Toward the Elimination of Cancer Disparities

Thesocietalburdenofcancerisoneofthemajorpublichealthchallengesofour time. Yetthatburdenisnotequallysharedbyall. Troublingdisparitieshave been documented not only by racial/ethnic group but also by social class, insurancestatus, geography, andahostofotherdimensions. Furthermore, suchdisparitiesrepresenttheendresultofaconstellationofforcesstemming frominsideandoutsidethehealthcaresystem. Manycancerdisparitiesshould bepreventable. Fewhaveattemptedtocapturethebreadthanddepthofthedimensionsof cancerdisparitiesfrombothclinicalaswellaspublichealthperspectives. To addressthisneed, wepresentthisvolumeto: broaden concepts of disparities beyond traditional discussions of race/ ethnicitytoexplorehow, where, andwhytheyoccur; focusoncancerdisparitiesintheUS, whilecitingsomemajorexamplesfrom abroad; analyzecertainmajorcancerswithrespecttodisparities, withemphasison socioeconomicposition; examinethesourcesofdisparitiesfrombothinsideandoutsidethehealth caresystem; identifyinitialinterventionsthatattempttoreduceandeliminatethesed- parities;and identifyissuesthatdeserveattentionwithrespecttofutureresearch. Ourmonographaddressescancerdisparitiesacrossthecontinuum(fromp- vention to mortality and by the domains of social inequality). We begin by exploringbroaddimensionsuchasdefinitionsofdisparities, datasystems, the roleofgenesandenvironment, andtheroleofworkandoccupationincancer disparities. Thenwemoveintospecificchallengesincancerdisparitiessuchas tobaccouseandlungcancer, breastcancer, colorectalcancer, prostatecancer, cervicalcancer, melanoma, andhepatocellularcarcinoma. Wethenconcludewith someavenuestoaddresscancerdisparities, includingpolicyandadvocacy, health v vi Preface communication, overcoming barriers to cancer care, and community-based approaches. Oureffortsarefarfromexhaustive, buttheyrepresentoneofthe firstattemptstoaddresscancerdisparitiesfromsuchacomprehensiveperspective. Thisvolumereflectstheworkofanumberofnationalexpertsincancer disparities. Many are members of the Executive Committee of the Cancer Disparities Program-in-Development of the Dana-Farber/Harvard Cancer Center. Still others are also investigators in the National Cancer Institute Community Network Program MassCONECT (Massachusetts Community NetworkstoEliminateCancerDisparitiesthroughEducation, Researchand Training). Also, thisvolumeupdatesandexpandsaearlier2005monographon thetopicpublishedinthejournalCancerCausesandControl. Allauthorsare dedicatedtothegoalofeliminatingcancerdisparitiesandIamindebtedto them. IamparticularlygratefultoRachelWarren, TerraZipoyrnSnider, andDr. ClaudiaArriggfortheirunendingencouragementandsupport. Itismyhope thatthismonographrepresentsanothercontributiontowardhelpingallpeople enjoytheirhighestattainablestandardofhealth. Boston, MA HowardK. Koh, MD, MPH Contents PartI DimensionsofCancerDisparities 1 Defining, Investigating, andAddressingCancerInequities: CriticalIssues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 NancyKrieger, KarenM. Emmons, andDavidWilliams 2 CancerDisparities: DataSystems, Sources, andInterpretation. . . . . 29 BarbaraD. Powe, AhmedinJemal, DexterCooper, andLokieHarmond 3 Genes, Environment, andCancerDisparities. . . . . . . . . . . . . . . . . . . 49 AlexandraE. Shields, StephanieM. Fullerton, andKennethOlden 4 WorkandOccupation: ImportantIndicatorsofSocioeconomic PositionandLifeExperiencesInfluencingCancerDisparities. . . . . . 83 GlorianSorensen, GraceSembajwe, AmyHarley, andLisaQuintiliani PartII SpecificChallengesinCancerDisparities 5 DisparitiesinTobaccoUseandLungCancer. . .

The societal burden of cancer is one of the major public health challenges of our time, yet that burden is not equally shared by all. Troubling disparities have been documented not only by racial/ethnic group but also by social class, insurance status, geography, and a host of other factors. Furthermore, such disparities represent the end result of a constellation of forces stemming from both within the health care system and outside of it. Many currently existing cancer disparities are preventable.

To date, few publications capture the breadth and depth of the dimensions of cancer disparities from both the clinical and public health perspective. This volume broadens concepts of disparities beyond traditional race/ethnicity discussions to explore a more systematic analysis of how, where, and why disparities occur across the cancer continuum.We will also analyze the issue of social disparities with respect to certain major cancers, with emphasis on the particular role of socioeconomic position.

This volume reflects the work of a number of experts in cancer disparities, led by members of the Executive Committee of the Program-in-Development for the Dana Farber / Harvard Cancer Center. In particular, this volume updates and expands an earlier 2005 monograph on the topic published in the journal Cancer Causes and Control (Nancy Krieger PhD, Editor).