From OncoLog, February 2011, Vol. 56, No. 2
Addressing Cancer-Related Health Disparities
By Zach Bohannan
Many people know that risk factors like smoking can cause cancer, but few can explain why cancer incidence and mortality rates vary among ethnic minority and underserved populations.
Understanding these variations and developing targeted policies and interventions to reduce disparities are two of the main goals of health disparities research.
Once people are aware that different ethnic populations have different cancer rates, the first cause that comes to mind is genetics. However, “our best estimation is that biology accounts for only 10%–20% of cancer-related health disparities,” said David Wetter, Ph.D., the chair of the Department of Health Disparities Research at The University of Texas MD Anderson Cancer Center. Consequently, the growing field of health disparities research includes a focus on potential risk factors, such as behavior and socioeconomic status. The breadth of this subject makes the research very diverse, although much of the research—especially that involving cancer—is focused on the effects of lifestyle alteration and outreach programs. “Although there is a genetic component to health disparities,” Dr. Wetter said, “the far more relevant factor is societal influence.”
Health disparities research
Often, the first step to understanding health disparities is to quantify their effects. For example, Melissa Bondy, Ph.D., a professor in the Department of Epidemiology, recently published a report on the incidence of breast cancer in Mexican-American women. She and her colleagues found that although Mexican-American women experience a lower overall incidence rate of breast cancer, the breast cancers they do have are much more likely to be early-onset breast cancer than those in other portions of the population. However, the latest U.S. Preventive Services Task Force guidelines for breast cancer screening recommended increasing the initial mammography age from 40 to 50 years. These recommendations may be appropriate for a general population, but when universally recommended, they may miss early-onset breast cancers in Hispanic women.
Although this early onset of breast cancer may have a genetic component, health disparities researchers are careful to distinguish between biology and race. As Lovell Jones, Ph.D., the director of the Center for Research on Minority Health and a professor in the Department of Molecular Biology and Biochemistry and the Department of Health Disparities Research, said, “Race is a social construct and has little to no meaning genetically.”
Taking research to the community
Besides biology, health disparities research also encompasses a variety of community and cultural research. One of the goals of the Center for Research on Minority Health is to help integrate these diverse studies. The center supports a wide range of programs designed to investigate and enhance minority health. Many of these programs are outreach-oriented. For instance, the center is currently administering a program to explore the genetic and cultural similarities and differences between African American communities and West African communities in an attempt to research the genetic causes of breast cancer and educate women about breast cancer’s risk factors and warning signs.
Dr. Wetter’s research also is aimed at designing, evaluating, and disseminating behavioral interventions. For example, some of his current studies focus on improving the effectiveness and reach of smoking-cessation help lines (quitlines) among underserved populations such as Hispanic smokers and smokers of low socioeconomic status. Quitlines provide behavioral counseling and, in many cases, pharmacotherapy. Unfortunately, quitlines are grossly underutilized by underserved populations. Research partnerships with organizations such as the Harris County Hospital District seek to dramatically expand quitline utilization among the underserved.
Another key area for concern among health disparities researchers is the prevalence of false or misleading beliefs among some populations about the nature of cancer and cancer treatment. Such beliefs can often persist despite contradictory evidence. Unfortunately, false beliefs lead many underserved populations to select substandard treatment options or to avoid treatment entirely. Furthermore, many individuals are reluctant to participate in clinical trials for historical reasons associated with unethical human experimentation. Fortunately, the trend of reluctance may be reversing, according to Harry Gibbs, M.D., the Chief Diversity Officer at MD Anderson. For example, a series of focus groups revealed that although older African Americans are reluctant to participate in clinical trials because of the infamous Tuskegee Syphilis Study, younger African Americans do not share the same reluctance.
These types of focus groups help health professionals understand the cultural beliefs of patients and study participants from all walks of life. And when these beliefs are understood, researchers can develop targeted programs to enhance patient recruitment for clinical trials.
A clear example of effective targeted recruiting is MD Anderson’s Minority and Women Clinical Trials Recruitment Program, which assists researchers in designing programs to increase the appeal of clinical trials to a broad cultural spectrum and then attempts to retain underserved populations in those trials. Dr. Wetter said, “Once they arrive at MD Anderson, underserved individuals show similar rates of participation in clinical trials relative to other populations.”
Breaking through barriers
Although clinical trials don’t always mean more successful treatment, they do often foster communication between patients and doctors or nurses. For instance, Dr. Jones described a clinical trial in which a diabetic patient from an underserved community insisted he was controlling his blood sugar even though his doctors believed he was noncompliant. After some investigation, the doctors and researchers realized that the patient didn’t have a refrigerator, so he had been given insulin and was injecting it, but without refrigeration, its effectiveness decreased to zero in a few days. “Doctors don’t have any government authority to ensure compliance,” Dr. Gibbs said. “We have to build trust with our patients.”
Another common barrier to the treatment of underserved populations is cultural differences between patients and health care providers. Dr. Gibbs emphasized the importance of cultural understanding, especially when end-of-life issues may arise. One of the many successful programs Dr. Gibbs has overseen is a nursing workshop devoted to these issues. Health disparities research can enable health care professionals to understand and accommodate the various beliefs about end-of-life and other treatment-related issues that may be encountered in a comprehensive cancer center.
Ultimately, the goal of health disparities research at MD Anderson is to eliminate avoidable differences in cancer incidence, morbidity, and mortality among various population groups, whether those groups are defined by socioeconomic status, race, ethnicity, gender, location, or other factors.
For more information, contact Dr. Melissa Bondy at 713-794-5264, Dr. Harry Gibbs at 713-563-5367, Dr. Lovell Jones at 713-563-2764, or Dr. David Wetter at 713-745-2682.