Health disparities are an important issue in cancer care, with ample evidence that people of different racial and ethnic groups, genders, ages, geographic locations, socioeconomic status, or other factors have different outcomes associated with these differences. Disparate outcomes may result from “poverty, lack of access to care, lack of health insurance, stigmas associated with cancer and death, linguistic and literacy barriers, and poor expectations of cancer treatment outcomes,”
1 as well as gene and gene-environment factors.
See Figure 1.
Some disparities appear at the level of health status: for example, black men have 136% times the incidence and 131% times the mortality of lung and bronchus cancer as white men.
2 In a study of the relationship between socioeconomic status (SES) and survival in melanoma, researchers found a significant association between an increasing level of SES and earlier stages at presentation. People with higher SES were also more likely to receive treatment with surgery and to have prolonged survival.
3 Disparities can also play a role in access to cancer care. For example, researchers have found associations between receiving a mammogram and income.
4
ASCO is involved in efforts to understand and decrease cancer care disparities in several ways, including educating its members about the care of patients from underserved and/or minority populations, increasing the diversity of the oncology workforce, supporting research in health disparities, and advocating policy that ensures access to cancer care for the underserved and that supports increased clinical cancer research in health disparities. ASCO’s Health Disparities Advisory Group identifies and targets needs, monitors progress, and recommends to the Board of Directors activities and strategies that the Society can undertake to address disparities in cancer care under the leadership of Otis W. Brawley, MD, and Derek Raghavan, MD, PhD.
ASCO’s Health Services Committee (HSC) guides the selection of topics and the development of all ASCO Clinical Practice Guidelines, under the leadership of Richard Theriault, DO, MBA, Lisa Newman, MD, MPH, and Sandra Wong, MD, MS. The ASCO Clinical Practice Guidelines program is planning to do its part to discuss health disparities. The HSC and its Methodology Subcommittee have approved including discussion of evidence on health disparities in ASCO Clinical Practice Guidelines and plans to send this proposal to the Board of Directors, for their consideration. The inclusion of health disparities in ASCO Guidelines, as relevant to the topic, was an initiative of Dr. Newman, of the University of Michigan, Past Chair of the HSC from 2007 to 2008.
“ASCO is quite proud of the overall high quality cancer care that is available in the United States, and our clinical practice guidelines provide testimony to that quality,” Dr. Newman said. “However, we also have an obligation to acknowledge and then eliminate inequities in our health care delivery system. The Health Services Committee can therefore play an important role in addressing disparities by documenting barriers to optimal cancer care related to race/ethnicity, geography, and/or socioeconomic status.”
ASCO Guidelines are publications based on evidence. Sharing evidence relevant to health disparities could aid clinicians in areas such as recommending or not recommending particular treatments, overcoming barriers to providing care, and explaining uncertainty to patients when information is not available, for example, when an agent as not been well-studied in a particular group of people. Evidence may include describing disparities at the level of clinical trial enrollment. For example, the participants in the large Prostate Cancer Prevention Trial, examining finasteride for the purpose of chemoprevention, were 92% non-Hispanic white and results of sub-group analyses by race were limited in their ability to make conclusions based on race.
5 In another example, people older than 65 or 70 years participate less in clinical trials than younger people.
6
There are other differences, such as those that affect drug metabolism. For example, there are variations in single nucleotide polymorphisms in many cytosolic sulfotransferases among ethnic groups, which could influence pharmacogenetics in these groups.
7 If research has shown that a treatment or practice has different effects based on polymorphisms or gene-environment interaction, the Guideline will describe that research.
The Health Disparities Advisory Group and Health Services Committee would like to collaborate on these areas of particular Guidelines, especially when the guideline discusses a treatment or practice which has a large-scale disparity. Beverly Moy, MD, MPH, of the Massachusetts General Hospital Cancer Center, serves as a liaison between ASCO’s Health Services Committee and the Health Disparities Advisory Group. Dr. Moy notes that although ASCO Guidelines provide evidence-based “recommendations on the best practices in disease management to provide the highest level of cancer care, it is important to note that many patients have limited access to medical care.” Dr. Moy continues, “The hope of this new collaboration is to increase awareness of these disparities in the context of ASCO's clinical practice guidelines as we strive to deliver the highest level of cancer care to these vulnerable populations.”
Through the collaboration of these two ASCO volunteer groups, it is hoped that the inclusion of health disparities information in ASCO Guidelines will increase awareness and assist clinicians in minimizing the relevance of disparities and delivering the highest quality care.
References
1. NCI Center to Reduce Cancer Health Disparitiesavailable at
http://crchd.cancer.gov/definitions/defined.html. Accessed June 3, 2003.
2. Ries LAG, Melbert D, Krapcho M, et al (eds).
SEER Cancer Statistics Review, 1975-2005, National Cancer Institute.
http://seer.cancer.gov/csr/1975_2005/, based on November 2007 SEER data submission, posted to the SEER web site, 2008.
Incidence: White men: 79.3 per 100,000 men Black men: 107.6 per 100,000 men
Mortality: White men: 71.3 per 100,000 men Black men: 93.1 per 100,000 men.
3.
Zell JA. Survival for patients with invasive cutaneous melanoma among ethnic groups: the effects of socioeconomic status and treatment. J Clin Oncol. 2008 Jan 1;26(1):66-75.
4.
Halliday, T et al. Socioeconomic Disparities in Breast Cancer Screening in Hawaii, Prev Chronic Dis. 2007 October; 4(4): A91.
5.
Thompson IM, Goodman PJ, Tangen CM, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med. 349:215-24, 2003.
6.
Owonikoko, TK. Lung Cancer in Elderly Patients: An Analysis of the Surveillance, Epidemiology, and End Results Database, J Clin Oncol., 2007 Vol 25,Dec 10 (25):5570-5577.
7.
Nowell S, Falany CN. Pharmacogenetics of human cytosolic sulfotransferasesl. Oncogene. 2006 Mar 13;25(11):1673-8.
