Impact of poverty and race/ethnicity on treatment and management of urologic cancers⁎

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Poverty and race/ethnicity have long been factors associated with disparities in access to care, severity of disease at diagnosis, receipt of treatment, and outcomes of care. It is important to understand the history of efforts to address these disparities as well as to recognize the significant progress that has already been made, even though disparities persist. Since 1959, poverty has been measured by the U.S. Census Bureau as a set of money income thresholds based on family size [1]. In the early 1960s, poverty rates were 22.2% overall and varied greatly by race, with a poverty rate of 18.1% among Whites, and an astounding 55.1% among Blacks [2]. On January 8, 1964, Lyndon Johnson took action, declaring a War on Poverty by instituting major health care, education, and jobs programs to address high poverty rates [3]. These programs included Medicare and Medicaid, Food Stamps, Job Corps, Upward Bound, Head Start, and College Work Study, all of which still exist today.

Poverty was not the only problem during this era. Mortality rates attributable to cancer were high and continuing to rise. Cancer had the second highest mortality rate among the various causes of death in the 1960s, varying from 193.9 per 100,000 population in 1960 to 198.6 per 100,000 population in 1970 [4]. Cancer mortality rates for Blacks increased 20% from 1950 to 1967, while remaining constant for Whites [5]. In an effort to strengthen the National Cancer Institute's ability to impact rising cancer mortality rates and hopefully eliminate cancer as a leading cause of death, President Nixon announced the War on Cancer in December 1971, approximately 8 years after Johnson's declaration of the War on Poverty [6], [7]. The signing of the National Cancer Act substantially expanded the scope and authority of the National Cancer Institute (NCI) to include the ability to award research contracts and grants, conduct cancer control activities, and fund the creation of new cancer centers and training programs. Since that time, substantial research efforts have been invested into understanding the causes of cancer as well as prevention and early detection efforts, particularly among the economically disadvantaged. The importance of poverty in the War on Cancer was highlighted in 1991 when the now former NCI director, Samuel Broder, declared “poverty as a carcinogen” [8].

Great progress has been made as a result of these legislative and programmatic initiatives. Poverty rates decreased by almost 50% from the early 1960s (22.4%) until 1970 (12.6%). However, poverty rates have remained relatively constant ever since (Table 1). Newly released data for 2010 reveal a poverty rate of 15.1% Approximately 43.6 million people are living in poverty, the highest number in the 52 years that the Bureau of the Census has been tracking poverty estimates [2]. Compared with Whites, Blacks remain disproportionally represented among the poor, 27.4% vs. 13.0%, respectively. Poverty rates for Hispanics and Asians were not reported until 1972 and 1987, respectively. However, poverty rates for Hispanics have generally mirrored those for Blacks, while poverty rates for Asians are similar to those for Whites.

Table 1. Percent below the Poverty Level by Race/Ethnicity, Selected Years (1960–2010)

Sources: U.S. Census Bureau, Historical Poverty Tables: Table 2. http://www.census.gov/hhes/www/poverty/data/historical/people.html, accessed August 19, 2011.

U.S. Census Bureau. Income, poverty, and health insurance coverage in the United States: 2010. http://www.census.gov/prod/2011pubs/p60-239.pdf, accessed September 14, 2011.

a Poverty rate estimate for Blacks is from 1959. No estimates available for 1960–1965.

b Poverty rate estimate for Blacks is from 1966. No estimate available for 1965.

c Poverty rate estimate is not available for Asians until 1987. Pacific Islanders are included with Asian grouping until 2001.

d Poverty rate estimate is not available for Hispanics until 1972. Hispanic includes people of any race.

In addition to substantial decreases in poverty rates since 1960, U.S. cancer mortality rates have also generally declined over the past 4 decades as measured by the annual percent change (APC) (1975–1990 = 0.5, 1990–1993 = −0.3, 1993–2001 = −1.1, 2001–2007 = −1.6) [9]. For the entire period 1975–2007, the average annual percent change (AAPC) was approximately −0.4. However, for the more recent decade for which data are available (1998–2007), the AAPC was −1.4. Comparable figures for Blacks and Whites for 1998–2007 were −2.0 and −1.3, respectively. Though U.S. cancer delay-adjusted incidence rates, which account for delays in reporting new cancer cases and updating existing cases, for the Surveillance Epidemiology and End Results (SEER) 9 areas increased annually from 1975 through the early 1990s, for the period 1998–2007, the AAPC was −0.5. The AAPC for Blacks and Whites over this time period was −0.8 and −0.4, respectively. This means that for the period 1998–2007 for the SEER 9 areas, Blacks had greater average decreases per year than Whites.

Improvements in screening and access to care over time have led to a narrowing of disparities in cancer stage at diagnosis. Though rates of distant stage disease at diagnosis were higher for patients with urologic cancers residing in high-poverty zip codes compared with those living in low-poverty areas, the differences were not that large (Table 2). In low-poverty zip codes, 3.9%, 10.2%, and 15.4% of prostate, testicular, and kidney cancer patients were diagnosed with distant stage disease compared with 5.1%, 15.3%, and 17.3% in high-poverty zip codes, respectively. Among urinary bladder cancer patients, the rate of in situ cancers was lower among patients residing in high-poverty areas (48.4%) compared with those residing in low-poverty areas (52.6%), once again suggesting that disparities existed but were not large.

Table 2. Stage at Diagnosis (2004–2008) by Cancer Site and Socioeconomic Status, Surveillance, Epidemiology, and End Results (SEER) (17 registries) data

Source: Data were released in April 2011 and based on the November 2010 submission (http://www.seer.cancer.gov/resources/).

⁎ Poverty: High is defined as >20% of individuals below the poverty level. Medium is defined as 10%–20% of individuals below the poverty level. Low is defined as <10% of individuals below the poverty level.

In spite of these improvements in health over the past several decades, a 2003 Institute of Medicine report, which defined disparities as those unrelated to insurance status, ability to pay, clinical appropriateness, and patient preferences, indicated that disparities in morbidity and mortality rates for many diseases such as cancer still exist [10]. Specifically, the report stated that racial and ethnic minorities experience lower quality health care and are less likely to be offered and receive routine medical procedures than are Whites, even when age, symptoms, comorbid conditions, income, and insurance status are taken into consideration. The Institute of Medicine report was published on the heels of Surgeon General David Satcher's launching of Healthy People 2010 with the goals of increasing survival time and quality of life and eliminating racial and ethnic disparities in health by 2010 [11].

Thus, the theme of this Seminars' section, “The impact of poverty and race/ethnicity on the treatment and management of urologic cancers,” is timely. Each article reviews the relevant literature for 1 of 4 urologic cancer sites: bladder, kidney, testicular, and prostate. Also discussed are race/ethnicity and socioeconomic status, encompassing employment, education, and income, because the common associations of these 2 factors with health status and outcomes are usually not independent. In the first of the 4 articles, Jacobs et al. [12] report notable disparities (particularly by race/ethnicity) among bladder cancer patients in terms of risk factors, disease presentation, treatment, and survival. Conversely, in reviewing the renal cell carcinoma (kidney cancer) literature, Hellenthal and Bermejo [13] note the lack of English language literature supporting a difference in either incidence or receipt of initial treatment based on either socioeconomic status or income, though differences in incidence have been demonstrated by these factors in countries outside the U.S.

In the third of the 4 articles, Richardson et al. [14] introduce the term socioeconomic position, a more encompassing definition of socioeconomic status, in their review of the testicular cancer literature. Socioeconomic position includes not only income, wealth, and education, but also social rank and status as measured by access to and consumption of goods, services, and knowledge. Differences in survival by socioeconomic position are identified, highlighting the need for additional research on testicular treatment disparities.

The last of the 4 articles [15] describes a highly successful statewide intervention to reduce access and treatment disparities for uninsured and underinsured prostate cancer patients in the state. Chamie et al. review the strengths and weaknesses of the Improving Access, Counseling, and Treatment for Californians with prostate cancer program as well as summarize the quantitative and qualitative outcomes assessments conducted to date. In demonstrating continued progress to reduce disparities, this article is an appropriate final article for this Seminars' section on “The Impact of Poverty and Race/Ethnicity on the Treatment and Management of Urologic Cancers.”

Clearly, additional research is needed, particularly in the design of interventions tailored to the cancer site and socio-demographic characteristics of the population requiring care. Though much research has been devoted to identifying disparities, few studies have successfully designed interventions that are feasible given resource constraints at the local level. It is hoped that readers will regard this collection of review articles as informative as well as a source of new research ideas.

The views expressed in this paper are those of the authors and should not be construed as reflecting the official position of the American Cancer Society or Emory University.

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