Lucile L. Adams-Campbell, PhD
Director, Cancer Center
Professor of Medicine
Howard University Cancer Center
Washington, DC
The problem of disparities in cancer incidence and outcomes among different groups has gained national attention during the past decade. In particular, there exists an unequal burden of cancer among minorities and the underserved, which is measured by several indicators including incidence, mortality, and survival rates. The overall annual incidence rate for all cancer sites is highest among African-Americans (526.6 per 100,000) as compared to Caucasians (480.4 per 100,000), Asian/Pacific Islanders (348.6 per 100,000), Hispanics (329.6 per 100,000), or Native Americans (244.6 per 100,000). The mortality rates for all cancers combined are approximately 30% higher in African-Americans as compared to Caucasians. However, among Asian/Pacific Islanders, Native Americans, and Hispanics, the mortality rates are approximately 58% lower than those for Caucasians. Most interestingly, African-Americans have the lowest five-year survival rates for most cancers compared to all the other ethnic groups.
To begin to address these cancer-related health disparities, it is important to first identify those critical components of effective cancer prevention programs that are specific to the targeted minority and underserved populations. Numerous barriers have been identified that impede underserved populations, including: (1) inadequate access to care; (2) mistrust of the health care system; (3) fear and fatalism; (4) lack of knowledge of cancer prevention and screening recommendations; (5) lack of cultural sensitivity; and (6) financial burden. These barriers warrant considerable attention in order to effectively address health disparities among this population.
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The improvement of cancer screening and early detection rates is of paramount importance to the control of diseases not yet shown to be preventable. It is necessary to identify organizational, physician, and patient factors that facilitate or impede participation in screening by discrete segments of the population. The Health Belief Model has been used for the exploration of patient attitudinal factors, such as perceptions of susceptibility, barriers, and benefits, associated with mammography, as one example, and other early detection behaviors. The model postulates that an individual's perception of susceptibility and severity of a disease is related to one's knowledge about the disease. Once an individual perceives a threat, the decision to engage in a health-protecting behavior depends in part on his/her perception of minimal barriers; this is thought to motivate an individual to initiate health behaviors.
Another important barrier to cancer control efforts has been linked to cost and the lack of physician referral for the economically disadvantaged. The fear of: (1) detecting cancer; and (2) the effects of treatment and costs have been reported as barriers to screening. Furthermore, knowledge about cancers among the underserved, regardless of race/ethnicity, has been shown to be poor. Community outreach programs must be utilized to continuously and effectively educate all minorities and underserved, particularly.
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Health disparities in cancer prevention also have been linked to well-known risk factors, including tobacco and alcohol use and sedentary lifestyle. Despite large declines in the prevalence of cigarette smoking over the last three decades, cigarette smoking remains the leading cause of preventable death in the US for both men and women. The trends in smoking reveal that between 1978-1995 cigarette smoking prevalence declined for Caucasians (34% to 26%), African-Americans (37% to 33%), Hispanics (30% to 19%), and Asian/Pacific Islanders (24% to 15%). Cigarette smoking was highest among Native Americans and Alaskan Natives (36%) and lowest among Asians (14%). Tobacco use, however, still causes the most significant morbidity and mortality among minority populations. It is realized that physicians (private or public/clinic) may inconsistently counsel patients against smoking. Thus, improvement in patient office counseling as well as smoking cessation programs are needed. Furthermore, primary tobacco prevention programs targeted to youth are needed in order to encourage a healthy lifestyle that will be maintained throughout life.
Alcohol is a risk factor for numerous cancers that could be prevented in minority and underserved populations in particular. Patterns of alcohol consumption derived from surveys of nationally representative samples show that frequent, heavy drinking (defined as consuming five or more drinks at a sitting at least once a week) has decreased among Caucasian men but has remained stable among African-American and Hispanic men; these trends are identical among women in these same groups. Social and cultural factors, such as drinking norms and attitudes, and, in some cases, genetic factors as well as biological factors, are thought to account for the differences in alcohol consumption and related problems. Alcohol consumption, combined with tobacco use, increases the likelihood of developing several cancers, including those of the mouth, larynx, and esophagus to a greater extent than the independent effects of either drinking or smoking alone.
Only one-third of all adults participate in regular leisure-time activity in the US. Physical activity levels are highest among Caucasians when compared to minorities, particularly African-Americans, and among men compared to women. Increased physical activity is another factor that represents a means for primary prevention of cancers. A sedentary lifestyle is also associated with increased rates of obesity. Among African-American women, as an example, the overall age-adjusted mortality rate exceeds that of Caucasian women by 50%. Although data are inconsistent, obesity has been linked to the development of breast, prostate, and colon cancers. There is a need to reduce the levels of obesity in an effort to reduce cancer incidence and enhance cancer survival rates.
Eliminating health disparities is an important means of reducing cancer morbidity and mortality in the US. It is essential that we address the barriers and impediments linked to the success of cancer prevention. Improvements in survival depend on the adoption of early detection methods associated particularly with preventable and modifiable behaviors.
