Disparities in health care: Hispanic communities
Disparities in health care: ?Hispanic communities
Health care disparities exist among all ethnic populations; and in times when health care reform continues to be transformed, disparities may affect some ethnic groups more than others. Health care disparities are the result of discrimination, differences in access to quality health care, socioeconomic barriers, and cultural barriers.1 The Hispanic or Latino population, the largest minority group in the United States, is at a great risk for poor health outcomes as a result of poor access to health care.2 Access to health care within the Hispanic community is encumbered by poverty, lack of insurance, legal status, and racial or minority status.1
Cancer is the second leading cause of death, behind cardiovascular disease, in this patient population. Disparities relative to screening rates, primary therapy, conservative surgical treatment, adjuvant therapies, and treatment follow-up occur in disproportionate numbers in the Hispanic population.3,4 Contributing factors widely discussed in the literature include country of origin, language, insurance coverage, income level, and cultural perceptions.1,3 The data continue to preclude that the most influential factor on outcomes is a lack of preventive care directly linked to poor access.2,4 As a result, this population is susceptible to higher morbidity and mortality, uncontrolled acute and chronic health conditions, and advanced-stage disease at diagnosis.
Health care disparities are not only based on access. The Institute of Medicine (IOM) reports that social and economic inequality, prejudice, and systematic biases are also significant factors.5 Addressing these factors is challenging due to the large geographical distribution of this population. The health care community needs to identify interventions that promote preventive care practices in this ethnic group to reduce their risk of cancer, as well as other diseases. The risk factors that predispose this ethnic group to certain disparities should be evaluated to determine how to reduce such risks and disparities in care.
Demographics A major goal is to reduce health care disparities in the United States.2 According to the 2000 US Census, approximately 13% of the US population is Hispanic, which includes Mexican, Puerto Rican, and Cuban Americans.6 From 1990 to 2000, the Hispanic population increased by 58%;1,2 and by 2004, 14.2% of the US population was Hispanic (40.6 million people), 72% of whom were US citizens. This group is estimated to increase to 29% of the population by 2040, comprising the largest proportion of national growth.1,3 Almost one third (32.1%) of the current Hispanic population is uninsured or underinsured, thus indicating limited access to health care for both documented and undocumented Hispanic people.2
CANCER IN THE HISPANIC POPULATION
The National Cancer Institute (NCI) reports the incidence of cervical cancer associated with human papillomavirus (HPV), stomach cancer associated with Helicobacter pylori infection, and liver cancer associated with hepatitis B or hepatitis C infection is greater within the Hispanic population.7 In addition, incidence of Hodgkin lymphoma in males, germ cell tumors, leukemia, retinoblastoma, and osteosarcoma is higher among Hispanic children compared with non-Hispanic white children.7
Incidence of most cancers was lowest in the Hispanic population from 1999 to 2003 compared with non-Hispanic whites during those years.7 However, the NCI reported increased diagnoses of myeloma and cancers of the stomach, liver, and cervix among Hispanic people residing in the United States within that same time period.7 In addition, Hispanic people are more likely to have metastatic disease at the time of diagnosis compared with non-Hispanic whites.7 Newer cases will vary by subtypes, stage at diagnosis, and malignancies not previously diagnosed in this population among the four Hispanic groups (Mexican, Puerto Rican, Central American, and South American).7
Cervical cancer represents one the greatest health disparities facing the Hispanic community. The incidence of cervical cancer among US Hispanic women is twice that of non-Hispanic white women, and mortality is at least 42% higher in this population.3 A recent geographical analysis reported the incidence of cervical cancer is higher in Hispanic women than in any other ethnic or racial group in every region of the United States.8
Current cancer statistics for the Hispanic population do not take into account subpopulations, but aggregate data of this population as a whole. The median age at diagnosis for any malignancy in Hispanic persons is 62 years compared with 68 years in non-Hispanic whites.8 The data translate to 1 in 2 Hispanic men and 1 in 3 Hispanic women receiving a diagnosis of cancer in their lifetime. Approximately 47,900 new cases of cancer were diagnosed in Hispanic men and 51,000 new cases diagnosed in Hispanic women in 2009.8 The most common diagnoses were prostate cancer in men and breast cancer in women. Of the estimated 14,400 cancer-related deaths, lung cancer accounted for approximately 22% of the total in men, followed by colorectal (11%) and liver (11%) cancers; in women, the most common cause of cancer deaths was breast cancer (15%), followed by lung (13%) and colorectal (10%) cancers.8
Some cancers associated with infectious sources are more prevalent in the US Hispanic population, especially among first-generation immigrants from Central and South America.8 Stomach cancer was diagnosed in approximately 2,600 persons in 2009, resulting in 1,400 deaths.8 Its incidence is predominantly associated with Helicobacter pylori bacteria, and H pylori infection was reported as the most commonly identified cause. Infection rates among US Hispanic persons are 2 to 3 three times that of non-Hispanic whites.
Worldwide, liver cancers are associated with chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). The incidence of liver cancer among Hispanic persons increased 3.1% per year in men and 2.5% per year in women from 1997 to 2006, and 5-year survival rate was 14% in Hispanic men and 17% in Hispanic women, although prevalence of HCV in the Mexican American population is comparable to that in non-Hispanic whites.8
Cervical cancer incidence and mortality rates among women in Mexico, Central America, and South America is approximately triple those of women in the United States due to lack of screening in these countries.7,8 Occurrence of cervical cancer is the highest among Hispanic women compared with any other racial/ethnic group in every region of the United States. The overall incidence of cervical cancer in Hispanic women living in the United States is about 70% higher than the incidence in non-Hispanic whites. However, the mortality rate (50%) is the same in both Hispanic and non-Hispanic white women. The contributing factor is human papillomavirus (HPV) infection; survey data from 2003-2004 demonstrated a higher prevalence of HPV infection in the Mexican-American population (aged 14 to 59 years).8
Lastly, gallbladder cancer, although rare, has a higher prevalence among Hispanic women than any other ethnic/racial group. Cancer of the gallbladder was diagnosed in an estimated 400 Hispanic women, and only about 10% of patients survived 5 years.8