality statistics has not narrowed appreciably in the past 50 years.[2,9]