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Keywords:

  • AANCART;
  • cancer;
  • Asian;
  • disparities;
  • pilot study

Abstract

  1. Top of page
  2. Abstract
  3. REFERENCES

The landmark Institute of Medicine Report on the “Unequal Burden of Cancer” urgently called for efforts to reduce cancer disparities by conducting research that could rapidly translate laboratory and clinical findings to benefit large segments of society. It also called for intensifying efforts to produce well-trained minority researchers as a way to increase the quantity, quality and community relevance of cancer control research. This manuscript summarized our strategies and successes in these two areas. Over a five year period, the Los Angeles site of the NCI-funded Asian American Network for Cancer Awareness, Research, and Training (AANCART-LA) conducted intensive community based cancer awareness activities through a coalition of over 20 Asian serving community organizations. In addition, a major focus of AANCART-LA was on increasing community-relevant research and on training scientists to conduct research among Asians. Strategies to reach these goals included a focus on pilot studies as a way of introducing the community to research, selection of promising junior scientists to submit applications for pilot funding, and close mentoring of these individuals by seasoned investigators. We describe four pilot project proposals that were selected for funding by the NCI peer review process. In addition, AANCART-LA was able to obtain peer reviewed funding for several other research projects targeting a variety of Asian sub-groups. These projects were the direct outcome of extensive cancer awareness activities in the community, the publicity associated with receiving peer-reviewed pilot project funding, and the collaborations established with multiple community based organizations. Cancer 2005. © 2005 American Cancer Society.

Racial and ethnic disparities in cancer incidence, morbidity, and mortality continue to persist, posing a significant challenge to the medical and public health communities to address these inequities. Considerable professional and public attention has been focused on the issue of cancer disparities in recent years, and multiple national, regional, and local agencies and bodies have made recommendations regarding steps that can be taken to tackle this problem.1–5 The landmark Institute of Medicine Report on the “Unequal Burden of Cancer” urgently called for cancer control efforts to reduce disparities by conducting state-of-the-art research that could rapidly translate laboratory and clinical findings to population-based approaches that would reach large segments of society.6 This report also drew attention to the disproportionate underrepresentation of ethnic minority individuals among the ranks of cancer control researchers. It called for intensifying efforts to produce well-trained minority researchers as a way to increase the quantity, quality, and community relevance of cancer control research.

In an effort to stimulate cancer research among minority populations, the National Cancer Institute (NCI) funded 18 Special Populations Networks (SPNs) around the country, of which the Asian American Network for Cancer Awareness, Research, and Training (AANCART) is one. AANCART is comprised of five centers, located throughout the country, that focus on multiple Asian subgroups. The Los Angeles site of AANCART conducted intensive community-based cancer awareness activities through a coalition of more than 20 community-based organizations that serve the Asian community. However, awareness alone is not sufficient to eliminate the disparities in cancer incidence, morbidity, and mortality in these communities. Therefore, a major goal was to simultaneously create an appreciation for the value and importance of conducting rigorous cancer control research among Asians as a way to learn about the most effective and efficient means to reduce the disproportionate cancer burden in this community. Taking this approach, AANCART-LA was particularly successful in achieving the ‘research’ and ‘training’ goals of the larger AANCART effort, and therefore we highlight our activities in these areas as our ‘best practices.’

One of our first decisions was to launch a series of small pilot projects to gather preliminary data that could be used to seek larger full-scale research project funding. The limited scope of the pilot projects was seen as an ideal mechanism to introduce our community partners to the intricacies of conducting research. We also considered the pilot project mechanism to be an ideal opportunity for providing research training to minority postdoctoral individuals, particularly those with Asian ancestries. The decision to initially pursue pilot project funding was also driven by the availability of such funding from multiple sources. At the University of California, Los Angeles (UCLA), the Jonsson Comprehensive Cancer Center provides peer-reviewed (internally within UCLA) funding for pilot projects. In addition, the NCI instituted a pilot project program for investigators affiliated with funded SPNs. Applications are submitted through individual networks and receive national peer review through an NCI special emphasis panel.

A common method for soliciting ideas for pilot projects is to ask interested investigators to submit concept papers, and then select one or more concept paper applicants for submission of full proposals. AANCART national used this strategy, whereby regional sites were asked to submit concept papers that were reviewed by the national Steering Committee, to determine which concept papers would be invited to write full proposals for submission to NCI. Although we have used this process in prior projects at UCLA, for the special situation presented by AANCART-LA we made a decision not to use this strategy to determine which concept papers would be submitted from UCLA for consideration by the Steering Committee. Instead, the senior faculty on the project identified a junior Asian American postdoctoral individual whom we judged to be the most ready to write a pilot project proposal and invited the individual to submit a concept paper to the larger AANCART group for consideration. Our reasoning, based on past experience, was that, given the very small number of eligible individuals, it would not be wise to create expectations that may not materialize, thus generating disillusionment. Also, we were concerned about engendering an atmosphere of competition among a very small group of junior scientists at the very start of a major project. Finally, and perhaps most important, there were real differences in academic preparation among eligible individuals, so it seemed reasonable to select the most prepared person in each round. Our strategy was very effective in that, in each of the first 4 years of AANCART, the pilot concepts submitted by UCLA were selected by the national Steering Committee for full proposals, and the proposals submitted were selected for funding by the NCI peer-review process. These projects are described in more detail below.

Another very important ingredient in our success strategy was the close mentoring each selected individual received in the preparation of the concept paper and the full research proposal. Each junior investigator was paired with a senior faculty member who had an extensive history of NIH-funded research. The mentor provided guidance in every aspect of the process, from conceptualization of the study to focusing the research questions, to finalizing a feasible scope of work and writing a credible application, including budget and budget justification, and human subjects concerns. Upon funding, mentoring continued at the same level of intensity and involved all aspects of getting a project off the ground, completing the work, and preparing manuscripts based on study findings. In addition to the primary mentor, a deliberate attempt was made to expose the pilot project principal investigator (PI) to a wide range of other faculty members engaged in cancer prevention and control research. A final key aspect of our mentoring strategy involved formulating plans for, and pursuing, additional research funding opportunities as steps toward achieving research independence on the part of the junior investigator. Below, we briefly describe the investigators and the projects that received pilot funding.

In the first call for pilot projects, Ninez Ponce, Ph.D., was funded to conduct a study examining macroeconomic factors that may impact vulnerable groups entitled “Does Competition Equally Benefit Minority Groups? An Examination of Competition's Effect on Colorectal Cancer Screening.” Dr. Ponce is a health economist and Assistant Professor at UCLA School of Public Health. The project examined whether competition in the health insurance market has an effect on colorectal cancer screening and whether there is a differential effect by race and ethnicity. The hypothesis was that while competition can raise the quality of care for certain groups who benefit from more choices—because they can assimilate this information and are able to navigate an increasingly complex healthcare system—it may leave other more vulnerable groups behind. Dr. Ponce explored this hypothesis using data from one of Dr. Bastani's studies that had recruited a large and ethnically diverse population-based sample of first-degree relatives of colorectal cancer cases. Findings from Dr. Ponce's study suggest that controlling for individual characteristics including income, insurance coverage, and percent lifetime in the U.S., even in this high-risk group, a higher percent of staff and group model Health Maintenance Organizations (HMOs) within a metropolitan statistical area (MSA)-bound market area lowers the likelihood of Asian Americans and Pacific Islanders (AAPIs) ever having received a sigmoidoscopy or colonoscopy in the past 5 years. A similar finding was not observed for other ethnic groups. This finding among AAPIs is in contrast with conventional wisdom, which suggests that group model HMOs are more likely to promote cancer screening for all ethnic groups.7 Not only did this pilot project lead to a noteworthy new finding, it provided the preliminary data that enabled Dr. Ponce to secure a 5-year Mentored Research Career Development Award (K07) from the NCI (2004), in which she will study the effects of socio-ecological factors on a variety of cancer screening behaviors using data from the population-based California Health Interview Survey. This is a success story for AANCART, and exactly the outcome that NCI envisioned in providing funding for the SPN initiative and the associated pilot project program.

In the second call for pilot projects, Angela Jo, M.D., M.S.H.S., received funding for a project entitled “Understanding Colorectal Cancer Screening among Korean-Americans.” Dr. Jo is a junior scientist at the UCLA Jonsson Comprehensive Cancer Center and a staff physician at the Korean Health, Education, Information, and Research (KHEIR) center, a community health center located in the Koreatown area of Los Angeles. Being a first-generation Korean American who is fluent in Korean, she is in an excellent position to conduct cancer control research in this population. Through the pilot project, Dr. Jo conducted interviews with six healthcare providers with mostly Korean American patients and found that most did not routinely recommend colorectal cancer screening. Reasons included lack of knowledge of screening guidelines, lack of a referral network, the potential hassle of false-positive findings, and the perception that Korean American patients would refuse preventive colorectal cancer screening because of embarrassment and lack of understanding of the concept of ‘preventive screening tests.’ Focus group discussions with a community sample of 180 Korean Americans age 40–70 years, however, suggest that they would obtain screening if their physician recommended it, despite being embarrassed.8 Other potential barriers to screening were also identified. Dr. Jo is currently pilot testing several intervention modalities for application in this population. In addition, she has received funding to educate primary care residents regarding the importance of cancer screening for their patients. Dr. Jo is now a clinical instructor at UCLA, continues to be involved in several research projects in our group, and is in the process of preparing a K07 application focusing on Korean churches as the vehicle for intervention delivery.

In the third call for pilot projects, Clifford Ko, M.D., M.S.H.S., was funded for a project entitled “Understanding Disparities in Colorectal Cancer Outcomes.” Dr. Ko is a colorectal cancer surgeon with a Master's degree in public health and an interest in cancer-related outcomes research. His project aims to first determine whether there are racial/ethnic disparities in the type and extent of treatment (e.g., surgery, chemotherapy, radiation) that patients receive for colorectal cancer. Once disparities in care are identified, the second phase of the study will attempt to determine whether and to what extent the disparities in care are related to disparities in cancer outcomes such as survival, mortality, local recurrence, complications, length of hospital stay, etc. While many studies have examined disparities in cancer care or cancer outcomes, what is unique about this study is that it will attempt to understand the pathways through which race, ethnicity, socioeconomic status, urban-rural residence, and other variables influence disparities in survival and mortality outcomes. The data for the project was obtained from two statewide population-based datasets: the California Cancer Registry and the Office of Statewide Health Planning and Development. The first phase of the study is complete, and results indicate that disparities do exist in several indicators of quality of care, such as appropriate adjuvant therapy. Analyses for Phase 2 are ongoing. Since receipt of this pilot funding, Dr. Ko was promoted to Associate Professor in the Department of Surgery at the UCLA School of Medicine. He has also received additional funding to expand his research in new directions.

The fourth pilot project is a departure from our philosophy of mentoring junior investigators, but nevertheless represents achievement of our goals to create an interest and capacity in the community for conducting research and draw senior investigators into focusing their research efforts on Asians. As a result of our extensive awareness activities in the community, and the fact that Dr. Jo's pilot project was funded, we were approached by KHEIR to identify a faculty member who could work with them on a tobacco-related project. This resulted in collaboration between William McCarthy, Ph.D., from UCLA and Soo-Young Chin, Ph.D., from KHEIR. Dr. McCarthy is an Associate Professor at the UCLA School of Public Health. Dr. Chin is the Director of Development and Research at KHEIR. They successfully competed in the fourth call for pilot projects with a study entitled “Eastern versus Western Ways to Quit Smoking in Korean Americans.” This project was Dr. McCarthy's first opportunity to focus on an Asian population. The project will pilot test two smoking cessation programs by randomly assigning eligible male Korean American smokers to each condition and follow them up at the end of treatment and again 5–6 months later. Dr. McCarthy subsequently formed a research partnership with the South Asian Network to win a contract from the State of California to conduct surveillance of adult Asian Indian tobacco use in the state. Dr. Chin is collaborating with UCLA on another project, with Annette Maxwell, Dr.P.H., that will develop and pilot test an intervention to increase repeat mammography screening among Korean women at KHEIR's breast screening program.

In addition to the four pilot projects, AANCART-LA was able to obtain peer-reviewed funding for several other research projects targeting a variety of Asian subgroups. These projects were the direct outcome of our extensive cancer awareness activities in the community, the publicity associated with receiving pilot project funding, and the collaborations we established with multiple community-based organizations. These relationships created an environment of trust between UCLA-based investigators and community agencies that facilitated the development of joint projects. In fact, as indicated above, in many cases it was the community-based organizations that approached AANCART-LA seeking collaboration to conduct research that they identified as being relevant for their particular constituencies.

Examples of research studies include:

  • Needs assessment among South Asians living in Southern California (South Asian Network and Bastani/Glenn).

  • A population-based tobacco survey among Asian Indians (South Asian Network and McCarthy/Bastani/Maxwell).

  • A study to understand factors related to repeat mammography receipt among Koreans (KHEIR and Maxwell/Chin/Bastani/Jo).

  • A pilot study to understand why Asian women do not participate in genetic testing for breast cancer risk (multiple community organizations and Bastani/Glenn).

  • A pilot project to understand hepatitis B and liver cancer awareness among Koreans (KHEIR and Bastani/Glenn/Maxwell/Jo).

  • A needs assessment with South Asian breast cancer survivors (Saath: South Asian Cancer Foundation and Glenn/Bastani).

  • A P01 proposal submitted to NCI to conduct liver cancer prevention interventions within multiple Asian communities (multiple community organizations and investigators from UCLA, UCSF, UC Davis, and the Fred Hutchinson Cancer Center).

  • A study to increase adherence to follow-up of breast abnormalities in Korean women (KHEIR and Maxwell/Jo/Bastani).

  • A survey to understand tobacco use among Filipino men (Filipino American Service Group and Maxwell/Berman).

  • A pilot study to increase repeat mammography screening among Filipino women (Asian Pacific Health Care Venture, Queens Care Clinic, and Maxwell/Berman).

  • A randomized trial to increase colorectal cancer screening among Filipino Americans (Filipino American Service Group and Maxwell/Bastani).

In conclusion, we were successful in training new investigators and in attracting senior investigators to the field of Cancer Prevention and Control in Asian populations with the help of the pilot projects funded by the NCI's Special Population Network. We believe that the choice of pilot investigators, the mentorship we provided, and the topics of their research proposals all contributed to this success. When inviting junior investigators to apply for a pilot project, we selected those with an outstanding track record and high potential for launching a successful research career. In each instance, we matched the junior investigator with a senior researcher and mentor who had an interest in the subject matter and extensive prior research experience. Although considerable time and effort is required to adequately mentor junior investigators, we believe it is well worth the effort. Training the next generation of scientists interested in working in the Asian community, especially Asian American scientists, is critical if we are to be successful in reducing cancer health disparities in this population.

REFERENCES

  1. Top of page
  2. Abstract
  3. REFERENCES
  • 1
    Los Angeles County Department of Health Services and UCLA Center for Health Policy Research. The Burden of Disease in Los Angeles County, January 2000.
  • 2
    Los Angeles County Department of Health Services, Office of Women's Health. Cervical Cancer Prevention and Education Initiative, January 2002.
  • 3
    Office of Statewide Health Planning and Development, State of California, Equitable Healthcare Accessibility for California, November 2000.
  • 4
    National Cancer Institute. The nation's investment in cancer research: reducing cancer-related health disparities. Bethesda: National Institutes of Health, 2003.
  • 5
    US Department of Health and Human Services. Healthy people 2010: understanding and improving health, 2nd edition. Washington, D.C.: U.S. Government Printing Office, 2000.
  • 6
    HaynesA, SmedleyBD, editors. The unequal burden of cancer: an assessment of NIH research and programs for ethnic minorities and medically underserved. Washington DC: National Academy Press, 1999.
  • 7
    Ponce NA, Huh S, Bastani R. Health care market structure and colorectal cancer screening among high risk Asians and Pacific Islanders. Fourth Annual Asian American Network in Cancer Awareness, Research, and Training (AANCART) Academy hosted by AANCART-Los Angeles, October 25, 2003.
  • 8
    Jo AM, Maxwell AE, Bastani R. Understanding colorectal cancer screening among Korean immigrants. Fourth Annual Asian American Network In Cancer Awareness, Research, and Training (AANCART) Academy hosted by AANCART-Los Angeles, October 25, 2003.