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. . .