Tumors of the prostate tend to be a higher grade in African American men who may experience a worse outcome, despite stage-for-stage detection rates similar to those seen in white men. Due to individual differences in baseline PSA values, some adjustment of target PSA values may be necessary to avoid excessive false-positive interpretations of an elevated PSA level in these populations.27,28
The overall effectiveness of some screening tests is controversial. There is active debate over the worse prognosis seen with colorectal cancer. Although a greater degree of advanced disease is seen in some racial groups, biologic differences in colorectal cancer may worsen the prognosis for these patients even when detected at equal stages.29,31
The treatment of cancer after diagnosis, includes surgery, radiotherapy, chemotherapy, biologic therapy, or a combination thereof. Both disparate and nondisparate populations tend to focus more on this part of cancer care than on better use of secondary techniques and the more important primary preventive measures. The rapidly escalating cost of cancer care in the United States and around the world reflects the enormous impact this has on the economy.20,23,32
Tertiary intervention tends to be the most anxiety provoking and cost-consuming aspect of oncology; interestingly, disparity in outcomes at this stage of cancer care is the lowest among the various patient populations.33 A person in the highest socioeconomic group is just as likely to succumb to advanced disease as the person on the lowest rung of the socioeconomic ladder.
ASSESSMENT OF QUALITY
A cancer diagnosis and making cancer-care decisions is an emotional experience. The media, as we know it today, can influence the decision-making of patients. Lay marketing works to promote the idea that outcomes may be better at one center than at another center. The reality is that all cancer treatment centers use the same medications and treatment regimens throughout the country. Patients, especially those in disparate populations, are often unaware that regulatory agencies such as the Commission on Cancer Certification by the American College of Surgeons evaluate a cancer center to determine if it, indeed, is meeting standards of care equivalent to others throughout the country.34,35
A difference in cancer treatment services occurs perhaps in the areas of surgery and radiation, and may vary. Centers with more surgical activity might be preferred for certain cancer surgeries. Occasionally, some radiation techniques provided at urban centers are not available in more rural areas. In regard to chemotherapy and chemobiologic regimens, however, there is not much difference in outcomes or techniques as these medications are “off-the-shelf” products, and physicians must adhere to National Comprehensive Cancer Network (NCCN) guidelines and the established regimens indicated for that cancer type and patient population. Some patients find it hard to believe that systemic therapies are the same at both rural and urban facilities.36,37 The concern arises with disparate patients who may believe that they are not receiving the best care locally and opt to stop therapy.38 Education can play a great role in correcting this situation.
In developing countries, cancer treatment, like preventive screening, lags behind that of developed countries. For example, mastectomies still prevail over breast conservation techniques,34,35,39 a practice still seen in isolated areas of the United States as well; breast cancer intervention involving radiation is replaced with a more aggressive surgery when such an option is available.40 In Africa, administering chemotherapy has been much more acceptable for some forms of lymphoma as opposed to radiation, even when the disease is localized.41
Beyond the prevention, detection, and treatment of cancer, the best use of supportive care, or hospice support services, varies with disparate populations. Disparate patients are often more reluctant to utilize these services, which may be related to a feeling of abandonment or belief that they are being denied active cancer therapy due to their socioeconomic status.30,42 The use of hospice may also be influenced by cultural beliefs. The duration of hospice care has been declining over the last decade, especially among the disparate.28
Solutions for the disparities in cancer care and outcomes in the United States often involve adding more money into the existing health care apparatus. The United States spends more money on health care per capita than any other country in the world, save Norway; yet, it has not produced similar improvements in life expectancy outcomes.32,43 Money is extremely important to achieve new goals, but it does not necessarily address the issues of disparity. Patient education focused on primary preventive measures such as healthy lifestyle habits and undergoing cancer screening is an invaluable tool for reducing cancer outcomes disparities.
Some encouraging trends, however, are emerging in the United States. Pharmaceutical companies are developing programs to help less fortunate patients to ensure they can obtain the most advanced yet expensive medications. Some companies report providing more medications than what they receive payment for in areas with larger disparate populations.43,44 Another promising trend has been a major reduction in the number of African American men who smoke, which has had an equalizing effect on the death rate in this patient population.43
The issue of disparities in cancer care is a complex one. Effective elimination of disparities involves ensuring the participation of diverse communities in planning infrastructure, services, and initiatives that can reduce disparity, and access to funding. ONA
Donald Fleming is an oncologist/hematologist at the Cancer Care Center, Davis Memorial Hospital, Elkins, West Virginia, and a member of the Oncology Nurse Advisor editorial board.
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1. Demark-Wahnefried W, Rock CL, Patrick K, Byers T. Lifestyle interventions to reduce cancer risk and improve outcomes. Am Fam Physician. 2008;77(11):1573-1578.
2. Satia JA. Diet-related disparities: understanding the problem and accelerating solutions. J Am Diet Assoc. 2009;109(4):610-615.
3. Brawer R, Brisbon N, Plumb J. Obesity and cancer. Prim Care. 2009;36(3): 509-531.
4. Grey N, Garces A. Cancer control in low- and middle-income countries: the role of primary care physicians. Prim Care. 2009;36(3):455-470.