Eliminating the Threat of Chronic Hepatitis B in the Asian and Pacific Islander Community: A Call to Action

Chronic hepatitis B in the Asian and Pacific Islander (API) population is among our nation’s greatest ethnicand racial health disparities. Despite comprising 4.3% of the population, API make up a disproportionate halfof the 1.2-2 million Americans living with chronic hepatitis B. As many as two-thirds of API are not aware oftheir infection because they have not been tested. This lack of knowledge prevents them from undergoing lifesavingliver cancer screening and potential treatment. Likewise, those not protected are unaware that theyshould be vaccinated. Instead, there is a pervasive lack of awareness among API and healthcare providers. Newconcerted public health actions are needed to eliminate this major health disparity.     

Cancer disparities: developing a multidisciplinary research agenda – preface

In this Special Issue, we present a series of papers concerned with developing a multidisciplinary research agenda to address social disparities in cancer. Motivating this Special Issue are two concerns: (1) despite major advances in knowledge during the 20th century about the extent, determinants, treatment, and prevention of cancer, social disparities in cancer, including within the United States, remain serious, persistent, and require redress; and (2) huge gaps in knowledge exist regarding the causes of and solutions to social disparities in cancer across the full cancer continuum, from prevention to occurrence to diagnosis to treatment and, all too often, to death. Consequently, critical research is critically needed, both to answer the unanswered questions and to ascertain why existing knowledge is not implemented to reduce and eliminate these disparities. To help advance work in this field, we share papers developed for a January 2004 workshop on cancer disparities held at the Dana Farber/Harvard Cancer Center (DF/HCC), in Boston, MA. Topics addressed include: the definition and magnitude of, and programmatic responses to, social disparities in cancer, plus development of a systematic approach to raising research questions to address cancer disparities, using the case examples of breast, cervix, colon, and prostate cancer.Address correspondence to: Nancy Krieger, PhD, Department of Society, Human Development, and Health, Harvard School of Public Health, Kresge 717, 677 Huntington Avenue, Boston, MA 02115, USA; Ph.: +1-617-432-1571; Fax: +1-617-432-3123; e-mail: nkrieger@hsph.harvard.edu     

Disparity in cancer care: a Canadian perspective

Canada is facing cancer crisis. Cancer has become the leading cause of death in Canada. Despite recent advances in cancer management and research, growing disparities in cancer care have been noticed, especially in socio-economically disadvantaged groups and under-served communities. With the rising incidence of cancer and the increasing numbers of minorities and of social disparities in general, and without appropriate interventions, cancer care disparities will become only more pronounced. This paper highlights the concepts and definitions of equity in health and health care and examines several health determinants that increase the risk of cancer. It also reviews cancer care inequity in the high-risk groups. A conceptual framework is proposed and recommendations are made for the eradication of disparities within the health care system and beyond.     

Race,ethnicity, and socioeconomic status influence the survival of patients with hepatocellular carcinoma in the United States

BACKGROUND:

Racial, ethnic, and socioeconomic disparities in the survival of patients with hepatocellular carcinoma (HCC) continue to exist. The authors of this report hypothesized that these differences result from inequities in access to care and in response to therapy.

METHODS:

Patients with HCC (n = 20,920) were identified from the Surveillance, Epidemiology, and End Results (SEER) database, and patients who underwent liver transplantation for HCC (n = 4735) were identified from the United Network for Organ Sharing (UNOS) database. Clinical and pathologic factors were compared after patients were stratified by race and ethnicity.

RESULTS:

The survival of patients with HCC improved over time for all racial, ethnic, and income groups (P < .001). Black and low income individuals had the poorest long‐term survival (P < .001). On multivariate analysis, black race was predictive of the poorest survival (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.09‐1.22; P < .001), whereas Asian race was associated with the best survival (HR, 0.87; 95% CI, 0.83‐0.91; P < .001). After liver transplantation, black patients had the worst graft survival and overall survival (median survival [MS], 30.5 months and 39.7 months, respectively; P < .001), whereas Hispanics had the best survival (MS, 83.4 months and 86.6 months, respectively; P < .001). In a multivariate analysis of transplantation patients, race and ethnicity were associated significantly with outcome.

CONCLUSIONS:

Significant racial and ethnic disparities in the outcome of patients with HCC persist despite the receipt of comparable treatment. The authors concluded that further investigations are warranted to identify the reasons for the stark disparity in outcomes between black patients and Hispanic patients after liver transplantation for HCC. Cancer 2010. © 2010 American Cancer Society.     

Associations between calcium and magnesium intake and the risk of incident gastric cancer: A prospective cohort analysis of the National Institutes of Health-American Association of Retired Persons (NIH-AARP) Diet and Health Study

Gastric cancer remains a leading cause of cancer-related mortality. Identifying dietary and other modifiable disease determinants has important implications for risk attenuation in susceptible individuals. Our primary aim was to estimate the association between dietary and supplemental intakes of calcium and magnesium and the risk of incident gastric cancer. We conducted a prospective cohort analysis of the National Institutes of Health-American Association of Retired Persons Diet and Health Study. We used Cox proportional hazard modeling to estimate the association between calcium and magnesium intakes with risk of incident gastric adenocarcinoma (GA) overall and by anatomic location, noncardia GA (NCGA) and cardia GA (CGA). A total of 536,403 respondents (59% males, 41% females) were included for analysis, among whom 1,518 incident GAs (797 NCGA and 721 CGA) occurred. Increasing calcium intake was associated with lower risk of GA overall (p-trend = 0.05), driven primarily by the association with NCGA, where the above median calcium intakes were associated with a 23% reduction in risk compared to the lowest quartile (p-trend = 0.05). This magnitude of NCGA risk reduction was greater among nonwhite ethnic group and Hispanics (hazard ratio [HR] 0.51, 95% confidence interval [CI]: 0.24–1.07, p-trend = 0.04), current/former smokers (HR 0.58, 95% CI: 0.41–0.81), obese individuals (HR 0.54, 95% CI: 0.31–0.96) and those with high NCGA risk scores (HR 0.50, 95% CI: 0.31–0.80). Among men only, increasing magnesium intake was associated with 22–27% reduced risk of NCGA (p-trend = 0.05), while for the cohort, dietary magnesium intake in the highest vs. lowest quartile was associated with a 34% reduced risk of NCGA (HR 0.66, 95% CI: 0.48–0.90). These findings have important implications for risk factor modification. Future investigations are needed not only to confirm our results, but to define mechanisms underlying these associations.     

Disentangling the effects of race on breast cancer treatment

BACKGROUND: African Americans (AA) have higher mortality from breast cancer compared with white Americans (WA). Studies using population-based cancer registries have attributed this to disparities in treatment after normalizing the AA and WA populations for differences in disease stage. However, those studies were hampered by lack of comorbidity data and limited information about systemic treatments. The objective of the current study was to investigate racial disparities in breast cancer treatment by conducting a comprehensive medical records review of women who were diagnosed with breast cancer at the Karmanos Cancer Institute (KCI) in Detroit, Michigan. METHODS: The study cohort consisted of 651 women who were diagnosed with primary breast cancer between 1990 and 1996 at KCI. Multivariable logistic regression analysis controlling for sociodemographic factors, tumor characteristics, comorbidities, and health insurance status was used to assess whether there were differences between WA and AA in the receipt of breast-conserving surgery (BCS), radiation, tamoxifen, and chemotherapy. RESULTS: There was no significant difference between WA and AA in the receipt of BCS versus mastectomy. Patients with local-stage disease who were enrolled in government insurance plans underwent mastectomy more often (vs BCS plus radiation) compared with patients who were enrolled in nongovernment plans. The rates of receipt of tamoxifen and chemotherapy were similar for local-stage WA and local-stage AA. However, WA were more likely to receive tamoxifen and/or chemotherapy for regional-stage disease. Married women with regional disease were more likely to receive chemotherapy than nonmarried women. CONCLUSIONS: The results from this study may be used to target educational interventions to improve the use of adjuvant therapies among AA women who have regional-stage disease.     

Melanoma knowledge, perception, and awareness in ethnic minorities in Chicago: recommendations regarding education

Objectives: To assess the level of melanoma awareness and risk perception among ethnic minorities and to identify ways to enhance the relevance of melanoma educational materials for ethnic minorities. Methods: Twelve focus groups composed of participants from a single ethnicity [African‐American (n=40), Hispanic (n=40), and Asian (n=40)], participated in a 2 h discussion on melanoma and skin cancer and commented on an educational brochure by the American Cancer Society and reacted to photographs of melanoma on ethnic skin. Participants also evaluated the ability to sunburn and tan and the skin cancer risk of images of celebrities before and after the discussion. Additionally, participants assessed the skin tone of celebrities as very fair, fair, olive, light brown, dark brown, and very dark. The audiotape recordings of the 12 focus groups were transcribed and analyzed with the Non‐numerical Unstructured Data Indexing Searching and Theorizing software for common themes. Results: The common themes were (1) lack of relevance of skin cancer to ethnic people, (2) understanding of skin cancer risk terminology is based on personal experience and what is acquired from the media, and (3) sources of health information for ethnic minorities are fragmented and physicians are not the primary source of information. Celebrity images representing the six skin tones were selected. Conclusions: Relevance of melanoma education to ethnic people may be improved by using ‘melanoma skin cancer’, photographs of early melanoma in people with dark skin, and providing guidance on how to inspect hands and feet for suspicious moles. Copyright © 2010 John Wiley & Sons, Ltd.     

Racial variation in tumor stage at diagnosis among Department of Defense beneficiaries

BACKGROUND:

Tumor stage at diagnosis often varies by racial/ethnic group, possibly because of inequitable health care access. Within the Department of Defense (DoD) Military Health System, beneficiaries have equal health care access. The objective of this study was to determine whether tumor stage differed between whites and blacks with breast, cervical, colorectal, and prostate cancers, which have effective screening regimens, based on data from the DoD Automated Cancer Tumor Registry from 1990 to 2003.

METHODS:

Distributions of tumor stage (localized vs nonlocalized) between whites and blacks in the military were compared stratified by sex, active duty status, and age at diagnosis. Logistic regression was used to further adjust for age, marital status, year of diagnosis, geographic region, military service branch, and tumor grade. Distributions of tumor stage were then compared between the military and general populations.

RESULTS:

Racial differences in the distribution of stage were significant only among nonactive duty beneficiaries. After adjusting for covariates, earlier stages of breast cancer after age 49 years and prostate cancer after age 64 years were significantly more common among white than black nonactive duty beneficiaries (P < .05), although the absolute difference was minimal for prostate cancer. Racial differences in stage for cervical and colorectal cancers were not significant after adjustment. Compared with the general population, racial differences in the military were similar or were slightly attenuated.

CONCLUSIONS:

Racial disparities in stage at diagnosis were apparent in the DoD equal‐access health care system among older nonactive duty beneficiaries. Socioeconomic status, supplemental insurance, cultural beliefs, and biologic factors may be related to these results. Cancer 2012;. © 2011 American Cancer Society.     

Targeting Health Disparity in Breast Cancer: Insights into Women’s Knowledge of their Cancer Profile in Malaysia

Objective: Poor health literacy is positively associated with poorer quality of health decision-making andhealth outcomes in women facing a cancer diagnosis. In developing countries, poor access to complete andaccurate information continues to pose a challenge for women. This paper describes the knowledge of Malaysianwomen with regard to breast cancer and how participation in a self-management program can improve thesituation. Methods: Secondary analysis of data collected during a clinical trial on women newly diagnosed withbreast cancer (n=147) was performed to examine baseline knowledge of breast cancer profile. Knowledge levelsof women in the experimental (n=69) group attending a self-management program were compared to a controlgroup (n=78) to determine change in the level of knowledge over time. Results: At baseline, a high percentageof women were unaware of their breast cancer profile. Not a single woman had knowledge of all six basiccharacteristics; 83% did not know their HER2 status, type of breast cancer (68%), grade of cancer cell (64%),hormonal receptor status (55%), size of breast cancer (18%) and/or their stage of breast cancer (13%). At postintervention, there was significantly better knowledge within the experimental group. Conclusion: Malaysianwomen in this cohort study demonstrated very low levels of knowledge of their cancer profile. Clinical implicationsfor countering treatment-decision difficulties include the need for a shift in the way information and servicesare delivered to allow women to take a more active role in their own care. Multi-modal efforts including basicinformation dissemination to increase women’s knowledge can contribute to narrowing of the gap in healthdisparity.     

Defining and investigating social disparities in cancer: critical issues

Research and action to address social disparities in cancer requires clarity about what constitutes and causes these persistent and onerous inequities in health. Currently, both scientific literature and government documents exhibit important disagreements, confused terminology, and considerable, if not deliberate, vagueness about the meaning of the phrase cancer disparities and the related term social disparities in health. This article accordingly reviews critical issues relevant to cohering understanding of what is meant by cancer disparities; offers a definition premised on the causal contention that social disparities in health, by definition, arise from social inequity; and considers its implications for developing a multidisciplinary research agenda on social inequalities in cancer. Tackling this issue will require rigorous and critical frameworks, questions, and methods derived from multiple disciplines, and will necessarily involve epidemiologic, clinical, and intervention research, both quantitative and qualitative. At issue is making conscious research choices: about which types of disparities we study, in relation to which aspect of cancer, so as to improve the likelihood our research will help inform a society-wide discourse about the extent, origins of, and remedies for social injustices in cancer, thereby aiding efforts to eliminate social inequalities in health. Financial support: This work was supported in part by the Dana Farber/Harvard Cancer Center (DF/HCC) Cancer Disparities program-in-development.