Health Inequity and Controversies in Cancer Screening. Doris Browne, MD, MPH Immediate Past President, NMA September

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1 Health Inequity and Controversies in Cancer Screening Doris Browne, MD, MPH Immediate Past President, NMA September

2 DISCLOSURE In compliance with ACCME Guidelines, I hereby declare: I do not have financial or other relationships with the manufacturer(s) of any commercial product(s) or service(s) discussed in this educational activity. Name: Doris Browne, MD, MPH Title: Immediate Past President National Medical Association

3 OVERVIEW Definition of Health Equity and the scope of cancer health disparities in the U.S. Which Health Inequities are most concerning and what can physicians do about them. How can health care professionals increase awareness of and utilize best practice to address health inequities What can we do to address Health Inequities?

4 HEALTH EQUITY DEFINITION Health Equity is the assurance of conditions for optimal health for all people To achieve Health Equity requires: Equally valuing all individuals and populations Recognizing and rectifying historical injustices; and Resources provided based on need When Health Equity is achieved there will be no health disparities

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6 CANCER HEALTH INEQUITIES Profound advances in biomedical science have contributed to increased longevity and improved quality of life for many Americans. Despite this progress, a heavier burden of disease is borne by some population groups in the United States, particularly people of color, the poor and underserved.

7 SCOPE OF HEALTH INEQUITIES Low Economic Status/Poverty Culture Social Injustice

8 SOCIAL DETERMINANTS OF HEALTH Neighborhoods Racism Zip codes Genetics Insurance (CHIP and ACA) Health Services Voting Collaboration

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10 HOW TO ADDRESS HEALTH INEQUITIES Shared vision and values Multi-sector collaboration Increased capacity building to shape outcomes Healthier, more effective outcomes Live and Learn Work Play Worship Policies and Laws

11 FRAMEWORK FOR HEALTH EQUITY

12 CANCER EPIDEMIOLOGY 2017 U.S. Cancer Statistics 1,688,780 estimated new cases of cancer 600,920 estimated deaths from cancer 2016 African American Statistics 189,910 new cases of cancer (93,990 men/95,920 women); 69,410 cancer deaths (35,660 men/33,750 women) BC incidence/mortality in AA: 30,700/6,310 (32%)/(19%) Lung ca mortality among men (27%)/women (22%) Prostate cancer incidence/mortality: 29,530/4,450 (31%)/(12%) Colorectal ca incidence/mortality: 19,240/7,030 (9%)/(11%-10%)

13 FOUR MOST COMMOM CANCERS Lung ca is leading cause of cancer death in AAs Breast ca is second leading cause of cancer death in AA women and mortality twice that of whites Prostate ca is second leading cause of cancer death in AA men Colorectal cancer is third leading cause of cancer death in AA Death rate for all cancers combined is 24% higher in AA men/14% higher in AA women than whites

14 CONTROVERSIES IN CANCER SCREENING Guidelines generated by major organizations are not always inclusive of our diverse population National Institutes of Health American Cancer Society National Comprehensive Cancer Network American Society of Clinical Oncology United States Preventive Services Task Force

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20 HEALTH DISPARITIES IN BREAST CANCER How much is biological and how much is socio-economic? Conflicting evidence from studies of AA and African women Powerful evidence from epidemiology in the U. S. How many of the 33,750 deaths due to breast cancer each year are attributable to inferior health care, and how many deaths could be prevented by improvements in delivery and elimination of differences in quality of health care to minorities?

21 DIFFERENCES IN TENDENCY TO DEVELOP CANCER Major single-gene defects have been identified in cancer onset Aggressive subtype of breast cancer Cancer biology Nutritional genomics Genetic polymorphisms Environmental factors Metabolic activation/detoxification Response to therapy

22 CRITICAL DETERMINANTS IN CANCER CELLS BIOLOGY Genetics (GSTs,CYPs, BRCA1, NAT2 ) Diet (obesity, fat) Environment Life-Style Factors (smoking) Drug Efficacy(MDR1) Methylation Status

23 BREAST TUMOR BIOLOGY How to determine racial differences in breast tumor biology? Studies with appropriate numbers Distribution of risk factors across race/ethnicity Why is it important? Information on populations affected Early diagnosis Knowledge about appropriate therapy Participation in clinical trials Information to health care providers Appropriate testing and treatment New therapies targeted to affected persons

24 BREAST TUMOR BIOLOGY What is known? Poor differentiation High-grade nuclear atypia High mitotic activity Higher S phase fraction ER-negativity/PR-negativity P53 mutations Younger age at presentation Overall poorer survival

25 NUTRITIONAL GENOMICS IN CANCER BIOLOGY Genetic polymorphisms may preclude some individuals from the benefit of a healthy diet, while others with a profile might benefit more from dietary favorable polymorphic change.

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27 OBESITY AND CANCER MORTALITY IN WOMEN Multiple myeloma Colon and rectum Ovary Liver All cancers Non-Hodgkin s lymphoma Breast Gallbladder All other cancers Esophagus Pancreas Cervix Kidney Uterus Calle, NEJM, Relative Risk

28 NMA ROLE IN REDUCING HEALTH INEQUITY Create a parallel Report to Guidelines that is specific to our constituents and addresses: Education Awareness Policy Value and Structure Laws

29 DETECTION AND PREVENTION STRATEGY Screening breast exams Mammograms Early Detection Prompt Treatment Prevention Research Strategy Improved access and compliance to screening Chemoprevention for high risk patients Tamoxifen Raloxifene

30 BARRIERS TO PREVENTIVE HEALTH Lack of knowledge Access to medical care Costs Poverty Insurance

31 FACTORS CONTRIBUTING TO POOR SURVIVAL Advanced stage at diagnosis Tumor biology Preventive health care behavior Knowledge, attitude, beliefs Screening/early detection practices Delay in diagnosis Access to health care Socioeconomic status

32 CLINICAL TRIALS Modern, preventive or therapeutic medical practice is based on evidence gained primarily through controlled clinical trials. It is the National Medical Association s position that African-American patient and physician representation in clinical trials is generally inadequate, thus compromising the quality and validity of clinical trial findings used to guide the treatment and prevention of people of color, especially African-American patients

33 WHY SHOULD YOU CARE? Clinical trials form the basis of modern medical practice Racial and ethnic minorities remain underrepresented in clinical trials Current clinical trials may favor the selection of therapies which meet needs of people of Western European descent

34 POTENTIAL CONSEQUENCES Low minority presence in the evidence for evidencebased medical practice Limited guidance on use of therapeutic interventions in diverse patient populations Gaps in data supporting personalized medicine Risk therapeutic solutions that are out of touch with the US population Perpetuation of health inequities

35 CONCLUSION The ability to reduce cancer incidence and mortality depends on you to become empowered to close the gaps in information transfer, demand optimal practice patterns, appropriate quality care, and to be represented equitably in clinical research.

36 AVAILABLE RESOURCES National Institutes of Health/ National Cancer Institute (NIH/NCI) American Cancer Society (ACS) Center to Reduce Cancer Health Disparities (CRCHD) Center for Disease Control and Prevention (CDC) Intercultural Cancer Council (ICC) Cancer Prevention and Control Research Network (CPCRN) African American Collaborative Obesity Research Network (AACORN) National Medical Association (NMA)

37 Organize - Strategize - Act

38 Thank you!

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41 RACISM Racism is a system of structures, policies, practices, and norms with value based on social interpretation of skin color (appearance) that disadvantages some individuals and communities or unfairly advantages other individuals and communities. Racism saps the strength of the entire society through wasted resources and energy and has 3 levels: Institutional Structural Personal

42 USPSTF GRADE DEFINITIONS Grade Definition Suggestions for Practice A B C D I Statement Recommends the service. There is high certainty that net benefit is substantial. Recommends the service. There is high certainty that net benefit is moderate or there is moderate certainty that net benefit is moderate to substantial. Recommends selectively offering or providing this service to individual pts based on professional judgment & pt preferences. There is at least moderate certainty that net benefit is small. Recommends against the service. There is moderate or high certainty that the service has no net benefit or that harms outweigh the benefits. Concludes that current evidence is insufficient to assess the balance of benefits & harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits & harms cannot be determined. Offer or provide this service. Offer or provide this service. Offer or provide this service for selected patients depending on individual circumstances. Discourage the use of this service. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

43 BREAST CANCER RISK FACTORS Age Early menarche Late menopause Nulliparity Late age at first birth Increased breast density History of breast cancer Family History Personal History Obesity and other lifestyle factors Exogenous hormone exposure

44 YOUNG AA WOMEN BC CHARACTERISTICS Larger tumors Higher grade histology Basal-like epithelial cell More likely positive nodes Poorer prognosis ER negative /PR negative/her-2 negative Higher p53 mutations Higher risk of recurrence

45 MAGNITUDE OF BC HEALTH INEQUITIES Overall, 20 to 30% of new BC cases are TNBC Complex heterogeneous disease not responsive to endocrine therapy Higher proportion of TNBC in women under age 50 AA women at increased risk of TNBC BRCA1 mutation carriers at increased risk of TNBC