The Forefront of Cancer Treatments and Lingering Disparities

Despite advances in recent years relating to cancer prevention, detection, and treatment, many minority groups in the United States continue to bear a greater cancer burden than whites.

According to the National Cancer Institute’s Center to Reduce Cancer Health Disparities, while one in three Americans will develop some form of cancer, it continues to be the number one cause of death for many minorities in the United States.  Nationwide, African Americans have a higher rate of death from cancer than Caucasians, and cancer has surpassed heart disease to become the leading cause of death among Hispanics and Asian Americans in the United States.

While the statistics are sobering, researchers say minority nurses can play an important role in working to reduce cancer disparities in their communities.

“Nurses are at the forefront of care and can have a major impact in eradicating cancer disparities by educating patients about the importance of cancer screenings, early detection, and access to care,” says Kimlin Ashing-Giwa, PhD, professor and director of the City of Hope’s Center of Community Alliance for Research and Education in Duarte, California. Ashing-Giwa’s work focuses on addressing the disparities in treatment and outcomes between patients with different access and cultural approaches to medicine.

How Breast Cancer Affects African American and Latina Women

“Although African American women are less likely than white women to be diagnosed with breast cancer, they are more likely to be diagnosed at a later stage and to die of their disease,” says Ashing-Giwa. “Despite the decline in overall breast cancer death rates in the past 20 years, black women continue to have higher death rates.”

A 2012 report from the Centers for Disease Control and Prevention (CDC) says that mammography may be used less frequently among black women than white women. It’s also more common for a longer amount of time to pass between mammograms for black women. Additionally, Ashing-Giwa notes that African American women commonly have subtypes of tumors that are harder to treat, especially an inflammatory form called triple negative breast cancer.

The CDC report also stresses the importance of educating women about the preventive benefits and coverage provided by the Affordable Care Act, including coverage of mammograms without co-pays in many health plans and, beginning in 2014, expanded access to health insurance coverage for 30 million previously uninsured Americans.

“Additionally, a woman’s best overall preventative health strategy is to reduce her known risk factors for breast cancer as much as possible by avoiding weight gain and obesity, engaging in regular physical activity, and minimizing alcohol intake,” says Ashing-Giwa, who encourages nurses to talk to patients about their risk of breast cancer and the importance of getting mammograms and doing breast self-exams.

If women can’t afford a mammogram, there are many free resources available that nurses can recommend to patients (see sidebar). In addition, black women are less likely to get prompt follow-up care when their mammogram shows that something is abnormal. Waiting longer for follow-up care can lead to cancerous tumors that are larger and harder to treat.

Follow-up care after mammograms is also a problem for Latinas. “While Latinas have lower incidences of breast cancer than white or African American women, breast cancer is the leading cause of cancer death for Latinas,” Ashing-Giwa says.

A March 2013 study conducted at the Institute for Health Promotion Research at the University of Texas Health Science Center at San Antonio and published in SpringerPlus found that it took Latinas 33 days longer to reach definitive diagnosis of breast cancer than non-Hispanic white women.  Researchers found that Latinas with abnormal mammograms benefitted significantly from the help of trained professionals called “patient navigators,” who were trained in providing culturally sensitive support. Patient navigators were also helpful in providing transportation, language, and childcare solutions.

“We need to move toward more prevention, screening, treatment, and follow-up that speaks to people in a language they understand,” says Ashing-Giwa.

Despite Being Preventable, Disparities Still Exist With Cervical Cancer

Also of concern are the large differences in rates of new cases and deaths from cervical cancer among African American and Latina women. “Latina women have the highest rates of cervical cancer, followed by African American women,” says Ashing-Giwa. “This is troubling because most cases of cervical cancer are largely preventable and treatable with regular Pap tests and follow-up.”

Mortality rates are also higher for women over 50.

“Many women believe that since they are single and not sexually active, they don’t need a Pap test,” Ashing-Giwa says. While stressing the need for older women to get regular Pap tests, she notes it’s also important for nurses to encourage younger women to get the human papillomavirus (HPV) vaccine and to use condoms. HPV infection is the leading cause of most cervical cancers.

“Cervical cancer should have been eradicated 30 years ago with the invention of the Pap test,” argues Ashing-Giwa. “Most women who are diagnosed with cervical cancer today are those who have never been screened for it.”

Minorities Less Likely to Get Screened for Colon Cancer

A 2012 study conducted at the Center for Health Policy at the University of Nebraska Medical Center College of Public Health and published in the public health journal, Health Affairs, found that minorities are less likely to be screened for colon cancer. The data revealed that 42% of Caucasians were screened for colorectal cancer, compared with 36% of African Americans, 31% of Asian and Native Americans, and 28% of Hispanics.

“The death rate for colon cancer has increased among African Americans and Hispanic people despite it being one of the most preventable forms of cancer, and if caught early, one of the most curable,” says Durado Brooks, MD, MPH, director of prostate and colorectal cancers for the American Cancer Society.

“Although many people of color are aware of colon cancer, they don’t always see how it applies to them,” says Brooks. “If they don’t have a family history of the disease or have symptoms, such as blood in their stools, they often don’t see the need to be screened.”

Only 10% of colon cancer cases are tied to family history, and by the time warning signs are apparent, the cancer has often progressed to an advanced stage where it’s harder to treat. And while it is currently recommended that regular colon screenings begin at the age of 50, it’s recommended that screenings for minorities begin at 45 since many colorectal cancers have been caught in African Americans and Hispanics at younger ages.

“Many people are unaware of the benefits of colorectal screenings,” says Brooks. “There’s the perception that cancer is a death sentence, yet up to 90% of colon cancer cases are preventable with screening.”

Brooks praises Kaiser Permanente for being proactive about screening its health plan members for colorectal cancer. “Rather than waiting for people to ask to be tested, Kaiser Permanente sends out fecal immunochemical testing kits, a type of fecal occult blood test, in the mail to their members who are 50 and older,” Brooks says. “Not all health care providers are as proactive with their approach.”

And while colonoscopies are still considered the gold standard for detecting colorectal cancer, they also require rigorous preparation—a point that prevents many people from getting tested. In an effort to increase testing for colon cancer, Brooks notes that it’s important to let patients know they have choices and that there are other screening options available.

A study published in the April 9, 2012 issue of Archives of Internal Medicine confirmed this by noting that patients were less compliant with screening for colorectal cancer when colonoscopy was the only option offered. Yet when patients were given a choice between a colonoscopy and fecal occult blood testing, 69% completed one of the two exams.

Latino Men at High Risk of Prostate Cancer

According to the American Cancer Society, prostate cancer is the most commonly diagnosed form of cancer among Latino men, and they are also the most likely to be diagnosed with later-stages of the disease.

A new study conducted by researchers at the University of California—Los Angeles (UCLA) and published in the March 2013 issue of Qualitative Health Research concluded that a combination of financial, cultural, and communication barriers play a role in preventing Latino men from accessing the care and treatment they need.

“These obstacles require a new focus on not only adequate health care coverage, but also on the array of hurdles that limit patient access,” says Sally L. Maliski, PhD, RN, FAAN, associate dean for academic affairs at the UCLA School of Nursing and senior author of the study.

Maliski cites inability to afford medical insurance, difficulty understanding insurance policies, a lack of health literacy among the men, and their limited proficiency in English as barriers throughout the entire prostate cancer-care process.

“Our findings made it clear that we need a system where not only is care affordable, but where we use a multi-faceted approach to improve access, increase health literacy, and greatly improve care coordination,” says Maliski.

Focusing on Cancer Disparities in the Asian Community

“The cancer burden in the Asian American community is unique because cancer has been the leading cause of death among Asian Americans for the past 13 years,” saysMoon Chen, Jr., PhD, MPH, principal investigator for the National Center for Reducing Asian American Cancer Health Disparities headquartered at the University of California-Davis Cancer Center. Chen adds that hepatitis B induced-liver cancer is the greatest cancer health disparity for Asian Americans.

“All Asian American immigrants and their children should be screened for hepatitis B to lead to earlier detection,” Chen says. “And Asian Americans who do not have hepatitis B immunity should also get the hepatitis B vaccine, [which is] the best way to stop the spread of hepatitis B.”

Chen and his colleagues have received a federal grant to increase screening for hepatitis B. Since December of last year, screening events have been held in Northern California at Asian health clinics, local churches, temples, health fairs, and community organizations.

Many Asian Americans don’t get regular cancer screenings, which also adds to poor cancer outcomes. “Until they have symptoms, many Asian Americans aren’t really concerned about cancer and don’t think screening is necessary,” Chen says. “Vietnamese women have the highest rates of cervical cancer, which can be detected and treated early through Pap smears.”

Chen says cigarette smoking is also a big problem among Asian American immigrants and that they are the racial group least likely to be counseled on smoking cessation.

“Smoking is the leading cause of death worldwide and it’s a preventable risk factor,” Chen says. “It’s a complicated message and often language can be a barrier. There’s a great need for smoking cessation programs that are culturally tailored to Asian populations, both in language and intent.”

Stomach cancer is also prevalent in Asian Americans and Chen attributes this to chronic infection with Helicobacter pylori bacteria, which is common in developing countries. In Koreans, diet is also to blame, specifically foods that are preserved with nitrates and nitrites, such as kimchi.

Since prevention and early detection are key components of cancer control, Chen recommends that nurses who work with different Asian American populations either learn the specific language of their demographics, or have cancer education materials readily available in different languages such as Vietnamese, Korean, Mandarin, and Tagalog.

“Nurses who can accommodate differences in language fluency, dietary practices, and cultural beliefs can help to remove some of the barriers that exist in screening and treating minority patients,” Chen says. “Nurses who have this expertise are often the bridge between health care systems and minority communities.”