Understanding and addressing cancer health disparities

Breaking down disparities

According to Thompson, most cancer health disparities can be traced to four factors.

• Access to care, she said, is the “most typical reason given for why disparities continue.” While the Affordable Care Act has made insurance available for many more people in underserved communities, there are still exceptions. The rate of insurance for members of the Hispanic population, for instance, has been “amazingly low,” she said, even after the ACA went into effect. “And we don’t know what will happen to that,” she added, referring to forthcoming health insurance changes. “Access to care continues to be a problem.”
• Lack of early detection is another key issue. Ethnicity and income both influence who gets screened for cancer and who doesn’t. “People who are poor are much less likely to get a mammogram than people who have money,” Thompson said. Black and multiracial groups are much less likely to get screened for cervical cancer or the presence of human papillomavirus, or HPV, which can lead to the disease. “Nobody should die from cervical cancer,” she said. “It’s a very curable cancer, easily detected if you get Pap testing or, most recently, HPV testing. [And there’s also] the HPV vaccination.”
• Social determinants of health such as poverty, income level, lack of insurance, low literacy, and cultural beliefs and attitudes (think avoidance, fatalism and distrust of the medical community) all have an impact on disparities when it comes to health, Thompson said. “African Americans have had centuries of mistreatment and oppression and there’s an expectation that they should now go and do everything that a white physician tells them,” she said. “There’s a distrust there that needs to be addressed.”
• Exposure to extreme events was perhaps the most intriguing reasons for cancer health disparities discussed at the symposium. Thompson said our genes can be affected by the environment in which we live, and exposure to certain environmental factors may drive a cancer later in life.

Thompson illustrated this last point by sharing research on the Dutch Famine of WWII, which her mother, pregnant with Thompson at the time, lived through. Due to German blockades, thousands of people suffered from or died of starvation in a grim stretch from September 1944 to May 1945. Thirty years later, researchers looked at women who’d lived through the famine and found their rates of breast cancer had increased substantially, some by as much as 48 percent.

“Things that happen to us in early life can affect what happens to us in later life,” she said, pointing to another study on high cancer rates in Holocaust survivors. “There’s some evidence that environmental stressors trigger norepinephrine and cortisol, which are thought to reduce the immune response and thereby may be increasing or accelerating cancer progression.”

But long-term exposure to extreme events is still happening today, Thompson said.

“Think about this in terms of our populations who live in poverty and areas that are filled with physical violence and hate,” she said. “People who have suffered sexual abuse and other traumatic abuse; people who live in constant depression and anxiety — it’s no wonder that they may have some of these effects … Studies demonstrate that living in an environment of hate has an effect on your health.”

‘Work with people where they are’

What can we do about this complex mix of factors that lead to health disparities?   

“This is my mantra,” Thompson said. “Go in search of people, begin with what they know, and build on what they have. If you want to change behavior of people who are underserved and oppressed, you need to work with people where they are. You can’t come in and do your typical non-Hispanic white research and hope that it’s going to make a difference.”

Thompson said working directly with the communities you’re researching is key, highlighting successful HDRC outreach with Latinos in Washington’s Lower Yakima Valley; African Americans in Seattle and Tacoma, and the Somali community in Puget Sound. HDRC teams, for instance, discovered many people in Yakima Valley hadn’t gone in for colorectal cancer screening because they didn’t know enough about colons.

“We asked, ‘What would make you more aware?’ And they said, ‘If we saw a colon,’” Thompson said. “So we bought a giant inflatable colon that’s 20 feet long … And people loved it.”

More than that, out of the 300 fecal occult blood test kits they handed out to people 50 and older who visited health fairs featuring CASPER, the inflatable colon, 75 percent of those kits were brought in for screening tests — an extremely good result, according to Thompson.

Thompson said HDRC researchers don’t reinvent the wheel — if something is working, they’ll stick with it — and they also don’t do “helicopter research,” where scientists swoop in, get the data, and swoop out.

“We make sure people understand why we’re there,” she said. “They help us with all aspects of the research, they help us write papers and they always get the study results back.”

Thompson’s talk was capped by representatives from four community-based organizations who presented findings from recent HDRC-funded research collaborations designed to break down disparities in health care. 

Delivering health support by phone

Dr. Eun Jeong Lee, national director of the Senior Community Service Employment Program with National Asian Pacific Center on Aging (NAPCA) spoke about a project designed to overcome language barriers which can contribute to health problems for many older Asian Americans and Pacific Islands.

This program tailored a version of “Check. Change. Control,” a high blood pressure program developed by the American Heart Association, so it could be delivered to older Chinese, Korean and Vietnamese-American adults by multi-lingual counselors via phone.

The counselors checked in with 14 participants regarding their blood pressure and other health issues on a regular basis for four months.

“We haven’t done a full analysis yet, but I can say that many of the participants, particularly Korean participants, were taking care of their health by themselves and had no social support,” said Lee. “So they were very happy to receive phone calls from counselors and felt much less isolated.”

Educating decision-makers

Suzanne Pak, director of community and behavioral health programs for the Korean Women’s Association, presented on a health equity project that focused on bringing more awareness to decision-makers in health social services, government agencies and health insurance companies about the high prevalence of stomach cancer in Asian Pacific Americans and Native Americans.

“Our specific aim was to improve early detection of stomach cancer among Asian Pacific Americans,” she said. “Oftentimes when you look at health disparity reports, you look at information based on race. But there’s actually a wide variation across different ethnicities in Asian Americans.  With Korean Americans, the incidence is like eight times more than the white American counterpart. That’s an extreme health disparity.”

The researchers worked with an advisory committee of doctors, researchers, health agencies, government agencies, patient advocates and others, then went on to host a stomach cancer conference which attracted 120 health leaders. A pre- and post-conference survey of participants showed increased awareness about stomach cancers and a willingness to share that knowledge with others. Researchers also learned via participants that the biggest barrier to stomach cancer screening was the lack of a U.S. screening guideline (no guidelines means no insurance coverage so tests would be out-of-pocket for patients).

Pak and her team looked into the possibility of policy change, such as the creation of a national screening guideline for at-risk populations, but felt it was unfeasible at this time.

“I found out that it is really hard to get the U.S. Preventive Services Task Force to change a national guideline,” she said. “That makes patient education around early detection harder. You can’t just say, ‘Get screened after a certain age.’”