ASCO 2008: Disparities in cancer care addressed, solutions offered

Several factors contribute to a disparity of cancer care and outcomes between minority and majority populations in the United States.

The 2 predominant underserved populations in the United States are black and Latino patients, but other underserved populations include Native American patients, white impoverished patients, older patients, and patients on Medicaid, said Derek Raghavan, MD, director of the Taussig Cancer Center at the Cleveland Clinic.

Although lower education levels are common among these underserved populations, contributing to lower awareness of cancer prevention, detection, and treatment, even well-educated minorities have a basal level of discomfort when presenting to hospitals serving mainly majority populations, he said.

One of the factors in disparities of cancer care is suspicion of a medical establishment that is not sufficiently diverse to meet minority needs, said Dr Raghavan. "It's difficult to look cross-culturally at the man in control and not feel vulnerable," he said. A lack of health insurance, money, and family support is another key contributor that was identified by the American College of Physicians in a 2004 position paper.

Some other factors involve the medical establishment, such as a distribution of physicians outside of areas with a low standard of living and a lack of time or knowledge regarding advances in cancer diagnosis and management in those medical personnel who are available to the underserved.

Disparities in care have resulted in a higher total incidence of cancer and a higher mortality rate in minority populations, Dr Raghavan said.

Harold A. Harvey, MD, professor of medicine at Penn State University in Hershey, Pennsylvania, noted the health disparities between black and white patients with breast cancer. One assumption that needs to be modified is that equal access and care result in equal outcomes, he said.

For example, disparities in tumor biology between black and white patients, with overexpression of higher-grade tumors, higher stages, and basal subtypes in black patients compared with white patients, contribute to worse outcomes among black patients.

Studies have demonstrated lower immediate reconstruction rates among black women with breast cancer compared with white, Hispanic, and Asian patients.

Even in clinical trials of adjuvant therapy for breast cancer in which black and white women were randomized to the same treatment, outcomes have been worse in black patients, said Dr Harvey.

Minority participation in clinical trials is generally low, resulting in less understanding of the effects of treatments on populations whose tumor characteristics may be different from those of the majority of patients enrolled in clinical trials.

A program at the Mayo Clinic in Jacksonville, Florida, that attempts to minimize disparities in women with early breast cancer was described by Edith A. Perez, MD, director of the Breast Cancer Program. The aim of the program is to eliminate diagnostic delays and provide services after abnormal screening mammograms among low-income women. The program employs a nurse navigator to increase the use of diagnostic services. Funding is provided by Mayo Clinic collaborators and foundations.

Thus far, the program has served 447 women, of whom 65% were white, 22% were black, and 11% were Hispanic. Among women with Breast Imaging Reporting and Data System (BIRADS) class 4/5 cancer (suspicious abnormality or highly suggestive of malignancy), 82% received a diagnosis within 60 days of screening. The median time from enrollment to diagnosis was 0 days for women with BIRADS class 3/4 cancer and 0.5 days for women with BIRADS class 5 cancer.

The program has yet to be reimbursed for the nurse navigator, Dr Perez said. Ongoing evaluation will attempt to document a beneficial effect of the nurse navigator on the underserved population.