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Addressing racial and ethnic disparities in cancer care delivery

Although progress has been made on several fronts, minority cancer populations still experience higher risk and poorer cancer outcomes. At the AACR 100th Annual Meeting 2009, Elena Martinez, Ph.D., M.P.H, professor of epidemiology and biostatistics at the University of Arizona Cancer Center, will moderate a press conference on Racial and Ethnic Disparities in Cancer Care Delivery that will address these issues. Martinez is a previous chair of AACR's Science of Cancer Health Disparities Conference.

The press conference will take place on Monday, April 20, 2009, at 1:45 p.m. MST, in room 108 of the Colorado Convention Center. Reporters who cannot participate in person can dial in via teleconference using the following information:

• U.S./Canada Dial-In: (888) 282-7404
• International Dial-In: (763) 488-9184
• Access Code: 88613001

"We need to stimulate research that will result in reducing disparities among underserved populations and support efforts that target improving access to medical care for everyone. We also need to increase minority recruitment to clinical trials and support the timely distribution of the findings," said Martinez.

On the individual level, Martinez said researchers and clinicians need to become more aware of the personal biases and practices that may have an impact on the care of patients from minority communities.

"We need to facilitate culturally competent and linguistically appropriate access to health services in the facilities in which we practice, as well as appreciate and address the structural barriers that minority patients face in seeking care," said Martinez.

1671. Enhancement of Recruitment of African-Americans to National Oncology Trials
Embargo: 1:00 p.m. MST, Sunday, April 19, 2009

African-Americans tend to have worse cancer outcomes and their enrollment in clinical trials continues to lag due to barriers of mistrust and communication, as well as lack of knowledge and access to the trials. However, researchers at Meharry Medical College and Vanderbilt Ingram Cancer Center believe they have found a way to overcome those barriers.

"Our research staff at Nashville General Hospital at Meharry is dedicated and permanent. We do not refer African-Americans to another center for clinical trial enrollment. We offer clinical trial participation right here as part of our best medical practices if an appropriate trial is available," said Debra Wujcik, Ph.D., R.N., director of the Cancer Clinical Trials Office.

Working with colleagues in the Meharry/Vanderbilt Cancer Partnership, and funded by a grant from the National Cancer Institute, Wujcik and colleagues sought to determine if they could increase the enrollment of African-Americans in clinical trials at their own center. The current national average for enrollment is about 2.5 percent.

Researchers established a procedure to identify every patient eligible for a clinical trial at the time of confirmed diagnosis. Prior to participation in the study, each clinician was offered training on how best to identify eligible patients and discuss the clinical trial option. No financial incentives were offered to the patient or the clinician.

"Most of the time, the clinical trial option is offered as an afterthought, which contributes to mistrust because African-Americans view themselves as part of an experiment that may not be to their benefit," said Wujcik.

From 2001 to 2004, researchers screened 569 patients, of whom 164 were eligible for a study (29 percent) and 95 agreed to enroll (17 percent). Overall, during this time period, 58 percent of those who were offered a study agreed to participate. Of the patients who did not enroll in a study, 66 percent were ineligible due to additional medical conditions. Only 3 percent refused because it was research.

From 2005 to 2007, researchers refined their techniques and screened 556 patients of whom 172 (32 percent) were eligible for a study and 138 (25 percent) agreed to participate. During this current interval, 80 percent of patients offered a clinical trial participated.

Since 2001, 1,125 patients have been screened, 30 percent of whom had a study available and 21 percent have enrolled.

"What that means is that 68 percent of patients who were eligible agreed to participate," said Wujcik. "This model is definitely replicable at a hospital with a permanent and consistent staff, adequate resources to conduct clinical trials and a patient-oriented, culturally sensitive environment."

Caucasian-American women tend to have higher rates of breast cancer, but African-American women tend to have more aggressive disease and higher mortality rates. Although this disparity is well known, the exact cause and risk factors have not been adequately examined.

Yong Cui, M.D., an assistant professor of medicine at Meharry Medical College, and colleagues, are conducting an epidemiologic study in Tennessee to examine risk factors among Caucasian-American and African-American women under support of a grant from the National Cancer Institute.

To date, this ongoing study has enrolled 1,826 Caucasian women with breast cancer, 1,766 healthy Caucasian control women, 360 African-American women with breast cancer, and 240 healthy African-American control women.

"Our initial data suggests that these women share some risk factors, but there may be distinctive risk factors as well," said Cui.

Lack of physical activity or overweight and obesity was linked with a 20 percent increased risk in both groups of women. The increased risk associated with a family history of breast cancer was similar in Caucasian-American and African-American women at 60 percent and 70 percent, respectively. A personal history of benign breast disease was linked with an 80 percent increased risk among Caucasian-American women and with a 40 percent increased risk among African-American women. Menarche after 12 years was associated with reduced risk up to 40 percent among Caucasian-American women, but not among African-American women.

When the racial groups of breast cancer patients were compared, African-American women were less likely to have a personal history of benign breast disease at 28 percent versus 49 percent. African-American patients were also more likely to be physically inactive at 58 percent versus 46 percent and to be overweight and obese at 80 percent versus 58 percent.

Noticeably, overweight/obesity and physical inactivity are two negative prognostic factors for breast cancer survival.

Cui said he and his colleagues continue to enroll patients and updated numbers will be presented at the AACR 100th Annual Meeting 2009.

Ineffective communication between medical providers and their patients, and the absence of strong primary care relationships, may contribute to the lack of colorectal cancer screening among African-Americans.

"These are barriers that can be overcome," said Jean G. Ford, M.D., associate professor in the department of epidemiology at the Johns Hopkins University Bloomberg School of Public Health.

Ford and colleagues surveyed 1,081 African-Americans in Baltimore City who were between the ages of 65 and 79. Those who had been screened for colorectal cancer were more likely to report better overall health status compared with those who had not been screened.

When Ford and colleagues analyzed what made an individual more likely to be screened, they found that if that individual said their doctor "explains things in a way you understand," they were 50 percent more likely to be screened.

If they had a doctor that they saw on a regular basis, the likelihood of being screened was 2.5-fold higher than those who did not have a regular doctor.

Supplemental health insurance was linked with a 40 percent increase in the likelihood of screening.

"The barriers to screening exist even when a population is insured. One of the key interventions to promote screening appears to be better communication, which fortunately, is a barrier that can be overcome," said Ford.

New data on microRNAs suggests that the same set of microRNAs offer different prognostic values depending on a patient's race/ethnicity.

"There is no common denominator that works for everyone. We need to consider race and ethnicity in the evaluation of the clinical utility of microRNAs," said Upender Manne, Ph.D., associate professor of pathology at the University of Alabama at Birmingham School of Medicine.

Recent studies have suggested that microRNAs have the potential to serve as prognostic and diagnostic biomarkers as well as therapeutic targets in human cancers. Manne and colleagues analyzed colorectal cancer samples collected from 26 African-American and 62 non-Hispanic-Caucasian patients.

The researchers identified five microRNAs that had higher expression in colorectal cancers, but there was a variance in the expression levels between races.

For example, the expression levels of microRNA-324-5p were higher when compared to non-cancerous tissues in colorectal cancer tissues of white patients, but lower in black patients. This increased expression was associated with an unfavorable prognosis in white patients, but decreased expression was associated with a favorable outcome in black patients.

Overall, the increased expression of microRNA-106a was associated with decreased survival in both blacks and whites. The increased expression of microRNA-20a and microRNA-181b, however, was associated with decreased patient survival in blacks, but not in whites.

By contrast, a higher expression level of microRNA-21 in blacks did not affect survival, but did decrease survival in whites.

"Obviously there are nuances among race and ethnicity that need to be considered when evaluating microRNAs as markers," said Manne.

The mission of the American Association for Cancer Research is to prevent and cure cancer. Founded in 1907, AACR is the world's oldest and largest professional organization dedicated to advancing cancer research. The membership includes more than 28,000 basic, translational and clinical researchers; health care professionals; and cancer survivors and advocates in the United States and nearly 90 other countries. The AACR marshals the full spectrum of expertise from the cancer community to accelerate progress in the prevention, diagnosis and treatment of cancer through high-quality scientific and educational programs. It funds innovative, meritorious research grants. The AACR Annual Meeting attracts more than 17,000 participants who share the latest discoveries and developments in the field. Special conferences throughout the year present novel data across a wide variety of topics in cancer research, treatment and patient care. The AACR publishes six major peer-reviewed journals: Cancer Research; Clinical Cancer Research; Molecular Cancer Therapeutics; Molecular Cancer Research; Cancer Epidemiology, Biomarkers & Prevention; and Cancer Prevention Research. The AACR also publishes CR, a magazine for cancer survivors and their families, patient advocates, physicians and scientists. CR provides a forum for sharing essential, evidence-based information and perspectives on progress in cancer research, survivorship and advocacy.

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