Cancer Care Equity Research Articles

Working together in cancer care: An academic community partnership for a diverse patient population.

10525 Background: The Massachusetts General Hospital Cancer Care Equity Program conducted a qualitative survey health assessment in the inner-city communities of Boston to study Black Bostonian patients’ perceptions of the barriers to cancer care. Findings revealed a level of mistrust toward large cancer centers and a request for more interactions with their trusted community health providers. At a subsequent community forum geared toward soliciting solutions to improve relationships with academic medical centers, community members recommended that academic oncologists increase engagement with their community health center (CHC) clinicians with a cancer lecture series. Methods: Academic oncologists from Massachusetts General Hospital and Boston Medical Center met with the leadership at two CHCs prior to the creation of the cancer lecture series. Feedback on how to best support CHC providers was established and a cancer care lecture series was created with continuing medical education (CME) credit provided. Five in-person lectures were given at each CHC. Topics included: Consultative Hematology, Breast Cancer, Prostate Cancer, Thyroid Cancer, Colon Cancer and Adrenal Masses. Survey evaluations (summative and formative) were distributed to all participants. An online portal was established to provide ongoing CME to providers. Results: Six academic physicians specializing in cancer care provided lectures at two CHCs. Currently, we have 176 surveys completed from both CHCs. Thus far, 98.3% surveys have indicated that the lectures have been “Excellent” or “Above Average,” and all participants have responded that the objectives of each presentation have been met. We have developed a website to provide ongoing CME for the lectures that were given: http://bucme.org/cancercare . Conclusions: This project aims to improve cancer care education and communication between providers from academic cancer centers and primary care providers at CHCs that care for a diverse and vulnerable patient population.

Abstract B32: Utilization and outcomes of cancer genetics referrals at a community cancer program

Abstract The majority of research on cancer genetic counseling and testing has been conducted in academic medical centers and among predominantly Caucasian cohorts. Unfortunately, underserved and minority populations who have a disproportionate burden of cancer have, historically, had limited access to and poor utilization of these services despite proven benefits of cancer risk reduction in high-risk individuals. Based on a unique co-location model that addresses this disparity gap, the Dana-Farber Cancer Institute (DFCI)'s Cancer Care Equity Program (CCEP) added a genetics arm to its Community Cancer Program (CCP), housed in a neighborhood Federally Qualified Community Health Center (FQHC) in 2013. The aim of this study was to determine clinic utilization rates, uptake, and outcomes of genetic evaluations as well as to describe the barriers to obtaining genetic testing among patients referred to the CCP. Methods: The intervention cohort consisted of patients referred to the CCP by their primary care providers (PCP) for cancer genetics counseling and testing between August 2013 and April 2017. A geneticist and a genetic counselor from DFCI's Cancer Risk and Prevention Program provided risk assessment and counseling according to the National Comprehensive Cancer Network (NCCN) guidelines. Prospective data approved by the IRB were collected on a secured REDcap database that was designed for the CCEP. Information including attendance at clinic, patient demographics, personal and family history of cancer or familial mutation, previous genetic testing for cancer, recommendation for genetic testing, uptake, and results were extracted and analyzed descriptively (JMP Pro version 12, SAS Institute Inc., Cary, NC). Results: Seventy out of 118 patients referred by PCPs attended clinic, indicating a no-show rate of 41%. Of the 70, 62 (89%) consented to research. The mean age of the study population was 43 (SD±11.6) years and 87% were women. More than half of the participants (57%) were Blacks/African Americans (Non-Hispanic-31% and Hispanic-26%), 32% were Whites (Non-Hispanic-13% and Hispanic-19%), and 8% were other races. Interpreter services, mainly Spanish, were provided for 32% of participants. The majority (76%) had Medicaid insurance, 8% had Medicare,13% had private insurance, and 3% had health safety net/free care. While not mutually exclusive, 66% of participants reported a family history of breast cancer, 32% ovarian cancer, 23% colorectal cancer, and 23% other cancers. There were two (3%) participants with a personal history of cancer, two (3%) with a presence of familial mutation among family members (BRCA 1/2), and two (3%) with prior genetic testing. Of the two who had prior testing, one had a familial mutation (APC). Overall, 43 (69%) participants were recommended for genetic testing. The most frequent reason for non-recommendation was that there was a better testing candidate in the family (53%). Another 21% were asked to clarify their family history before completing cancer risk assessment. Of the 43 who were recommended for testing, 32(74%) completed testing with nearly all (91%) testing for multigene panels. Lack of insurance coverage was the most frequent (73%) reason for not undergoing a test. Among those who completed testing, a pathogenic mutation (MUTYH) was identified in one participant (3%), while 13 (39%) had variants of unknown significance (VUS) and 18 (59%) had no mutations identified. Conclusions: Our findings highlight the need for increased knowledge of family history and utilization of cancer genetic services among underserved and minority populations. Additionally, efforts should be made to improve insurance coverage for genetic testing in high-risk underserved individuals. Further research on the clinical significance of variants of uncertain significance identified in ethnic minority populations is also advised. Citation Format: Ruth N. Akindele, Huma Q. Rana, Sarah R. Cochrane, Ludmila A. Svoboda, Christopher S. Lathan. Utilization and outcomes of cancer genetics referrals at a community cancer program [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B32.

Abstract C52: Clinic utilization and smoking cessation practices among ethnic minority patients referred for paired lung cancer screening and tobacco treatment services at a community cancer program

Abstract Background: Studies on outcomes of lung cancer screening and smoking cessation programs among underserved and ethnic minority populations are scarce. These patients, however, have the greatest potential to benefit from these services. African Americans have the highest incidence and mortality rates for lung cancer, often as a result of multiple factors including factors related to disparities in access to quality care. The aim of this study was to determine clinic utilization rates and smoking cessation practices among underserved and ethnic minority patients referred for paired lung cancer screening and smoking cessation services at a community cancer program. Methods: The Dana-Farber Cancer Institute (DFCI)'s Cancer Care Equity Program (CCEP) added lung cancer screening to the established tobacco treatment arm of its community cancer program, housed in a neighborhood Federally Qualified Community Health Center (FQHC) in 2014. Nearly half (46%) of patients, aged 55 to 77 years who received care at the center in 2015 did not have a recorded smoking history. The paired intervention was offered at no cost to patients. Prospective data approved by the IRB was collected on a secured REDcap database that was designed for the CCEP. Patients referred by primary care providers at the health center had a low-dose computed tomography (LDCT) scan scheduled if they met the U.S. Preventive Services Task Force (USPSTF) criteria for lung cancer screening at their first visit. Concurrently, and at subsequent follow-up visits to review results of LDCT scans, patients who had not quit smoking were encouraged to enroll in the tobacco treatment program (TTP), which is individualized, one-on-one and available in both English and Spanish. A yearly surveillance LDCT plan was established for all participants who had negative scans while those with positive scans (based on American College of Radiology Lung-RADs risk stratification system) received further care at DFCI's main campus. Study outcomes include clinic show rates, smoking status, recommendations for LDCT, attendance at LDCT appointments, willingness to enroll in the TTP, and TTP participation rates. Descriptive statistical analysis on data collected between September 2014 and May 2016 was performed using JMP Pro (version 11, SAS Institute Inc., Cary, NC). Results: Fifty two out of 70 patients referred for lung cancer screening and tobacco treatment presented to the clinic, indicating a no show rate of 26%. Of the 52, 46 (88%) were current smokers. Among 47 (90%) participants who consented to research, mean age was 59.8 years (SD±5.8), 49 % were men, 74% were African American/Black, and 89% were current smokers. Most participants (87%) met the USPSTF criteria and were recommended for LDCT. Of these, 93% attended their appointments and were screened. None of the participants had a positive screen. While 83% of current smokers were screened and 87% initially expressed willingness to enroll in the TTP, only a third (33%) participated in the TTP. Conclusion: Compared to a high percentage of attendance at LDCT screenings, study participants had a low attendance at the TTP despite having expressed willingness to participate in the program. Further studies are needed to elucidate the causative factors for this difference. Additionally, the impressive utilization of a free LDCT service by patients who were referred when compared to the much larger number of patients who would fit into the criteria who were not referred, underscores the importance of mitigating health disparities by improving access to care. Efforts should be made to improve smoking-history taking in order to identify and appropriately refer eligible underserved candidates who might benefit from lung cancer screening and tobacco treatment. Citation Format: Ruth N. Akindele, Ludmila A. Svoboda, Sabrina G. Gonzalez, Christopher S. Lathan. Clinic utilization and smoking cessation practices among ethnic minority patients referred for paired lung cancer screening and tobacco treatment services at a community cancer program. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C52.

Prospective study of the financial burden of cancer clinical trial patients referred to a cancer care equity program (CCEP).

e18056Background: Clinical trials (CTs) often represent the best option for patients (pts) with cancer, yet the financial burden (FB) of CT pts is understudied. We sought to assess the FB of CT pts...

Equity in Cancer Care and Outcomes of Treatment: A Different Type of Cancer Moonshot.

“For the loved ones we’ve all lost, for the families we can still save, let’s make America the country that cures cancer once and for all.”1 With those stirring words, President Obama challenged the nation to advance the science and care of cancer to alleviate the burden of cancer-related morbidity and mortality. However, deaths from cancer are not equally distributed in the US population. Without the equivalent of a moonshot effort to achieve equality of outcomes in both the length and quality of survival, further advances in the early diagnosis and treatment of cancer will continue to favor the well off and well educated, leaving the poor and poorly educated behind.

Pursuing equity in cancer care: implementation, challenges and preliminary findings of a public cancer referral center in rural Rwanda.

BackgroundCancer services are inaccessible in many low-income countries, and few published examples describe oncology programs within the public sector. In 2011, the Rwanda Ministry of Health (RMOH) established Butaro Cancer Center of Excellence (BCCOE) to expand cancer services nationally. In hopes of informing cancer care delivery in similar settings, we describe program-level experience implementing BCCOE, patient characteristics, and challenges encountered.MethodsButaro Cancer Center of Excellence was founded on diverse partnerships that emphasize capacity building. Services available include pathology-based diagnosis, basic imaging, chemotherapy, surgery, referral for radiotherapy, palliative care and socioeconomic access supports. Retrospective review of electronic medical records (EMR) of patients enrolled between July 1, 2012 and June 30, 2014 was conducted, supplemented by manual review of paper charts and programmatic records.ResultsIn the program’s first 2 years, 2326 patients presented for cancer-related care. Of these, 70.5 % were female, 4.3 % children, and 74.3 % on public health insurance. In the first year, 66.3 % (n = 1144) were diagnosed with cancer. Leading adult diagnoses were breast, cervical, and skin cancer. Among children, nephroblastoma, acute lymphoblastic leukemia, and Hodgkin lymphoma were predominant. As of June 30, 2013, 95 cancer patients had died. Challenges encountered include documentation gaps and staff shortages.ConclusionButaro Cancer Center of Excellence demonstrates that complex cancer care can be delivered in the most resource-constrained settings, accessible to vulnerable patients. Key attributes that have made BCCOE possible are: meaningful North–south partnerships, innovative task- and infrastructure-shifting, RMOH leadership, and an equity-driven agenda. Going forward, we will apply our experiences and lessons learned to further strengthen BCCOE, and employ the developed EMR system as a valuable platform to assess long-term clinical outcomes and improve care.

Abstract A26: Developing a community-based partnership to facilitate a multilevel community engaged study exploring barriers to cancer care and clinical trial participation among black Bostonians

Abstract In Boston, Massachusetts, disparities persist for Black residents across a myriad of chronic conditions including cancer. To assess perceptions in Boston's Black community about cancer and cancer care, the Lazarex-MGH Cancer Care Equity Program (CCEP) partnered with the Center for Community Health Education Research and Services, Inc. (CCHERS), a trusted community-based organization, to perform a specific cancer-focused community assessment. This exploratory community engaged research (CEnR) partnership set out to (1) determine the perceived barriers to participation in clinical trials and cancer care as perceived by diverse Black Bostonians; and (2) develop a grassroots interventional strategy designed to a) reduce barriers to cancer care and b) increase awareness of clinical trials. Communities are complex and comprise multiple layers. CEnR partnerships can facilitate the development of culturally relevant and community specific strategies to tackle disparities, while simultaneously empowering communities. CEnR is an asset-based research approach that emphasizes the importance of building on existing community knowledge, relationships, and resources to implement sustainable, community-relevant interventions. In addition, CEnR approaches can facilitate the dissemination of intervention results in a way that equally benefits providers, policy-makers, and participants at the local level. For this project, a multi-level approach is employed. Phase one of the study involved key informant interviews (n=20) with health care providers and patient advocates in community health centers, organizers from grassroots coalitions focused on health (namely cancer), and Black cancer survivors who may or may not have participated in clinical trials. Phase one (P1) data was coded thematically using a consensus coding strategy. Themes from P1 will be used used to develop a focus group script for Phase two (P2) of the study. In P2, a series of focus groups (n=9) will be held in three Boston neighborhoods with residents self-identifying as Black to explore 1) conceptualizations of clinical trials, 2) perceptions of barriers to clinical trial participation and general cancer care, and 3) potential strategies to reduce identified barriers. Coded data will then be presented in “town hall meeting format” to a broader group of community residents and stakeholders. Findings from P1 are consistent with the literature indicating generational differences in how barriers to cancer care and clinical trials are perceived. In addition, we identified disconnects in what religious leaders and oncologists view as barriers to care. Beyond medical mistrust the overall structure of care presented as barriers. By partnering with community stakeholders we were able to engage a “hard to research population” in exploratory cancer care research the results of which will be used to guide institutional planning. Citation Format: Karen Winkfield, Elizabeth Powell, Chidinma Osuagwa, Elmer Freeman, Linda Sprague-Martinez. Developing a community-based partnership to facilitate a multilevel community engaged study exploring barriers to cancer care and clinical trial participation among black Bostonians. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A26.

Health disparities in cancer care: Exploring Canadian, American and international perspectives.

CANO/ACIO’s vision is to be “a driving force nationally and an influencing force internationally in advancing excellence in cancer nursing across the cancer control spectrum.” We want to see “Canadians across the cancer spectrum have timely access to high quality nursing” (CANO/ACIO, p. 8). With this end in view, a panel of experts came together to explore health inequities in cancer care from a variety of national and international perspectives at the 25 th Annual CANO/ACIO conference, held in Vancouver in October 2013. Represented on the panel were experts in health disparities research (Dr. Colleen Varcoe and Dr. Christina Sinding), past presidents of the Oncology Nursing Society (ONS) (Dr. Mary Gullatte) and the International Society of Nurses in Cancer Care (ISNCC) (Dr. Greta Cummings), and leadership from the Canadian Partnership Against Cancer (CPAC) (Dr. Margaret Fitch). Oncology nurses are uniquely positioned to positively influence health equity in cancer care at national and international levels. What follows are summaries of the panelists’ presentations.

Patient navigation to improve follow-up of abnormal mammograms among disadvantaged women.

Patient navigation (PN) can improve breast cancer care among disadvantaged women. We evaluated the impact of a PN program on follow-up after an abnormal mammogram. Between 2007 and 2010, disadvantaged women with an abnormal mammogram (Breast Imaging-Reporting and Data System [BI-RADS] codes 0, 3, 4, 5) cared for in a community health center (CHC) with PN were compared to those receiving care in 11 network practices without PN. Multivariable logistic regression and Cox proportional hazards modeling were used to compare the percentages receiving appropriate follow-up and time to follow-up between the groups. Abnormal mammography findings were reported for 132 women in the CHC with PN and 168 from practices without PN. The percentage of women with appropriate follow-up care was higher in the practice with PN than in non-PN practices (90.4% vs. 75.3%, adjusted p=0.006). RESULTS varied by BI-RADS score for women in PN and non-PN practices (BI-RADS 0, 93.7% vs. 90.2%, p=0.24; BI-RADS 3, 85.7% vs. 49.2%, p=0.003; BI-RADS 4/5, 95.1% vs. 82.8%, p=0.26). Time to follow-up was similar for BI-RADS 0 and occurred sooner for women in the PN practice than in non-PN practices for BI-RADS 3 and 4/5 (BI-RADS 3, adjusted hazard ratio [aHR], 95% confidence interval [CI]: 2.41 [1.36-4.27], BI-RADS 4/5, aHR [95% CI]: 1.41 [0.88-2.24]). Disadvantaged women from a CHC with PN were more likely to receive appropriate follow-up after an abnormal mammogram than were those from practices without PN. Expanding PN to include all disadvantaged women within primary care networks could improve equity in cancer care.

Abstract A27: Addressing cancer disparities through use of a novel community-based oncology program

Abstract Purpose: This study evaluates a novel approach to address cancer disparities by incorporating a comprehensive clinical oncology outreach facility within the context of a primary care setting in Boston. We hypothesize that this unique oncology program will improve access to care for underserved populations, and may serve as a model system for other health disparity initiatives. Methods: The Whittier Street Health Clinic (WSHC) is a Federally Qualified Health Center, that provides comprehensive primary health care and support services for vulnerable communities. In 2012, the Dana-Farber Cancer Institute's Cancer Care Equity Program partnered with WSHC to develop an initiative aimed at streamlining cancer care and services to address cancer disparities in the underserved population Whittier serves. A retrospective chart review was performed to evaluate the impact of the program on patient outcomes, specifically timeliness of care/time to resolution and time to initiation of treatment. We have identified a cohort of patients (N = 50) who have been provided cancer-related services through this initiative from December 2012 to July 2013. All patients were ≥ 18 years old. Timeliness of care/time to resolution is defined as the amount of time elapsed between patient presentation until their reason for visit to the oncology facility has been resolved. Time to initiation of treatment was measured only for patients with newly diagnosed cancer; it is defined as the amount of time elapsed between patient presentation at the oncology facility to the start of treatment. T-tests and one-way ANOVA were carried out to determine if there were any statistically significant differences in the timeliness of care/time to resolution for different demographic subgroups. Results: In this cohort, 48% of patients self-identify as Black/African-American, 48% Hispanic, and 2% other. Forty-eight percent are men; 52% are women. Although the majority of patients are English-speaking (58%), a large proportion (38%) speaks Spanish. The average time to resolution for subjects was 29 days and 19 days for imaging and clinical evaluation respectively. This presents an overall reduction compared to baseline data (N = 38) from WSHC, which had an average of 67.7 days for time to resolution, which was mainly diagnostic resolution. A similar trend was also observed in time to initiation of treatment (52.5 days vs. baseline of 67.6 days). There is no statistically significant difference in the timeliness of care/time to resolution between different demographic subgroups served by the oncology program (e.g. English speakers vs. Spanish speakers, p = 0.336). Conclusion: The data supports our hypothesis that employing the use of a comprehensive oncology program within the context of an established community center improves access to specialized oncologic care for vulnerable populations. This unique model improves timeliness of care by reducing time to diagnostic resolution, which may ultimately help improve cancer outcomes. Citation Format: Ann Oluloro, Ann Oluloro, Karen M. Winkfield, Ludmila Svoboda, Laura Tesler Waldman, Christopher S. Lathan. Addressing cancer disparities through use of a novel community-based oncology program. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A27. doi:10.1158/1538-7755.DISP13-A27

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours.

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

Disparities in cancer care: Perspectives from the front line

The purpose of this qualitative study was to investigate how frontline healthcare professionals witness and understand disparity in cancer care. Six healthcare providers from a range of care settings, none with < 15 years of frontline experience, engaged with researchers in an iterative process of identifying and reflecting on equity and disparity in cancer care. This knowledge exchange began with formal interviews. Thematic analysis of the interviews form the basis of this article. Participants drew attention to health systems issues, the meaning and experience of discontinuities in care for patients at personal and community levels, and the significance of social supports. Other concerns raised by participants were typical of the literature on healthcare disparities. Providers at the front lines of care offer a rich source of insight into the operation of disparities, pointing to mechanisms rarely identified in traditional quantitative studies. They are also well positioned to advocate for more equitable care at the local level.

Equity in Cancer Care: Pathways, Protocols, and Guidelines

The quality of patient care varies based on numerous factors, such as health care setting, geographic location, access to medications, insurance coverage, and treatment protocols. Recently, the issue of whether use of clinical pathways can reduce costs and inappropriate variability in care has been the subject of much debate. As clinical treatment guidelines and pathways are increasingly deployed in oncology practice, they have a growing impact on the quality of treatment and how it is delivered. To fulfill the current need to discuss the use of pathways and clinical treatment guidelines in oncology and to address how patient care is impacted by their use, the National Comprehensive Cancer Network convened the NCCN Oncology Policy Summit: Equity in Cancer Care-Pathways, Protocols, and Guidelines. The summit was a forum to discuss the use and implementation of pathways, including how much flexibility pathways should allow in care, pathways' impact on public and private health insurance benefit design, what data is used to select pathway regimens and protocols, and ultimately what impact pathways may have on variation in care. The use and implementation of clinical treatment guidelines in practice was also explored from a variety of perspectives.

Abstract A18: Development and implementation of a community-based clinical cancer outreach initiative.

Abstract Background: Research has described widespread racial disparities in cancer outcomes across the spectrum of prevention, screening, diagnosis, and treatment. A recent study suggested treatment disparities were mediated when patients were treated at NCI cancer centers. Participation of underserved groups in these centers, however, has been historically poor. In January, 2012, Dana-Farber Cancer Institute (DFCI), in conjunction with Whittier Street Health Center (WSHC), a federally qualified health center in Roxbury Massachusetts, initiated a clinical outreach program as part of a comprehensive Cancer Care Equity Program. A conceptual model was developed to combine prevention, diagnosis, education, and treatment interventions. Methods: The intervention was developed inductively through the identification of several contributing factors to cancer disparities derived from observations during clinical practice. Most importantly, the lack of integrated cancer care spanning the continuum from prevention to treatment and end of life, in community health centers that predominately cared for the underserved. These observations were confirmed by review of the clinical literature, indicating that there were few clinical cancer outreach programs in the urban community; moreover, no program providing comprehensive cancer care was identified within an established community health center. The development and integration of services between the community health care center and cancer center, including medical, administrative, financial, interpreters, and social support, was achieved by incorporating clinical and administrative stakeholders from each institution into working group sessions through a structured facilitation process. Results: The intervention, funded by philanthropic support, incorporates a community cancer clinic, staffed by DFCI personnel, within a primary health care center. Primary care providers refer patients to the clinic for diagnostic evaluation, abnormal screening, and selected non-chemotherapy follow-up. Patients with previous cancer histories are also referred to re-establish connections with oncology. The integrated evaluation service is provided on-site at the community cancer clinic. All medical records are maintained within the primary health care center's database so that the primary care providers can track their patients. Patients with an active cancer-related issue are then referred to the Dana-Farber Cancer Institute, with patient navigation and access management services to facilitate a smooth transition. To promote collaborations between the primary health care center and community cancer clinic, formal and informal provider-provider consultations, didactic sessions, and community-level educational sessions have also been established. The conceptual model details the patient referral pathways and services across institutions. Conclusion: The intervention's impact is currently being evaluated. The formation of this model demonstrates collaboration between academic centers and a primary health care center, focused on eliminating cancer disparities and emphasizing a cohesive clinical service in a novel manner. Citation Format: Laura T. Waldman, Brian F. Young, Ludmila A. Svoboda, Christopher S. Lathan. Development and implementation of a community-based clinical cancer outreach initiative. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A18.

Health-related Internet use among cancer survivors: data from the Health Information National Trends Survey, 2003–2008

Increasing prevalence of Internet and new technologies are changing the communication pattern for patients and caregivers across the cancer care continuum. To date, little is known on how cancer survivors in the USA utilize the Internet for health-related purposes. This knowledge is crucial in developing effective communication programs to achieve quality and equitable cancer care. Data from 2003, 2005, and 2008 iterations of the NCI-sponsored Health Information National Trends Survey(HINTS) were analyzed to: (1) compare health-related Internet use (hereafter HRIU) between individuals with and without a cancer diagnosis, (2) report trends, prevalence, and user profiles of HRIU, including support group participation, e-mailing provider, buying medicine online, and cancer information seeking on the Internet. Descriptive analyses and weighted multivariate logistic regression analyses were performed. While Internet penetration is growing over the years across the USA, cancer survivors access the Internet at a lower rate than general population (49.4% to 56.4% vs. 63.1% to 66.3%). Once on the Internet, they are more likely to use it for health-related purposes. Disparities in Internet access persists, as higher likelihood of Internet access is associated with younger age, higher education, non-Hispanic White race/ethnicity, metropolitan residence, and better self-rated health. On the other hand, among Internet-accessing survivors, socio-demographic, and health factors do not play a significant role in determining the pattern of HRIU. The study identifies an increasing trend in HRIU among survivors, though the digital divide remains in Internet access. The findings also point to opportunities for narrowing the divide and using Internet to better serve survivors' needs, as individuals from wide-ranging backgrounds and experiences are equally engaging in health-related activities on the Internet. IMPLICATIONS FOR SURVIVORS: To increase equity and effectiveness in communication and cancer care, Internet access, functions, and technology literacy are important factors to be considered.

Income and Long-Term Breast Cancer Survival: Comparisons of Vulnerable Urban Places in Ontario and California

Effects of socioeconomic status on the long-term survival of 808 women with node-negative breast cancer in Canada and the United States were observed. Ontario and California samples diagnosed between 1988 and 1990 were followed until 2006. Socioeconomic data were taken from population censuses. Compared with their California counterparts, residents of low-income urban areas in Ontario experienced a significant 15-year survival advantage (RR = 1.66 [95% CI: 1.00, 2.76]). In these and other vulnerable, lower-middle- to working-class neighborhoods, significantly more Ontario residents gained access to adjuvant radiation therapy (RR = 1.75 [1.21, 2.53]) which seemed associated with better long-term survival (RR = 1.36 [0.99, 1.86]). This stage-adjusted, historical cohort analysis suggests much greater cancer care equity in Canada than in the United States.

Wait times for surgical and adjuvant radiation treatment of breast cancer in Canada and the United States: Greater socioeconomic inequity in America

The demand for cancer care has increased among aging North American populations as cancer treatment innovations have proliferated. Gaps between supply and demand may be growing. This study examined whether socioeconomic status has a differential effect on waits for surgical and adjuvant radiation treatment (RT) of breast cancer in Canada and the US. Ontario and California cancer registries provided 929 and 984 breast cancer cases diagnosed between 1998 and 2000 in diverse urban and rural places. Residence-based socioeconomic data were taken from censuses. Cancer care variables were reliably abstracted from health records: stage, receipt of surgery and RT, and waits from diagnosis to initial and initial to adjuvant treatment. Median waits were compared within- and between-country with the non-parametric Mann-Whitney U-test. Categorically long, age-adjusted wait comparisons used the Mantel-Haenszel chi-square test. There were significant associations between lower socioeconomic status and longer surgical waits, lower access to adjuvant RT and to longer RT waits across diverse places in California. None were observed in Ontario. The two cohorts did not practically differ on access to surgery or on surgical waits. Compared with their counterparts in California, low-income Ontarians, particularly those in small urban places, gained greater access to RT, while high-income Americans had shorter waits for RT. This historical study contextualized Canada's "waiting-list problems" with evidence on breast cancer care, where lower income Americans seemed to have waited as long as similar Canadians. Many more low-income Americans seemed to experience the longest wait of all for adjuvant care. They simply did not receive it. In contrast to stark American socioeconomic inequity, this study evidenced remarkable equity in Canadian breast cancer care.