Screening and Early Diagnosis are Key to Addressing the Disparity in Who Survives Cancer

By Alayna Younger, MPH, CPH, Peak Vista Community Health Centers

logo_na2016_pms274This is the first in a series of “NACCHO Annual preview” blog posts, which feature interviews with and essays from presenters in advance of NACCHO Annual 2016. In honor of National Cancer Survivors Day, Alayna Younger, MPH, CPH, Epidemiologist at Peak Vista Community Health Centers, shares some insights from her upcoming presentation, “Understanding Racial Disparities in Cancer: Use of Cancer Screening Services by Race and Ethnicity in El Paso County, CO.” Register for the conference on or before June 9 to get the early-bird rate.

Between 2003 and 2012, the state of Colorado observed a 16% reduction in overall cancer mortality, a reflection of the trend that has been observed on a national level since the early 1990s. Despite such progress, however, cancer remains the leading cause of death in the state, surpassing mortality rates from heart disease for the past decade. Additionally, not all racial and ethnic groups have benefited equally from the reduction in cancer mortality. For example, all-site cancer mortality among females declined by about 13% during that time span, but mortality among black women actually rose by about 3%. This appears to be driven, in part, by notable disparities in breast cancer survivorship; breast cancer mortality among black women in Colorado increased by 58% from 2003 to 2012, compared to a 16% and 22% decrease among non-Hispanic white women and Hispanic white women, respectively.

A substantial body of research has provided compelling evidence to suggest that reductions in cancer mortality are closely tied with utilization of cancer screening. One study found that more than half of the reduction in colorectal cancer mortality from 1975 to 2000 was due to screening and early detection, while lifestyle changes and treatment accounted for only 35% and 12%, respectively. Additionally, introduction of the Pap test to detect cervical cancers in its early stages contributed to a near 70% decline in cervical cancer deaths in the United States since the 1950s.

Such evidence suggests that the disparity in cancer mortality observed among Coloradans may be due to differences in utilization of screening services, making certain racial and ethnic groups less likely to be diagnosed when their cancer is in its earlier stages.  State surveillance data from 2011 supports this theory, showing that 47% of colorectal cases among non-Hispanic whites were diagnosed in their earliest stages, compared to only 42% of Hispanics and 36% of blacks. Similarly, 73% of female breast cancer cases were diagnosed either in situ or during the localized stage for non-Hispanic white women, in contrast with only 68% and 69% of cases for Hispanic and black women, respectively. These trends suggest that the lower rates of early diagnosis via screening may play a substantial role in the increased cancer mortality observed among non-whites and Hispanics. The implication of this for public health professionals is that increasing access to and utilization of cancer screenings among non-white and Hispanic groups may increase the proportion of cancer cases diagnosed in  earlier stages, when both treatment options and odds of survival are greater.

At NACCHO Annual 2016, I will present my research on racial and ethnic disparities in cancer screening utilization in El Paso County, (CO). The goals of the research were two-fold: first, to examine how pervasive disparities in cancer screening are within the community that my organization serves; and second, to quantify the relative contribution of selected clinical, behavioral, and social factors to the observed differences in meeting screening recommendations by racial and ethnic groups. The results of my research show that, when compared to non-Hispanic whites, non-white and Hispanic groups in El Paso County (CO) have between 109% and 254% greater odds of not meeting screening recommendations for breast, cervical, and colorectal cancers. During my presentation, I will describe the methods and results of multivariable logistic regression models that allow for the computation of the explained fraction, or the proportion of the observed excess risk, which can be explained by specific behavioral, social, and clinical factors. By quantifying the proportion of excess risk that can be attributed to each mediating factor, attendees will be able to inform potential goals and set priorities for interventions within their own communities.

As I will present in greater detail this July, the results of my research indicate that neither behavioral nor clinical factors alone explain a majority of the excess risk of not meeting breast, cervical, and colorectal screening recommendations among non-white and Hispanic groups. To me, this suggests that neither local health departments (LHDs) nor healthcare delivery systems can adequately address this complex issue on their own; rather, a multi-sectoral response is needed to successfully reduce the disparity. By considering collaborations with community health centers and other community groups, LHDs may be better able to comprehensively address the range of behavioral, clinical, and cultural factors that prevent non-white and Hispanic groups from receiving recommended cancer screenings, and within a timely fashion.

As a Chronic Disease Epidemiologist at a Federally Qualified Health Center, I know my institution is actively working towards developing a more integrated relationship with our own LHD. We recognize that at the end of the day, we share the same overarching goal of improving health outcomes at the population level, with an eye towards reducing health disparities and inequities among disadvantaged populations. I attend NACCHO Annual because it allows for the opportunity to engage with public health professionals from all over the country who share similar interests and passions. I greatly anticipate the opportunity to engage in discussions with other LHDs to learn more about the successes and challenges they have encountered while addressing similar concerns in their own communities.

To learn about cancer screening strategies you can implement in your community, participate in Alayna’s session at NACCHO Annual 2016. For details on the dozens of sharing sessions available, visit http://www.nacchoannual.org.  To take advantage of early-bird registration, register on or before June 9.

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