Download Document

Disparities in Cancer
September 22, 2008
Introduction
•
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.
•
Underlying causes of cancer disparities are
interrelated and complex.
– Causes of cancer disparities can be linked to social,
behavioral, and economic factors such as
•
•
•
•
persistent inequalities in access to care,
language barriers
unhealthy environments
racial discrimination
Unequal progress can also increase disparities.
At the same time that exposure to environmental tobacco smoke decreased,
disparities have increased.
Age-adjusted percent with detectable serum cotinine,
age 4 and older
100
90
1988-94
1999-2000
93.9
87.8
83.4
80
72.0
70
60
52.0
50
44.1
40
30
20
10
0
Mexican American
Black, non-Hispanic
I 95% confidence interval
* Nonsmokers defined by serum cotinine levels < 11 ng/mL.
**Detectable serum cotinine levels: > .05 ng/mL and < 10 ng/mL.
Notes: Age adjusted to the 2000 standard population.
Data for other Hispanics, American Indians,/Alaska Natives, Asians/Pacific Islanders are unreliable.
Source: National Health and Nutrition Examination Survey (NHANES), NCHS, CDC.
White, non-Hispanic
3
Having insurance makes a difference.
Uninsured persons are less likely than privately insured persons to receive
timely cancer screenings.
Uninsured
Percent
83%
Medicaid
Private
88%
75%
68%
56%
48%
40%
38%
19%
Received recommended
Pap Test in Past
colorectal cancer screening in Three Years, 2005
past 10 years, 2005
Women, 18-64
Adults, 50-64
Mammogram in Past Two
Years, 2005
Women, 40-64
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.
4
Health care providers can make a difference.
Racial and ethnic minorities are less likely to be advised to quit smoking.
Likelihood
Hispanic
1.00
0.69 0.70
Screened for
tobacco use
Black
1.00
0.64
White
1.00
0.72
Advised to quit
smoking
0.59 0.60
Used tobacco cessation
treatments in the past year
5
SOURCES: Vilma 2008
Costs of care impact persons of lower socioeconomic status more.
Small copays for mammography are more likely to deter lower education women from receiving
mammograms.
Percent
Percent decrease in mammography due to copays
6
SOURCES: ayanian 2008
African Americans are more than 50% more likely than whites to be diagnosed with prostate cancer…
Prostate Cancer Incidence Rates, 2004
Per 100,000 population
White, Non-Hispanic
161.4
140.8
Incidence
Hispanic
255.5
African American, Non-Hispanic
96.5
Asian and Pacific Islander
American Indian/Alaska Native
68.2
7
Note: Data are age adjusted to the 2000 standard population. SOURCE: National Cancer Institute, Surveillence, Epidemiology,
and End Results (SEER) Program; National Vital Statistics System--Mortality, NCHS, CDC.
But African Americans are twice as likely than whites
to die of prostate cancer.
Prostate Cancer Death Rates, 2005
Per 100,000 population
White, Non-Hispanic
22.6
18.5
Deaths
Hispanic
53.3
African American, Non-Hispanic
Asian and Pacific Islander
American Indian/Alaska Native
10.4
17.6
8
Note: Data are age adjusted to the 2000 standard population. SOURCE: National Cancer Institute, Surveillence, Epidemiology,
and End Results (SEER) Program; National Vital Statistics System--Mortality, NCHS, CDC.
Incidence rates of breast cancer are highest in white women…..
Breast Cancer Incidence Rates, 2005
Incidence
Per 100,000 population
White, Non-Hispanic
132.5
89.3
Hispanic
118.3
African American, Non-Hispanic
89
Asian and Pacific Islander
American Indian/Alaska Native
69.8
9
Note: Data are age adjusted to the 2000 standard population. SOURCE: National Cancer Institute, Surveillence, Epidemiology,
and End Results (SEER) Program; National Vital Statistics System--Mortality, NCHS, CDC.
….but death rates from breast cancer are
highest in African American women.
Breast Cancer Death Rates, 2005
Per 100,000 population
White, Non-Hispanic
23.4
15
Deaths
Hispanic
32.8
African American, Non-Hispanic
Asian and Pacific Islander
American Indian/Alaska Native
12.2
15.2
10
Note: Data are age adjusted to the 2000 standard population. SOURCE: National Cancer Institute, Surveillence, Epidemiology,
and End Results (SEER) Program; National Vital Statistics System--Mortality, NCHS, CDC.
Cancer mortality disparities vary greatly by region.
For example, Blacks are more likely to die of breast cancer in Chicago than in New York City.
New York City
US
Chicago
2.20
2.16
2.00
Mortality Rate Ratio
1.80
1.68
1.66
1.60
1.62
1.53
1.47
1.40
1.39
1.36
1.39
1.36
1.36
1.31
1.20
1.21
1.13
1.03
1.01
1.04
1.08
1.00
2000
2001
2002
2003
2004
2005
Year
11
Despite progress in fighting cancer, racial disparities can grow.
The difference in black and white colorectal cancer death rates is
almost 50 times larger than in 1978.
Colorectal Cancer Death Rates
Per 100,000 population
35
30
White
Black
25
20
15
1973
1978
1983
1988
1993
1998
2003
12
Note: Data are age adjusted to the 2000 standard population. SOURCE: National Vital Statistics System--Mortality, NCHS, CDC.
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
Likelihood of being diagnosed with Stage III/IV breast
cancer vs. Stage I breast cancer
Insurance
Status
Private
1.0
2.9
Uninsured
2.7
Medicaid
Medicare, 65+
1.2
13
Note: Model adjusted for insurance type, race/ethnicity, age at diagnosis, income, proportion without high school degree, US census region, year of
diagnosis, and facility type. SOURCE: Halpern et al, 2007
Race and 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.
Odds ratio of receiving inappropriate treatment
Race/Ethnicity
White, Non-Hispanic
1.0
1.3
Mexican
1.5
Black, Non-Hispanic
Asian and Pacific Islander
0.9
1.7
American Indian/Alaska Native
14
SOURCE: Li et al. 2003. Differences in Breast Cancer Stage, Treatment, and Survival by Race and Ethnicity. Archives of Internal
Medicine. 163:49-56.
As 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.
Me dicaid
Me dicare , 65+
Me dicare , 18-64
Uninsure d
2001
2003
Private
% Receiving SLNB
70%
60%
50%
40%
30%
20%
1998
1999
2000
2002
2004
2005
15
Chen et al., Journal of Clinical Oncology 2008
Blacks are less likely than whites to use hospice services
prior to their deaths from cancer.
Percent
100
White
80
All P<0.001
60
46
44
40
Black
36
45
38
43
37
48
38
36
20
0
All cancers
Lung
Colorectal
Breast
Prostate
16
Virnig et al, Med Care 2002
Conclusion
• Eliminating disparities in cancer
screening, diagnosis, treatment, and
mortality is an essential step toward
improved health outcomes for all
Americans with cancer.
• Reducing cancer disparities can be
achieved by instituting cost-effective
public health programs that promote
overall wellness and save lives.
Thank You!