(left to right) Sharon Kibwana, MPH, health program analyst; Diane R. Brown, PhD, executive director, professor; Denise C. Fyffe, PhD, MA, senior research associate; Joanne K. Fagan, PhD, MPH, director of research, assistant professor, all from the Institute for the Elimination of Health Disparities at UMDNJ, SPH.

Disparities in cancer morbidity and mortality rates by Diane R. Brown

C

ancer is a major cause of morbidity and mortality among New Jersey residents and is largely associated with aging. Cancer death rates are highest among those 65 years and older, but the burden of cancer is not distributed equally among subgroups of the population. Racial and ethnic minority groups experience a greater incidence and mortality for most cancer sites, although the rates vary by subgroup of the population. A very racially and ethnically diverse state, New Jersey is consistently ranked among the 10 highest in the nation for cancer morbidity and mortality.

In New Jersey, major disparities exist in the following cancers:

Prostate: Prostate cancer rates among African-American men are particularly high. According to the most recent tumor registry data, the age-adjusted incidence rate per 100,000 persons was 202.9 for white men and 280.8 for African-American men in 2002, and in the same year the age-adjusted death rate was 23.8 for white men and 58.1 for African-American men.

Breast: While invasive breast cancer incidence rates are higher among white women (133.7 per 100,000) than African-American (113.3 per 100,000), the death rates are higher among African-American women (36.0 per 100,000) than white women (28.1 per 100,000).

Lung and bronchus: In 2002, the age-adjusted incidence rates for lung and bronchial cancer were 83.2 per 100,000 for Caucasian men and 103.3 for African-American men. In the same year, the age-adjusted mortality rates from lung and bronchial cancer were 64.6 for Caucasian men and 79.9 for African-American men. (Incidence rates were 58.5 for Caucasian women vs. 51.3 for African-American women, and mortality rates were 42.0 for Caucasian women vs. 41.0 for African- American women).

Colorectal: Between 1997 and 2001, the age adjusted death rates for colorectal cancer were 27.9 per 100,000 for African Americans, 23 for whites, 13.6 for Hispanics and 9.5 for Asians/Pacific Islanders.

Cervical: Data for Hispanic women from 2002 indicate a higher incidence rate of cervical cancer (15.5 per 100,000) in comparison to African-American and Caucasian women.

Liver: An emerging disparity is associated with the higher age-adjusted incidence rates of liver cancer for African-American men (11.0 per 100,000) compared to 7.0 for Caucasian men.

The causes of cancer disparities are complex and multifaceted; they encompass an interplay of biological, economic, social and cultural factors. Social and economic risk factors may stem from poor nutrition, physical inactivity, obesity and tobacco use, while low income, low education and lack of health insurance coverage diminish access to clinical services for early detection and treatment. For example, some minority women are less likely to use preventive services such as Pap tests, mammography, and clinical breast exams, and therefore are more likely to be diagnosed at a later and less treatable stage of cancer. Social factors such as racial discrimination and language barriers may also result in unequal healthcare treatment. At the same time, some minority individuals may hold cultural beliefs and engage in alternative health practices that contribute to health disparities.

We have focused our research on understanding some of the social and cultural factors that impact cancer disparities as well as developing and testing interventions that may improve cancer knowledge and screening, access to cancer care and survivors’ quality of life. Our approach also takes into consideration the life-span perspective on disparities, the higher rates of comorbidities in minority populations and the importance of community participation in finding feasible solutions.

Among our major research efforts is Project EXPORT, funded by NIH’s National Center on Minority Health and Health Disparities (NCMHD). The overall focus of EXPORT is to build capacity for the conduct of health disparities research designed to eliminate cancer disparities among minorities in New Jersey. A major research thrust is reducing prostate cancer among African-American men in Essex County, given their high rates of morbidity and mortality. In accomplishing this, we needed to be able to reach them with information and education about prostate cancer, to get them into screening, where appropriate, and to encourage them to participate in clinical trials. However, the population of African-American men is one that is often difficult to reach. Working with our community advisory group and our partners from New Jersey City University, we have utilized the geographic information system (GIS) to target locations for a prostate cancer intervention. The research has involved using census data on the geographic distribution of African-American men, 40 years of age and older, combined with data on the location of barbershops, churches and other community institutions. Outreach strategies using the GIS are being compared to other non-geographical-based efforts.

Proportion of Breast Cancer Cases with Advanced Disease by Age & Race

Because the population of New Jersey is very ethnically and racially diverse, efforts are underway to develop interventions and healthcare services that are culturally responsive to the needs of these residents. To better understand how to meet the needs of underserved residents and to address their barriers to cancer care, we conducted focus groups with African-American and Latino male and female residents in Newark. Questions were asked pertaining to: their knowledge of cancer symptoms and screening guidelines; awareness of services available in the community; screening, education and treatment services for breast, prostate, lung and colon cancer.

The major issues appeared to be lack of health insurance and lack of access to healthcare, mistrust of the healthcare system, low health literacy, and fear of a cancer diagnosis. For many participants, knowledge about cancer was acquired from family members and friends. While some sought information from physicians and nurses, others expressed suspicion toward health professionals because of cultural, racial and language differences. Fear of a cancer diagnosis was an impediment to seeking care. Participants were least informed about colon cancer, its symptoms, and procedures for screening. Awareness of clinical trials was also minimal. Our team’s next step is to utilize participants’ suggestions to develop interventions to improve awareness and facilitate access to cancer education, screening, and treatment services available to them.

Providing access to quality healthcare is viewed as critical to eliminating health disparities in minority populations. Quality healthcare is associated with early detection, increased patient satisfaction, more frequent physician interaction, increased patient involvement in the treatment decision process and increased satisfaction with treatment outcomes. One of our projects seeks to ascertain the extent to which African Americans with cancer receive different treatment and to determine if they are offered clinical trials as part of their treatment. With funding support from The Cancer Institute of New Jersey (CINJ), the project is a follow-up to several efforts undertaken in New Jersey to publicize and recruit persons into cancer clinical trials such as NJ Cancer Clinical Trials Connect and Project IMPACT. Working in collaboration with the NJ Cancer Epidemiological Services, we are identifying breast, prostate, and colon cancer survivors from the tumor registry and conducting a telephone survey of 100 African-American and 100 Caucasian cancer survivors diagnosed before and after major clinical trials initiatives. Findings from the study are expected to provide a basis for future interventions.

Breast cancer among minority women is another focus of our cancer disparities research, particularly related to late stage diagnoses. In 2000, 68 percent of the new cases of breast cancer in white women were diagnosed in early stages, compared with 60 percent in African-American women. Using data from 394 breast cancer patients diagnosed at UMDNJ between 1999 and 2004, we examined several predictors of poor medical outcomes. We found significant differences by race and age in advanced disease. A significantly higher percent of Hispanic women under 40 years of age (41.7 %) were more likely to be diagnosed with late stage breast cancer when compared to African-American (29.2%) and Caucasian (14.3%) women. As shown in the figure, these findings suggest the need to reach younger Hispanic women with educational messages about breast cancer screening and early detection. When looking at women older than 64, African- American women (35.4%) were more likely to be diagnosed with late stage breast cancer than were Hispanic (14.3%) and Caucasian women (26.4%).

Diane R. Brown, PhD, is executive director of the Institute for the Elimination of Health Disparities at UMDNJ. She is also a professor of Health Education and Behavioral Science at SPH. Prior to joining UMDNJ, Dr. Brown was director of the Urban Health Program at Wayne State University in Detroit. She has also been a health scientist administrator at the NIH and a faculty member at Howard University. Her research has encompassed a variety of issues impacting minority populations. Dr. Brown received her PhD in medical sociology from the University of Maryland. This was followed by a postdoctoral fellowship in psychiatric epidemiology from the Johns Hopkins School of Public Health. She has an extensive list of scholarly publications. She is a native of Newark, New Jersey.