When addressing the challenges and solutions to the problems of disparate cancer care, one can compartmentalize these issues into several key areas: design and implementation of cancer prevention and control strategies; rationalization of early diagnosis; improvement in access and strategies for treatment; and measurement of useful outcomes that are important to the community.
Prevention
Many factors contribute to the reduced participation by minorities in programs of cancer prevention.[10-12] Similar factors pertain to each of the specific areas of disparity, including poverty and lack of family support, social habits (diet, lack of exercise, industrial toxin exposure), attitudes and access to health care, and intercurrent medical problems, including obesity.[10,12]
Many factors contribute to the reduced participation by minorities in programs of cancer prevention.[10-12] Similar factors pertain to each of the specific areas of disparity, including poverty and lack of family support, social habits (diet, lack of exercise, industrial toxin exposure), attitudes and access to health care, and intercurrent medical problems, including obesity.[10,12]
In addition to showing lower rates of smoking cessation, higher rates of unhealthy diets, and a greater likelihood of having dangerous workplace exposures, minority populations avail themselves less often of genetic testing to identify individuals at increased risk of cancer who may benefit from preventive strategies. For example, Armstrong et al[13] have shown that minority women tend to be more reluctant to undergo BRCA1/2 testing, even when they have a positive family history for breast or ovarian cancer. This, in turn, interferes with their ability to benefit from prophylactic mastectomy or oophorectomy. A similar situation exists for minorities at increased risk of colorectal cancer.
Diagnosis
Delay in diagnosis of cancer is also found in patients of lower socioeconomic status, particularly in minority populations. As with other disparities, this is associated with lack of health insurance, absence of a regular "home" for health care, lack of access to health care, attitudes and beliefs, and health provider factors (overload, errors of clinical practice, language barriers, social stereotyping).[2,10-13] For example, negative attitudes among minority patients to cancer screening[12] and genetic testing[13] are strong negative predictors of use of such services (eg, mammography). Similar cultural paradigms are present for most common cancers.
Treatment
One of the more disturbing issues related to health-care disparity is the concern that the differences in outcome of cancer treatment are not solely due to delays from lack of access to care and problems with prevention and diagnosis, but may also reflect inferiority of some medical services in underprivileged areas.[14] This assertion is extremely difficult to characterize, and may reflect differences in resources, staffing, patient population, and many other factors.
For example, evidence suggests that competing causes of death, associated with increases in comorbidity, may contribute significantly to impaired cancer survival statistics in some minority populations.[15] Inferior outcomes may represent a summation of more advanced presentation and differences in applied treatment.[16] Clearly, more information should be acquired prospectively to allow our community to understand these issues and to respond to them appropriately.
Outcomes
The ultimate measure of disparities in cancer care would be reflected in outcomes-specifically, national incidence and mortality figures. It is quite clear that minority populations have a higher total incidence of cancer and a higher total death rate.[9,10] It is also clear that specific tumor types are associated with higher death rates, including the commonest malignancies—cancers of the lung, prostate, colorectum, and breast produce higher death rates among African-American and Hispanic patients. One of the biggest problems is the lack of good quality information that is collected prospectively with clearly defined endpoints.
In the case of African-Americans, these figures may not necessarily reflect socioeconomic status, although this issue is controversial. It has been suggested that there is a higher death rate from cancer in African-Americans than in Caucasians of equivalent socioeconomic status. Most data suggest that the differences in outcome between non-Latino Caucasians and Latinos in the United States reflect socioeconomic status. Despite the increasing recognition of disparities in cancer care, it does not appear that the gap in survival is narrowing to any great extent.
Potential Solutions
As summarized in Table 1, each of the major issues discussed above has potential solutions, but it will require practical and fiscal commitment from the general community to ensure that major progress occurs in a timely fashion. It is clear that the biomedical community is increasing its efforts to address the problems discussed above, but most of these issues require community-based resolution, such as improved legislation with the creation of safety nets, community-linked patient navigator and access systems, improved social support and increased community health education.
Recent attention by the National Cancer Institute (NCI) to enforce the requirement of minority participation in clinical trials as well as minority representation on evaluation panels have already led to definable improvements in trial accrual and minority research focus within the NCI-supported cancer centers and collaborative research groups. Professional organizations are also taking a more active role. For example, the American Society of Hematology has initiated a mentorship program for young minority students, to give them more exposure to oncology science and clinical practice, emphasizing the potential for career pathways. The American Society of Clinical Oncology has created a Diversity Task Force with a specific advisory role for the Board of Directors; to date, this has resulted in the creation of a specific scientific symposium at each Annual Scientific Meeting, allocation of funds for research in disparities of cancer care, and initiatives for increased mentorship and training for young minority physicians and scientists.
We must take this problem seriously and muster specific resources to acquire finite solutions to the problems that exist. In northeastern Ohio, a task force has been established, incorporating representatives of the NCI-supported cancer centers, the political establishment, the African-American physicians' association, the church, and representatives of minority communities and consumer groups. This group has taken on the task of addressing disparities in cancer care in the region, including the provision of a safety net for the indigent and the development of more accessible clinical studies and management programs for these communities.
Through active involvement of the broad spectrum of our community, it may be possible to improve outcomes. It is simply not enough to target surrogates of success, such as increased accrual to clinical trials or greater numbers of cases in screening programs. We must target finite endpoints of importance. Ultimately, for programs addressing disparities in care to be truly successful, we must see a minimization of the gap between the majority and minority populations in cancer incidence and cure rates.
