Reduce Cancer Disparities Research Articles

Abstract IA40: Maximizing the benefits of precision medicine for cancer disparities

Abstract Disparities, defined as differences that are unnecessary and avoidable, exist in cancer incidence, mortality, and survival. They occur by race/ethnicity, socioeconomic status, geography (rural versus urban), and other factors. Although cancer deaths for all types of cancer decreased for both African-Americans and whites in the United States between 1999 and 2011, for example, African-American males and females had both higher cancer incidence and cancer mortality than white males and females and showed less marked improvement over that time period. Warnecke and colleagues published a multi-level framework of the determinants of cancer disparities that included three basic levels, namely distal, intermediate, and proximal.1 Distal determinants include population-level social conditions such as variation in rates of disease or poverty. Their roots are embedded in shared social norms or social practices and socioeconomic disadvantage. Intermediate determinants include the immediate social and physical contexts and social relationships in which distal effects are experienced, such as neighborhoods. Proximal determinants include biological and genetic factors and individual-level factors like health behavior. The sequencing of the human genome and increased understanding of its function have allowed the identification of genetic variants that lead to common diseases like cancer. Yet, awareness is growing, too, that genetic variants alone cannot account for cancer expression and outcomes. Consistent with the Warnecke et al. framework, it seems to be the case that social, environmental, and behavioral factors interact with genetic predisposition to produce disease, and that differential exposures and behaviors across populations and subpopulations might help to explain cancer disparities. Both the genetic variants and the exposures and behaviors must be present to produce cancers. The Precision Medicine Initiative (PMI), announced by President Obama on January 30, 2015 seeks to advance our understanding of genetic variations within diseases and develop treatments for them, beginning with cancer. President Obama requested $215 million in the next fiscal year to collect genetic data and data from electronic medical records, lab test results, and information about diet, tobacco use, lifestyle, and environment on 1,000,000 Americans. In this presentation, we argue that while the PMI has the potential to reduce cancer disparities: (1) preventing cancer and reducing death rates for everyone in the population requires collecting and analyzing consistent, accurate, reliable, and sufficiently detailed data that represent all segments of the population and that (2) developing risk assessments and interventions that are effective for everyone requires evidence on the distribution and impact of causes across subpopulations. Collecting and analyzing data that represents all segments of the population poses significant challenges essential for the PMI to contribute to decreasing disparities in cancer and other common diseases. Minority groups historically have had low participation in research, such as in clinical research trials. The 1993 NIH Revitalization Act (http://orwh.od.nih.gov/about/pdf/NIH-Revitalization-Act-1993.pdf) established a mandate that funded research would be based on valid analysis of whether the variables being studied in the trial affect minority groups. Yet a 2014 review found that only 20% of randomized controlled studies in a major cancer journal reported analyzing results by race/ethnicity.2 Likewise, a survey of its members and the general public by the American Association for the Advancement of Science (AAAS) found that while 92% of AAAS scientists considered US scientific achievement to be the best in the world or above average, only 54% of the public endorsed this ranking.3 The presentation will conclude with two recommendations for improving the PMI's role in eliminating cancer and other disparities. First, make the effort to recruit a cohort that reflects the US population in terms of race/ethnicity, socioeconomic status, and geography. Second, do not recruit entirely from clinic populations or rely entirely on electronic medical records for social data, because this will miss those most without consistent health care, a group for whom disparities are rife. In addition, for Precision Medicine practice to contribute to the elimination of disparities, it will be important that: (1) the cost of genetic testing is covered under Medicaid, other public insurance, and less generous marketplace insurance plans; (2) the collection of social variables be systematized so that they capture the lives of minority groups; and (3) the capacity of genetic counseling is increased and that counseling services are available to all who have genetic testing.

Abstract A86: Challenges and opportunities for increasing the rates of HPV vaccination

Abstract Purpose: The purpose of this study is to determine the association between awareness of human papillomavirus (HPV), cervical cancer, and HPV vaccine and intention to vaccinate preteens and teens against HPV. Background: Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, and results in 14 million new cases each year. Around 50% of new HPV infections occur among persons aged 15-24 years old. Cervical cancer is primarily attributable to HPV, and the yearly cost of cervical cancer screening as well as treatment of HPV-related diseases is around $8 billion. In 2009, around 35,000 HPV-related cancers were reported in the United States. The level of coverage for 3 HPV vaccine doses for females aged 13-15 years was only 30% in 2011. This is far below the 80% target coverage level set by Healthy People 2020. The 2013 National Immunization Survey-Teen found that only 50% of Maryland females aged 13-17 years and only 34.2% of male adolescents reported beginning the HPV vaccine series. According to the 2013 Maryland Cancer Data, Maryland had the 25th highest cervical cancer mortality rate from 2006-2010. During these years, more black women were diagnosed with cervical cancer than White women, and their rate of cervical cancer incidence has been increasing at a rate of 4.9% more per year than white women. We investigate the relationship between HPV, cervical cancer, and HPV vaccine awareness and intention to vaccinate preteens and teens against HPV. Methods: Utilizing the principles of community-based participatory research (CBPR), the Johns Hopkins Center to Reduce Cancer Disparities, in collaboration with its Community Advisory Groups in Baltimore City and Prince George's County, developed and implemented a survey to assess the knowledge, awareness and behavioral intentions on cervical cancer, HPV and HPV vaccine. The study was approved by the Johns Hopkins School of Medicine's Institutional Review Board and implemented between March 2015 and July 2015 in Baltimore City and Prince George's County. Four hundred and three individuals recruited through community events completed the assessment. Upon completion of the assessment, participants were given feedback on their responses to address any knowledge gap and educational materials. Binary and multinomial logistic regression were used to determine the association between awareness of HPV, cervical cancer, and HPV vaccine and intention to vaccinate children between the ages of 11 and 18 years against HPV. Results: The majority of study participants were female (78%), black or African American (87%), have at least one year of college or technical school (55%) and have an annual household income of less $20,000 (38%). Awareness of the existing of HPV vaccine is significantly associated (OR=2.54, P<0.0007, CI 1.487-4.355) with the intention to vaccinate children against HPV. We also found that individuals who never heard of the HPV vaccine are significantly less likely (OR=0.394, p<0.0007, CI 0.230-0.673) to vaccinate their children against HPV than those who have heard of the vaccine. Furthermore, those who are aware of HPV are significantly more likely to know that HPV can cause cervical cancer (OR=5.25, P<0.0001, CI 3.272-8.454) and to know that HPV is transmitted through sexual contact (OR=3.66, P<0.0001, CI 2.199-6.100) compared to those who never heard of HPV. Conclusion: Awareness of HPV, cervical cancer, and HPV vaccine are significantly associated the intention to vaccinate children between the ages of 11 and 18 years against HPV. Increasing knowledge of cervical cancer and the importance of HPV vaccination among parents and caretakers of preteens and teens have the potential to increase the rates of HPV vaccination and prevent future cervical cancers. More research is needed to explore other factors that are related to HPV vaccination. Citation Format: Ahmed Elmi, Saad Tassaduq, Olive Mbah, Ashleigh DeFries, Lee Bone, Anjani Kapadia, Theron Scott, Nichole Tuite, Adrian Dobs. Challenges and opportunities for increasing the rates of HPV vaccination. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A86.

Abstract C76: Mechanistic implications of advanced glycation end-products to prostate cancer and racial disparity

Abstract Poor diet, low income, obesity and a lack of exercise are established lifestyle factors that are known to increase cancer burden and are often more prevalent in African American communities. As our understanding of tumor biology advances, it is becoming increasingly clear that these inter-related lifestyle factors have distinct molecular consequences on the biological make-up of tumors, altering cell signaling events and gene expression profiles to contribute to cancer disparity outcomes such as its earlier development or its progression to more aggressive disease. Sparse information exists about the genetic and biological factors that contribute to differential cancer survival and mortality rates observed in minority populations. A greater understanding of the interplay between risk factors and the molecular mechanisms associated with cancer disparity will significantly impact minority health. Advanced glycation end products (AGEs) are reactive metabolites produced as a by-product of sugar metabolism. Failure to remove these highly reactive metabolites can lead to protein damage, aberrant cell signaling, increased stress responses, and decreased genetic fidelity. Critically, AGE accumulation is also directly affected by our lifestyle choices such as poor diet, low income, obesity and a lack of exercise. We recently reported a potential mechanistic link between AGEs and prostate cancer which may provide a molecular consequence of our lifestyle choices that can directly impact tumor biology and contribute to cancer disparity. We examined circulating and intra-tumoral AGE metabolite levels in clinical specimens and identified a race specific, tumor dependent pattern of accumulation in prostate cancer serum and tumor. Further mechanistic studies in immortalized prostate cancer cell lines show that AGE treatment increases the expression of the receptor for AGEs (RAGE) to activate cancer-associated signaling cascades. Loss of function studies show that AGE mediated increases in cancer associated processes was dependent upon RAGE expression. Significantly, we show that AGEs are secreted into the tumor microenvironment by cancer cells and may function as signaling molecules to promote immune cell recruitment. These data implicate the AGE-RAGE signaling axis as a potential biological mechanism promoting prostate cancer and may represent a biological mechanism promoting prostate cancer disparity. AGE metabolites may have high potential impact as prognostic/diagnostic markers and/or as a novel area of potential therapeutic intervention to reduce cancer disparity. Citation Format: Danzell M. Smith, Dion Foster, Van Phan, Victoria J. Findlay, Lourdes M. Nogueira, Laura Spruill, Mahtabuddin Ahmed, Judith D. Salley, Marvella E. Ford, David P. Turner. Mechanistic implications of advanced glycation end-products to prostate cancer and racial disparity. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C76.

Institutional Alliances to Reduce Cancer Disparities in Chicago.

A partnership formed between Northeastern Illinois University (NEIU) and the Robert H. Lurie Comprehensive Cancer Center of Northwestern University sought to address well-documented cancer health disparities in Chicago by developing a collaborative research, training, and educational infrastructure between a minority-serving institution and a National Cancer Institute designated comprehensive cancer center. With a critical examination of partnership documentation and outputs, we describe the partnership's community-engaged approaches, challenges, and lessons learned. Northeastern Illinois University and the Lurie Cancer Center engaged in a yearlong partnership-building phase, identified interdisciplinary research teams, formed a governance structure, and identified collective aims. Partnership outcomes included funded inter-institutional research projects, new curriculum, and an annual research trainee program. Significant challenges faced included uncertain fiscal climate, widespread turnover, and dissimilar institutional demands. Lessons learned from this minority serving institution and comprehensive cancer center partnership may be useful for bridging distinct academic communities in the pursuit of ameliorating health disparities.

Integrating evidence-based practices for increasing cancer screenings in safety net health systems: a multiple case study using the Consolidated Framework for Implementation Research.

BackgroundImplementing evidence-based practices (EBPs) to increase cancer screenings in safety net primary care systems has great potential for reducing cancer disparities. Yet there is a gap in understanding the factors and mechanisms that influence EBP implementation within these high-priority systems. Guided by the Consolidated Framework for Implementation Research (CFIR), our study aims to fill this gap with a multiple case study of health care safety net systems that were funded by an American Cancer Society (ACS) grants program to increase breast and colorectal cancer screening rates. The initiative funded 68 safety net systems to increase cancer screening through implementation of evidence-based provider and client-oriented strategies.MethodsData are from a mixed-methods evaluation with nine purposively selected safety net systems. Fifty-two interviews were conducted with project leaders, implementers, and ACS staff. Funded safety net systems were categorized into high-, medium-, and low-performing cases based on the level of EBP implementation. Within- and cross-case analyses were performed to identify CFIR constructs that influenced level of EBP implementation.ResultsOf 39 CFIR constructs examined, six distinguished levels of implementation. Two constructs were from the intervention characteristics domain: adaptability and trialability. Three were from the inner setting domain: leadership engagement, tension for change, and access to information and knowledge. Engaging formally appointed internal implementation leaders, from the process domain, also distinguished level of implementation. No constructs from the outer setting or individual characteristics domain differentiated systems by level of implementation.ConclusionsOur study identified a number of influential CFIR constructs and illustrated how they impacted EBP implementation across a variety of safety net systems. Findings may inform future dissemination efforts of EBPs for increasing cancer screening in similar settings. Moreover, our analytic approach is similar to previous case studies using CFIR and hence could facilitate comparisons across studies.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0477-4) contains supplementary material, which is available to authorized users.

Communication strategies to reduce cancer disparities: Insights from African-American mother–daughter dyads.

Mothers and daughters share a powerful and unique bond, which has potential for the dissemination of information on a variety of women's health issues, including the primary and secondary prevention of breast and cervical cancer. This study presents formative research from a long-term project examining the potential of mother-daughter communication in promoting cancer screening among African American women. Thirty-two mother-daughter pairs (N = 64) completed orally administered surveys regarding their cancer knowledge, beliefs and attitudes, and barriers to care. This study compares the attitudes and beliefs of low-income, urban, African American mothers and their adolescent daughters regarding cervical and breast cancer screening. Both mothers and daughters had fairly high levels of knowledge about breast and cervical cancer. In addition, there was a high concordance rate between mothers' and daughters' responses, suggesting a potential sharing of health knowledge between mother and daughter. These results have implications for selecting communication strategies to reduce health disparities, and support that the mother-daughter dyad could be a viable unit to disseminate targeted screening information. (PsycINFO Database Record

Associations between contextual factors and colorectal cancer screening in a racially and ethnically diverse population in Texas

BackgroundColorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer death in the United States. Increased attention has been given to understanding the role of local contexts on cancer screening behaviors. We examined the associations between multiple tract-level socioeconomic measures and adherence to colorectal cancer screening (CRCS) in Harris County and the City of Houston, Texas. MethodsWe conducted a cross-sectional multilevel study linking individual-level data on CRCS from the 2010 Health of Houston Survey with contextual data from the U.S. Census and the U.S. Department of Housing and Urban Development. We examined tract-level poverty, education, employment, income inequality, and foreclosure measures across 543 Census tracts. Analyses were limited to individuals aged 50–74 years (N=1720). ResultsOverall, 58.0% of the sample was adherent to any recommended CRCS test. In bivariate analyses, increasing levels of area poverty, low education, unemployment, and foreclosures were associated with lower odds of adherence to CRCS. After controlling for individual-level covariates, only tract-level unemployment remained associated with adherence to CRCS (adjusted OR=0.80; 95% CI: 0.66–0.99; P=.037). ConclusionsNeighborhood socioeconomic disadvantage is increasingly recognized as a determinant of health, and our study suggests that the contextual effect of area unemployment may extend to cancer screening outcomes. Our finding is important to cancer control planners because we identified a contextual marker of disparity that can be used to target local interventions to promote CRCS and thereby reduce cancer disparities among non-adherent individuals who reside in communities with high unemployment rates.

Abstract A28: Enrolling African Americans into a cancer-related biobank

Abstract Background: Biobanks serve as essential resources for genetic and public health research. Despite their potential utility in elucidation of cancer susceptibility and development of novel cancer surveillance, diagnostic, and therapeutic approaches, most genomic research studies rely on samples with limited ethnic diversity. There is also a suggestion that disparities in participation in cancer biospecimen research have already translated into fewer efficacious treatments for under-represented groups. Inclusion of more diverse populations in biospecimen banks could ultimately contribute to a reduction in disparities in cancer morbidity and mortality that adversely impact U.S. minority groups. Research Objectives: We hypothesized that a deliberative group consent process related to cancer biobank donation would increase African American community engagement, foster an open dialogue between community members and researchers present at the discussion, allow participants to have their concerns addressed, and improve community members' knowledge and attitudes, leading to donation of biospecimens. Methods: We employed a two-stage study design. During the first stage, the Johns Hopkins Center to Reduce Cancer Disparities (JHCRCD) used a Community Based Participatory Research (CBPR) framework that explored the knowledge and attitudes of African American adults in Maryland regarding participation in a cancer biospecimen repository. We completed eight focus groups with primarily African American communities in Baltimore City and Prince George's County. Results: Stage-one results indicate that African American residents of Baltimore and Prince Georges County face limited understanding and lack of awareness in genetics and genomics. Our baseline analyses revealed limited community knowledge about biobanking and initial reluctance to donate biospecimen samples. Some participants expressed distrust in the research enterprise. After some discussion, however, participants were able to identify personal, familial, and societal benefits to participation. Moreover, focus group participants identified a number of strategies to overcome concerns and to enhance participation, including mechanisms for enhanced communication with researchers and suggestions related to building the biobank's community presence. In spite of initial concerns expressed during the focus groups, most participants stated their willingness to donate a specimen in the future if their concerns were properly addressed. Conclusions and Next Steps: Future reductions in cancer morbidity and mortality among minority groups will depend upon increasing the diversity of populations donating samples. The proposed project will provide data to support early communication and transparency to build community trust from the earliest stages of the cancer research process. Stage two of the project will commence in September of 2014. During the second stage, we propose: (a) To examine the impact of a deliberative group consent process on community members' attitudes and knowledge related to donating specimens to a pilot cancer biobank; (b) To identify participant characteristics (including genetic literacy, educational status, gender, personal cancer history, family cancer history, attitudes, and knowledge) that predict actual donation to a pilot cancer biobank; and (c) To create a pilot (small scale) cancer biobank with samples from the African American community for use in future genomic and epigenomic studies Citation Format: Fahcina P. Lawson, Oluwasina Folawiyo, Francesca Pirini, Blanca L. Valle, David Sidransky, Jean Ford, Lori Erby, Rafael Guerrero-Preston. Enrolling African Americans into a cancer-related biobank. [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 A28.

Abstract A10: Community navigators for breast and cervical cancer screening and follow up

Abstract Purpose: Recent multi-site trials evaluating the efficacy of patient navigation programs have found only modest effects on reducing follow-up time among patients with abnormal breast and cervical cancer screening tests. However, patient navigators in these efficacy trials have primarily been situated within a hospital or clinic – not nested within the community. We sought to further elucidate the potential impact of patient navigation by exploring how patient navigation initiatives in various community settings can address complex barriers to care. Methods: We present four case studies to provide insight on the value of community-nested navigators in increasing breast and cervical cancer screening and follow-up. Case studies include: (1) a community-level adaptation of patient navigation to Chicago's Chinatown; (2) a community navigation and outreach program in the racially/ethnically diverse Chicago Lawn; (3) a county-wide dissemination of navigation in suburban DuPage County; and (4) a state-wide scaling of a patient navigation model to the Illinois Department of Health and Family Services. Case study data were derived from focus groups, key informant interviews, medical records review, and patient surveys. Results: Case studies describe the roles of community navigators and the challenges of navigating immigrant, non-English proficient patients in particular. Translating clinic-based patient navigators into community navigators to guide women through clinics, specialty referrals, diagnostic/testing sites, and wrap around services (e.g., transportation, housing, support groups, legal counseling) may help alleviate complex barriers to care in resource-thin environments. Conclusion: Community navigators are promising connectors and advocates for health care services delivery and prevention for culturally and linguistically isolated populations as well as communities with limited health care safety net systems. The community, county, and state-wide scaling of patient navigation described in these case studies serve as viable models for future patient navigation initiatives in low-resource settings to reduce cancer disparities. Citation Format: Melissa A. Simon, Laura S. Tom, Erika E. de la Riva, Emily L. Malin. Community navigators for breast and cervical cancer screening and follow up. [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 A10.

Abstract IA41: Standard of care and clinical disparities in epithelial ovarian cancer

Abstract Ovarian cancer afflicts approximately 204,000 women worldwide, with ∼125,000/year deaths. In the United States more than 22,000 new cases of ovarian cancer diagnosed with over 14,000 disease-related deaths.[1] The standard of care in ovarian cancer includes expedient access to the health care system, consultation with a gynecologic oncologist, surgical intervention, and multiagent platinum-based chemotherapy. Prognostic factors for improved survival in women with ovarian cancer include younger age; early stage; low-grade and serous histology; good performance status; disease biology (BRCA1 and 2 mutation carriers have a better prognosis); and low volume of residual disease at the time of cytoreductive surgery. In contrast, African-American race, low socioeconomic status (SES), geographic location, and insurance status have been associated with worse survival and increased probability of not receiving appropriate standard of care treatment.[2-7] These differences in ovarian cancer outcomes linked to race, social, and economic factors indicate that health care disparities exist in the treatment of this gynecologic cancer. In this presentation, we will (1) review the standard of care for epithelial ovarian cancer treatment, (2) discuss the variables affecting the outcome for patients with epithelial ovarian cancer, (3) describe the factors contributing to healthcare disparities, and (4) discuss the evidence for clinical disparities in epithelial ovarian cancer care and outcomes. Causes of healthcare disparities are complex and include differences in race/ethnicity, SES, insurance status, education level, geographic location, culture, healthcare system factors (adherence to treatment guidelines, and access to care), and disease biology.[2-7] The following are highlighted in this presentation: Population-based studies have demonstrated that African-American women are at increased risk of ovarian cancer death compared to non-Hispanic Caucasian women.Population-based studies have demonstrated that African-American women are less likely to undergo site-specific surgery or surgical staging for ovarian cancer compared to Caucasian women.African-American women were less likely to seek care at high-volume hospitals or be operated on by high-volume surgeons.African-American women and those with Medicaid/Medicare payer status are less likely to receive standard of care therapy based on National Comprehensive Cancer Network (NCCN) guidelines.Geographic location away from a high-volume hospital is associated with increased risk of non-adherent ovarian cancer care.Geographic barriers to standard treatment disproportionately affect racial minorities and women of low-SES.In contrast to population-based studies, retrospective single academic institution studies and ancillary analysis of large cooperative group phase III trials in advanced ovarian cancer have demonstrated no difference in overall survival in women of African-American and Caucasian descent. The reported research in ovarian cancer indicates that unequal delivery of quality care, obstacles to the delivery of recommended care, and limited access to expert care may account for the disparities seen in ovarian cancer care. The U.S. Department of Health and Human Services has targeted disparities in access to health care as the centerpiece of the Healthy People 2020 campaign and the Department of Health and Human Services (HHS) has unveiled an action plan to reduce racial and ethnic Health disparities.[8, 9] The 5 goals of the HHS Disparities Action Plan are: (1) transform health care; (2) strengthen the nation's Health and Human Services infrastructure and workforce; (3) advance the health, safety, and well-being of the American people; (4) advance scientific knowledge and innovation; and (5) increase the efficiency, transparency, and accountability of HHS programs. The HHS Disparities initiative will specifically target programs to increase knowledge of, access to, and utilization of biomedical and behavioral procedures to reduce cancer disparities.[9] Listed below are future research objectives that will reduce and potentially eliminate health care disparities in ovarian cancer in the United States: Improve our knowledge of the interaction between race, ethnicity, SES, geographic location and ovarian cancer health care disparities across the United States to harmonize existing data and identify opportunities for intervention.Improve our knowledge regarding cultural barriers to care.Promote community-based participatory research to increase ovarian cancer awareness and review standards of care.Develop interventions to provide expedient access to expert care by trained specialists in Gynecology Oncology, cytoreductive surgery, and administration of multiagent platinum-based chemotherapy in order to increase the likelihood of NCCN adherent standard of care therapy.

Impact of patient navigation in eliminating economic disparities in cancer care.

Patient navigation may reduce cancer disparities associated with socioeconomic status (SES) and household factors. This study examined whether these factors were associated with delays in diagnostic resolution among patients with cancer screening abnormalities and whether patient navigation ameliorated these delays. This study analyzed data from 5 of 10 centers of the National Cancer Institute's Patient Navigation Research Program, which collected SES and household data on employment, income, education, housing, marital status, and household composition. The primary outcome was the time to diagnostic resolution after a cancer screening abnormality. Separate adjusted Cox proportional hazard models were fit for each SES and household factor, and an interaction between that factor and the intervention status was included. Among the 3777 participants (1968 in the control arm and 1809 in the navigation intervention arm), 91% were women, and the mean age was 44 years; 43% were Hispanic, 28% were white, and 27% were African American. Within the control arm, the unemployed experienced a longer time to resolution than those employed full-time (hazard ratio [HR], 0.85; P = .02). Renters (HR, 0.81; P = .02) and those with other (ie, unstable) housing (HR, 0.60; P < .001) had delays in comparison with homeowners. Never married (HR, 0.70; P < .001) and previously married participants (HR, 0.85; P = .03) had a longer time to care than married participants. There were no differences in the time to diagnostic resolution with any of these variables within the navigation intervention arm. Delays in diagnostic resolution exist by employment, housing type, and marital status. Patient navigation eliminated these disparities in the study sample. These findings demonstrate the value of providing patient navigation to patients at high risk for delays in cancer care.

Disparities in Cancer Incidence, Stage, and Mortality at Boston Health Care for the Homeless Program.

Homeless people have a high burden of cancer risk factors and suboptimal rates of cancer screening, but the epidemiology of cancer has not been well described in this population. We assessed cancer incidence, stage, and mortality in homeless adults relative to general population standards. We cross-linked a cohort of 28,033 adults seen at Boston Health Care for the Homeless Program in 2003-2008 to Massachusetts cancer registry and vital registry records. We calculated age-standardized cancer incidence and mortality ratios (SIRs and SMRs). We examined tobacco use among incident cases and estimated smoking-attributable fractions. Trend tests were used to compare cancer stage distributions with those in Massachusetts adults. Analyses were conducted in 2012-2015. During 90,450 person-years of observation, there were 361 incident cancers (SIR=1.13, 95% CI=1.02, 1.25) and 168 cancer deaths (SMR=1.88, 95% CI=1.61, 2.19) among men, and 98 incident cancers (SIR=0.93, 95% CI=0.76, 1.14) and 38 cancer deaths (SMR=1.61, 95% CI=1.14, 2.20) among women. For both sexes, bronchus and lung cancer was the leading type of incident cancer and cancer death, exceeding Massachusetts estimates more than twofold. Oropharyngeal and liver cancer cases and deaths occurred in excess among men, whereas cervical cancer cases and deaths occurred in excess among women. About one third of incident cancers were smoking-attributable. Colorectal, female breast, and oropharyngeal cancers were diagnosed at more-advanced stages than in Massachusetts adults. Efforts to reduce cancer disparities in homeless people should include addressing tobacco use and enhancing participation in evidence-based screening.

Economic evaluation of a community health worker-led health literacy intervention to promote cancer screening among Korean American women.

The study's objectives were to calculate the costs and evaluate the cost-effectiveness of implementing a health literacy-focused intervention to promote breast and cervical cancer screenings among Korean American women overdue for these tests. Researchers estimated the costs of a cluster-randomized controlled trial that evaluated this intervention. Effectiveness was measured as the number of breast or cervical cancer screenings received by women in either the intervention and control arms of the study. Cost-effectiveness was calculated as the incremental cost of each additional screening received by the intervention group. Comparing the intervention and control group, the incremental cost-effectiveness ratio was estimated to be US$236 per screening, without program development costs. These findings suggest this program, when compared with others, offered a more cost-effective approach for promoting cancer screening. Local health officials could use this information to guide decisions about reducing cancer disparities among recent immigrant women.

Upward Communication About Cancer Screening: Adolescent Daughter to Mother

Substantial breast and cervical cancer disparities exist in the United States, particularly among African American women with low socioeconomic status. There is considerable potential for discussions about cancer prevention between mothers and daughters. However, upward communication, from child to parent, remains a relatively novel research area, and it remains unclear how receptive mothers would be to messages from their daughter about cancer, a topic that may be considered culturally inappropriate for daughters to initiate. In this study, the authors simulated cancer message delivery to daughters and then conducted direct observation of daughters as they recalled and shared the message with their mother or female elder. The authors found that daughters were able to successfully recall and deliver a cancer appeal to their mother and mothers were generally receptive to this message. Not only did mothers listen to their daughters’ appeals, but also daughters’ knowledge of cancer was considerably improved by the opportunity to educate her female elder. Moreover, daughters’ nonverbal communication suggested a surprisingly relaxed demeanor. The potential of young people to have an effect on the screening behavior of their female elders is very promising in terms of reducing cancer disparities.

Considering the Role of Stress in Populations of High-Risk, Underserved Community Networks Program Centers.

Cancer disparities are associated with a broad range of sociocultural determinants of health that operate in community contexts. High-risk populations may be more vulnerable to social and environmental factors that lead to chronic stress. Theoretical and empirical research indicates that exposure to contextual and sociocultural stress alters biological systems, thereby influencing cancer risk, progression, and, ultimately, mortality. We sought to describe contextual pathways through which stress likely increases cancer risk in high-risk, underserved populations. This review presents a description of the link between contextual stressors and disease risk disparities within underserved communities, with a focus on 1) stress as a proximal link between biological processes, such as cytokine responses, inflammation, and cancer and 2) stress as a distal link to cancer through biobehavioral risk factors such as poor diet, physical inactivity, circadian rhythm or sleep disruption, and substance abuse. These concepts are illustrated through application to populations served by three National Cancer Institute-funded Community Networks Program Centers (CNPCs): African Americans in the Deep South (the South Carolina Cancer Disparities Community Network [SCCDCN]), Native Hawaiians ('Imi Hale-Native Hawaiian Cancer Network), and Latinos in the Lower Yakima Valley of Washington State (The Center for Hispanic Health Promotion: Reducing Cancer Disparities). Stress experienced by the underserved communities represented in the CNPCs is marked by social, biological, and behavioral pathways that increase cancer risk. A case is presented to increase research on sociocultural determinants of health, stress, and cancer risk among racial/ethnic minorities in underserved communities.

Targeting and Tailoring Health Communications in Breast Screening Interventions.

Members of underrepresented minority (URM) groups are at higher risk of disproportionately experiencing greater breast cancer-related morbidity and mortality and thus, require effective interventions that both appropriately target and tailor to their unique characteristics. We sought to describe the targeting and tailoring practices used in the development and dissemination of three breast cancer screening interventions among URM groups. Three national Community Network Programs (CNPs) funded by the National Cancer Institute have focused on breast cancer screening interventions as their major research intervention. Each targeted different populations and used participatory research methods to design their intervention tailored to the needs of their respective audience. The Alameda County Network Program (ACNP) to Reduce Cancer Disparities partnered with community members to design and conduct 2-hour "Tea Party" education sessions for Afghan women. The Kansas Community Cancer Disparities Network co-developed and deployed with community members a computerized Healthy Living Kansas (HLK) Breast Health program for rural Latina and American Indian women. The Johns Hopkins Center to Reduce Cancer Disparities employed a train-the-trainer COACH approach to educate urban African-American women about breast cancer. Each CNP program targeted diverse URM women and, using participatory approaches, tailored a range of interventions to promote breast cancer screening. Although all projects shared the same goal outcome, each program tailored their varying interventions to match the target community needs, demonstrating the importance and value of these strategies in reducing breast cancer disparities.

A community partnered-participatory research approach to reduce cancer disparities in South Los Angeles.

Community-academic partnerships may offer opportunities to improve population health in communities that suffer from cancer-related health disparities. This project describes a community partnered effort to promote cancer research and reduce local cancer-related disparities. We used a community-partnered participatory research (CPPR) model and modified Delphi method approach to bring together community and academic stakeholders from South Los Angeles around reducing cancer disparities. The 36-member Community-Academic Council consisted of cancer survivors, academics, and representatives of local community-based organizations and churches. Forty-nine unique cancer-related community priorities were collaboratively used to develop shared products. Early CPPR products included convening of a community conference, a collaboratively developed survey instrument, and new partnerships resulting in externally funded projects. Our approach demonstrates the feasibility of the use of a replicable model of community and academic engagement that has resulted in products developed through collaborative efforts.

Neighborhood factors associated with time to resolution following an abnormal breast or cervical cancer screening test.

The effect of neighborhood and healthcare access factors on cancer outcomes among patients enrolled in navigator programs is not clearly understood. This study assessed associations between: (i) neighborhood factors and diagnostic time to resolution (TTR) and (ii) geographic access and TTR following an abnormal breast or cervical cancer screening test among women participating in the Ohio Patient Navigator Research Program (OPNRP). Patient (demographic, socioeconomic status, home-to-clinic distance) and neighborhood (deprivation, racial segregation) characteristics of 801 women living in one of 285 census tracts (CT) in greater Columbus, Ohio were examined. Randomization to receive navigation occurred at the clinic level. Multilevel Cox regression and spatial analysis were used to estimate effects of various factors on TTR and assess model assumptions, respectively. TTR increased as neighborhood deprivation increased. After adjustment for age, friend social support, education, and healthcare status, the TTR among women living in a neighborhood with a moderate median household income (between $36,147 and $53,099) was shorter compared with women living in low median household income neighborhoods (<$36,147; P < 0.05). There is little evidence that unmeasured confounders are geographically patterned. Increased neighborhood socioeconomic deprivation was associated with longer TTR following an abnormal breast or cervical cancer screening test. These results highlight the need for addressing patient- and neighborhood-level factors to reduce cancer disparities among underserved populations.

The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.

We describe a community-engaged research process used to develop multilevel interventions (caregivers, providers, system) to improve the uptake of human papillomavirus vaccine among adolescents by partnering with members from two underserved populations in Ohio. We began by conducting focus groups to better understand the knowledge and attitudes of caregivers and providers about the human papillomavirus vaccine and to develop teams of community members to assist with development of the interventions. The process continued with conducting writing sessions to determine the content and format of the interventions, and initial feedback was obtained during review sessions to refine the interventions prior to implementation. Using this approach, we were able to consider contextual factors that made the interventions more acceptable and relevant to members of the priority populations. Challenges included development and maintenance of a team of community members to participate in the entire intervention development process, rejection of ideas presented by academic researchers, the need to balance community members' suggestions with what was known from evidence-based research, and the time, cost, and effort associated with partnering with community members. The benefits, however, outweigh the challenges associated with using a community-engaged research process to develop interventions aimed at reducing cancer disparities among underserved populations.

Abstract PR1: Financial strain and cancer risk factors among African American adults

Abstract Background: Early screening and treatment advances have resulted in an overall decline in cancer death rates over the past two decades in the United States (US). However, considerable ethnic disparities still exist in terms of which groups most benefit from these trends. Cancer statistics (2013) suggest that overall cancer incidence and death rates are higher among African Americans as compared to Whites for several cancer sites. Modifiable risk behaviors (smoking, heavy alcohol use, insufficient physical activity, poor diet) and associated outcomes (overweight/obesity) have been causally linked to cancer incidence and related mortality among adults of all ethnicities. However, even after accounting for differences in risk behavior prevalence, African Americans tend to disproportionately suffer from the adverse consequences of behavior risk factors for cancer relative to other ethnic groups. Social determinants, including socioeconomic influences, have been cited as factors contributing to these disparities. There has been recent interest in how financial strain, or an unfavorable income to needs ratio, might uniquely contribute to engagement in modifiable behavioral risk factors for cancer over and above other socioeconomic indicators, but these relations have not been previously examined among African Americans. The current study addressed this gap. Objectives: To examine associations between financial strain and multiple modifiable behavioral risk factors for cancer (smoking, heavy alcohol use, insufficient physical activity, insufficient fruit and vegetable intake, overweight/obesity, and multiple risk factors) among 1278 African American adults (age=46.5+12.6, 77% female), and explore potential mediators (stress and depressive symptoms) of those associations. Methods: A series of regression models were used to examine associations between financial strain and cancer risk factors. All analyses were adjusted for age, sex, partner status, total annual household income, educational level, and employment status. Analyses involving overweight/obesity status additionally controlled for fruit and vegetable intake and physical activity. Statistical significance was set at p&amp;lt;.008 due to multiple comparisons. Nonparametric bootstrapping procedures were used to assess mediation, using conventional significance levels. Results: Greater financial strain was associated with greater odds of insufficient physical activity (p&amp;lt;.003) and smoking (p=.005) and was positively associated with the total number of cancer risk factors (p&amp;lt;.0001). Additionally, there was a significant indirect effect of both stress and depression on the association between financial strain and physical inactivity and on the association of financial strain and the total number of cancer risk factors. Greater financial strain was associated with greater perceived stress and more severe depressive symptoms, which were each associated with a higher likelihood of physical inactivity and more risk factors in covariate-adjusted analyses (ps&amp;lt;.05). Conclusions: Financial strain may contribute to higher cancer risk among African Americans through associations with insufficient physical activity, smoking, and multiple behavioral risk factors for cancer. Greater stress and depressive symptoms may lie along the causal pathway. Future interventions aimed at reducing cancer disparities need to focus on African Americans experiencing higher financial strain while addressing their stress and depressive symptoms. Although additional studies with longitudinal designs are needed to confirm these results, potential theoretical, intervention, and policy implications are discussed. This abstract is also presented as Poster B1. Citation Format: Pragati Advani, Lorraine Reitzel, Nga Nguyen, Felicia Fisher, Elaine Savoy, Adolfo Cuevas, David Wetter, Lorna McNeill. Financial strain and cancer risk factors among African American adults. [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 PR1. doi:10.1158/1538-7755.DISP13-PR1