Health disparities have been viewed as a chain of events signified by inequities or inequalities that result in differences in 1) environment (e.g., presence of sidewalks, crime rates); 2) access to, utilization of, and quality of care; 3) health status; and/or 4) health outcomes.1 Cancer disparities are defined as differences in the incidence, prevalence, mortality, and burden of cancer and related adverse health conditions that exist among specific populations in the United States. These populations groups may be characterized by gender, age, ethnicity, education, income, social class, disability, geographic location, or sexual orientation.1 This definition is evidenced by the fact that African Americans are more likely to develop and die from cancer than any other group. African American men have a 40% death rate and African American women an 18% higher rate compared to Caucasians.2, 3 In fact, death rates from prostate, stomach, and cervical cancer are more than twice the rates of Caucasians. Similarly, Hispanic/Latino populations have the highest incidence of cervical cancer (females) and are more likely to die from cancers of the liver and bile duct.2 These disparities are often masked by statistics that show the death rate from all cancers combined has decreased since 1993 by 1.5% per year among men and by 0.8% among women.3 What is even more alarming is the fact that these data represent aggregate data and do not account for differences in cancer incidence and mortality rates within these racial/ethnic groups. Thus, the disparities may actually be larger than what is visible on the surface. This missing piece of the discussion is critical, because it is often at this microlevel that cancer control strategies and interventions need to be implemented. However, perhaps Freeman4 stated it best when he wrote, “There is a disconnect between what we develop (i.e., technology, early detection, treatment modalities) and what we deliver” (p 72). So while decreases in cancer mortality rates may be evident, they have not eliminated the gap or disparities in cancer between the groups.
Thus, in 2006, we are still faced with Former Surgeon General Dr. David Satcher's charge to the nation to eliminate health disparities by the year 2010.5 It will come as no surprise that the nation has not yet achieved this goal. So what will it take to move the agenda forward? The answer to this question is far-reaching and well beyond the scope of this commentary. However, several key areas must be raised for discussion and resolution in order to eliminate disparities.
It must be acknowledged that, there is no single answer, no single intervention, no single person, entity, or organization that can fix, reduce, or eliminate cancer disparities in isolation. Instead, it is time to embrace, understand, and seek long-term sustainable strategies within a disparities elimination paradigm. This paradigm must encompass strategies targeting patients, providers, health care system barriers, access, financial barriers, and political, as well as cultural and historical barriers, to name a few, that in tandem contribute both independently and interdependently to these disparities. This paradigmatic view promotes a framework in which multiple partners (community, governmental, civic, business, political) can begin to speak the same language about disparities, develop common goals and objectives, and form action plans that capitalize on each group's strengths. The end result would be multiple groups working toward common goals and measurable outcomes in a unified manner. A benefit of this type of interagency collaboration is that the shared vision would allow each agency to carve out the piece of the plan that it is best suited to address given their overall organizational plan and resources. Well planned communication strategies could facilitate the collaborative work of these agencies, who would then share ownership and responsibility of the outcomes. Without this type of collaboration and integration, multiple agencies will spend countless resources working on the same small piece of the disparities agenda in isolation, frustration, and with limited success.
Second, it is important to recognize that factors such as poverty, culture, and social injustice are interrelated and play a critical role in cancer disparities above and beyond the role of poverty alone.4 For example, there should be little argument that poverty is associated with factors such as lack of resources, high risk behaviors, poor housing, inability to access care (e.g., finding providers, copayments, navigating systems), and lack of knowledge about cancer (e.g., resources, cancer information, literacy), to name a few. Further, one's culture (shared values, beliefs, communications, traditions, physical, and social environments) also influence how cancer is perceived.4, 6 This influence cannot be explained and/or changed by increasing one's income. Intertwined with poverty and culture is the influence of social injustices such as racism and discrimination, which are believed to play a role in creating and maintaining health disparities.4, 7–10 For example, even when economic and insurance status are equal to that of Caucasians, African Americans are less likely to receive state-of-the-art care, so that income or poverty in isolation does not adequately explain or offer a solution to disparities.4, 11
Third, in order to eliminate disparities resources must be allocated to initiate, support, and maintain programs and initiatives focused on research, demonstration projects, community services and programs, health literacy, technology, and capacity building within communities, to name a few. For example, it is not sufficient to have 1 African American or Hispanic/Latino on staff and send them to their respective communities and expect these single interventions to change the disparate conditions. Instead, all staff, regardless of race/ethnicity, must embrace this issue as an organizational priority. While in some situations, it is desirable to have workers of the same racial/ethnic group, it is imperative to recognize that culture differs even within racial/ethnic groups, and all workers should be equipped to effectively interact within these settings. Efforts to promote racial/ethnic diversity in leadership positions of organizations are critical. It is time to move beyond having racial/ethnic minorities relegated to leadership positions that focus only on ‘disparities’ or ‘diversities,’ but rather this talented pool of racial/ethnic minorities should be appointed to leadership positions (e.g., CEO, medical director, vice-president, chairman of the board) throughout these organizations. This way, there is a greater integration of diverse ideas from racial/ethnic minority groups, which can strengthen the organization and facilitate elimination of disparities as a ‘way of organizational life’ and does not relegate this objective to the responsibility of a particular person or group.
Lastly, more resources are needed to mentor, train, and support (e.g., grant funding) researchers who represent racial/ethnic minority groups. The body of research surrounding disparities and the unique needs of racial/ethnic minority groups are increasing but lags well behind other areas of research. Although the need for descriptive research continues, the questions that are being asked and answered require careful review. For example, it is not enough to ask if African Americans, Hispanic/Latinos, and Caucasians have different rates of participation in colorectal cancer screening. The literature supports the answer ‘no’ to this question. It is now time to move this level of inquiry forward to testing the data collection tools to make sure they are reliable in communities of color, employing methodologies to aid in the recruitment of persons of color, testing interventions among samples that include at least 40–50% or more of persons of color, and investing in scientists from underrepresented groups to join with their colleagues in the development, implantation, and interpretation of these data.
The American Cancer Society has identified the elimination of cancer disparities as a pillar that supports and cuts across its national leadership roles and objectives. Recognizing the need to further understand the state of the science regarding cancer disparities, the Society convened the conference, Exploring Models to Eliminate Cancer Disparities among African American and Latino Populations: Research and Community Solutions on April 21–22, 2005. This conference marked the first time that the Society brought together researchers and community groups within this type of forum to address these issues. The 1½ day conference opened to a capacity crowd with a reception and presentation of 32 posters addressing topics such as use of community health advisors to increase mammography screenings among African American women; the training of lay health advisors (promotoras) to reach Latino populations; and enhancing recruitment and retention of breast cancer patients for improved treatment adherence and outcomes. Keynote speakers for the plenary sessions were David Satcher, MD, PhD, US Surgeon General from 1998–2002 and interim president of the Morehouse School of Medicine, Atlanta, Georgia; Elmer Huerta, MD, MPH, founder and director, Cancer Preventorium, Washington Cancer Institute, and a vice president of the American Cancer Society's National Board; and Mark McClellan, MD, PhD, administrator of the Centers for Medicare and Medicaid Services. Breakout sessions featured research and reports on best practices for a variety of interventions to reduce disparities. This supplement to Cancer contains the peer-reviewed reports of some of the work presented at this inaugural conference. A complete list of the titles and authors of all of the presentations is included in the Agenda.