the causes and consequences of cancer health disparities · cause of the cancer differs across...
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The Causes and Consequences of Cancer Health Disparities
Bríd M. Ryan, PhD, MPHLaboratory of Human Carcinogenesis,
Center for Cancer Research, [email protected]
TRACO 2017
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Overview
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Race and Ethnicity
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Health Disparities in the United States
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Disparities
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Definition
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Black White
Hispanic
A/PIAI/AN
Incidence Rates by Race/Ethnicity and Sex, U.S., 1999-2012
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Younger age at diagnosis for most cancers
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Younger age at diagnosis for most cancers
Cancers mainly diagnosed at younger age in black men and womenNHL, anal cancer, Kaposi sarcoma and soft tissue
Etiologic heterogeneity Cause of the cancer differs across groups, causes cancer at different agesSubtypes can be caused by different factors – can contribute to disparities
Timing or intensity of exposureFor example, exposure to tobacco could occur earlier in one population
Timing, prevalence and frequency of early cancer detectionScreening, or through follow after an incidental finding
NCI Early Onset Malignancy InitiativeThe Center for Cancer Genomics (CCG) in collaboration with the Division of Cancer Prevention’s NCI Community Oncology Research Program (NCORP) invited the twelve Minority/Underserved NCORP sites to participate in this project
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s
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Cancer Health Disparities: Second cancers
African Americans also have a higher risk of certain second cancersSite-specific risk of second primary cancer in women with endometrial cancer according to race (1973-2007)
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Mortality Rates by Race/Ethnicity and Sex, U.S., 1999-2012
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AA vs. EA
Hispanic vs. EA
Asian vs. EA*
s
merican
r
Survival Health Disparities by Cancer Site African Americans have the highest rate of cancer specific mortalityRacial differences are not reducing over time (overall)Breast cancer—disparities might be increasingProstate cancer—disparities might be improving
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Contributing factors are multifactorial
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Geographical factors contribute to cancer disparities
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Geographical factors
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Rural-urban disparities in cancer incidence
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Rural-urban disparities
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Rural-urban cancer disparities
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Tobacco disparities
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Tobacco disparities
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Tobacco disparities
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Tobacco disparities
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➢ Racial differences in continued smoking may be attributable to several factors Socioeconomic vulnerabilities (including poverty, stress, and secondhand smoke exposure)
Although the majority of black smokers express a desire to quit, they are less likely to receive and use evidence-based treatments (e.g., screening for tobacco use and advice to quit, smoking cessation pharmacotherapy, and counseling).
In addition, black smokers are less likely to enroll in smoking cessation trials.
Black smokers are more likely to smoke mentholated cigarettes, which might be harder to quit than nonmentholated cigarettes, which leads to poorer cessation outcomes
Less accurate knowledge about the risks and prevalence of smoking and about the benefits and risks of effective smoking cessation treatments.
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Disparities in cancer mortality
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➢Some of the reasons for disparities in cancer mortality: Access to screening? Possibly for some cancers
Breast cancer mammography use similar in equal access to care setting (Cancer 2013 Oct 1;119(19):3531-8)
Colorectal cancer screening is lower among African Americans even in an equal access to care setting (Cancer. 2013; 4(3): 270–280)
Uptake of screening for other cancers, such as HPV, may also be lower in minority populations
But the differences exist even in cancers where there is no validated screening modality (liver, esophagus, etc)
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Lung cancer screening
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Access to care
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Access to care
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Access to care
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Oncologist map
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Uptake of care
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Uptake of care
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➢Perception and Behavior African Americans were more likely to hold beliefs about lung cancer that could interfere with prevention and treatment (Health Information National Trends Survey)3 times less likely to get a lung cancer check up
2 times more likely to expect symptoms before diagnosis
2 times less likely to agree that getting checked for lung cancer could help find the disease early
Perceptions expressed unlikely to affect lung cancer incidence – more related to outcome
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➢Potential factors that influence uptake of care Personal beliefsFearCulturePatient-doctor relationshipPatient biasProvider biasPatient-doctor communicationCo-morbid conditions
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Quality care
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Disparities persist
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Is biology a contributing factor
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Biological factors
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Prostate cancer
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Genetic susceptibilityRacial differences in prevalence of 8q24 prostate cancer susceptibility variants (~ 50%)
Admixture mapping identified 8q24 as a locus of increased risk for African-American men when compared to European-American men (PNAS 2006, 103: 14068-73)Risk alleles are more common among African-American men, leading to the highest population attributable risk conferred by 8q24 in this population (Nat Genet 2007, 39: 638 – 44 & 954 – 6)Excess of African ancestry at 8q24 (Hum Genet 2009 Nov;126(5):637-42)Risk variants rs114798100 and rs111906923 are only found in men of African descent (JNCI 2016 108 (7))
Racial differences in prevalence of 17q21 prostate cancer susceptibility variants (~ 10%)Risk alleles of a new locus, rs7210100 are more common in populations of African descent (Nat Gen 2011, 43: 570-573)
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Germline genetics
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Germline genetics
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Germline genetics
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➢Germline Genetics Increased proportion of Native American ancestry is associated with increased risk of childhood acute lympoblastic leukemic
Screening implications
Also related to treatment—Children with more than 10% Native American ancestry need an additional round of chemotherapy to respond to the treatment (Yang et al., Nature Genetics 2011 43(3); 237-241)
Ancestry informative markers provide a greater granularity to studying race in genetic and genomics studies
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Somatic genetics
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Somatic genetics
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Molecular subtype
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Molecular subtype
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Transcriptome
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Cell Biology
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Different biomarkers
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Key determinants
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Summary
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Rural-urban disparities