American Cancer Society's report on the status of cancer disparities in the United States, 2021.

In this report, the authors provide comprehensive and up-to-date US data on disparities in cancer occurrence, major risk factors, and access to and utilization of preventive measures and screening by sociodemographic characteristics. They also review programs and resources that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. The overall cancer death rate is 19% higher among Black males than among White males. Black females also have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. There are also substantial variations in death rates for specific cancer types and in stage at diagnosis, survival, exposure to risk factors, and receipt of preventive measures and screening by race/ethnicity, socioeconomic status, and geographic location. For example, kidney cancer death rates by sex among American Indian/Alaska Native people are ≥64% higher than the corresponding rates in each of the other racial/ethnic groups, and the 5-year relative survival for all cancers combined is 14% lower among residents of poorer counties than among residents of more affluent counties. Broad and equitable implementation of evidence-based interventions, such as increasing health insurance coverage through Medicaid expansion or other initiatives, could substantially reduce cancer disparities. However, progress will require not only equitable local, state, and federal policies but also broad interdisciplinary engagement to elevate and address fundamental social inequities and longstanding systemic racism.

Blueprint for cancer research: Critical gaps and opportunities.

We are experiencing a revolution in cancer. Advances in screening, targeted and immune therapies, big data, computational methodologies, and significant new knowledge of cancer biology are transforming the ways in which we prevent, detect, diagnose, treat, and survive cancer. These advances are enabling durable progress in the goal to achieve personalized cancer care. Despite these gains, more work is needed to develop better tools and strategies to limit cancer as a major health concern. One persistent gap is the inconsistent coordination among researchers and caregivers to implement evidence-based programs that rely on a fuller understanding of the molecular, cellular, and systems biology mechanisms underpinning different types of cancer. Here, the authors integrate conversations with over 90 leading cancer experts to highlight current challenges, encourage a robust and diverse national research portfolio, and capture timely opportunities to advance evidence-based approaches for all patients with cancer and for all communities.

Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy.

Although cancer mortality rates declined in the United States in recent decades, some populations experienced little benefit from advances in cancer prevention, early detection, treatment, and survivorship care. In fact, some cancer disparities between populations of low and high socioeconomic status widened during this period. Many potentially preventable cancer deaths continue to occur, and disadvantaged populations bear a disproportionate burden. Reducing the burden of cancer and eliminating cancer-related disparities will require more focused and coordinated action across multiple sectors and in partnership with communities. This article, part of the American Cancer Society's Cancer Control Blueprint series, introduces a framework for understanding and addressing social determinants to advance cancer health equity and presents actionable recommendations for practice, research, and policy. The article aims to accelerate progress toward eliminating disparities in cancer and achieving health equity.

Design of a cluster-randomized minority recruitment trial: RECRUIT.

BACKGROUND: Racial/ethnic minority groups remain underrepresented in clinical trials. Many strategies to increase minority recruitment focus on minority communities and emphasize common diseases such as hypertension. Scant literature focuses on minority recruitment to trials of less common conditions, often conducted in specialty clinics and dependent on physician referrals. We identified trust/mistrust of specialist physician investigators and institutions conducting medical research and consequent participant reluctance to participate in clinical trials as key-shared barriers across racial/ethnic groups. We developed a trust-based continuous quality improvement intervention to build trust between specialist physician investigators and community minority-serving physicians and ultimately potential trial participants. To avoid the inherent biases of non-randomized studies, we evaluated the intervention in the national Randomized Recruitment Intervention Trial (RECRUIT). This report presents the design of RECRUIT. Specialty clinic follow-up continues through April 2017. METHODS: We hypothesized that specialist physician investigators and coordinators trained in the trust-based continuous quality improvement intervention would enroll a greater proportion of minority participants in their specialty clinics than specialist physician investigators in control specialty clinics. Specialty clinic was the unit of randomization. Using continuous quality improvement, the specialist physician investigators and coordinators tailored recruitment approaches to their specialty clinic characteristics and populations. Primary analyses were adjusted for clustering by specialty clinic within parent trial and matching covariates. RESULTS: RECRUIT was implemented in four multi-site clinical trials (parent trials) supported by three National Institutes of Health institutes and included 50 associated specialty clinics from these parent trials. Using current data, we have 88% power or greater to detect a 0.15 or greater difference from the currently observed control proportion adjusting for clustering. We detected no differences in baseline matching criteria between intervention and control specialty clinics (all p values > 0.17). CONCLUSION: RECRUIT was the first multi-site randomized control trial to examine the effectiveness of a trust-based continuous quality improvement intervention to increase minority recruitment into clinical trials. RECRUIT's innovations included its focus on building trust between specialist investigators and minority-serving physicians, the use of continuous quality improvement to tailor the intervention to each specialty clinic's specific racial/ethnic populations and barriers to minority recruitment, and the use of specialty clinics from more than one parent multi-site trial to increase generalizability. The effectiveness of the RECRUIT intervention will be determined after the completion of trial data collection and planned analyses.

Health-related quality of life in elderly black and white patients with cancer: results from Medicare managed care population.

OBJECTIVE: To compare differences in various aspects of health-related quality of life (HRQOL) between Black and White individuals diagnosed with cancer. DESIGN: The data were extracted from 2005-2007 Medicare Health Outcome Survey, a health outcomes measure for the Medicare population in managed care settings. A total of 14089 Black and White respondents aged > or = 65 with cancer were included in the study. Multivariable linear regressions were used to assess the association between race and the HRQOL after accounting for age, sex, education years, marital status, and non-cancer comorbid conditions. RESULTS: When compared with their White counterparts, Black patients had lower scores for the physical component summary (PCS) and mental component summary (MCS), and all health domains with the exception of vitality. After adjusting for demographic features and comorbid conditions, the MCS scores of Black patients were still lower than that of White patients. However, the mean PCS was not different for Black and White patients. Black patients had significantly lower HRQOL in general health, social functioning, and role emotion, whereas they had a higher mean score in vitality. CONCLUSIONS: Race had a significant impact on quality of life for older cancer patients. The effect was likely to be moderated by comorbid conditions and socioeconomic indicators. To optimize cancer outcomes at the population level, it is important to identify subgroups of cancer patients with an increased risk of low quality of life and to develop appropriate supportive interventions of cancer care.

Racial/ethnic disparities, social support, and depression: examining a social determinant of mental health.

OBJECTIVE: We examined the risk of depression as it relates to social support among individuals from African American, Caribbean black, and non-Hispanic White backgrounds. METHODS: 6,082 individuals participated in the national survey of American life (NSAL), a nationally representative, psychiatric epidemiological, cross-sectional survey of household populations. The survey is designed to explore racial and ethnic differences in mental disorders. NSAL survey questions were used as a proxy for social support. Logistic regression analysis was used to examine the correlates between having a DSM-IV diagnosis of major depressive disorder in the past year, demographic variables, and social support. RESULTS: African American race/ethnicity was associated with decreased odds of depression when compared to non-Hispanic whites, even when controlling for social support variables and demographics (OR = 0.51, 95% CI = 0.43-0.60). We found a three-fold increase in risk of depression among individuals who reported feeling "not very close at all" with family members compared to those who reported feeling "very close" to family (OR = 3.35, 95% CI = 1.81-6.19). CONCLUSIONS: These findings reinforce previous research documenting the important relationship between social support and depression, and perhaps should lead us to reexamine the individualistic models of treatment that are most evaluated in United States. The lack of evidence-based data on support groups, peer counseling, family therapy, or other social support interventions may reflect a majority-culture bias toward individualism, which belies the extensive body of research on social support deficits as a major risk factor for depression.

Combining web-based and mail surveys improves response rates: a PBRN study from PRIME Net.

PURPOSE: The advent of Web-based survey tools has provided the investigator with an alternative to paper-based survey methods that in many instances may be less expensive to implement than traditional paper-based surveys. Newer technology, however, does not diminish the importance of obtaining an adequate response rate. METHODS: We analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was first implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders. RESULTS: Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase. CONCLUSIONS: Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs.

Presence of a community health center and uninsured emergency department visit rates in rural counties.

CONTEXT: Community health centers (CHCs) provide essential access to a primary care medical home for the uninsured, especially in rural communities with no other primary care safety net. CHCs could potentially reduce uninsured emergency department (ED) visits in rural communities. PURPOSE: We compared uninsured ED visit rates between rural counties in Georgia that have a CHC clinic site and counties without a CHC presence. METHODS: We analyzed data from 100% of ED visits occurring in 117 rural (non-metropolitan statistical area [MSA]) counties in Georgia from 2003 to 2005. The counties were classified as having a CHC presence if a federally funded (Section 330) CHC had a primary care delivery site in that county throughout the study period. The main outcome measure was uninsured ED visit rates among the uninsured (all-cause ED visits and visits for ambulatory care sensitive conditions). Poisson regression models were used to examine the relationship between ED rates and the presence of a CHC. To ensure that the effects were unique to the uninsured population, we ran similar analyses on insured ED visits. FINDINGS: Counties without a CHC primary care clinic site had 33% higher rates of uninsured all-cause ED visits per 10,000 uninsured population compared with non-CHC counties (rate ratio [RR] 1.33, 95% confidence interval [CI] 1.11-1.59). Higher ED visit rates remained significant (RR 1.21, 95% CI 1.02-1.42) after adjustment for percentage of population below poverty level, percentage of black population, and number of hospitals. Uninsured ED visit rates were also higher for various categories of diagnoses, but remained statistically significant on multivariate analysis only for ambulatory care sensitive conditions (adjusted RR = 1.22, 95% CI 1.01-1.47). No such relationship was found for ED visit rates of insured patients (RR 1.06, 95% CI 0.92-1.22). CONCLUSIONS: The absence of a CHC is associated with a substantial excess in uninsured ED visits in rural counties, an excess not seen for ED visit rates among the insured.

Practical barriers to timely primary care access: impact on adult use of emergency department services.

BACKGROUND: Most Americans report having a usual source of medical care, but many also report significant barriers to timely access to such care. This can lead patients to use the emergency department (ED) as a ready alternative to their usual source of medical care, even when such care could be provided more cost-effectively in a primary care setting. The purpose of this study was to examine the relationship between ED visits and perceived barriers to receiving timely primary care. METHODS: Among 30,677 adults 18 years or older participating in the adult sample section of the National Health Interview Survey, 23,413 who reported having a usual source of medical care other than the ED and answered the questions related to barriers were included in our analyses. Associations between perceived timely access barriers and reported use of ED in the previous 12 months were examined using logistic regression to control for covariates that also affect ED use. RESULTS: For those reporting no access barriers, 1 in 5 adult Americans in the noninstitutionalized civilian population visited an ED at least once during the preceding year. For those reporting 1 or more barriers, the proportion having an ED visit was 1 in 3. Four of the 5 following timely access barriers was independently associated with ED use, even after adjusting for other socioeconomic and health-related factors: (1) "couldn't get through on phone" (OR [odds ratio], 1.27; 95% confidence interval [CI], 1.02-1.59); (2) "couldn't get appointment soon enough" (OR, 1.45; 95% CI, 1.21-1.75); (3) "waiting too long in doctor's office" (OR, 1.20; 95% CI, 1.02-1.41); (4) "not open when you could go" (OR, 1.24; 95% CI, 0.99-1.55); and (5) "no transportation" (OR, 1.88; 95% CI, 1.50-2.35). CONCLUSIONS: The benefits of having a usual source of medical care are diminished by barriers that limit effective and timely access to such care. Interventions to improve effective access to medical care such as open access scheduling might have benefits not only for individual patients and practices but also for health policy related to cost-effective health care delivery systems and our need to relieve overcrowded conditions at EDs.

A crash-course in cultural competence.

America is a multi-cultural society. Yet, there are cultural dimensions to the clinician-patient relationship that have not been systematically addressed in medical education or in clinical practice. Lack of diversity and lack of cross-cultural skills in the medical profession may contribute to health disparities in America. Cultural competence for the medical profession represents a core set of skills that can be learned to respectfully and effectively communicate healthcare information with diverse patient populations. The authors blended their extensive literature review with the knowledge and experience of a culturally diverse medical team to develop the CRASH-Course in Cultural Competency training program for medical professionals. CRASH is a mnemonic for the following essential components of culturally competent health care--consider Culture, show Respect, Assess/Affirm differences, show Sensitivity and Self-awareness, and do it all with Humility. The goal of the CRASH-Course in Cultural Competency is to build confidence and competence in the clinician's ability to communicate effectively with diverse patient populations.

Being uninsured: impact on children's healthcare and health.

PURPOSE OF REVIEW: There are 8.4 million uninsured children in the United States. Many are eligible for coverage. Current literature on how lack of health insurance affects the quality and outcome of children's healthcare in the United States is reviewed, and effective solutions are identified. Recent policy changes have produced restrictions on basic preventive and curative services, despite concurrent major efforts to increase insurance coverage rates for children. RECENT FINDINGS: With more than 70% of currently uninsured children eligible for either Medicaid or the State Children's Health Insurance Program, these public programs have not yet produced expected levels of coverage. Health systems and provider accountability for the primary care of uninsured children is not optimal. Families of uninsured children face non-financial access barriers to care such as lack of continuity with a primary care provider and inadequate visit time. These barriers are compounded for uninsured children with special healthcare needs. SUMMARY: Pediatric primary care effectiveness is significantly reduced by insurance shortfalls. Lack of coverage inhibits appropriate care seeking; diminishes provider availability; compromises care content, quality, and satisfaction; and ultimately harms the entire family unit. However, provision of insurance alone is not a panacea.

Translation squared: improving asthma care for high-disparity populations through a safety net practice-based research network.

To assess the effectiveness of an intervention designed to increase compliance with national asthma care guidelines in primary care safety net health centers serving high-disparity patient populations, we conducted a group-randomized controlled trial (seven intervention sites and nine control sites) in federally funded community health centers in eight southeastern states. There were three components involved in the intervention: resources (asthma kits including peak flow meter, MDI spacer device, plus educational materials), training of all health center staff in asthma care guidelines, and tools or templates for practice-level systems change (asthma flow sheets and standing orders). Control group sites received only copies of the national asthma guidelines. Chart reviews were performed to determine practitioner's compliance with national guidelines for asthma care. Clinicians practicing in intervention health centers showed significantly (p < 0.01) greater improvement on some measures than did the control health centers, although postintervention compliance with guidelines was still suboptimal. Disseminating national guidelines is not enough. Providing training and guideline-specific resources, in combination with tools for practice change, improved care significantly even in safety net health centers serving high-disparity patient populations.

Modifiable determinants of healthcare utilization within the African-American population.

BACKGROUND: Significant health disparities directly affect the African-American population. Most previous studies of disparities in access to and utilization of healthcare have focused on black-white differences rather than focusing on "within-group" analysis of African Americans. OBJECTIVE: To tease out the differential effects of modifiable risk factors (such as health insurance, usual source of care, and poverty) from personal characteristics (age, gender, rural residence) on healthcare utilization within the African-American population. METHODS: Secondary data analysis of 3462 records from African-American respondents to the 1999 Medical Expenditure Panel Survey (MEPS) Household File, a nationally representative survey of the civilian, noninstitutionalized U.S. population in 1999. RESULTS: We found significant variation in the number of office visits, outpatient clinic visits, hospital discharges, days hospitalized, and fills of prescribed medication among 3462 African-American respondents who represent a U.S. population of 36,538,639 persons. Personal nonmodifiable characteristics such as age and gender were significantly related to healthcare utilization. Poverty and rural residence were also significantly correlated, but the strongest modifiable predictors of healthcare utilization for Afrcan-American persons in 1999 were whether or not individuals had health insurance and/or a usual source of care. Emergency department visits were the only form of care that showed remarkably little variation based on these modifiable risk factors. CONCLUSIONS: The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients and could be independently targeted for intervention.