Grubbs SS, et al. J Clin Oncol. 2013;doi:10.1200/JCO.2012.47.8412.
Petrelli reports no relevant financial disclosures.
Much has been written in the literature about disparities in cancer care. It’s almost literature overload.
COVID-19 has not helped the situation. For example, in Delaware, when we compared 2020 to 2021 Screening for Life results, we saw a 68% decrease in the number of cervical cancer screenings, 73% decrease in colorectal screenings and 58% decrease in breast cancer screenings performed from March 2020 to February 2021 vs. the same time frame from 2019 to 2020. These missed cancer screenings will lead to the diagnosis of advanced-stage cancers and increased cancer deaths in the coming years.
To add insult to injury, in Delaware, Black women are more likely to be diagnosed with advanced breast cancer and those aged 40 to 64 years have a 56% higher mortality rate compared with their white counterparts. Also, our state leads the nation in triple-negative breast cancer incidence rates. A little-known fact is Delaware has the highest rates of alcohol-attributed breast cancer in the United States, which accounts for 19% of breast cancers.
Reasons for optimism
We obviously have our work cut out for us. However, we have every reason to be optimistic.
We are entering the 20th year of the Delaware Cancer Advisory Council and Consortium, which in less than a decade has taken Delaware out of the top 10 states for cancer mortality. We also have an excellent track record in our statewide colorectal screening program. Through a statewide effort, we ended the disparity between white and African-American individuals in colorectal screening in 2008. This program continues to date. However, keep in mind that the algorithm for colorectal screening is fairly straightforward. Colonoscopy is primary prevention and removal of polyps prevents cancer. The algorithm for low-dose CT scanning for lung cancer and mammography for breast cancer is secondary prevention and more complicated.
Hence, the approach to answering health-equity questions in lung and breast cancer screening needs to rise to another level. It’s not just a matter of setting up a process for individuals to get their mammogram or low-dose CT scan, but the whole domains of social determinants of health. The latter involves economic stability, the neighborhood and physical environment, education experience, access to healthy food, support systems and, last but not least, health coverage. It’s complicated, and reducing disparities requires a multidisciplinary program approach. I emphasize reducing disparities because it is almost impossible to eliminate them. I call your attention to a quote by football coach Vince Lombardi, who said, “Perfection is not attainable, but if we chase perfection we can catch excellence.” In this context, if we strive to end disparities, we will reduce disparities.
Addressing ‘complex interplay of factors’
In this complex environment, our cancer center has established a Community Research Advisory Board (CRAB) for our breast cancer health equity research/screening program. CRAB members include breast cancer survivors, primary care physicians, scientists and local community leaders. We have adopted a multidisciplinary, research-driven, precision population/science intervention strategy designed to reduce breast and lung cancer disparities. We are employing geospatial and behavioral science methods to assess exposures such as alcohol, tobacco, diet and the environment together with genetic factors and the metabolome.
Our community outreach and education team has taken cues from the communities it serves on how best to disseminate information the community is asking for. Our health outreach and education Spanish language Facebook page has more than 400 followers. With support from our marketing and communication staff, the outreach and education team responds to the concerns and questions of community members.
The above are only a few examples of how we are approaching the racial disparities in breast and lung cancer mortality, which are driven by a complex interplay of factors spanning the molecular to sociological scales. It comes down to targeting underserved communities with high cancer incidence through focused processes and resources. It involves screening accessibility along with addressing the social determinants of health and improving access to care, and member engagement at all levels. Lastly, achieving better health outcomes will require policy changes within and beyond health care.
Obviously, all of this won’t happen overnight. It took close to 10 years to just about end disparities between African-American and white individuals for colorectal cancer screening in Delaware. It will take much longer for breast and lung cancer screening. But we have no choice. This must be accomplished. It is our responsibility for present and future generations of all people.
- Grubbs SS, et al. J Clin Oncol. 2013;doi:10.1200/JCO.2012.47.8412.
- Siegel SD, et al. Cancer Epidemiol Biomarkers Prev. 2022;doi:10.1158/1055-9965.EPI-21-1031.
- Siegel SD, et al. Cities & Health. 2021;doi:10.1080/23748834.2021.1935141.
- Sims-Mourtada J, et al. Cancer Stud Molr Med Open J. 2019;doi:10.17140/CSMMOJ-5-e007.
- For more information:
- Nicholas J. Petrelli, MD, FACS, is Bank of America endowed medical director of ChristianaCare’s Helen F. Graham Cancer Center & Research Institute and associate director of translational research at Wistar Cancer Institute. He also serves as Associate Editor of Surgical Oncology for HemOnc Today. He can be reached at firstname.lastname@example.org.