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Cancer and Disparities in Health Status, Healthcare Delivery, and Survival Presented November 30, 2010 ECU Center for Health Disparities Research Lecture.

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Presentation on theme: "Cancer and Disparities in Health Status, Healthcare Delivery, and Survival Presented November 30, 2010 ECU Center for Health Disparities Research Lecture."— Presentation transcript:

1 Cancer and Disparities in Health Status, Healthcare Delivery, and Survival
Presented November 30, 2010 ECU Center for Health Disparities Research Lecture Series C. Suzanne Lea, PhD MPH Associate Professor, Epidemiology Department of Public Health, Brody School of Medicine, ECU

2 Objectives Define health disparities
Describe factors related to health disparities Provide evidence of disparities in: Health status Health care delivery Cancer survival Describe efforts to reduce health disparities

3 Conceptualizing Health Disparities
Three broad categories of disparities will be introduced: Health Status Disparities Health Care Disparities Survival Disparities Causes of each are likely related, though different phenomena. Thus, the solutions may differ. Which comes first?

4 What is a Health Disparity?
Conceptual issues: Inequities – avoidable, unfair, unjust Differences in condition, rank Lack of equality as of opportunity, treatment, or status Inequalities – differences that do not necessarily arise from inequities, measurable gaps between groups. Krieger N. Defining and Investigating social disparities in cancer: critical issues. Cancer Causes and Control 2005;16:5-14.

5 Definition of Health Disparity
What is a "health disparity"? In 2000, United States Public Law , also known as the "Minority Health and Health Disparities Research and Education Act," which authorized the National Center for Minority Health and Health Disparities, provided a legal definition of health disparities: “A population is a health disparity population if there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality or survival rates in the population as compared to the health status of the general population.” Minority Health and Health Disparities Research and Education Act United States Public Law (2000), p. 2498 What are "cancer health disparities"? The NCI defines "cancer health disparities" as "differences in the incidence, prevalence, mortality, and burden of cancer and related adverse health conditions that exist among specific population groups in the United States.“ Does this sound like a health status disparity or health care disparity?

6 Who are the populations?
Population Groups Other Special Populations American Indian/Alaska Native (AI/AN) Asian American Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander Socio economic status Geography (urban or rural) Gender Age Disability status Risk status related to sex and gender Does that include everyone but white middle class and upper class heterosexual men?

7 Demographic Shift We cannot discuss health disparities today in the context of population groups without looking toward the future…..

8

9 Population trends in the United States by age and race/origin, 1980 to 2030
Population trends in the United States by age and race/origin, 1980 to Data for 1980 and 1990 are derived from the United States Census for these years.1,3 Data from 2000 onward are derived from the 2000 Census and projections for population growth thereafter.2 Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol Jun 10;27(17): Epub 2009 Apr 29. PubMed PMID: Smith B D et al. JCO 2009;27: ©2009 by American Society of Clinical Oncology

10 Projected cases of all invasive cancers in the United States by race and origin.
A 99% increase in cancer in minorities is expected compared to 31% in non-Hispanic whites: 64% blacks, 132% API, 142% Hispanic by Projected cases of all invasive cancers in the United States by race and origin. (*) Nonmelanoma skin cancers were excluded from projections. The Hispanic origin group contains individuals of any race. The race groups white, black, Asian/Pacific Islander (PI), American Indian (AI)/Alaska Native (AN), and multiracial contain only non-Hispanic individuals. Smith B D et al. JCO 2009;27: ©2009 by American Society of Clinical Oncology

11 As a result of population growth, all racial/ethnic groups have increased in numbers over the last two decades. However, as you can see in the chart above, proportionately the Hispanic population has seen the largest increase. The Hispanic/Latino population has risen steadily in North Carolina - from just 1.2% of the resident population in 1990 to 7.7% of the NC population in The growth in the Latino population represents both an increase in migration to the state, as well as an increase in births. In 1990, 1.7% of all NC resident births were to Hispanic/Latina mothers. By 2009, 16% of all births were to Hispanics.

12

13 What are the Causes of Disparities in
Health Status, Health Care, and Outcomes? Biologic What are some factors? Write on board.In 2003, the Institute of Medicine (IOM) published a comprehensive review of racial and ethnic disparities in health care.7 The IOM report and other authoritative reviews8 describe a model in which health care disparities arise from a complex interplay of economic, social, and cultural factors (Figure 1). Socioeconomic factors influence cancer risk factors such as tobacco use, poor nutrition, physical inactivity, and obesity. Income, education, and health insurance coverage influence access to appropriate early detection, treatment, and palliative care. Poor and minority communities are selectively targeted by the marketing strategies of tobacco companies, may have limited access to fresh foods and healthy nutrition, and are provided with fewer opportunities for safe recreational physical activity. Social inequities, such as the legacy of racial discrimination in the United States, can still influence the interactions between patients and physicians, as noted in the IOM report.7 Cultural factors also play a role in health behaviors, attitudes toward illness, and belief in modern medicine versus alternative forms of healing.3,4,8 From Ward, E. et al. CA Cancer J Clin 2004;54:78-93. Copyright ©2004 American Cancer Society

14 Model for Analysis of Population Health and Health Disparities
Warnecke RB, Oh A, Breen N, Gehlert S, Paskett E, Tucker KL, Lurie N, Rebbeck T, Goodwin J, Flack J, Srinivasan S, Kerner J, Heurtin-Roberts S, Abeles R, Tyson FL, Patmios G, Hiatt RA. Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health Sep;98(9): Epub 2008 Jul 16. PubMed PMID: ; PubMed Central PMCID: PMC Warnecke RB et al. AJPH 2008

15 Interplay between Economic, Social, Cultural factors, and Biologic Factors
SES Income Education – low literacy Employment Insurance Behavioral Tobacco use Poor nutrition Physical inactivity-obesity Drug use Cultural Nutrition customs Attitude about illness Hx racial discrimination Belief in alternative med Mistrust Religious beliefs

16 Interplay between Economic, Social, Cultural Factors, and Biologic Factors
Social Environment segregated neighborhoods geographic location of neighborhoods lack the basic resources for a healthy life assess to healthy food safe/clean housing living-wage job decent schools supportive social networks, negative social support access to health care Does economic, social, and cultural factors address the institutional context of the health care system?

17 Living in Rural America
Around 60 million (~1 in 5) Americans live rural areas. Compared with their urban counterparts, rural Americans are more likely to: Be older, to describe their health as poor or fair, and to lack private health insurance. Have higher smoking and obesity rates. Not receive preventive services (i.e., cancer screening) Face longer distances to reach hospital or other health care services, especially medical specialty care (i.e., cancer treatment). More poverty? AHRQ 2002

18 Health Indicators Social and economic well being
% Living in Poverty / household Income % Completing High School Insurance coverage Risk Behavior and Health Promotion Smoking Alcohol Obesity Physical Inactivity

19 Poverty, Limited Education, and No Insurance
US Health Indicators: Poverty, Limited Education, and No Insurance presents summary measures of socioeconomic status, educational attainment, and access to medical care for the five largest racial and ethnic groups in the United States. In general, when compared with non-Hispanic Whites, racial and ethnic minorities had higher rates of poverty, lower educational status, and less access to health care coverage or a source of primary care (Table 1). Within the 11 SEER areas, 49.5% of African Americans, 47.5% of American Indians/Alaskan Natives, and 40.7% of Hispanics/Latinos lived in census tracts with a poverty rate of over 20%, compared with 7.0% of non-Hispanic Whites and 16.0% of Asian Americans/Pacific Islanders.17 From Ward, E. et al. CA Cancer J Clin 2004;54:78-93

20 US Health Insurance Coverage Among Individuals
Under Age 65 Years, 2006 (in Millions) Most Americans under age 65 years receive their health insurance coverage through their own employer or the employer of a family member (Figure 1). Nearly all companies with more than 200 employees offer health insurance coverage.9 In 2007, the average costs to employers and employees, respectively, were $3,785 and $694 per year for individual coverage and $8,824 and $3,281 per year for family coverage.10 The employer-based system of health insurance has several advantages, most notably the creation of work-based risk pools in which healthy low-risk participants subsidize the health costs of sick and high-risk participants.11 However, there are some serious disadvantages to this system. Not all companies offer health benefits, not all workers are eligible for coverage, and not all employees choose to participate or can afford their share of the health premium.12 From Ward, E. et al. CA Cancer J Clin 2008;58:9-31. Copyright ©2008 American Cancer Society

21 Cumulative Changes in Health Insurance Premiums, Overall Inflation, and
Workers' Earnings, 2000 to 2007 Moreover, the cost of health insurance premiums has been rising much faster than the rate of overall inflation and workers' earnings (Figure 2).10 An important disadvantage of employer-sponsored health insurance is that people who develop a serious illness, such as cancer, may not be able to keep their employment and may lose access to their insurance. From Ward, E. et al. CA Cancer J Clin 2008;58:9-31. Copyright ©2008 American Cancer Society

22 Social and Economic Well-Being Indicators, North Carolina, 2008 Race
% Poverty <18 % of Single Parent Families Median Family Income % High School Dropout 2008 Ratio to Whites All 19.9 25.9 56,588 5 White 11.3 1 17.8 64,879 4.3 African American/Black 33.4 3 52.8 37,897 0.6 6 1.4 American Indian 28.3 2.5 36.6 2.1 40,849 7 1.6 Asian/Pacific Islander 12.8 1.1 12.7 0.7 69,277 2.2 0.5 Hispanic/Latino 34.3 32.9 1.8 33,814 6.9 All indicators were largely improved from measures in 2004 except % white single parent families and white high school drop out increased since was the peak of the economic rise. Source: Racial and Ethnic Health Disparities in North Carolina. Report Card Office of Minority Health and Health Disparities and State Center for Health Statistics. NC-DHHS.

23 Adult Health Indicators, North Carolina, 2008
Race % age with no health insurance % not see a doctor in last 12 months due to cost 2008 Ratio to Whites All 21.3 16.5 White 14.2 1 13.5 African American/Black 23.1 1.6 20.6 1.5 American Indian 28.3 2 25.3 1.9 Asian/Pacific Islander 16.7 1.2 15.7 Hispanic/Latino 65 4.6 29.1 2.2 Source: Racial and Ethnic Health Disparities in North Carolina. Report Card Office of Minority Health and Health Disparities and State Center for Health Statistics. NC-DHHS.

24 (Based on Weighted BRFSS Survey Data)
Percentages of North Carolina Adults with Selected Risk Factors/Conditions, by Race/Ethnicity (Based on Weighted BRFSS Survey Data) African American White Current smoking1 22.4 22.2 Did not get recommended level of physical activity2 63.6 53.6 No leisure-time physical activity1 29.4 21.3 Consumption of less than 5 servings of fruits and vegetables per day2 82.2 76.2 Binge Drinking1 9.5 12.8 Overweight/Obese1 74.9 62.3 –2008 /2007 Source: State Center for Health Statistics and Office of Minority Health and Health Disparities. North Carolina Minority Health Facts: African Americans. June Retrieved from:

25 Implications for Cancer Control?
Falling incomes Higher levels of poverty Higher levels of insufficient insurance Declining levels of education Aging population Population diversity

26 Health Indicators Incidence rates Mortality rates

27 Age-Adjusted Death Rates
Age-Adjusted Death Rates* for Major Causes of Death by Race/Ethnicity, North Carolina Residents, 2004–2008 Cause of Death African American White Chronic Conditions Heart disease 236 192.6 Cancer 224 185.2 Stroke 73.5 49.2 Diabetes 51 19.5 Chronic lower respiratory diseases 30.4 51.1 Kidney disease 36.5 14.8 Chronic liver disease 8.4 9.3 Infectious Diseases Pneumonia/influenza 19.2 20.2 Septicemia (blood poisoning) 22.3 12.3 HIV disease 16.5 1.2 Injury and Violence Motor vehicle injuries 18 18.1 Other unintentional injuries 21.8 30.9 Homicide 16.4 3.6 Suicide 5 14.4 * Rates are age-adjusted to the 2000 U.S. standard population and are expressed as deaths per 100,000 population using underlying cause of death. Minority Health Facts ♦ African Americans — July Office of Minority Health and Health Disparities and State Center for Health Statistics Source: State Center for Health Statistics and Office of Minority Health and Health Disparities. North Carolina Minority Health Facts: June Retrieved from:

28 Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for Cancer: U.S., 2005
Updated 6/2/08 by SB. Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for All Causes: U.S., 2002 Compelling evidence that race and ethnicity correlate with persistent, and often increasing, health disparities among U.S. populations demands national attention. Indeed, despite notable progress in the overall health of the Nation, there are continuing disparities in the burden of illness and death experienced by African Americans, Hispanics/Latinos, American Indians and Alaska Natives (AI/ANs), and Native Hawaiian and Other Pacific Islanders (NHOPIs), compared to the U.S. population as a whole.  Current information about the biologic and genetic characteristics of minority populations does not explain the health disparities experienced by these groups compared with the white, non-Hispanic population in the United States. These disparities are believed to be the result of the complex interaction among genetic variations, environmental factors, and specific health behaviors. (1) The death rate for African Americans is 2.3 times as high as for AAPIs, and 1.3 times as high as for white Americans. African Americans have comparatively high death rates for many of the leading causes of death, such as cardiovascular disease (CVD), Diabetes, and AIDS. (JW) Multiple factors contribute to racial/ethnic health disparities, including socioeconomic factors (e.g., education, employment, and income), lifestyle behaviors (e.g., physical activity and alcohol intake), social environment (e.g., educational and economic opportunities, racial/ethnic discrimination, and neighborhood and work conditions), and access to preventive health-care services (e.g., cancer screening and vaccination). Recent immigrants also can be at increased risk for chronic disease and injury, particularly those who lack fluency in English and familiarity with the U.S. health-care system or who have different cultural attitudes about the use of traditional versus conventional medicine. Approximately 6% of persons who identified themselves as Black or African American in the 2000 census were foreign-born. (8) For blacks in the United States, health disparities can mean earlier deaths, decreased quality of life, loss of economic opportunities, and perceptions of injustice. For society, these disparities translate into less than optimal productivity, higher health-care costs, and social inequity. By 2050, an estimated 61 million black persons will reside in the United States, amounting to approximately 15% of the total U.S. population. (8) Slide source (9)

29 Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for Breast Cancer: U.S., 2005 Updated 6/2/08 by SB.

30 Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for Prostate Cancer: U.S., 2005 Updated 6/2/08 by SB.

31 Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for Colon, Rectum & Anus Cancer: U.S., 2005 Updated 6/2/08 by SB.

32 Age-Adjusted Death Rates per 100,000 Persons by Race and Hispanic Origin for Trachea, Bronchus & Lung Cancer: U.S., 2005 Updated 6/2/08 by SB.

33 Figure 1. Cancer mortality rates for African American and Whites for all cancers combined, lung cancer, other smoking-related cancers, colorectal, breast, and prostate cancers, National Center for Health Statistics, 1975 to 2004 Trends in B W cancer mortality. Reducing Mortality shows the effect of early diagnosis, prevention benefits, treatment, survival. DeLancey, J. O. L. et al. Cancer Epidemiol Biomarkers Prev 2008;17: Copyright ©2008 American Association for Cancer Research

34 Source: Racial and Ethnic Health Disparities in North Carolina
Source: Racial and Ethnic Health Disparities in North Carolina. Report Card Office of Minority Health and Health Disparities and State Center for Health Statistics. NC-DHHS.

35 Source: Racial and Ethnic Health Disparities in North Carolina
Source: Racial and Ethnic Health Disparities in North Carolina. Report Card Office of Minority Health and Health Disparities and State Center for Health Statistics. NC-DHHS.

36 Cancer Mortality In NC, all cause cancer in eastern NC has been declining since the about Projections are that the B/W and M/F differences will begin to converge. However, ENC will not meet the 2010 goal of 160 cancer deaths / 100,000 ECU CHSRD CJ Mansfield 03/18/09

37 Part II: Health Disparities in Healthcare
Underlying determinants such as individual preferences, provider factors, and the organization and delivery of care at the practice or health system level.7provider factors—including knowledge, attitudes, bias, and even financial incentives—also influence health or health care disparities. Providers -subconscious processes such as bias or stereotyping, especially within busy health care settings,24 which in turn can adversely affect patient engagement in care. Although the clinical encounter is a key focal point for understanding disparities, fundamental aspects of the health care system (e.g., organization, financing, delivery) also are likely to play a role in explaining disparities. FIGURE 2—Understanding the origins of health and health care disparities from a health services research perspective: key potential determinants of health disparities within the health care system, including individual, provider, and health care system factors. Kilbourne et al. AJPH 2006;96:2113–2121

38 Model of Health Care Disparities The model views health care disparities as resulting from characteristics of the health care system, the society’s legal and regulatory climate, discrimination, bias, stereotyping and uncertainty. Not all dissimilarities in care are necessarily a disparity. Access to Care Clinical Appropriateness and Need Non-Minority Dissimilarity Patient Preferences Difference Operation of healthcare systems and legal and regulatory Climate Minority Disparity Discrimination: Biases, Stereotyping, and Uncertainty Quality of Care Source: Gomes, C. and McGuire T.G Identifying the sources of racial and ethnic disparities in health care use. Unpublished manuscript cited in: IOM, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley, B., A. Stith and A. Nelson, eds. Washington DC: National Academy Press

39 Disparities in Healthcare Treatment
Patient preferences Provider factors Health care organization and system

40 Patient Preferences or Barriers
Once in care, minorities express impediments: Religious or cultural beliefs regarding decisions not to have care or treatment Lack of social support or care provider Lack of regular source of medical care in community Mitchell et al. JOURNAL OF WOMEN’S HEALTH 2002;11: Religious Beliefs and Breast Cancer Screening. Farmer D, Reddick B, D'Agostino R, Jackson SA. Psychosocial correlates of mammography screening in older African American women. Oncol Nurs Forum Jan;34(1): PubMed PMID:

41 Provider Factors Stereotype patients who hold beliefs that contrast with standard medical practice. Unconscious bias and stereotypes. Limited questioning, less dialogue, and fewer explanations for non-white patients. Perceptions of physicians as uninterested and less engaging for non-white patients. Perceptions that physicians do not understand background and values of minority patient. Social Cognition Research. Johnson RL. Racial and Ethnic Differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004;19: ; Burgess DJ. Why do providers contribute to disparities and what can be done about it? J Gen Int Med 2004;19:

42 Provider Factors More verbally dominant with African American (43%) than with White patients (24%) Less patient centered with African American patients (1.02 [95% CI = 0.89, 1.14] than with White (1.31 [95% CI = 1.02, 1.60] ). Physicians’ affective tone as less positive during medical visits with African American Patients (11.90%) than with White patients (12.68%). No difference when adjusting for physician demographics or duration of visit. Johnson RL et al. Patient Race/Ethnicity and Quality of Patient-Physician Communication During Medical Visits. Am J Public Health 2004;94: White, 21 AfricanAmerican, 9 Asian or Indian American, and 1 other race/ethnicity physicians (n=61) representing managed care, fee-for-service, and community health centers, 767 patients. Tape recorded visits, coded by 2 white women.

43 Provider Factor: Physician Recommendation
Of the 558 women (82%) who had ever had a mammogram, the main reason that they had it done was that their doctor had recommended it (67%). Physician’s recommendation was the most important determinant of treatment selection in prostate cancer. Farmer et al. Psychosocial Correlates of Mammography Screening in Older African American Women. ONCOLOGY NURSING FORUM 2007; 34:117; Hoffman et al. Racial Differences in Initial Treatment for Clinically Localized Prostate CancerJ GEN INTERN MED 2003; 18:845–853.

44 Provider Factors: Communication
Overall, the evidence suggests that the way that a clinician relates to and communicates with patients can have a profound impact on them and their family, including on their psychosocial adjustment, decision making, treatment compliance, and satisfaction with care. It confirms much of the clinical wisdom that has permeated the field of cancer care in recent decades regarding greater honesty in the communication of medical information, balanced with empathy and the provision of hope. – G. Rodin Rodin G, Mackay JA, Zimmermann C, Mayer C, Howell D, Katz M, Sussman J, Brouwers M. Clinician-patient communication: a systematic review. Support Care Cancer Jun;17(6): Epub 2009 Mar 4. Review. PubMed PMID:

45 Health Care Treatment Access to high quality cancer care varies by socio-economic status and race. Stage at diagnosis is the most consistent predictor of 5-year survival. Non-white race presents with later stage. Choice of treatment modalities differ within stage at diagnosis by race: chemotherapy, surgery, radiation, watch-ful waiting. Disparities in care are associated with higher mortality among minorities. (e.g., Bach et al., 1999; Peterson et al., 1997; Bennett et al., 1995)

46 Treatment Modality Studies
Data-based studies using SEER with linkage to Medicaid roles may lack detailed information on: physician recommendations Co-morbid conditions of patients Values of patient leading to decision-making Include only CoC accredited hospitals Consistent results across a range of clinical settings including: public and private hospitals teaching and non-teaching hospitals

47 Health Care Treatment A study of the SEER data found that:
African-American and Hispanic men had longer time intervals between diagnosis and receipt of medical monitoring visit. Nearly 6% of African-American men and 5% of Hispanic men compared to 1% of white men did not have any medical monitoring visits or procedures during the 60-month follow up period. Shavers VL, Brown ML, Klabunde CN, Potosky AL, Davis WW, Moul JW, Fahey A. “Race/ethnicity and the intensity of medical monitoring under ‘watchful waiting’ for prostate cancer. Medical Care, March 2004, 42 (3): Shavers VL, Brown ML, Klabunde CN, Potosky AL, Davis WW, Moul JW, Fahey A. “Race/ethnicity and the intensity of medical monitoring under ‘watchful waiting’ for prostate cancer. Medical Care, March 2004, 42 (3):

48 Differences in Initial Treatment in Localized Prostate Cancer
Adjusted Percentage Distributions for Patients to Receive Treatment by Tumor Aggressiveness Conservative Radiation Prostatectomy p-value Gleason < 8 and PSA < 20 ng/mL NHW 15.5 27.8 56.7 0.21 AA 20 20.6 59.5 Gleason ≥ 8 or PSA ≥ 20 ng/mL 16.3 31.7 52 0.003 38.9 25.9 35.2 Standard is aggressive treatment. Conservative management with aggressive disease, comorbid conditions did no explain differences. Physician concerned about poor outcome with surgery, pt not understanding options? Or not want surgery? Hoffman RM, Harlan LC, Klabunde CN, Gilliland FD, Stephenson RA, Hunt WC, Potosky AL. Racial differences in initial treatment for clinically localized prostate cancer. Results from the prostate cancer outcomes study. J Gen Intern Med Oct;18(10): PubMed PMID: ; PubMed Central PMCID: PMC

49 Percent receiving the procedure
Health Care Disparity In a study of race differences in the use of three cancer screening procedures among Medicare patients (age 65 for older), African-American patients are less likely than white patients to receive each procedure. Percent receiving the procedure Source: Cooper GS, Koroukian SM “Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries” Cancer Jan 15;100(2): * Statistically significant difference between African Americans and whites all categories.

50 Race/ ethnicity 60-Day Delay 90-Day Delay RR (95% CI) White 1.0
Women undergoing treatment experience delay Multivariate Regression Analysis of Factors Related to Day Chemotherapy Delay, Patients With Breast Cancer, NCDB, Race/ ethnicity 60-Day Delay 90-Day Delay RR (95% CI) White 1.0 Hispanic 1.31 ( ) 1.41 ( ) Black 1.36 ( ) 1.56 ( ) Asian 1.13 ( ) 1.14 ( ) Recommend Chemo after surgery within 49 to 56 days (7 to 8 weeks). AA had a 56% increased risk of delay compared to white patients. Delay may be due to lack of access to care, geographic distance to treatment, and transportation, navagating health system and language are factors. Fedewa SA et al. Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study , J Clin Oncol 28: No stage difference with 90 day but 20% delay for Hispanics and black at 60 days. Adjusted for insurance, age, region, stage, HR status, year dx, comorbidity index, high school grad, hospital type

51 Disparities Exist Among Insured Women
Commerical Health Plan in Southeast US. AA were younger 49 v 53. Figure 1. Breast cancer stage is illustrated at diagnosis by race. White women (55.2%) were more likely than African-American women (38.4%) to be diagnosed with stage 0 or stage I disease (asterisks), and approximately twice as many African-American women (6.1%) compared with white women (3.6%) were diagnosed with stage IV disease (P < .05). Short LJ, Fisher MD, Wahl PM, Kelly MB, Lawless GD, White S, Rodriguez NA, Willey VJ, Brawley OW. Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention. Cancer Jan 1;116(1): PubMed PMID: Figure 1. White women (55.2%) were more likely than African- American women (38.4%) to be diagnosed with stage 0 or stage I disease (asterisks), and approximately twice as many African-American women (6.1%) compared with white women (3.6%) were diagnosed with stage IV disease (P < .05). Short et al. Cancer 2010;116:193–202.

52 Unexplained Disparity in Health Plan
Black women with insurance were diagnosed with later stage at younger age and had higher mortality. Greater comorbid conditions – hypertension and renal disease, BMI More negative hormone receptor status Documentation gaps in medical charts Patient education needed Short et al. Cancer 2010;116:193–202

53 Health Care Center Patients Experience Fewer SES/Race Disparities
Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care for US Health Center Patients Compared With Non–Health Center Patients, J Ambulatory Care Manage 2009; 32:342–350, Shi et al. Results of the study show that health center patients experience fewer racial/ethnic and socioeconomic disparities in access to care and quality of care, compared with non–health center patients nationally

54 subtypes of breast cancer
Disparities in Biology Survival frequencies (weighted %) and hazard ratios (all-cause mortality) for race (AA vs. White)-overall and stratified by IHC triple subtypes of breast cancer Overall ER−PR−HER2− ER−PR−HER2+ ER/PR+HER2+ ER/PR+HER2− N, Overall survival (%) 479 (71.6) 135 (68.6) 33 (43.1) 36 (70.3) 272 (77.4) AA % 60.5 59.5 13.1 68.5 69.1 White % 76.4 77.3 62.7 70.9 79.7 Lund MJ, Trivers KF, Porter PL, Coates RJ, Leyland-Jones B, Brawley OW, Flagg EW, O'Regan RM, Gabram SG, Eley JW. Race and triple negative threats to breast cancer survival: a population-based study in Atlanta, GA. Breast Cancer Res Treat Jan;113(2): Epub 2008 Mar 7. PubMed PMID: Lund et al. 2009

55 Evidence of Racial and Ethnic Disparities in Healthcare
Disparities consistently found across a wide range of disease areas and clinical services. Disparities are found even when clinical factors, such as stage of disease presentation, co-morbidities, age, and severity of disease are taken into account. National Institute of Medicine Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

56 Five-Year Relative Survival Rates Among Patients Diagnosed with Selected Cancers by Race and Stage at Diagnosis, US, 1999 to 2005. Jemal et al. Cancer Statistics CA: Cancer Journal for Clinicians

57 Five-Year Cancer Survival Rates, All-sites Combined,
by Race, Gender and Poverty, Among people who develop cancer, the five-year survival rate is more than 10 percentage points higher for persons who live in affluent census tracts than for persons who live in poorer census tracts (Figure 2). This gradient is seen in all racial and ethnic groups with the exception of American Indians/Alaskan Natives. Even when census tract poverty level is accounted for, however, African American, American Indian/Alaskan Native, and Asian/Pacific Islander men and African American and American Indian/Alaskan Native women have lower five-year survival than non-Hispanic Whites.17

58 Solutions: Health Disparities
Academic Medicine Report in response to IOM report regarding heathcare disparities:   * Disparities are unacceptable. * Occur in the context of broader historic and contemporary social and economic inequality, and are * Evidence of persistent racial and ethnic discrimination in many sectors of American life. * Many sources—including health systems, health care providers, patients, and utilization managers—may contribute to racial and ethnic disparities in health care. * Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care. * A small number of studies suggest that certain patients may be more likely to refuse treatments, yet these refusal rates are generally small and do not fully explain health care disparities. Betancourt JR. Eliminating racial and ethnic disparities in health care: what is the role of academic medicine? Acad Med Sep;81(9): PubMed PMID:

59 Reduce Disparities in Healthcare
Train more minority Health providers Improve training in cultural competence Introduce concepts in med/nursing school Create med school/community partnerships Provide evidence-based solutions as CME Structural change in HC that allows more time with patient, less time pressure

60 Reduce Disparities in Healthcare
Reduce barriers to participation in clinical trials? Lack of insurance Lack of access to trials due to transportation, language, lack of understanding Lack of provider cultural competency 83% of cancer patients treated in private practices that do not participate in clinical trials. Closure of public hospitals in urban centers Lack of physician Medicare reimbursement Colon-Otero et al. Cancer 2008;113:447

61 Other Solutions Better health literacy Patient navigation Medical home

62 External Barriers to Good Health:
More than just Cancer Health Nexus and Ontario Chronic Disease Prevention Alliance, Primer to Action: Social Determinants of Health, Toronto 2008. Source: Primer to Action: Social Determinants of Health, Toronto 2008

63 Definition Revision Social disparities or health disparities?
Population groups: includes everyone but white affluent, urban, able-bodied, heterosexual, middle-aged men? Gold standard? Are health disparities really underlying differences in social status?

64 How to begin to eliminate health disparities?
“Poverty is a carcinogen.” Dr. Sam Broder, 1991 (former Director, National Cancer Institute) What will be the interventions?

65 References Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Institute of Medicine, NAS, 2002 Krieger N. Defining and Investigating social disparities in cancer: critical issues. Cancer Causes and Control 2005;16:5-14. Smith B D et al. JCO 2009;27: Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol Jun 10;27(17): Epub 2009 Apr 29. PubMed PMID: Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, Thun M. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin Mar-Apr;54(2): Review. PubMed PMID: Ward E, Halpern M, Schrag N, Cokkinides V, DeSantis C, Bandi P, Siegel R, Stewart A, Jemal A. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin Jan-Feb;58(1):9-31. Epub 2007 Dec 20. PubMed PMID: DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in Black-White disparities in cancer mortality. Cancer Epidemiol Biomarkers Prev Nov;17(11): PubMed PMID: Warnecke RB, Oh A, Breen N, Gehlert S, Paskett E, Tucker KL, Lurie N, Rebbeck T, Goodwin J, Flack J, Srinivasan S, Kerner J, Heurtin-Roberts S, Abeles R, Tyson FL, Patmios G, Hiatt RA. Approaching health disparities from a population perspective: the National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health Sep;98(9): Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health Dec;96(12): Epub 2006 Oct 31. PubMed PMID: ; PubMed Central PMCID: PMC Mitchell J, Lannin DR, Mathews HF, Swanson MS. Religious beliefs and breast cancer screening. J Womens Health (Larchmt) Dec;11(10): PubMed PMID: JOURNAL OF WOMEN’S HEALTH 2002;11: Religious Beliefs and Breast Cancer Screening.

66 References Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in adjuvant chemotherapy treatment among patients with breast cancer are more likely in African American and Hispanic populations: a national cohort study J Clin Oncol Sep 20;28(27): Epub 2010 Aug 9. PubMed PMID: Farmer D, Reddick B, D'Agostino R, Jackson SA. Psychosocial correlates of mammography screening in older African American women. Oncol Nurs Forum Jan;34(1): PubMed PMID: Short LJ, Fisher MD, Wahl PM, Kelly MB, Lawless GD, White S, Rodriguez NA, Willey VJ, Brawley OW. Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention. Cancer Jan 1;116(1): PubMed PMID: Johnson RL. Racial and Ethnic Differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med 2004;19: ; Burgess DJ. Why do providers contribute to disparities and what can be done about it? J Gen Int Med 2004;19: Johnson RL et al. Patient Race/Ethnicity and Quality of Patient-Physician Communication During Medical Visits. Am J Public Health 2004;94: Hoffman et al. Racial Differences in Initial Treatment for Clinically Localized Prostate Cancer. J GEN INTERN MED 2003; 18:845–853. Rodin G, Mackay JA, Zimmermann C, Mayer C, Howell D, Katz M, Sussman J, Brouwers M. Clinician-patient communication: a systematic review. Support Care Cancer Jun;17(6): Epub 2009 Mar 4. Review. PubMed PMID: Shavers VL, Brown ML, Klabunde CN, Potosky AL, Davis WW, Moul JW, Fahey A. “Race/ethnicity and the intensity of medical monitoring under ‘watchful waiting’ for prostate cancer. Medical Care, March 2004, 42 (3): Hoffman RM, Harlan LC, Klabunde CN, Gilliland FD, Stephenson RA, Hunt WC, Potosky AL. Racial differences in initial treatment for clinically localized prostate cancer. Results from the prostate cancer outcomes study. J Gen Intern Med Oct;18(10): PubMed PMID: ; PubMed Central PMCID: PMC

67 References Cooper GS, Koroukian SM “Racial disparities in the use of and indications for colorectal procedures in Medicare beneficiaries” Cancer Jan 15;100(2): Lund MJ, Trivers KF, Porter PL, Coates RJ, Leyland-Jones B, Brawley OW, Flagg EW, O'Regan RM, Gabram SG, Eley JW. Race and triple negative threats to breast cancer survival: a population-based study in Atlanta, GA. Breast Cancer Res Treat Jan;113(2): Epub 2008 Mar 7. PubMed PMID: Jemal et al. Cancer Statistics CA: Cancer Journal for Clinicians Shi et alRacial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care for US Health Center Patients Compared With Non–Health Center Patients, J Ambulatory Care Manage 2009; 32:342–350,. Betancourt JR. Eliminating racial and ethnic disparities in health care: what is the role of academic medicine? Acad Med Sep;81(9): PubMed PMID:


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