Reducing Cancer-Related Health Disparities
Goal
The Challenge
Progress Toward Meeting the Challenge
Highlights of Recent Research on Cancer-Related Health Disparities
2003 Plan and Budget Increase Request
Goal
Understand the causes of cancer health disparities and develop effective interventions to reduce or eliminate them.
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The Challenge
The unequal burden of disease in our society is a challenge to science and a moral and ethical dilemma for our Nation.
Cancer-related health disparities occur among all people. This is because cancer develops due to a combination of factors related to genes, individual behaviors, and social and environmental circumstances. The interaction among these determines:
- Who is born healthy
- Who grows up healthy
- Who sustains health throughout his or her life
- Who survives disease
- Who maintains a good quality of life after diagnosis and treatment
NCI-supported research has helped us make enormous strides in understanding:
- How biological and behavioral factors determine risks for developing or dying from cancer
- How interventions can modify these risks
We know much less, however, about the effects of social position, economic status, cultural beliefs and practices, and environmental exposures on cancer risk.
Further research is needed for us to separate myth from reality and explain:
- The relative importance of these social, cultural, and environmental determinants of cancer
- How they interact with biological and behavioral determinants
- By what mechanisms they may increase cancer incidence and mortality and contribute to disparities in cancer incidence, prevention, care, and outcomes
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Progress Toward Meeting the Challenge
As a result of external and internal reviews of cancer health disparity issues and research programs, NCI is working in several high priority areas to better understand the relationship between what we know about cancer care and how and to whom it is provided.
Special Populations Networks
Cancer patient education
Access to clinical trials
Translating research into improved outcomes
Training opportunities
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NCI-sponsored Special Populations Networks for Cancer Awareness Research and Training (SPNs) were established at 18 research institutions in 2000 to:
- Build relationships with community-based programs.
- Foster cancer awareness activities.
- Increase minority enrollment in clinical trials.
- Develop junior biomedical researchers in minority and underserved communities.
In the first year of this program, each SPN has:
- Developed new culturally and educationally appropriate cancer awareness campaigns focused on African American, Asian American, Pacific Islander, Latin American, Native American, and low-income Appalachian white populations
- Built collaborative, community-based infrastructures for cancer control research
Fourteen of the SPNs have worked to increase the competitiveness of junior and minority investigator-initiated research applications submitted for peer review by participating in developmental research grant programs sponsored by NCI.
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Two new series of cancer patient education materials for low-literacy populations focus on information in two areas important to these groups, pain management and clinical trials. The clinical trials series was created specifically for African American and Native American groups.
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NCI collaborated with two Minority-Serving Institutions to increase access to and involvement in clinical trials by underrepresented populations, minority researchers, and patients and physicians. NCI provided support for the development of culturally appropriate patient education materials and for clinical trials data management.
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NCI is focusing increased attention on how best to translate research into improved outcomes for all populations. For example:
- NCI leadership helped organize the Department of Health and Human Services (DHHS) task force on the dissemination of health promotion and disease prevention interventions.
- Through collaboration with the American Cancer Society (ACS) and the Centers for Disease Control and Prevention (CDC), NCI has contributed to the training of state health department staff and volunteers from 17 divisions of ACS in best practices for using data to improve cancer control planning.
- We also have worked with the CDC to develop a targeted dissemination plan for evidence-based cancer control interventions to be included in the Guide to Community Preventive Services.
- NCI has worked with the Agency for Healthcare Research and Quality and CDC to promote the adoption of best practices for clinical and public health approaches to tobacco control.
- The Institute is working with the ACS and NCI-funded researchers to disseminate a dietary intervention through faith-based organizations, tested with NCI 5-A-Day research grant support, and found to be effective in two studies conducted among six African American churches in North Carolina and Georgia.
- Working with ACS regional and African American church volunteers, NCI is supporting dissemination research of a unified Body and Soul program in nine matched pairs of African American churches in three regions, and ACS will provide sustained support for the intervention.
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Highlights of Recent Research on Cancer-Related Health Disparities
Treatment Disparities for Lung Cancer Related To Surgical Practices
Unnecessarily High Cervical Cancer Mortality Must Be Addressed
HPV Clinical Trials Expected To Help Improve Control of Cervical Cancer
Cancer Survivorship in Minority and Underserved Addressed by Cancer Centers
Treatment Disparities for Lung Cancer Related To Surgical Practices
An NCI-funded study found that the lower survival rate among African American patients with early-stage, non-small-cell lung cancer, as compared with White patients, is largely explained by the lower rate of treatment through surgery among African Americans. This study of 10,984 patients 65 years of age or older, of whom 860 were African American and 10,124 were non-Hispanic White, showed that:
- The rate of surgery was 12.7 percentage points lower for African American patients than for White patients (64.0 percent versus 76.7 percent).
- The 5-year survival rate was also lower for African Americans (26.4 versus 34.1 percent).
- For patients who had surgery, survival was similar for the two racial groups.
- For patients who did not have surgery, survival was also similar.
Study results suggest that increased use of surgery for African American patients would improve survival.
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Unnecessarily High Cervical Cancer Mortality Must Be Addressed
Research is needed to determine why, despite a three-fold reduction in cervical mortality nationwide in the past 50 years, counties stretching from Maine southwest through Appalachia to the Texas/Mexico border as well as in many Southeastern states and in the Central Valley of California have experienced persistently higher cervical cancer mortality rates.
To address this 50-year disparity for a cancer from which no woman in this Nation should die, NCI and its national, state, and local partners are working to:
- Synthesize research knowledge.
- Identify core findings.
- Articulate program and policy options.
- Disseminate this information to Federal, state, and local policy makers.
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HPV Clinical Trials Expected To Help Improve Control of Cervical Cancer
Comprehensively controlling the human papillomavirus (HPV) would virtually eliminate cervical cancer, which disproportionately affects economically and socially disadvantaged women around the world. For the past 2 years, NCI has been following the medical condition of more than 5,000 women in Guanacaste, Costa Rica, who are enrolled in a randomized clinical trial to evaluate HPV DNA testing and visual and automated cytology techniques and determine the optimum strategy for managing low-grade cervical abnormalities.
An HPV vaccine trial to compare the efficacy of two vaccines developed by NCI also is underway in Costa Rica. From 15,000 to 20,000 women will be invited to participate in the trial, which is expected to run for the next 8 years.
Cancer Survivorship in Minority and Underserved Addressed by Cancer Centers
Investigators at NCI-supported Comprehensive Cancer Centers are using supplemental funding to examine:
- The physical and psychosocial needs of medically underserved cancer survivors and/or their families and how these needs compare with those found in cancer survivors and/or their families from majority populations
- Sociocultural variables that affect cancer survivorship, particularly those that affect quality of life
- The nature and effectiveness of existing post-treatment medical and support services designed for cancer patients from underserved communities
- The effectiveness and feasibility of behavioral measures and interventions aimed at assessing and reducing secondary physical and psychological consequences for minority or underserved cancer survivors and their families
See a report on the Digital Divide Pilot Projects initiative through the Cancer Communications Extraordinary Opportunity.
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The Plan - Reducing Cancer-Related Health Disparities
Goal
Understand the causes of health disparities in cancer and develop effective interventions to reduce these disparities.
Fiscal Year 2003 Objectives, Milestones, and Funding Increases Needed
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| Objective 1: Create and implement a comprehensive plan for NCI activities in health disparities research, education, training, and health services support. |
- Expand the capacity of the NCI Center to Reduce Cancer Health Disparities to support NCI health disparities research opportunities.
| $2.00 M |
- Disseminate findings on the relationship between disparity factors and cancer care including the cost of untreated cancer to society, the cost/benefit of extending Medicare coverage to cancer patients without insurance, and the influence of the concept of race on scientific inquiry.
| $1.5 M |
- urther develop and implement NCI's integrated low-literacy program by customizing materials with cultural and language appropriateness for different audience groups.
| $1.0 M |
| TOTAL | $4.5 M |
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| Objective 2: Improve capacity and accelerate knowledge through fundamental cancer control and population research. |
- Establish Centers for Population Health and Cancer to:- Expand understanding of the social and environmental determinants of cancer and the psychosocial, behavioral, and biologic factors that mediate them.- Develop hypotheses for cancer control research at social, institutional, and policy levels.- Develop, apply, and evaluate interventions to improve cancer outcomes and reduce outcome disparities.
| $8.00 M |
- Expand epidemiologic investigations to explore racial and ethnic cancer disparities with a focus on cancers for which these disparities are greatest (e.g., breast, cervix, kidney, prostate).
| $1.50 M |
- Support research on the biologic variability in cancer in terms of tumor aggressiveness, differential response to therapy, genetic polymorphism, and psychoneuroimmunologic factors as mediators of social environment.
| $2.00 M |
- Build on findings from the Prostate Cancer Outcomes Study to examine risk factors associated with late-stage disease - lifestyle, biological and clinical characteristics, and access to care - while accounting for state-of-the-art measures of socioeconomic status.
| $1.00 M |
| TOTAL | $12.5 M |
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| Objective 3: Expand our ability to define and monitor cancer-related health disparities. |
- Develop new data collection methods for socioeconomic and cultural factors including measures, data sources, and data linkage.
| $1.00 M |
- Examine informed consent provided with prostate cancer screening and treatment in different age, race-ethnicity, and socioeconomic groups as a measure of quality of care in situations where there is uncertainty about the efficacy of interventions.
| $1.00 M |
- Conduct methodological evidence-based research to ensure that survey, epidemiological, and clinical research involving cancer risk factors exhibits cross-cultural equivalence.
| $1.00 M |
- Enhance use of the NCI Cancer Progress Report process to monitor health disparity reductions and reach Healthy People 2010 goals.
| $0.50 M |
| TOTAL | $3.5 M |
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| Objective 4: Expand cancer control intervention research in prevention, early detection, treatment, and communications. |
- Expand the developmental research grant support for the Special Populations Networks for Cancer Awareness Research and Training program.
| $2.00 M |
- Collaborate with the Centers for Disease Control and Prevention to support new intervention research on barriers to screening for women who underuse or never use breast and cervical screening and on sociocultural determinants in planning, implementing, and evaluating these interventions.
| $3.50 M |
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- Provide supplemental funding to Cancer Centers for health disparities research that will reduce the heaviest cancer burdens among disadvantaged populations and address disparities in risk factors, access to prevention interventions (e.g., smoking cessation, dietary change, physical activity), quality cancer care, and clinical trials.
| $2.00 M |
| TOTAL | $7.5 M |
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| Objective 5: Reduce outcome disparities in special populations by increasing access to state-of-the-art clinical trials in cancer prevention and treatment. |
- Expand Clinical Trials Outreach Programs to increase participation by underrepresented populations, establish clinical trials units at minority-serving medical institutions, and strengthen clinical trials units at minority-based community oncology sites.
| $3.00 M |
- Increase clinical trials participation by implementing an NCI fellowship training program for healthcare providers and forums for minority scientist input into the development of clinical trials that address issues of special importance for minority and special populations.
| $1.00 M |
- Use the radiation oncology-based Cancer Disparities Research Program to expand clinical research infrastructure in communities with disproportionate cancer-related health disparities and examine novel approaches to more closely link these groups with cancer researchers.
| $2.50 M |
| TOTAL | $6.5 M |
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| Objective 6: Expand the channels for research dissemination and diffusion. |
- Expand support for advanced training of state health department staff and American Cancer Society volunteers in best practices for using surveillance and intervention evidence data in comprehensive cancer control planning.
| $2.00 M |
- Establish and maintain local and regional partnerships to understand and overcome cancer control infrastructure barriers that contribute to health disparities. Establish new comprehensive cancer control program initiative with the Washington, D.C. Department of Health. Develop and demonstrate approaches for bringing the latest interventions in cancer screening, care, and treatment, including access to clinical trials, to Native American populations through national and regional Indian health boards, tribal organizations, the Indian Health Service, and established Native American investigators.
| $1.50 M |
- Fund supplements to NCI research grants for dissemination of evidence-based interventions specifically aimed at reducing health disparities.
| $2.00 M |
| TOTAL | $5.5 M |
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| Objective 7: Expand minority investigator competition for and minority population involvement in health disparities research. |
- Recruit two additional minority scientists and physicians to the Cancer Prevention Fellowship Program to specifically focus on health disparities research.
| $0.50 M |
- Fund 30 new cancer education grants for the continuing education of healthcare providers, outreach and education programs in underserved and minority communities, and the accrual of minority and underserved populations to NCI-sponsored treatment and prevention trials.
| $9.00 M |
- Develop community-based participatory research in cancer control through partnerships among NCI-funded Comprehensive Cancer Centers, Special Populations Networks, and Minority-Serving Institutions.
| $1.00 M |
- Further expand underserved and minority-based clinical investigator training under the radiation oncology-based Cancer Disparities Research Program.
| $0.70 M |
| TOTAL | $11.2 M |
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