Objectives Introduction

6/13/2013

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Cancer DisparityCancer Disparity

Produced by the Alabama Department of Public Health

Video Communications and Distance Learning Division

Produced by the Alabama Department of Public Health

Video Communications and Distance Learning Division

Satellite Conference and Live Webcast

Monday, June 17, 20131:00 – 3:00 p.m. Central Time

Satellite Conference and Live Webcast

Monday, June 17, 20131:00 – 3:00 p.m. Central Time

FacultyFaculty

Windy Dean-Colomb, MD, PhD

Medical OncologistAssistant Professor

Interdisciplinary Clinical Oncology

University of South Alabama Mitchell Cancer Institute

Mobile, Alabama

Windy Dean-Colomb, MD, PhD

Medical OncologistAssistant Professor

Interdisciplinary Clinical Oncology

University of South Alabama Mitchell Cancer Institute

Mobile, Alabama

ObjectivesObjectives

• Discuss cancer disparity and some

of its root causes

• Discuss cancer disparities in breast,

cervical, prostate, and colorectal

cancer

• Discuss avenues to address

inequalities in cancer care across

the continuum

• Discuss cancer disparity and some

of its root causes

• Discuss cancer disparities in breast,

cervical, prostate, and colorectal

cancer

• Discuss avenues to address

inequalities in cancer care across

the continuum

IntroductionIntroduction

• Cancer is a major public health

problem in the United States

– Estimated that over 1.6 million

new cases in 2013

– Estimated 580,350 deaths

– Corresponds to 1,600 deaths

each day

• Cancer is a major public health

problem in the United States

– Estimated that over 1.6 million

new cases in 2013

– Estimated 580,350 deaths

– Corresponds to 1,600 deaths

each day

IntroductionIntroduction• However, substantial gains have

been made:

– Incidence rates in the most recent

5 years have decreased in males

by 0.6% per year and were stable

in females

– Cancer death rates have

decreased by 1.8% per year for

males and 1.5% per year for

females

• However, substantial gains have

been made:

– Incidence rates in the most recent

5 years have decreased in males

by 0.6% per year and were stable

in females

– Cancer death rates have

decreased by 1.8% per year for

males and 1.5% per year for

females

2013 Estimated New Cases

2013 Estimated Deaths

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Trends in Incidence Rates for Selected Cancers by Sex from 1975 to 2009

Trends in Incidence Rates for Selected Cancers by Sex from 1975 to 2009

The Lifetime Probability of Developing Cancer for Women, 2007- 2009*

The Lifetime Probability of Developing Cancer for Women, 2007- 2009*

The Lifetime Probability of Developing Cancer for Men, 2007- 2009*

The Lifetime Probability of Developing Cancer for Men, 2007- 2009*

Cancer Death Rates* by Sex, U.S., 1975-2009

Cancer Death Rates* by Sex, U.S., 1975-2009

Cancer Death Rates* Among Men, U.S.,1930-2009

Cancer Death Rates* Among Men, U.S.,1930-2009

Cancer Death Rates* Among Women, U.S.,1930-2009

Cancer Death Rates* Among Women, U.S.,1930-2009

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Introduction: Cancer DisparityIntroduction: Cancer Disparity

• The NCI defines “cancer health

disparities” as “differences in the

incidence, prevalence, mortality, and

burden of cancer and related adverse

health conditions that exist among

specific population groups in the

United States”

• The NCI defines “cancer health

disparities” as “differences in the

incidence, prevalence, mortality, and

burden of cancer and related adverse

health conditions that exist among

specific population groups in the

United States”

Introduction: Cancer DisparityIntroduction: Cancer Disparity

• Despite notable advances in cancer

prevention, screening, and treatment,

a disproportionate number of the

uninsured, minorities, and other

medically underserved populations

are still not benefiting from such

important progress

• Despite notable advances in cancer

prevention, screening, and treatment,

a disproportionate number of the

uninsured, minorities, and other

medically underserved populations

are still not benefiting from such

important progress

Cancer Incidence Rates* by Race and Ethnicity, 2005-2009

Cancer Incidence Rates* by Race and Ethnicity, 2005-2009

MW

MM

M M

WW

W W

Cancer Incidence Rates* by Sex and Race, U.S.,1975-2009Cancer Incidence Rates* by

Sex and Race, U.S.,1975-2009Cancer Death Rates* by Race and Ethnicity, U.S., 2005-2009Cancer Death Rates* by Race and Ethnicity, U.S., 2005-2009

M

M

MM M

WW

W

WW

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Cancer Death Rates* by Sex and Race, U.S., 1975-2009

Cancer Death Rates* by Sex and Race, U.S., 1975-2009

Total Number of Cancer Deaths Averted from 1991 to 2009 in Men

and 1992 to 2009 in Women

Total Number of Cancer Deaths Averted from 1991 to 2009 in Men

and 1992 to 2009 in Women

Blue line represents actual number of cancer deaths recorded each year and the red line represents the number of cancer deaths that would have been expected if cancer death rates had remained at their peak

Men Women

833,300 Cancer

Deaths Averted

344,000 Cancer Deaths Averted

Trends in Five-year Relative Cancer Survival Rates (%), 1975-2008

Trends in Five-year Relative Cancer Survival Rates (%), 1975-2008

Five-year Relative Cancer Survival Rates (%) by Race, 2002-2008

Five-year Relative Cancer Survival Rates (%) by Race, 2002-2008

Disparity Across the Cancer Spectrum


• Cancer disparity exists across the

cancer spectrum from screening to

palliative care

• Cancer disparity exists across the

cancer spectrum from screening to

palliative care



• Cancer disparity is related to a

number of contributing factors

related to:

– Health care delivery

– Patient-related / cultural factors

– Socioeconomic factors

• Cancer disparity is related to a

number of contributing factors

related to:

– Health care delivery

– Patient-related / cultural factors

– Socioeconomic factors

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• To truly address cancer disparity it

will take a multi-faceted, community-

wide approach

• To truly address cancer disparity it

will take a multi-faceted, community-

wide approach

Incidence Rates of Breast Cancer Are Highest in White Women

Incidence Rates of Breast Cancer Are Highest in White Women

• Per 100,000 population

– White, non-Hispanic: 132.5

– Hispanic: 89.3

– African American, non-Hispanic:

118.3

– Asian and Pacific Islander: 89

– American Indian / Alaskan Native: 69.8



– Hispanic: 89.3


118.3

– Asian and Pacific Islander: 89


Death Rates from Breast Cancer Highest in African American Women

Death Rates from Breast Cancer Highest in African American Women



– Hispanic: 15


32.8

– Asian and Pacific Islander: 12.2




– Hispanic: 15


32.8



Race / Ethnicity Affects Access to High Quality Treatment


• Compared to whites, blacks are

50% less likely to receive appropriate

treatment for breast cancer

– American Indians are 70%

less likely

• Compared to whites, blacks are

50% less likely to receive appropriate

treatment for breast cancer

– American Indians are 70%

less likely



• Odds ratio of receiving inappropriate

treatment


– Mexican: 1.3

– Black, non-Hispanic: 1.5



• Odds ratio of receiving inappropriate

treatment


– Mexican: 1.3

– Black, non-Hispanic: 1.5



African Americans 68% More Likely than Whites to be Diagnosed with Prostate Cancer

African Americans 68% More Likely than Whites to be Diagnosed with Prostate Cancer



– Hispanic: 140.8


255.5





– Hispanic: 140.8


255.5



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African Americans 2.5 Times as Likely than Whites to Die of Prostate Cancer

African Americans 2.5 Times as Likely than Whites to Die of Prostate Cancer



– Hispanic: 18.5


53.3





– Hispanic: 18.5


53.3



Having Insurance Makes a DifferenceHaving Insurance

Makes a Difference• Uninsured persons are less likely

than privately insured persons to

receive timely cancer screenings

• Uninsured persons are less likely

than privately insured persons to

receive timely cancer screenings

68%

38%40%

83%

56%48%

88%

75%

19%

Uninsured Medicaid Private

Received recommended colorectal cancer screening in past 10 years, 2005

Pap Test in Past Three Years, 2005

Adults50-64

Mammogram in Past Two Years, 2005

Women40-64

Women 18-64

SOURCES: Ward, Elizabeth, et al. "Association of Insurance with Cancer Care Utilization and Outcomes." CA: A Cancer Journal for Clinicians 58.1 (2008): 9-31.

19%

68%

38%

U

U

U

M

M

MP

P

P

Having Health Insurance Matters


• Uninsured, publicly insured women

are three times more likely to be

diagnosed with a later stage of

breast cancer than privately insured

women

• Uninsured, publicly insured women

are three times more likely to be

diagnosed with a later stage of

breast cancer than privately insured

women



• Likelihood of being diagnosed with

Stage III / IV Breast Cancer vs. Stage

I Breast Cancer

– Private Insurance: 1.0

– Uninsured: 2.9

– Medicaid: 2.7

– Medicare, 65+: 1.2

• Likelihood of being diagnosed with

Stage III / IV Breast Cancer vs. Stage

I Breast Cancer

– Private Insurance: 1.0

– Uninsured: 2.9

– Medicaid: 2.7

– Medicare, 65+: 1.2

Adjusted Colorectal Cancer Survival by Stages and Insurance Status Among

Patients Diagnosed in 1999 - 2000

Adjusted Colorectal Cancer Survival by Stages and Insurance Status Among

Patients Diagnosed in 1999 - 2000

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Costs of Care Impact Persons of Lower

Socioeconomic Status More



• Small co-pays for mammography are

more likely to deter lower education

women from receiving mammograms

• Small co-pays for mammography are

more likely to deter lower education

women from receiving mammograms





8.4

12.3

4.6

High education area Medium education area

Low education area

Medium

Low

High

Breast Cancer Screening Guides


• Annual mammograms beginning at

age 40

• Clinical breast exam

– Ages 20-39 as part of a periodic

health exam at least every three years

– Ages 40+ prior to mammogram as

part of a periodic health exam annually

• Annual mammograms beginning at

age 40

• Clinical breast exam

– Ages 20-39 as part of a periodic

health exam at least every three years

– Ages 40+ prior to mammogram as

part of a periodic health exam annually



• Breast self-exam

– Optional

• Beginning in their early 20s,

women should be told about the

benefits and limitations of breast

self-examination

• Breast self-exam

– Optional

• Beginning in their early 20s,

women should be told about the

benefits and limitations of breast

self-examination


Breast Cancer Screening Guides–Women should know how their

breasts normally feel and

report changes to their health

care provider

–Women should know how their

breasts normally feel and

report changes to their health

care provider

Trends in Annual Mammography Use by Health Insurance Status, U.S., 2000-2010Trends in Annual Mammography Use by Health Insurance Status, U.S., 2000-2010

20

00

20

00

20

00

20

05

20

05

20

05

2010

20

10

20

10

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Cervical Cancer Screening Guidelines


• Cervical cancer screening should

begin at age 21

• Preferred screening test/s and

frequency vary by age:

• Cervical cancer screening should

begin at age 21

• Preferred screening test/s and

frequency vary by age:

Age Frequency Test

21-29 Every 3 years Pap test*

30-65† Every 5 years HPV and Pap tests* Conventional or liquid-based test

† Every 3 years with the Pap test alone is acceptable



• Women should stop screening:

1. At age 66 with adequate negative

prior screening

• ≥ 3 consecutive negative Pap

tests within 10 years

–Most recent within 5 years OR

• Women should stop screening:

1. At age 66 with adequate negative

prior screening

• ≥ 3 consecutive negative Pap

tests within 10 years

–Most recent within 5 years OR


Cervical Cancer Screening Guidelines• ≥ 2 consecutive negative HPV

and Pap tests within 10 years

– Most recent within 5 years

2. After hysterectomy

• ≥ 2 consecutive negative HPV

and Pap tests within 10 years

– Most recent within 5 years

2. After hysterectomy

Trends in Pap Test Prevalence* by Health Insurance Status, U.S., 2000-2010

Trends in Pap Test Prevalence* by Health Insurance Status, U.S., 2000-2010

20

00

20

05

20

10

20

00

20

05

20

10

20

00

20

05

20

10

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Colorectal Cancer Screening Guidelines*

Colorectal Cancer Screening Guidelines*

• Beginning at age 50, men and women

should follow one of the following

examination schedules:

• Beginning at age 50, men and women

should follow one of the following

examination schedules:Test Time Interval

Fecal occult blood test Annual

Flexible sigmoidoscopy 5 years

Double contrast barium enema 5 years

Colonoscopy 10 years

CT Colonography 5 years* For people at average risk; individuals at higher risk should talk with a doctor about a different testing

schedule

Trends in Prevalence of Fecal Occult Blood Test* by Health Insurance Status

Trends in Prevalence of Fecal Occult Blood Test* by Health Insurance Status

20

00

20

05

2010

20

00

20

00

20

05

2010

Flexible Sigmoidoscopy or Colonoscopy Prevalence* by Race / Ethnicity and Health

Insurance Status, U.S., 2010

Flexible Sigmoidoscopy or Colonoscopy Prevalence* by Race / Ethnicity and Health

Insurance Status, U.S., 2010

NW

NW

NW

NB

NB

N

BH

HH AA

A

Despite Progress Fighting Cancer, Racial Disparities Grow


• The difference in black and white

colorectal cancer death rates is

almost 50 times larger than in 1978

• The difference in black and white

colorectal cancer death rates is

almost 50 times larger than in 1978

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15

20

25

30

35

1973 1978 1983 1988 1993 1998 2003

White

Black

Colorectal Cancer Death Rates(per 100,000 population)

National Vital Statistics System--Mortality, NCHS, CDC.

35

30

25

20

151973 1978 1983 2003199819931988

White

Black

As New Treatment Technology Is Used, Disparities May GrowAs New Treatment Technology Is Used, Disparities May Grow

• Disparities in the receipt of sentinel

node lymph biopsy by insurance

status have grown as the technology

has become more popular

• Disparities in the receipt of sentinel

node lymph biopsy by insurance

status have grown as the technology

has become more popular

As New Treatment Technology Is Used, Disparities May GrowAs New Treatment Technology Is Used, Disparities May Grow

20%

30%

40%

50%

60%

70%

1998 1999 2000 2001 2002 2003 2004 2005

% R

ec

eiv

ing

SL

NB

Medicaid Medicare, 65+ Medicare, 18-64 Uninsured Private

Chen et al., Journal of Clinical Oncology 2008

Blacks Less Likely to Use Hospice Prior to Death from Cancer

Blacks Less Likely to Use Hospice Prior to Death from Cancer

44 46 45 4348

36 38 37 38 36

0

20

40

60

80

100

All cancers Lung Colorectal Breast Prostate

White Black

Virnig et al, Med Care 2002

100

80

60

40

20

0

4436

46 45 4348

38 37 38 36

White Black

All P<0.001

All Cancers

Lung Colorectal Breast Prostate

Healthcare Providers Can Make a DifferenceHealthcare Providers

Can Make a Difference• Racial and ethnic minorities are less

likely to be advised to quit smoking

• Racial and ethnic minorities are less

likely to be advised to quit smoking

Healthcare Providers Can Make a DifferenceHealthcare Providers

Can Make a Difference

0.640.59

0.70 0.72

0.60

1.00 1.00 1.00

0.69

Hispanic Black White

Screened for tobacco use

Advised to quit smoking

Used tobacco cessation treatments in past year

Vilma 2008

H HH B

BB

W W W

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8090

100110120130140150160170180190200210220

75 78 81 84 87 90 93 96 99 '02 '05 '08 '11 '14

2015 Goal – 50% Reduction from Baseline2015 Goal – 50% Reduction from Baseline

1991 Baseline215.1

2015 Goal 107.6

Incidence and mortality rates per 100,000 and age-adjusted to 2000 US standard populationSEER Cancer Statistics Review 1975-2007.

2007

178.2

(�� 17.2% from

baseline)

(Current trend to 2015 - �� 30.0% from baseline)(The latest joinpoint trend (2001-2007) shows a

-1.6 APC in age-adjusted rates)

2015 Projected

Rate –150.6

All Sites: Mortality Rates by Year of Death, All Races, Males, and Females

All Sites: Mortality Rates by Year of Death, All Races, Males, and Females

Total Number of Cancer Deaths Avoided from 1991-2007 in Men and 1992-2007 in Women

Total Number of Cancer Deaths Avoided from 1991-2007 in Men and 1992-2007 in Women

Blue line represents actual number of cancer deaths recorded each year and the red line represents the expected number of cancer deaths if cancer death rates had remained the same

since 1990/1991

Men Women

649,300 Cancer

Deaths

248,600 Cancer

Deaths

Total Number Premature (Ages 25-64) Cancer Deaths that Could Have Been Avoided in 2007

by Eliminating Economic and Racial Disparities

Total Number Premature (Ages 25-64) Cancer Deaths that Could Have Been Avoided in 2007 by

Eliminating Economic and Racial Disparities Among African Americans

Deaths Averted from 1991-2020

Blue solid line represents actual number of cancer deaths recorded and blue dashed line represents projected cancer deaths

based on decreasing trends in cancer death rates during 2003-2007. Green dashed line represents projected number of cancer

deaths if rates continue to decline at twice the current rate (2003-2007) beginning in 2013. Red line represents expected

number of cancer deaths if cancer death rates had remained the same since 1990 (males) and 1991(females).


• The consequences of cancer

disparities is that cancers are more

often diagnosed at later stages when

the severity is likely to be greater and

options for treatment, as well as the

odds of survival, are decreased







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• Thus, eliminating disparities in

cancer screening, diagnosis,

treatment, and mortality is an

essential step toward improved

health outcomes for all Americans

with cancer

• Thus, eliminating disparities in

cancer screening, diagnosis,

treatment, and mortality is an

essential step toward improved

health outcomes for all Americans

with cancer


• We cannot hope to address the

differences in the burden of cancer in

these populations without creative

public health interventions that seek

to overcome the financial, cultural,

geographic, and educational barriers

to care

• We cannot hope to address the

differences in the burden of cancer in

these populations without creative

public health interventions that seek

to overcome the financial, cultural,

geographic, and educational barriers

to care

Comprehensive Cancer ControlComprehensive Cancer Control

• Integrated and coordinated approach

to reduce cancer incidence,

morbidity, and mortality

• Integrated and coordinated approach

to reduce cancer incidence,

morbidity, and mortality

Comprehensive Approaches to Cancer Control

Comprehensive Approaches to Cancer Control

• Science data or evidence-based

agenda

• Infrastructure support

• Horizontal planning

• Diverse partnerships

• Planned dissemination /

institutionalization

• Science data or evidence-based

agenda

• Infrastructure support

• Horizontal planning

• Diverse partnerships

• Planned dissemination /

institutionalization

Comprehensive Cancer Control

IF THEN

ProvideEducation

BuildPartnerships

EnhanceInfrastructure

Utilize

Research &

Data

Integrated &

Coordinated

Plans withEffective

InterventionsIndividual

BehaviorChange

System,

Environmental,

& PolicyChanges

AppropriateRehabilitationand Support

Effective

Palliation

New CasesPrevented

Cancers

DetectedEarlier

State-of-the-Art

Treatment

Decrease

Morbidity

Decrease

Mortality

Reduce

Disparities

IncreaseQuality of

Life

IF THENAddressing Cancer DisparityAddressing Cancer Disparity













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Addressing Cancer DisparityAddressing Cancer Disparity

• Have to address some of the root

causes

– Persistent inequalities in access to

care

– Socioeconomic barriers

– Cultural barriers

– Language barriers

• Have to address some of the root

causes

– Persistent inequalities in access to

care

– Socioeconomic barriers

– Cultural barriers

– Language barriers

Addressing Cancer DisparityAddressing Cancer Disparity

– Educational barriers

– Unhealthy environments

– Racial discrimination

– Educational barriers

– Unhealthy environments

– Racial discrimination

Areas to AddressAreas to Address

• Acknowledge that cancer disparities

exist

• Provide access to care via affordable

insurance for all and adequate

funding and infrastructure support to

institutions

• Acknowledge that cancer disparities

exist

• Provide access to care via affordable

insurance for all and adequate

funding and infrastructure support to

institutions


• Address barriers to screening by

fully funding the National BCCEDP

and state programs

• Provide culturally appropriate cancer

education to patients

• Provide funding for patient navigator

services to increase screening and

follow-up

• Address barriers to screening by

fully funding the National BCCEDP

and state programs

• Provide culturally appropriate cancer

education to patients

• Provide funding for patient navigator

services to increase screening and

follow-up


• Cultural sensitivity training to

medical providers and accountability

for care

• Building partnership with

stakeholders

• Cultural sensitivity training to

medical providers and accountability

for care

• Building partnership with

stakeholders

Alabama Department of Public Health


• Breast and Cervical Cancer Early

Detection Program (ABCCEDP)

• FITway

– Colorectal cancer screening

• Breast and Cervical Cancer Early

Detection Program (ABCCEDP)

• FITway

– Colorectal cancer screening

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• Collaboration with community

partners:

– Alabama Comprehensive Cancer

Control Coalition

– University of South Alabama

Mitchell Cancer Institute

– Joy to Life

– American Cancer Society

• Collaboration with community

partners:

– Alabama Comprehensive Cancer

Control Coalition

– University of South Alabama

Mitchell Cancer Institute

– Joy to Life

– American Cancer Society

ConclusionConclusion

• Eliminating disparities in cancer

screening, diagnosis, treatment, and

mortality is an essential step toward

improved health outcomes for all

Americans with cancer

• Eliminating disparities in cancer

screening, diagnosis, treatment, and

mortality is an essential step toward

improved health outcomes for all

Americans with cancer

ConclusionConclusion• Reducing cancer disparities can be

achieved by:

– Instituting cost-effective public

health programs that promote

overall wellness and save lives

– Developing community

partnerships that allows for cost-

sharing and benefit across the

healthcare spectrum

• Reducing cancer disparities can be

achieved by:

– Instituting cost-effective public

health programs that promote

overall wellness and save lives

– Developing community

partnerships that allows for cost-

sharing and benefit across the

healthcare spectrum

Thank you!Thank you!

Documents

Objectives Introduction