Despite enormous advances in cancer treatment, some racial, ethnic, and socioeconomic groups still bear an especially large burden from the disease, with higher incidence rates for many cancers and poorer outcomes.
Decades of research has documented these disparities. Among adult patients, for example, African Americans have the highest mortality rate of any racial or ethnic group for all cancers combined, according to data from the U.S. Department of Health and Human Services Office of Minority Health. Black men have the highest rates of cancer, according to the American Cancer Society (ACS).
“The causes of these inequalities are complex and reflect social and economic disparities and cultural differences that affect cancer risk, as well as differences in access to high-quality health care,” the ACS notes. “Structural racism — the combination of institutions, culture, history, ideology, and codified practices that generate and perpetuate inequity across racial and ethnic groups — also contributes to disparate health outcomes.”
Figures published by the National Cancer Institute show that people with lower socioeconomic status (SES) also have disproportionately higher cancer death rates than those with higher SES, regardless of factors such as race and ethnicity. The ACS notes that socioeconomic disparities result in unequal access to opportunities and resources, such as work, wealth, income, education, housing, healthy food, and overall standard of living. These factors and more can contribute to disparate outcomes.
As part of Dana-Farber’s mission to reduce the burden of cancer for all people, Institute researchers conduct a wide range of studies into the causes of cancer disparities and approaches to alleviating them. Dana-Farber investigators have worked in the lab, clinic, and the community to improve access to quality cancer care, heighten awareness of cancer risk and prevention, and improve treatment outcomes for Black, Latinx, and other people of color or underserved groups.
“Progress against cancer is meaningful only to the extent that it is shared equally — that no community is left behind,” says Dana-Farber President and CEO Laurie H. Glimcher, MD. “There is much to be done to reduce and ultimately eliminate cancer disparities in our society. But we are committed as an institution and as individuals to taking up the challenge of breaking down barriers and creating better access to lifesaving cancer care for all patients.”
A different model of cancer care
Christopher Lathan, MD, MS, MPH, medical director of Dana-Farber Cancer Institute at St. Elizabeth’s Medical Center and faculty director for Cancer Care Equity, has conducted a range of studies into the potential benefits of a community health center-based model of cancer care.
Lathan is the director of the Dana-Farber clinical service at Whittier Street Health Center in Roxbury, Mass., a majority-Black Boston neighborhood. Lathan and his colleagues are examining whether the affiliation with Whittier Street is helping increase the number of Black, Latinx, and other marginalized groups treated at Dana-Farber. The team is also examining whether this model of cancer care results in shorter wait times for diagnosis and treatment, increases awareness of treatment and prevention, and brings cancer practitioners closer to vulnerable communities.
Lathan is currently working to expand the Whittier Street program and evaluate its benefits for patients. He is also developing a program to help patients navigate the world of cancer precision medicine, in which treatment targets the specific molecular characteristics of each patient’s cancer. “We want to make sure that people coming from underserved communities will be able to have next-generation sequencing [which identifies genetic mutations and other abnormalities driving cancer], and we hope to figure out what some of the barriers are to such treatment so we can fix them,” Lathan comments.
Lathan and Huma Rana, MD, MPH, clinical director of Cancer Genetics and Prevention at Dana-Farber, co-led a recent study that pointed to the need for more community-outreach efforts. The study found that patients receiving genetic counseling at Dana-Farber were more likely to have already been in contact with genetics services than those receiving such counseling at the Whittier Street clinic, pointing to the need for more community-outreach efforts.
Addressing the impact of prostate cancer on Black men
Tim Rebbeck, PhD, focuses on the causes and prevention of cancers in which racial disparities are particularly pronounced — including prostate cancer, which has a higher incidence and mortality rate among Black men than white men.
Because prostate cancer is a complex disease, influenced by biology, social influences, and care, Rebbeck and his colleagues look for connections between multiple factors, including genetic and genomic influences on the disease’s onset and progression, with the goal of identifying interventions that will benefit all patients. Rebbeck is a leader of the Men of African Descent and Carcinoma of the Prostate (MADCaP) Network, with involves men of African descent in the U.S. and Africa and aims to better understand the complex causes and influences on prostate cancer among men of African ancestry.
“While incidence and mortality are both influenced by multiple factors, recent evidence suggests that the development of prostate cancer is influenced in part by genetics and screening, while the death rate is more strongly influenced by social and economic factors including access to health-care services,” Rebbeck states. “We’re investigating the interplay of these factors to improve outcomes worldwide.”
Recently, Rebbeck helped launch the Precision Care, Interventions, Screening, and Empowerment (PRECISE) Initiative, which is creating a model for identifying populations at increased risk for prostate cancer and tailoring screening recommendations for each group.
“The field of cancer disparities research is at a major inflection point,” Rebbeck says. “We now have good quality research in a variety of areas that provide strong evidence for the sources of disparities. It is clear that there are contributions from genetic and biological influences, social influences, lifestyle, behavior, and access to health care. The next major push in the field is to translate this knowledge into interventions that can begin to eliminate these disparities in the general population. This work will require we know when, how, and in whom we can intervene to maximize cancer health equity. Progress will require effective public health interventions as well as policy decisions.”
Socioeconomic disparities in childhood cancer
Kira Bona, MD, MPH, studies how poverty affects outcomes in children with cancer who are treated in clinical trials. Because cancer is much rarer in children than adults, the model of care differs significantly from that of adults, with a greater reliance on clinical trial-based care delivery. By analyzing data from completed multi-center trials, Bona and her colleagues have found that lower socioeconomic status is linked to worse disease outcomes in childhood leukemia, and neuroblastoma and inferior patient-reported outcomes in palliative care for advanced cancer.
To address these disparities, Bona is piloting the Pediatric Cancer Resource Equity (PediCARE) intervention, the first poverty-targeted intervention for children with cancer. Currently being tested for feasibility at Dana-Farber and the University of Alabama at Birmingham, PediCARE provides transportation and groceries for a six-month period to low-income families with a child newly diagnosed with cancer. Ultimately, Bona will investigate whether integrating PediCare into therapeutic drug trials can improve outcomes for children with cancer.
Bona’s research group also collaborates with laboratory scientists to explore whether the chronic stress of living in poverty results in physiologic changes that make cancer cells resistant to chemotherapy or immunotherapy. Data from this research could result in better tailoring of therapy to individual patients.
Ensuring treatment works for everybody
Led by Deborah Schrag, MD, MPH, the Division of Population Sciences at Dana-Farber conducts a wide range of research into cancer care delivery. This includes ensuring that potential new cancer treatments work for everyone.
“When drugs are tested in clinical trials, we need to make sure they’re tested in a diverse array of patients. If we don’t, we end up with knowledge gaps,” Schrag says. “Once we have treatment innovations that we know can work, we focus on what is necessary to ensure they work for everybody.”
Schrag is working with a consortium of eight other cancer centers nationwide to engage patients from a wide array of backgrounds and ethnicities in tracking their symptoms during chemotherapy treatment. “If we can help patients manage their symptoms effectively, we can not only help them feel better, we should be able to keep them out of the hospital and emergency room and enable them to continue their treatments,” Schrag says.
“We know that individuals living in poverty, residents of rural areas, non-English speakers and individuals who belong to racial, ethnic or LGBTQ minority groups face higher risks of cancer and of having suboptimal treatment outcomes. Without creating stigma, we need to ensure that we can deliver state of the art cancer care to everyone and that we adopt nimble solutions to make this a reality,” she continues. “There are different types of disparities and the solutions are not all the same. For non-English speakers the solution may be having acess to print and video materials in other languages or translation services. For Black and Hispanic patients, the solutions include recognizing the legacy of structural racism, the pervasive effects of unconscious bias, and the need to overcome a legacy of mistrust.”
To move toward this goal, Dana-Farber’s Nadine McCleary, MD, MPH, is spearheading efforts to systematically capture information about the social determinants of health for all patients at Dana-Farber. Her efforts will help the Institute identify the resources and support services to help all patients achieve the best possible outcomes.
In a related area, the PROMISE study led by Irene Ghobrial, MD, and Catherine Marinac, PhD, seeks to identify people with conditions that are precursors of multiple myeloma — a blood cancer that disproportionately affects African Americans — and track their health over time. The study, which is ongoing, has reached out to African Americans and others with a heightened risk of multiple myeloma to participate in the research. Because the PROMISE study permits ascertainment of blood specimens at labs all over the country, participants can engage with their family members regardless of where they live.
There is much more to do
While these studies and projects aim to analyze and reduce the burden of cancer on marginalized groups, there is much more work to do — including research in the causes and consequences of structural racism. Evidence that such work can reduce disparities and improve lives comes in a recent study that tied a decline in smoking rates and lung cancer in the Black community to programs centered around the harms of tobacco use.
A comprehensive look at current efforts to reduce cancer disparities, and the impact of these efforts, can be found in the Cancer Disparities Progress Report for 2020 issued by the American Association for Cancer Research.