What's Being Done about Inequality in Health Care?

By Jane Farrell

Although there has been substantial progress in cancer treatment, screening, diagnosis, and prevention over the past several decades, addressing cancer health disparities—such as higher cancer death rates, less frequent use of proven screening tests, and higher rates of advanced cancer diagnoses—in certain populations is an area in which progress has not kept pace.

These disparities are frequently seen in people from low-socioeconomic groups, certain racial/ethnic populations, and those who live in geographically isolated areas.

Documented cancer health disparities include:

A higher incidence of a particularly aggressive form of breast cancer (the triple-negative subtype) among African American women than women of other racial/ethnic groups

Substantially higher rates of prostate cancer incidence and death among African-American men than men of other racial/ethnic groups

Higher rates of kidney cancer among American Indian and Alaska Natives than other racial/ethnic groups

Higher rates of liver cancer among Asian and Pacific Islanders than other racial/ethnic groups

Higher rates of cervical cancer incidence and death among Hispanic and African American women than women of other racial/ethnic groups

Many of the same population groups that experience cancer health disparities are also significantly underrepresented in cancer clinical trials.

There has been some recent evidence of progress against cancer health disparities, including reductions in lung and prostate cancer deaths among African-American men over the past decade. But researchers and public health officials agree that progress has come too slowly, and the cost of disparities—in terms of premature deaths, lost productivity, and the impact on communities—remains substantial and must be addressed.

Cancer Health Disparities Research

As recognition of cancer health disparities has grown, so have efforts to move beyond simply documenting the problem toward understanding all of its causes and developing and testing interventions to remedy it.

Numerous studies have shown that access to care is a critical element that contributes to cancer health disparities. Access to care is influenced by a web of factors, such as insurance status and proximity to health care facilities. Changes that have been implemented as a result of the Affordable Care Act are already helping to address the issue of access to health care by making recommended cancer screening and prevention interventions more affordable and expanding Medicaid.

Patient navigation, which is a strategy to help patients maneuver through our complex health care system, has also shown promise as a means of addressing cancer health disparities. Navigators can help patients overcome the multitude of barriers that can derail access to quality care, such as insufficient finances and lack of transportation.

As the issue of disparities has gained more attention in the cancer research and public health communities, it has produced more opportunities for collaboration among researchers. One such area of collaboration involves efforts to increase the diversity of participants in clinical trials, which can ensure that trial findings are applicable to a broader patient population.

The greater recognition of cancer health disparities is also prompting researchers to test community-level interventions that address the unique needs of specific populations in which disparities are particularly problematic, such as Native American and Appalachian populations.

Moreover, as researchers fine tune their understanding of the underlying biology of cancer, they are learning more about the biological differences that may contribute to cancer health disparities, potentially producing more tailored approaches to prevention, diagnosis, and treatment.

Challenges to Reduce Cancer Health Disparities

Developing ways to improve access to quality cancer care—from access to smoking cessation programs and recommended cancer screenings to timely treatment—continues to be one of the most daunting challenges facing the cancer research community.

Access to care is affected by many socioeconomic and policy-level factors that are beyond the control of the research and public health communities. Some of these factors include lack of access to health care facilities, state and federal policies on health insurance, and hospital and physician payment rules.

Beyond access, it can be difficult to tease apart the complex mix of factors that may contribute to differences in disease outcomes among different racial/ethnic groups—including environmental (e.g., exposure to secondhand smoke), behavioral (e.g., higher rates of alcohol use and physical inactivity), cultural (e.g., mistrust of the health care system and fatalistic attitudes about cancer), and biological factors.

Researchers are working hard to overcome these hurdles and to design and test interventions that can address the various drivers of disparities in different population groups.

NCI is addressing cancer health disparities on numerous fronts—from basic research on the biology behind disparities to community-level programs that aim to overcome barriers to cancer care to population-based registries that help to document the extent of the problem and highlight areas for further study.

NCI’s Center to Reduce Cancer Health Disparities (CRCHD) supported a Patient Navigation Research Program (PNRP) to better understand how patient navigation may help address issues of access and quality of cancer care in populations experiencing health disparities. PNRP demonstrated, for example, that patient navigation may help reduce disparities in breast and colorectal cancer incidence and mortality among African Americans by improving screening rates for these cancers and the rate of follow-up care among patients who received an abnormal result on a screening test.

The CRCHD Community Networks Programs Centers (CNPC) program brings research programs directly to communities in which cancer health disparities are common. For example, CRCHD-funded researchers from the University of Wisconsin are collaborating with The Spirit of the Eagles, a CNPC focused on reducing disparities among Native American and Alaskan Native populations, on a 3-year tobacco cessation study—the first tribal-sponsored clinical trial in the United States.

NCI research programs such as the Surveillance, Epidemiology, and End Results (SEER) Program, which is part of NCI’s Division of Cancer Control and Population Sciences (DCCPS), are also helping researchers better understand some of the potential biological factors that may influence disparities. For example, a recent analysis using SEER data confirmed that African American women have higher rates of triple-negative breast cancer, as well as higher rates of tumors with more aggressive features, regardless of the subtype of their tumor.

Other research supported by DCCPS is helping to address cancer health disparities, including interventions aimed at improving physical activity in overweight African American and Hispanic women to help reduce their cancer risk.

Reprinted with permission of the National Cancer Institute. For comprehensive information on cancer, visit NCI’s website; click here.