1. Cancer and Minorities Norma Kanarek, MPH, PhD Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health Department of Oncology, Johns Hopkins School of Medicine

2. Cancer Health Disparities Differences by among disadvantaged groups defined by –Race –Ethnicity –Sexuality –Wealth/income –Gender –Disability status

3. Ways to think about differences among population groups Poverty/policies the root cause of disparities?? Differences by cancer site Differences by person, place and time Key determinants of health disparities Data issues and sources

5. Poor Breast Cancer Survival in Blacks May Not Be Due to Race Many factors, including access to health care, could affect outcome, analysis finds WEDNESDAY, June 23 (HealthDay News) -- Underinsured black breast cancer patients have worse survival outcomes than underinsured white patients, a new U.S. study has found. Researchers analyzed the records of 574 breast cancer patients treated at Wishard Memorial Hospital in Indianapolis between Jan. 1, 1997 and Feb. 28, 2006, and found that 84 percent of these patients were underinsured. The study authors noted that black patients had more advanced breast cancer at diagnosis and poorer cancer-specific survival outcomes than whites. But after adjusting for age, cancer stage and other factors, they found that race was no longer significantly associated with breast cancer-related death. In addition, contrary to previous study findings, black women were as likely as white women to opt for breast-conserving procedures and "adjuvant" therapy, which is therapy given after the completion of the initial treatment -- such as chemotherapy, radiation or hormone therapy -- to lower the risk of cancer recurrence. "Despite the similar surgical care and adjuvant therapy, African American women in this study had lower overall and breast cancer-specific survival compared with non-Hispanic white women. After adjustment for competing causes of death, the survival disparity between African American and non-Hispanic white women appears to be attributable in part to differences in clinical and socio-demographic factors between the groups," Dr. Ian K. Komenaka Socio- demographic factors include variables such as income, education level and access to health care, they explained.

6. Mammography Use by Race Percent of American Women Over 40 Who Have Had a Mammogram Within Past 2 Years White Black, Non-Hispanic Hispanic American Indian/Alaska Native Asian American 70.4% 70.4% 66.1% 68.6% 58.8% 69.3% Source: American Cancer Society, 2005. Based on 2003 data.

7. Risk of surviving cancer lessens with advanced stage, SEER 1975-2007 Female Breast Cancer Stage 5-year Relative Survival Rate 0100% I IIA92% IIB81% IIIA67% IIIB54% IV20%

9. Differences by Cancer site

10. 2003-07 Major Cancer Sites Source: SEER Cancer Statistics Review, 1975-2007 Incidence* –Prostate 69.9 ↓ –Breast 66.5 ↓ –Lung & bronchus 62.5 ↓ –Colon & rectum 47.9 ↓ –Urinary Bladder 21.1 ↓ –Melanoma of the skin 20.1 ↑ –Non-Hodgkin Lymphoma 19.6 → Mortality* –Lung & bronchus 52.5 ↓ –Colon and rectum 17.6 ↓ –Breast 13.5 ↓ –Pancreas 10.7 ↑ –Prostate 9.5 ↓ –Leukemia 7.1 ↓ –Non-Hodgkin Lymphoma 6.9 ↓ –Liver & IBD 5.2 ↑ –Ovary 4.8 ↓ –Esophagus 4.4 → *rate per 100,000 people, age adjusted to year 2000 standard

11. Top 5 Cancer Mortality Sites by Race White: Lung & bronchus, colon &rectum, breast, pancreas, prostate Black: Lung & bronchus, colon &rectum, prostate, breast, pancreas Asian/Pacific Islander: Lung & bronchus, colon &rectum, liver & IBD, pancreas, stomach American Indian/Alaska Native: Lung & bronchus, colon &rectum, breast, pancreas, liver & IBD Hispanic: Lung & bronchus, colon &rectum, breast, pancreas, liver &IBD

12. 2003-07 Major Cancer Mortality by Site Source: SEER Cancer Statistics Review, 1975-2007 Males* –Lung & bronchus 68.8 ↓ –Prostate 24.7 ↓ –Colon & rectum 21.2 ↓ –Pancreas 12.3 → –Leukemia 9.7 ↓ –Non-Hodgkin Lymphoma 8.7 ↓ –Esophagus 7.8 → Female* –Lung & bronchus 40.6 → –Breast 24.0 ↓ –Colon and rectum 14.9 ↓ –Pancreas 9.4 ↑ –Ovary 8.6 ↓ –Non-Hodgkin Lymphoma 5.5 ↓ –Uterine 4.1 → *rate per 100,000 people, age adjusted to year 2000 standard

13. Cancer by Person, Place and Time

14. Person, Place, Time

15. Cancer death rates per 100,000 population, Europe & US #1 Netherlands:433Netherlands # 2 Italy:418Italy # 3 Hungary:411Hungary # 4 Luxembourg:409.7Luxembourg # 5 Slovakia:405.3Slovakia # 6 Ireland:357.6Ireland # 7 Czech Republic:335.4Czech Republic # 8 New Zealand:327.3New Zealand # 9 United States:321.9United States # 10 Australia:298.9Australia http://www.nationmaster.com/graph/hea_dea_fro_can-health-death-from-cancer, OECD 2004

16. Hispanic Cancer Rates Change After U.S. Immigration After Arrival, Habit Changes Affect Cancer Risks By JOSEPH BROWNSTEIN ABC News Medical Unit Aug. 6, 2009

18. Risk of developing cancer increases with age Probability of Developing Breast Cancer Within the Next 10 years By age 20 By age 30 By age 40 By age 50 By age 60 By age 70 Lifetime 1 out of 1,760 1 out of 229 1 out of 69 1 out of 42 1 out of 29 1 out of 27 1 out of 8

19. Person: Race, Ethnicity, Gender Breast Cancer Death Rates by Race Race/EthnicityFemale All Races White Black Asian/Pacific Islander American Indian/Alaska Native Hispanic 25.5 per 100,000 women 25.0 per 100,000 women 33.8 per 100,000 women 12.6 per 100,000 women 16.1 per 100,000 women 16.1 per 100,000 women

21. Key Determinants of Disparities

22. James, SA Epidemiologic Reviews 31(1):1-6

23. Prostate Cancer Incidence and Death Rates Racial/Ethnic GroupIncidenceDeath All168.027.9 African American/Black255.562.3 Asian/Pacific Islander 96.511.3 Hispanic/Latino140.821.2 American Indian/Alaska Native 68.221.5 White161.425.6 Statistics are for 2000-2004, age-adjusted to the 2000 U.S. standard million population, and represent the number of new cases of invasive cancer and deaths per year per 100,000 men.** http://www.cancer.gov/cancertopics/factsheet/disparities/cancer-health-disparities

24. Key Determinants of Disparities Prostate Cancer and African Americans James, SA Epidemiologic Reviews 31(1):1-6 B>W Obesity Diet B>W PSA use B>W Cancer Incidence B>W GSTP1 RARß2 SPARC TIMP3 NKX2-5 B>W B=W TX Outcomes Red: worse, orange: same as, and green: better. Data issues and sources

25. Cancer Mortality in the US by Education Level and Race, Albano JD, et al. JNCI 99(18):1384.

26. Data Issues and Sources

27. Cancer graphics/tables will have: Caveats about the statistics Source of data Data availability issues How and when it was created For example, due to data availability issues, the time period used in the calculation of the joinpoint regression model may differ for selected racial groups or counties.

29. Surveillance epidemiology and End Results (NCI) Racial/Ethnic Patterns of Cancer in the United States, 1988-1992 http://seer.cancer.gov/publications/ethnicity/ http://seer.cancer.gov/publications/ethnicity/

30. Cancer Control P.L.A.N.E.T. –State Cancer Profiles –Research seminars –Partners in Cancer Control –General information by cancer topic