Social inequities along the cervical cancer continuum: a structured review

ObjectiveTo reveal areas of research/knowledge related to social inequities and cervical cancer. Methods: A Medline search was performed looking for US based research on cervical cancer and social inequities since 1990. The papers found were organized into cells defined by a cancer disparities grid. Results: The majority of research published about cervical cancer and social inequities in the US, lies within the social domains of: race/ethnicity and socioeconomic position. Conflicting information exists as to whether race/ethnicity is a good predictor of screening and survival. Some research implied that differentials based on race/ethnicity are likely secondary to differentials in socioeconomic position. Some research about age, insurance status, and immigrant status and cervical cancer was found. Scarce information was found relating to sexuality, language, disability and geography and cervical cancer. Discussion: The cancer disparities grid facilitated a systematic and visual review of existing literature on social inequities and cervical cancer. The grid helped to elucidate uncontested existing social inequities, conflicting social inequities, and areas where social inequity data does not exist. The cancer disparities grid can be used as a research tool to help identify areas for future research, clinical programs, and political action related to cervical cancer and social inequities.Address correspondence to: Sara J. Newmann MD, MPH, 15 Massachusetts General Hospital, Vincent Gynecology and Obstetrics, 55Fruit Street, Boston, MA 02114, USA.     

American Cancer Society's report on the status of cancer disparities in the United States, 2021

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.     

Do racial or socioeconomic disparities exist in lung cancer treatment?

BACKGROUND:

Determine the effects of race, socioeconomic status, and treatment on outcomes for patients diagnosed with lung cancer.

METHODS:

The Florida cancer registry and inpatient and ambulatory data were queried for patients diagnosed from 1998‐2002.

RESULTS:

A total 76,086 of lung cancer patients were identified. Overall, 55.6% were male and 44.4% were female. The demographic distribution of patients was 92.7% Caucasian, 6.7% African American, and 5.7% Hispanic. The mean age of diagnosis was 70 years old. African American patients presented at a younger age, with more advanced disease, and were less likely to undergo surgical therapy than their Caucasian counterparts. Median survival time (MST) for the entire cohort was 8.7 months, while MST for African American patients was 7.5 months. Patients who received surgery, chemotherapy, or radiation therapy demonstrated significantly improved outcomes. Stepwise multivariate analysis revealed that African American race was no longer a statistically significant predictor of worse outcomes once corrections were made for demographics and comorbid conditions, suggesting that the originally reported disparities in lung cancer outcomes and race may be in part because of poor pretreatment performance status. In contrast, patients of the lowest socioeconomic status continue to have a slightly worse overall prognosis than their affluent counterparts (hazard ratio = 1.05, P = .001).

CONCLUSIONS:

Lung cancer continues to carry a poor prognosis for all patients. Once comorbidities are corrected for, African American patients carry equivalently poor outcomes. Nonetheless, emphasis must be placed on improving pretreatment performance status among African American patients and efforts for earlier diagnosis among the impoverished patients must be made. Cancer 2010. © 2010 American Cancer Society.     

Racial disparities and treatment trends in a large cohort of elderly African Americans and Caucasians with colorectal cancer, 1991 to 2002

BACKGROUND.

Racial differences have been demonstrated in patients who receive treatment for colorectal cancer. However, little is known about whether these disparities have changed over time. The objective of this study was to determine whether racial disparities in receiving standard therapy have declined between 1991 and 2002.

METHODS.

The study population consisted of 59,803 Caucasians and African Americans aged ≥65 years who were diagnosed with colorectal cancer (American Joint Committee on Cancer stages I, II, and III) between 1991 and 2002 and were identified from the Surveillance, Epidemiology, and End Results Program/Medicare‐linked database. Standard therapy for colorectal cancer was defined based on the Physician Data Query guidelines from the National Cancer Institute. The crude and age‐ and sex‐adjusted percentages and the odds ratios (ORs) of receiving standard therapy were reported.

RESULTS.

From 1991 to 2002, the percentage of patients who did not receive standard therapy for colorectal cancer decreased for both Caucasians (from 24.5% to 22.4%) and African Americans (from 30.4% to 26.4%). Overall, African Americans were 16% less likely to receive standard therapy for colorectal cancer (OR, 0.84; 95% confidence interval [CI], 0.78‐0.90) than Caucasians, but the difference was not significant after the analysis was adjusted for other factors (OR, 0.96; 95% CI, 0.88‐1.05). The gap for not receiving standard therapy was relatively stable, peaked in 1997 (7.2%), and decreased from 1999 to 2002 (from 7.1% to 4%).

CONCLUSIONS.

The percentage of patients receiving standard therapy for colorectal cancer increased over time, but disparities remained and decreased in recent years. Future studies should include other ethnic groups and should incorporate provider and system factors that may contribute to treatment disparities. Cancer 2008. © 2008 American Cancer Society.     

Racial disparities and treatment trends in a large cohort of elderly black and white patients with nonsmall cell lung cancer

BACKGROUND:

This study investigated whether there was a significant gap in receipt of treatment for nonsmall cell lung cancer (NSCLC) between blacks and whites, and whether the gap or disparity changed during the past 12 years from 1991 to 2002.

METHODS:

The study population consisted of 83,101 patients including 75,141 (90.4%) whites and 7960 (9.6%) blacks aged ≥65 years who were diagnosed with American Joint Committee on Cancer (AJCC) stages I‐IV NSCLC identified from the Surveillance, Epidemiology, and End Results (SEER) program's Medicare database. Age‐adjusted and sex‐adjusted rates and crude and adjusted odds ratios for receiving appropriate stage‐specific treatment of NSCLC were reported.

RESULTS:

For stages I‐II NSCLC combined, blacks were 37% less likely (OR, 0.63; 95% confidence interval [CI], 0.55‐0.73) to receive surgery, 42% less likely (OR, 0.58; 95% CI, 0.36‐0.92) to receive chemotherapy, and for stages III‐IV combined, 57% less likely (OR, 0.43; 95% CI, 0.30‐0.61) to receive chemotherapy compared with whites. Older patients, women, and those in lower socioeconomic quartiles had greater disparities in receipt of treatment compared with the highest income quartile. Disparity trends were not significantly narrowed during the past 12 years between blacks and whites for receipt of the above treatments.

CONCLUSIONS:

There have been substantial disparities in receiving recommended treatments between blacks and whites, and these disparities have been relatively stable without a significant trend of narrowing during the past 12 years. Efforts should focus on providing appropriate quality treatment and educating blacks on the value of having these treatments to reduce these disparities in receipt of treatment for NSCLC. Cancer 2009. © 2009 American Cancer Society.     

Racial disparities and survival for nonsmall‐cell lung cancer in a large cohort of black and white elderly patients

BACKGROUND:

This study aimed to examine disparities in survival and associated factors for patients with nonsmall‐cell lung cancer (NSCLC) and to determine whether racial disparities varied over time (1991‐1995, 1996‐1999, and 2000‐2002).

METHODS:

The authors studied 70,901 patients aged ≥65 years with stage I‐IV NSCLC identified from Surveillance, Epidemiology, and End Results/Medicare data. Multivariate time‐to‐event survival analyses were completed using Cox proportional regression modeling.

RESULTS:

The 5‐year observed lung cancer‐specific survival rates were 52.7% for whites and 47.5% for blacks with stage I‐II disease, and 17.7% and 19.6% for whites and blacks, respectively at stages III‐IV. After controlling for standard treatment, socioeconomic status (SES), and other factors, there were no significant differences in all‐cause mortality, or lung cancer‐specific mortality between black and white patients with stage I‐II or III‐IV lung cancer. However, blacks had an increased risk for overall all‐cause mortality at stage I‐IV (hazard ratio [HR], 1.24; 95% confidence interval, 1.13‐1.35), and during 2000‐2002 at stage III‐IV for all‐cause mortality (HR, 1.22; 95% CI, 1.02‐1.47) and lung cancer‐specific mortality (HR, 1.24; 95% CI,1.01‐1.53). Standard treatment was significantly associated with increased survival, whereas poor SES was associated with increased mortality.

CONCLUSIONS:

There were no significant differences in survival between blacks and whites with NSCLC within stage stratifications after adjusting for covariates, except for black patients at overall stage for all‐cause mortality and at stage III‐IV diagnosed in 2000‐2002. Receiving stage‐specific evidence‐based standard therapy was associated with significantly increased survival. Cancer 2009. © 2009 American Cancer Society.     

Racial disparities in colorectal cancer survival

BACKGROUND:

Racial/ethnic differences in colorectal cancer (CRC) survival have been documented throughout the literature. However, the reasons for these disparities are difficult to decipher. The objective of this analysis was to determine the extent to which racial/ethnic disparities in survival are explained by differences in sociodemographics, tumor characteristics, diagnosis, treatment, and hospital characteristics.

METHODS:

A cohort of 37,769 Medicare beneficiaries who were diagnosed with American Joint Committee on Cancer stages I, II, and III CRC from 1992 to 2002 and resided in 16 Surveillance, Epidemiology, and End Results (SEER) regions of the United States was identified in the SEER‐Medicare linked database. Survival was estimated using the Kaplan‐Meier method. Cox proportional hazards modeling was used to estimate hazard ratios (HRs) of mortality and 95% confidence intervals (CIs).

RESULTS:

Black patients had worse CRC‐specific survival than white patients, but the difference was reduced after adjustment (adjusted HR [aHR], 1.24; 95% CI, 1.14‐1.35). Asian patients had better survival than white patients after adjusting for covariates (aHR, 0.80; 95% CI, 0.70‐0.92) for stages I, II, and III CRC. Relative to Asians, blacks and whites had worse survival after adjustment (blacks: aHR, 1.56; 95% CI, 1.33‐1.82; whites: aHR, 1.26; 95% CI, 1.10‐1.44). Comorbidities and socioeconomic Status were associated with a reduction in the mortality difference between blacks and whites and blacks and Asians.

CONCLUSIONS:

Comorbidities and SES appeared to be more important factors contributing to poorer survival among black patients relative to white and Asian patients. However, racial/ethnic differences in CRC survival were not fully explained by differences in several factors. Future research should further examine the role of quality of care and the benefits of treatment and post‐treatment surveillance in survival disparities. Cancer 2010. © 2010 American Cancer Society.     

Racial segregation and disparities in breast cancer care and mortality

BACKGROUND.

Questions have existed as to whether residential segregation is a mediator of racial/ethnic disparities in breast cancer care and breast cancer mortality, or has a differential effect by race/ethnicity.

METHODS.

Data from the Surveillance, Epidemiology, and End Results–Medicare database on white, black, and Hispanic women aged 66 to 85 years with breast cancer were examined for the receipt of adequate breast cancer care.

RESULTS.

Blacks were less likely than whites to receive adequate breast cancer care (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.71‐0.86). Individuals, both black and white, who lived in areas with greater black segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.64‐0.82). Black segregation was a mediator of the black/white disparity in breast cancer care, explaining 8.9% of the difference. After adjustment, adequate care for Hispanics did not significantly differ from whites, but individuals, both Hispanic and white, who lived in areas with greater Hispanic segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.61‐0.89). Although Blacks experienced greater breast cancer mortality than whites, black segregation did not substantially mediate the black‐white disparity in survival, and was not significantly associated with mortality (hazards ratio, 1.03; 95% CI, 0.87‐1.21). Breast cancer mortality did not differ between Hispanics and whites.

CONCLUSIONS.

Among seniors, segregation mediates some of the black‐white disparity in breast cancer care, but not mortality. Individuals who live in more segregated areas are less likely to receive adequate breast cancer care. Cancer 2008. © 2008 American Cancer Society.     

Racial disparities in the use of hospice services according to geographic residence and socioeconomic status in an elderly cohort with nonsmall cell lung cancer

BACKGROUND:

The authors investigated whether there were racial disparities in the receipt of hospice services within geographic residence and socioeconomic status (SES) levels.

METHODS:

In total, 117,894 patients aged ≥66 years with nonsmall cell lung cancer (NSCLC) were identified from the Surveillance, Epidemiology, and End Results‐Medicare linked database who had received hospice services in the last 6 months before death and who died between January 1, 1991 and December 31, 2005. Multivariate odds ratios (ORs) with 95% confidence intervals (CIs) using mixed‐effects logistic regression models were used to describe relations.

RESULTS:

In urban areas, there were significant disparity trends in age/sex‐adjusted rates for blacks and Asians/Pacific Islanders compared with whites (P = .003 and P = .036, respectively). Blacks (OR, 0.79; 95% CI, 0.75‐0.82), Asians/Pacific Islanders (OR, 0.42; 95% CI, 0.39‐0.46), and Hispanics (OR, 0.81; 95% CI, 0.73‐0.91) were less likely to receive hospice services. In rural areas, blacks were 21% less likely to receive hospice services (OR, 0.79; 95% CI, 0.63‐0.98). Patients in the poorest socioeconomic status (SES) quartile were 7% less likely to receive hospice services (OR, 0.93; 95% CI, 0.86‐1.00). Moreover, within stratified SES quartiles, blacks and Asians/Pacific Islanders had lower receipt of hospice services, and Asians/Pacific Islanders were the least likely to receive hospice services, particularly those in the poorest SES quartile. In general, older patients and women were more likely to receive hospice services.

CONCLUSIONS:

There were substantial disparities in the receipt of hospice services among ethnic minorities within urban and rural areas and within SES levels. The results indicated that efforts are needed to identify barriers, enhance support, and educate patients on the benefits of hospice services. Cancer 2010. © 2010 American Cancer Society.     

Socioeconomic and demographic disparities in breast cancer stage at presentation and survival: A Swiss population‐based study

We explored socioeconomic and demographic disparities in breast cancer (BC) stage at presentation and survival in a Swiss population‐based sample of female BC patients linked to the census‐based Swiss National Cohort. Tumor stage was classified according to Surveillance, Epidemiology and End Results Program summary stage (in situ/localized/regional/distant). We used highest education level attained to estimate SEP (low/middle/high). Further demographic characteristics of interest were age at presentation (30–49/50–69/70–84 years), living in a canton with organized screening (yes/no), urbanity of residence (urban/peri‐urban/rural), civil status (single/married/widowed/divorced) and nationality (Swiss/non‐Swiss). We used ordered logistic regression models to analyze factors associated with BC stage at presentation and competing risk regression models for factors associated with survival. Odds of later‐stage BC were significantly increased for low SEP women (odds ratio 1.19, 95%CI 1.06–1.34) compared to women of high SEP. Further, women living in a canton without organized screening program, women diagnosed outside the targeted screening age and single/widowed/divorced women were more often diagnosed at later stages. Women of low SEP experienced an increased risk of dying from BC (sub‐hazard ratio 1.22, 95%CI 1.05–1.43) compared to women of high SEP. Notably, these survival inequalities could not be explained by socioeconomic differences in stage at presentation and/or other sociodemographic factors. It is concerning that these social gradients have been observed in a country with universal health insurance coverage, high health expenditures and one of the highest life expectancies in the world.     

Meta-analysis of racial disparities in survival in association with socioeconomic status among men and women with colon cancer

BACKGROUND: Few studies have addressed racial disparities in survival for colon cancer by adequately incorporating both treatment and socioeconomic factors, and the findings from those studies have been inconsistent. The objectives of the current study were to systematically review the existing literature and provide a more stable estimate of the measures of association between socioeconomic status and racial disparities in survival for colon cancer by undertaking a meta-analysis. METHODS: For this meta-analysis, the authors searched the MEDLINE database to identify articles published in English from 1966 to August 2006 that met the following inclusion criteria: original research articles that addressed the association between race/ethnicity and survival in patients with colon or colorectal cancer after adjusting for socioeconomic status. In total, 66 full articles were reviewed, and 56 of those articles were excluded, which left 10 studies for the final analysis. RESULTS: The pooled hazard ratio (HR) for African Americans compared with Caucasians was 1.14 (95% confidence interval [95% CI], 1.00-1.29) for all-cause mortality and 1.13 (95% CI, 1.01-1.28) for colon cancer-specific mortality. The test for homogeneity of the HR was statistically significant across the studies for all-cause mortality (Q=31.69; P<.001) but was not significant across the studies for colon cancer-specific mortality (Q=7.45; P=.114). CONCLUSIONS: Racial disparities in survival for colon cancer between African Americans and Caucasians were only marginally significant after adjusting for socioeconomic factors and treatment. Attempts to modify treatment and socioeconomic factors with the objective of reducing racial disparities in health outcomes may have important clinical and public health implications.     

Genomics of racial and ethnic disparities in childhood acute lymphoblastic leukemia

Although the cure rates of childhood acute lymphoblastic leukemia (ALL) have improved dramatically in the past 40 years, not all children have benefited equally from this impressive progress. Racial and ethnic disparities in the incidence and treatment outcome of childhood ALL persist, with Hispanic children having an elevated risk of developing ALL and one of the lowest survival rates after ALL therapy. A critical barrier to progress is the lack of an understanding of the causes of ALL disparities, particularly racial and ethnic differences in ALL biology. In this review, the authors summarize the current knowledge on population variation in childhood ALL incidence and treatment outcome, discuss the contributing genetic and nongenetic variables, and highlight possible therapeutic interventions to mitigate disparities in ALL. Cancer 2014;120:955–962 . © 2013 American Cancer Society.