Lesbians and cancer: an overlooked health disparity

Objective  To evaluate the breast, cervical, ovarian, lung, and colorectal cancer literatures using a novel application of the cancer disparities grid to identify disparities along domains of the cancer continuum focusing on lesbians as a minority population. Methods  Computerized databases were searched for articles published from 1981 to present. Cumulative search results identified 51 articles related to lesbians and disparities, which were classified by domain. Results  The majority of articles identified were related to breast and cervical cancer screening. Barriers to adequate screening for both cancers include personal factors, poor patient-provider communication, and health care system factors. Tailored risk counseling has been successful in increasing lesbian’s mammography and Pap screening. Ovarian, lung, and colorectal cancer have been virtually unexplored in this population. An “Adjustment to Illness/Quality of Life” domain was added to capture literature on psychosocial aspects of cancer. Conclusions  This review revealed a lack of research for specific cancers and for specific aspects of the cancer continuum. The limited number of studies identified focused on issues related to screening/prevention in cervical and breast cancers, with almost no attention to incidence, etiology, diagnosis, treatment, survival, morbidity, or mortality. We present implications for social and public health policy, research, and prevention.     

Social disparities across the continuum of colorectal cancer: a systematic review

Objective:The purpose of this review is to evaluate the published literature to assess social inequalities in colorectal cancer using the cancer disparities grid. Methods: Three computerized databases were searched from January 1990 to January 2004 to identify published English language articles that collected data from study participants living in the United States. Abstracts were reviewed and articles that dealt with social inequality and colorectal cancer were selected. A total of 46 articles were identified and classified into the appropriate cell of the cancer disparities grid. Results: The majority of research identified for the grid has focused primarily in one domain of inequality, race/ethnicity and racism, and within one column of the cancer continuum, cancer screening. About one-third of the articles focused on multiple aspects of social inequalities. There were few or no published research articles within many of the domains of social inequality along the continuum of colorectal cancer prevention, treatment, and outcomes. Conclusions: This review found only a modest amount of research has been conducted that has examined the influence of social inequalities on colorectal cancer. Findings suggest that a multidisciplinary approach is needed to measure and remedy these social inequalities.Address correspondence to: Richard C. Palmer, DFCI-CCBR, 44 Binney Street, Smith 272, Boston, MA 02115, USA; Ph.: 617-632-4223; Fax: 617-632-3161; e-mail: richard_palmer@dfci.harvard.edu     

Possible socioeconomic and ethnic disparities in quality of life in a cohort of breast cancer survivors

Background This paper describes the ethnic and socioeconomic correlates of functioning in a cohort of long-term nonrecurring breast cancer survivors. Methods Participants (n = 804) in this study were women from the Health, Eating, Activity, and Lifestyle (HEAL) Study, a population-based, multicenter, multiethnic, prospective study of women newly diagnosed with in situ or Stages I to IIIA breast cancer. Measurements occurred at three timepoints following diagnosis. Outcomes included standardized measures of functioning (MOS SF-36). Results Overall, these long-term survivors reported values on two physical function subscales of the SF-36 slightly lower than population norms. Black women reported statistically significantly lower physical functioning (PF) scores (P = 0.01), compared with White and Hispanic women, but higher mental health (MH) scores (P < 0.01) compared with White and Hispanic women. In the final adjusted model, race was significantly related to PF, with Black participants and participants in the “Other” ethnic category reporting poorer functioning compared to the White referent group (P < 0.01, 0.05). Not working outside the home, being retired or disabled and being unemployed (on leave, looking for work) were associated with poorer PF compared to currently working (both P < 0.01). Conclusion These data indicate that race/ethnicity influences psychosocial functioning in breast cancer survivors and can be used to identify need for targeted interventions to improve functioning.     

Social disparities and prostate cancer: mapping the gaps in our knowledge

To evaluate the current state of our knowledge regarding social disparities and prostate cancer and to map the domains where substantial knowledge has been acquired as well as those where little is known, with the purpose of identifying important areas for future research.A Medline research was conducted to identify published papers regarding social disparities in prostate cancer since 1990. The results of this review are presented in a social disparities and prostate cancer grid designed to highlight which domains of social disparities have been researched and which neglected.The major social disparity in prostate cancer concerns the extremely high prostate cancer incidence and mortality seen among black Americans. This is also the area where the most research has been performed. Low socioeconomic position is associated with poorer prostate cancer outcomes but not with higher prostate cancer incidence. It remains poorly defined to what extent racial/ethnic differences in prostate cancer result from differences in socioeconomic position (SEP). Understanding the causes of the high prostate cancer mortality seen among black men remains the major challenge in the area of social disparities and prostate cancer.     

Clinical and Molecular Characteristics and Burden of Kidney Cancer Among Hispanics and Native Americans: Steps Toward Precision Medicine

Cancer disparities in Native Americans (NAs) and Hispanic Americans (HAs) vary significantly in terms of cancer incidence and mortality rates across geographic regions. This review reports that kidney and renal pelvis cancers are unevenly affecting HAs and NAs compared to European Americans of non-Hispanic origin, and that currently there is significant need for improved data and reporting to be able to advance toward genomic-based precision medicine for the assessment of such cancers in these medically underserved populations. More specifically, in states along the US-Mexico border, HAs and NAs have higher kidney cancer incidence rates as well as a higher prevalence of kidney cancer risk factors, including obesity and chronic kidney disease. They are also more likely to receive suboptimal care compared to European Americans. Furthermore, they are underrepresented in epidemiologic, clinical, and molecular genomic studies of kidney cancer. Therefore, we maintain that progress in precision medicine for kidney cancer care requires an understanding of various factors among HAs and NAs, including the real kidney cancer burden, variations in clinical care, issues related to access to care, and specific clinical and molecular characteristics.     

Does where you live play an important role in cancer incidence in the U.S.?

Some studies have shown disproportionate cancer incidence burden in rural areas which may be attributable partly due to the use of ‘rural’ as a generic term implying homogeneity of risk/protective factors across wide geographic spans. Counties in SEER 18 registries (years 2001-2011) were classified by their Rural-Urban Continuum Code (RUCC) and aggregated into urban, adjacent rural, and non-adjacent rural and were also aggregated into 3 regions: North, South, and West. Two-way ANCOVA was performed with region and RUCC as factors with adjustment for rates of common risk factors obtained from the County Health Rankings (2013). RUCC has a significant effect on incidence rate in urban areas on breast (P =0.001) and prostate (P =0.009). Colorectal significantly varies by region (P<0.0001), and the effect of rurality significantly varies across regions with North highest (P=0.0005). Lung rates significantly vary across both region and RUCC (P<0.0001 and P=0.0001, respectively). The analysis shows that risk-adjusted cancer incidence varies significantly across regions. However, we also found that rural cancer incidence significantly varied across otherwise-similar rural areas implying that ‘rural’ is not a homogeneous classification.     

Increasing Disparity in Colorectal Cancer Incidence and Mortality Among African Americans and Whites: A State's Experience

Objectives

To measure disparities between African Americans and whites in colorectal cancer incidence and mortality rates between 1995-2006 in Wisconsin.

Methods

Cancer incidence data were obtained from the Wisconsin Cancer Reporting System. Cancer mortality data were accessed from the SEER. Trends in incidence and mortality rates were calculated and changes in relative disparity were measured using rate ratios.

Results

The relative disparity in incidence grew from 1.0 in 1995 and 1.3 in 2006. The relative disparity in death rates for African Americans widened as well, from 1.2 to 1.5.

Conclusion

A persistent and widening colorectal cancer racial disparity exists.     

Do patients with schizophrenia receive state‐of‐the‐art lung cancer therapy? A brief report

Objective: Patients with schizophrenia sometimes receive substandard medical care. This study explored such disparities among lung cancer patients with underlying schizophrenia. Methods: This retrospective study focused on patients with pre‐existing schizophrenia (or in some instances schizoaffective disorder) and a lung cancer diagnosis made between 1980 and 2004. ‘Disparity’ was defined as a patient's having been prescribed less aggressive therapy for a potentially curable cancer based on state‐of‐the‐art treatment standards for the time and for the cancer stage. Qualitative methods were used to assess healthcare providers' decision‐making. Results: 29 patients were included. The median age was 59 years; 38% were men. Twenty‐three had non‐small cell lung cancer and 6 small cell lung cancer; 17 had potentially curable cancers. Five of 17 had a ‘disparity’ in cancer care: (1) no cancer therapy was prescribed because of chronic obstructive pulmonary disease; (2) no cancer therapy was prescribed because of infection; (3) no chemotherapy was prescribed because the patient declined it; radiation was provided; (4) no chemotherapy was prescribed because of the patient's schizophrenia symptoms; radiation was administered; and (5) no surgery was performed because of disorientation from a lobotomy; radiation was prescribed. Comments from healthcare providers suggest reflection and ethical adjudication in decision‐making. Conclusion: Schizophrenia was never the sole reason for no cancer treatment in patients with potentially curable lung cancer. This study provides the impetus for others to begin to assess the effect of schizophrenia on lung cancer management in other healthcare settings. Copyright © 2007 John Wiley & Sons, Ltd.     

Ethnic Disparities in Cancer Mortality Among Residents of Guam

Cancer mortality data collected by the Guam Cancer Registry for the period 1998 through 2002 were analyzedby cancer site, age, and ethnicity. Ethnicity and site specific age-adjusted cancer mortality rates for Guam werecalculated utilizing Guam 2000 census data, the US 2000 standard population and compared to U.S. 2002 ageadjustedcancer mortality rates. Age-adjusted cancer mortality rates for ethnic populations represented on Guam,except those of leukemia and non-Hodgkins lymphoma, were high in relation to other population groups and higherthan U.S. averages. Some highlights include: 1.Chamorros had high age-adjusted mortality rates for mouth andpharynx (247.2 vs. 193.5 U.S.), nasopharynx (9.1 vs. 0.2 U.S.), lung and bronchus (66.9 vs. 54.9 U.S.), colon-rectumanus(28.6 vs. 19.7 U.S.), breast (32.0 vs. 28.0 U.S.) and prostate cancer (40.9 vs. 27.9 U.S.); 2.Chamorros (6.4 vs. 2.5U.S.) and Micronesians (6.3) had high and nearly identical age-adjusted mortality rates for cancer of the mouth andpharynx when nasopharyngeal cancers were excluded; 3.Micronesians had the highest mortality rate for liver cancerover all ethnicities documented (43.5 vs. 4.9 U.S.); 4.Asians had the highest mortality rates for pancreatic (12.5 vs.10.5 U.S.) and cervical cancer (8.5 vs. 2.6 U.S.); 5.Caucasians had the highest mortality rates for leukemia (19.9 vs.7.5 U.S.) and Non-Hodgkin’s lymphoma (17.6 vs. 7.6 U.S.). Suggestions are made for further research on bothexplaining and ameliorating cancer mortality disparities among ethnic groups on Guam.     

Canadian cancer screening disparities: a recent historical perspective

Across Canada, introduction of the Pap test for cervical cancer screening, followed by mammography for breast cancer screening and, more recently, the fecal occult blood test for colorectal cancer screening, has contributed to a reduction in cancer mortality. However, another contribution of screening has been disparities in cancer mortality between certain populations. Here, we explore the disparities associated with breast and cervical cancer screening and preliminary data concerning disparities in colorectal cancer screening.Although some disparities in screening utilization have been successfully reduced over time (for example, mammography and Pap test screening in rural and remote populations), screening utilization data for other populations (for example, low-income groups) clearly indicate that disparities have existed and continue to exist across Canada. Organized screening programs in Canada have been able to successfully engage 80% of women for regular cervical cancer screening and 70% of women for regular mammography screening, but of the women who remain to be reached or engaged in regular screening, those with the least resources, those who are the most isolated, and those who are least culturally integrated into Canadian society as a whole are over-represented. Population differences are also observed for utilization of colorectal cancer screening services.The research literature on interventions to promote screening utilization provides some evidence about what can be done to increase participation in organized screening by vulnerable populations. Adaption and adoption of evidence-based screening promotion interventions can increase the utilization of available screening services by populations that have experienced the greatest burden of disease with the least access to screening services.     

Social and geographic disparities in access to reference care site for patients with colorectal cancer in France

The aim of this study was to investigate the relationship between social and geographic characteristics and the type of care centre for initial colorectal surgery in France. Patients living far from a reference cancer site were less frequently treated in a reference cancer site than those who were living near a reference cancer site OR(a)=(0.50 (0.33-0.76)). As for topography and emergency presentation, place of residence (urban/rural), occupation and marital status were not associated with the type of the care centre. Improvements in diagnosis and treatment and of clinical practice guidelines are therefore crucial to ensure equality in health care in France.     

Racial disparities in surgical treatment and survival of epithelial ovarian cancer in United States

OBJECTIVE: To compare the racial differences in treatment and survival of epithelial ovarian cancer patients. METHODS: Data were obtained from the Surveillance, Epidemiology, and End Results Program between 1988 and 2001 and analyzed using Kaplan-Meier methods and Cox proportional hazards regression. RESULTS: Of the 24,038 women, 22,407 (93.2%) were non-Hispanic White, and 1,631 (6.8%) were African-American. Median age of Whites versus African-Americans was 65 versus 63 years, respectively (P < 0.001). Of the patients with early-stage (I-II) disease, 38.8% of Whites underwent lymphadenectomy with their primary surgery compared to only 32.8% of African-Americans (P = 0.005). In the overall study group, the 5-year disease-specific survival of Whites was significantly higher compared to the African-Americans (44.1% vs. 40.7%, P = 0.001). On multivariable analysis, age, race, stage, cell type, and grade of disease were all independent prognostic factors for survival. CONCLUSION: Our data suggest that race is an independent prognostic factor for survival in epithelial ovarian cancer. In addition, African-Americans with early-stage cancer were less likely to undergo lymphadenectomy with their staging procedure. Furthermore, patient/physician education is needed to increase the number of patients undergoing surgical staging procedures for epithelial ovarian cancer.     

Insurance and inpatient care: Differences in length of stay and costs between surgically treated cancer patients

BACKGROUND:

Early research demonstrated that patients' length‐of‐stay and inpatient costs varied according to their health insurance status. The authors of the current report studied a population‐based sample of privately insured, Medicaid‐insured, and uninsured inpatients ages 21 to 64 years who underwent surgical resection for either nonsmall cell lung cancer (NSCLC) (n = 781) or colorectal cancer (CRC) (n = 8190) or who underwent mastectomy (n = 6201) to compare length of stay and inpatient costs by insurance status.

METHODS:

Data for this study were derived from all civilian, acute‐care hospitals in Virginia from 1999 to 2005. Hierarchical generalized linear models were used to estimate the relation between the explanatory variables and lengths of stay and costs. All analyses controlled for patient characteristics and hospital random effects.

RESULTS:

Medicaid‐insured patients with NSCLC had longer lengths of stay (39% or 2.64 days longer) and higher inpatient costs (20% or $2479 higher costs). Uninsured and Medicaid‐insured patients with CRC had longer lengths of stay and higher inpatient costs. In contrast, uninsured patients with breast cancer had 11% shorter lengths of stay and 12% lower inpatient costs than privately insured patients. Medicaid‐insured patients had 10% lower inpatient costs than privately insured patients. Differences were no longer statistically significant when reconstruction was added to the models.

CONCLUSIONS:

Health insurance affected the need for health care and the amount of health care received. Uninsured and Medicaid‐insured patients with lung cancer and colon cancer who underwent resection had longer lengths of stay and higher inpatient costs than privately insured patients, but they had shorter lengths of stay when reconstruction was not provided. Among the patients with breast cancer, patients and/or providers economized on discretionary procedures. Cancer 2012. © 2012 American Cancer Society.