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.
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.
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. Among members of the same prepaid health care plan, Hispanic women were more likely to report never having had a mammogram or Pap smear.
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.
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 Centers Health Policy Symposium.
Dr. Susan Scrimshaws 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.
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).
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. 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, 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.
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]