Addressing Areas of Public Health Emphasis

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Reducing Cancer-Related Health Disparities


Understand the fundamental causes of health disparities in cancer, develop effective interventions to reduce these disparities, and facilitate their implementation.
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The Challenge

The unequal burden of cancer in our society is more than a scientific and medical challenge. It is a moral and ethical dilemma for our Nation. Certain populations experience significant disparities in cancer incidence, the care they receive, and the outcomes of their disease. These differences have been recognized, or at least suspected, for some time. They now are being documented with increasing frequency and clarity.

Our challenge today is to:

  • Fully understand the fundamental causes of cancer health disparities, including the influence of social position, economic status, cultural beliefs and practices, environmental exposures, genetics, and individual behavior.
  • Develop effective interventions to address these disparities.
  • Actively facilitate their implementation.

If there are ways we fund or perform cancer research that favor one person or group over another, we must discover and mend those ways. If there are ways we distribute the benefits of our research that contribute to the very real social and economic disparities in who develops cancer, who survives cancer, and the quality of that survival, we must improve our distribution. And if we can influence policy to improve care, we must exercise that influence.

Recognizing that disparities must be overcome if we are to significantly reduce the Nation's cancer burden, NCI established a dedicated center to direct and coordinate an Institute-wide plan to address key disparities issues. The scope of planning will incorporate all research areas within NCI's organizational structure - basic biology, epidemiology, genetics, prevention, communication, cancer control, diagnostics and treatment development, and survivorship.

Healthcare policymakers, providers, payers, and other stakeholders must be empowered and encouraged to provide equal access to proven interventions for cancer prevention and control for all populations. NCI must collect and synthesize the scientific evidence and provide leadership to help ensure that policies and services bring the benefits of research to all Americans.

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Progress Toward Meeting the Challenge

NCI is working with public, private, academic, and community-based partners to identify cancer health disparities and their underlying causes. For example, NCI together with national, state, and local partners is investigating the socioeconomic, cultural, health system related, and other causes of disparities in cervical cancer mortality. While mortality for this disease has fallen three-fold nationwide in the past 50 years, some geographic areas experience persistently high cervical mortality rates. Researchers, clinicians, patient advocates, and others will meet to review surveillance and background data for high mortality areas and articulate the key issues and recommendations for action. This information will be disseminated to Federal, state, and local policy makers.

NCI has funded a landmark, five-year Southern Community Cohort Study that will enroll and follow 105,000 people - two thirds of whom will be African Americans - in six southeastern states to determine why African Americans are more likely to develop and die from cancer. Genetic, environmental, and lifestyle factors that contribute to cancer development will be identified, and important health information about low income and rural populations of all races is also anticipated.

NCI has launched an investigation into the impact of the "racialization" of populations, society, science, and the healthcare system on scientific inquiry and disparate patient outcomes. We are also working to establish interdisciplinary research Centers for Population Health and Health Disparities to better understand the interaction of social, cultural, and physical environmental determinants of cancer incidence and outcomes and the behavioral and biologic factors that contribute to them. This trans-NIH initiative is also supported by the National Institute of Environmental Sciences, the National Institute on Aging, and the Office of Behavioral and Social Science Research and seeks to develop more effective interventions.

The California Health Interview Survey, modeled after the National Health Interview Survey, samples diverse subpopulations among more than 55,000 respondents in the state. NCI has supported the development and implementation of the survey, which is expanding understanding of the interplay of race, ethnicity, socioeconomic factors, and other social and cultural influences on cancer risk factors such as tobacco use, diet, and screening.

With several partners, NCI has implemented programs to address the cancer health disparities that are being identified. For example, NCI sponsors 18 Special Populations Networks for Cancer Awareness Research and Training that build relationships with community-based programs, foster cancer awareness activities, increase minority enrollment in clinical trials, pilot projects that will lead to the development of grant applications for new and innovative research, and develop junior biomedical researchers from minority and underserved communities. Collaborations with NCI Divisions and clinical/academic partnerships among Network awardees and Cancer Centers, academic institutions, and Clinical Cooperative Groups are essential to all of these activities.

NCI is partnering with the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and the Institute for Healthcare Improvement in a Health Disparities Collaborative to reduce cancer-related health disparities for the underserved populations served by HRSA-supported community health centers throughout the United States. The Collaborative focuses on improving the delivery and quality of colorectal, breast, and cervical cancer screening and clinical follow-up for people who traditionally lack access to quality healthcare.

In 2003, the radiation oncology-based Cancer Disparities Research Partnerships Program (CDRP) will support the expansion of radiation oncology clinical trials in three geographically dispersed and ethnic and culturally diverse institutions serving large numbers of Native Americans, African Americans, Hispanics and rural Appalachians. CDRP also is expanding dissemination and diffusion channels using novel telemedicine and teleconferencing architecture to connect CDRP and participating institutions, their academic partners, and NCI clinical facilities and experts.

NCI continues to provide health disparities training for new scientists through the Cancer Prevention Fellowship Program. Interest in health disparities continues to grow, with 6 of 15 entering fellows in 2002 expressing strong interest in disparities research compared with none in 1999. In 2003, the CDRP will support minority clinical investigators, nurses, data managers, and others at institutions new to cancer disparities research.

The Plan - Reducing Cancer-Related Health Disparities

Understand the fundamental causes of health disparities in cancer, develop effective interventions to reduce these disparities, and facilitate their implementation.

Objectives, Milestones, and Funding Increases Required for Fiscal Year 2004

1. Expand research to understand the causes of health disparities in cancer.$16.2 M
2. Develop effective interventions to reduce cancer health disparities. $9.5 M
3. Expand our ability to define and monitor cancer-related health disparities.$6.0 M
4. Facilitate the implementation of new policy, community and clinical interventions, and evaluate their impact on health disparities.$17.9 M
5. Expand minority investigator competition for and minority population involvement in health disparities research. $9.75 M
Management and Support $2.0 M
TOTAL $61.35 M

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Objective 1: Expand research to understand the causes of health disparities in cancer.
  • Identify factors contributing to cancer health disparities and gaps in research by reviewing Federal and voluntary organization research portfolios. Use findings to update NCI's strategic plan to reduce disparities, guide research and partnership efforts, and set priorities for new cancer health disparities research support.
$5.2 M
  • Expand the knowledge base through fundamental cancer control research, including:
    • International collaborative studies on social determinants of cancer and cancer-related disparities through supplements to NCI-supported Centers for Population Health and Health Disparities.
$2.0 M
    • Expanded epidemiologic studies exploring racial/ethnic cancer disparities, focusing both on cancers with the greatest disparities and on specific understudied populations.
$3.0 M
    • Investigations of physician, patient, and health system factors influencing cancer care quality among racial/ethnic minorities and other underserved populations.
$3.0 M
    • Research on biologic pathways through which behavioral, social, physical, and environmental factors influence cancer-related health disparities, including genetic polymorphisms, psychoneuroimmunologic factors, and differential responses to therapy.
$3.0 M
TOTAL$16.2 M

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Objective 2: Develop effective interventions to reduce cancer health disparities.
  • Increase collaborative research among the Special Populations Networks for Cancer Awareness Research and Training, NCI, and other Federally funded research networks.
$3.0 M
  • Assess the efficacy and cost effectiveness of patient navigator programs in populations experiencing serious cancer-related health disparities through evaluation supplements to navigator demonstration programs and other studies.
$1.0 M
  • Collaborate with service delivery components of the Federal government (e.g., Centers for Disease Control and Prevention, Health Resources and Services Administration, U. S. Department of Agriculture) to support new intervention research for women who have not been screened or who are substantially under screened for breast and cervical cancer, emphasizing sociocultural determinants in planning, implementing, and evaluating these interventions.
$3.5 M
  • Address disparities in risk factors, access to prevention interventions, quality cancer care, and clinical trials through formal affiliations and supplemental funding to NCI Cancer Centers using existing links with and direct funding to Minority-Serving Institutions.
$2.0 M

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Objective 3: Expand our ability to define and monitor cancer-related health disparities.
  • Enrich understanding of cancer health disparities through new population-based state and regional surveys that provide information on socioeconomic and cultural factors influencing disparities.
$1.0 M
  • Conduct methodologic research to ensure cross-cultural equivalence in survey, epidemiological, and clinical research involving cancer risk factors.
$1.0 M
  • Collect risk factor and screening data in small or sparse populations defined by geography, race/ethnicity, socioeconomic, and other characteristics, for which information is insufficient, using national, state, or regional sampling.
$4.0 M

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Objective 4: Facilitate the implementation of new policy, community and clinical interventions, and evaluate their impact on health disparities.
  • Support a series of meetings with representatives of policy making, healthcare delivery, public and private payers, advocates, and other stakeholders to review evidence, develop collaborations, and create action plans for interventions to reduce or eliminate cancer health disparities.
$0.5 M
  • Increase minority and underserved population access to state-of-the-art prevention and treatment clinical trials:
    • Expand clinical trials outreach programs to under-represented populations and increase participation in trials at established minority based community oncology sites.
$3.0 M
    • Provide supplements to fund a nurse case manager and a patient navigator at each of approximately 15 Cancer Centers, 20 Cooperative Group sites, and 10 Community Clinical Oncology Programs sites that have demonstrated a commitment to expand minority participation in clinical trials.
$4.4 M
  • Expand the channels to disseminate research results and promote adoption of evidence-based interventions to reduce cancer health disparities.
    • Expand local and regional partnerships to overcome cancer control infrastructure barriers contributing to health disparities among medically underserved populations. Disseminate lessons learned and models for success to communities with similar infrastructure barriers.
$2.5 M
    • Expand support for research-practice partnerships between Federally funded cancer control investigators and state and local health program practitioners to increase community based participatory cancer prevention and control research, and evidence-based interventions in underserved communities.
$2.0 M
    • Establish a Dissemination/Diffusion Research Grants Program to (1) study social, environmental, and behavioral barriers to adopting evidence-based cancer prevention and control interventions by public health and community clinicians, (2) test new hypotheses for reaching underserved populations in under-resourced community health settings, and (3) develop, apply, and evaluate dissemination and diffusion interventions to increase adaptation/adoption of interventions to reduce cancer health disparities.
$4.0 M
    • Expand NCI's integrated low literacy program by customizing, with cultural and language appropriateness, cancer information materials for targeted audiences.
$1.5 M
TOTAL$17.9 M

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Objective 5: Expand minority investigator competition for and minority population involvement in health disparities research.
  • Recruit three additional minority scientists and physicians to the Cancer Prevention Fellowship Program to focus on health disparities research.
$0.75 M
  • Expand the Continuing Umbrella of Research Experiences Program to encourage high school to graduate level minority students to enter careers in health disparities research.
$2.0 M
  • Increase minority participation in clinical trials through an NCI fellowship training program for healthcare providers and other forums for minority scientist input into clinical trials development.
$1.0 M
  • Expand support for the Science Enrichment Program to attract minority high school students to careers in science and medicine.
$1.0 M
  • Fund 20 new cancer education grants for healthcare provider continuing education, outreach programs in underserved communities, and accrual of minority and underserved populations to NCI-sponsored treatment and prevention trials.
$5.0 M
TOTAL$9.75 M

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Results of Recent Research on Cancer-Related Health Disparities

Social Circumstances May Contribute to Lower Survival Among African American Patients with Advanced Non-Small Cell Lung Cancer (NSCLC). The NCI-supported Cancer and Leukemia Group B (CALGB) assessed more than 500 patients receiving systemic chemotherapy in CALGB studies for advanced NSCLC between 1989-1998. The effect of race/ethnicity on survival was assessed after adjustment for other known prognostic factors. African Americans in the study were more likely to present with a poor performance status and greater weight loss. They also were more likely to be unmarried and Medicaid recipients and to be affected by disability and unemployment. An independent effect of race/ethnicity on survival disappeared after adjustment for these factors. The findings suggest that social circumstances lead to African Americans presenting with poorer prognostic profiles.

Educational Interventions Increase Cervical Cancer Screening Among Chinese Americans. NCI-funded investigators in Seattle found that direct mailing of culturally and linguistically appropriate educational materials and home visits by outreach workers can increase participation in cervical cancer screening in the Chinese-American population.

African American Men Are at Greater Risk for Advanced Prostate Cancer. NCI-supported researchers examined racial and ethnic differences among men who develop advanced prostate cancer. African American men were at greater risk of advanced disease than Hispanic men and had about twice the risk of non-Hispanic Whites. Differences in socioeconomic status, symptoms, and tumor characteristics seem to account for differences between non-Hispanic Whites and Hispanics, but do not explain part of the African American disparities.

After adjusting for clinical and sociodemographic variables, risk remained significantly higher for African Americans but not for Hispanics. African American and Hispanic men lacking a high school education or private insurance were more likely to have advanced prostate cancer. With higher socioeconomic status, the difference for African Americans persisted but disappeared for Hispanics. Additional research on biologic markers, genetic susceptibility, and other socioeconomic factors such as health system use, distance from care, diet, literacy, and health beliefs is needed to better explain disparities and determine how this information can help reduce cancer risk for these populations.