Toward the Elimination of Cancer Disparities

Thesocietalburdenofcancerisoneofthemajorpublichealthchallengesofour time. Yetthatburdenisnotequallysharedbyall. Troublingdisparitieshave been documented not only by racial/ethnic group but also by social class, insurancestatus, geography, andahostofotherdimensions. Furthermore, suchdisparitiesrepresenttheendresultofaconstellationofforcesstemming frominsideandoutsidethehealthcaresystem. Manycancerdisparitiesshould bepreventable. Fewhaveattemptedtocapturethebreadthanddepthofthedimensionsof cancerdisparitiesfrombothclinicalaswellaspublichealthperspectives. To addressthisneed, wepresentthisvolumeto: broaden concepts of disparities beyond traditional discussions of race/ ethnicitytoexplorehow, where, andwhytheyoccur; focusoncancerdisparitiesintheUS, whilecitingsomemajorexamplesfrom abroad; analyzecertainmajorcancerswithrespecttodisparities, withemphasison socioeconomicposition; examinethesourcesofdisparitiesfrombothinsideandoutsidethehealth caresystem; identifyinitialinterventionsthatattempttoreduceandeliminatethesed- parities;and identifyissuesthatdeserveattentionwithrespecttofutureresearch. Ourmonographaddressescancerdisparitiesacrossthecontinuum(fromp- vention to mortality and by the domains of social inequality). We begin by exploringbroaddimensionsuchasdefinitionsofdisparities, datasystems, the roleofgenesandenvironment, andtheroleofworkandoccupationincancer disparities. Thenwemoveintospecificchallengesincancerdisparitiessuchas tobaccouseandlungcancer, breastcancer, colorectalcancer, prostatecancer, cervicalcancer, melanoma, andhepatocellularcarcinoma. Wethenconcludewith someavenuestoaddresscancerdisparities, includingpolicyandadvocacy, health v vi Preface communication, overcoming barriers to cancer care, and community-based approaches. Oureffortsarefarfromexhaustive, buttheyrepresentoneofthe firstattemptstoaddresscancerdisparitiesfromsuchacomprehensiveperspective. Thisvolumereflectstheworkofanumberofnationalexpertsincancer disparities. Many are members of the Executive Committee of the Cancer Disparities Program-in-Development of the Dana-Farber/Harvard Cancer Center. Still others are also investigators in the National Cancer Institute Community Network Program MassCONECT (Massachusetts Community NetworkstoEliminateCancerDisparitiesthroughEducation, Researchand Training). Also, thisvolumeupdatesandexpandsaearlier2005monographon thetopicpublishedinthejournalCancerCausesandControl. Allauthorsare dedicatedtothegoalofeliminatingcancerdisparitiesandIamindebtedto them. IamparticularlygratefultoRachelWarren, TerraZipoyrnSnider, andDr. ClaudiaArriggfortheirunendingencouragementandsupport. Itismyhope thatthismonographrepresentsanothercontributiontowardhelpingallpeople enjoytheirhighestattainablestandardofhealth. Boston, MA HowardK. Koh, MD, MPH Contents PartI DimensionsofCancerDisparities 1 Defining, Investigating, andAddressingCancerInequities: CriticalIssues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 NancyKrieger, KarenM. Emmons, andDavidWilliams 2 CancerDisparities: DataSystems, Sources, andInterpretation. . . . . 29 BarbaraD. Powe, AhmedinJemal, DexterCooper, andLokieHarmond 3 Genes, Environment, andCancerDisparities. . . . . . . . . . . . . . . . . . . 49 AlexandraE. Shields, StephanieM. Fullerton, andKennethOlden 4 WorkandOccupation: ImportantIndicatorsofSocioeconomic PositionandLifeExperiencesInfluencingCancerDisparities. . . . . . 83 GlorianSorensen, GraceSembajwe, AmyHarley, andLisaQuintiliani PartII SpecificChallengesinCancerDisparities 5 DisparitiesinTobaccoUseandLungCancer. . .