Mapping cancer mortality-to-incidence ratios to illustrate racial and sex disparities in a high-risk population.

BACKGROUND: Comparisons of incidence and mortality rates are the metrics used most commonly to define cancer-related racial disparities. In the US, and particularly in South Carolina, these largely disfavor African Americans (AAs). Computed from readily available data sources, the mortality-to-incidence rate ratio (MIR) provides a population-based indicator of survival. METHODS: South Carolina Central Cancer Registry incidence data and Vital Registry death data were used to construct MIRs. ArcGIS 9.2 mapping software was used to map cancer MIRs by sex and race for 8 Health Regions within South Carolina for all cancers combined and for breast, cervical, colorectal, lung, oral, and prostate cancers. RESULTS: Racial differences in cancer MIRs were observed for both sexes for all cancers combined and for most individual sites. The largest racial differences were observed for female breast, prostate, and oral cancers, and AAs had MIRs nearly twice those of European Americans (EAs). CONCLUSIONS: Comparing and mapping race- and sex-specific cancer MIRs provides a powerful way to observe the scope of the cancer problem. By using these methods, in the current study, AAs had much higher cancer MIRs compared with EAs for most cancer sites in nearly all regions of South Carolina. Future work must be directed at explaining and addressing the underlying differences in cancer outcomes by region and race. MIR mapping allows for pinpointing areas where future research has the greatest likelihood of identifying the causes of large, persistent, cancer-related disparities. Other regions with access to high-quality data may find it useful to compare MIRs and conduct MIR mapping.

Breast cancer disparities in South Carolina: early detection, special programs, and descriptive epidemiology.

A discrepancy exists between mortality and incidence rates between African-American and European-American women in South Carolina. The relationship between tumor grade and the estrogen/ progesterone receptor status is different in African-American and European-American women. African-American women with breast cancer should be encouraged to participate in clinical trials, with the goal of identifying biological factors that might facilitate the detection of tumors at an earlier stage and the development of more effective therapies. The most important of our goals is to design studies to reduce the incidence of the disease and interventions to improve survival and quality of life. The importance of participation in research cannot be overstated. Reproductive factors such as early pregnancy and multiple pregnancies are strongly related to breast cancer risk, however, promotion of these factors as a "prevention strategy," clearly does not lead to cogent, comprehensive public health messages. Data from ecological and migrant studies point clearly to other factors that may be important such as diet. Additional research around primary prevention strategies is needed. In addition, yearly mammograms (secondary prevention) are recommended for women over 50 years old or those with relatives who have developed breast cancer. The Best Chance Network, as a provider of screenings to low-income, uninsured women, has helped to narrow the racial gap in screening that otherwise might exist (see Figures 3 and 4) to a large extent. The determination for timing of surgery after diagnosis needs additional consideration. For example, factors such as effective screening in younger women, timing of screening and surgery in relationship to the ovulatory cycle, and season of screening and surgery may have a great impact on outcomes and may offer some insight into the process of carcinogenesis and therapeutic efficacy. Research into this area is so novel that the impact on possible ethnic disparities is completely unknown. The South Carolina Cancer Disparities Community Network (SCCDCN) has identified the following areas as potential research foci: Identification of small media interventions as an effective strategy to motivate targeted populations, especially those least likely to seek screening for breast cancer and those least likely to participate in research programs (African-Americans). Utilization of breast cancer survivors, self-identified as community natural helpers, can share their experiences with their church congregation. A replication of such a program in South Carolina has great potential because of the strong presence of the church, especially in rural parts of the state. Programs that closely integrate religion with screening women for breast cancer are promising in this state. Development of a mammography registry whereby information on all mammography procedures would be collected within a single database system (much like a central cancer registry). This would aid in identifying population groups that could be targeted for special programs and in the examination and exploration of the most appropriate modalities of detection. Such a resource could also be a useful tool to encourage screening. Thus, this focus area has the potential to benefit epidemiologic and health promotion research on many different levels. Additional breast cancer screening methods should not be overlooked as a potential research focus. Mammography is not the only valid screening method for breast cancer. Magnetic resonance imaging has shown some promise for screening among women with a genetic predisposition for cancer. Another promising avenue is thermography. Because detection rates may depend on age, ethnicity, and breast mammographic characteristics, women for whom regular screening methods do not detect their cancers (e.g. older age, African-American ethnicity, dense breasts) must be identified and other screening methods promoted within these populations. The above-mentioned mammography registry would support this type of research.

Prostate cancer disparities in South Carolina: early detection, special programs, and descriptive epidemiology.

Available evidence suggests that there may be qualitative differences in the natural history of PrCA by race. If this is true then additional etiologic research is needed to identify places in the causal chain where we can intervene to lower PrCA rates in AA men. South Carolina may prove to be a useful context in which to study prostate cancer etiology, because of the presence of unique environmental exposures. For example, soil selenium and cadmium concentrations unique to South Carolina might have a differential affect in the rural areas of the state where ground water use is more common and where AAs are more likely to live. These metals are important in terms of prostate metabolism and cancer. The possible interaction of geological factors with underlying biological factors such as metal transporter gene expression by race needs to be explored in South Carolina. Diet and exercise are consistently seen as possible primary prevention strategies for prostate and other cancers, as noted above. There may be very good reasons to intervene on diet and physical activity, but if the intention is to make a health claim with real, specific meaning for PrCA prevention and control then studies must be designed to test the effect of these modalities in rigorous ways at specific points in the natural history of prostate carcinogenesis. Nutrition and exercise programs need to be developed in South Carolina that are seen as acceptable by people at risk of PrCA; and they will need to focus on effective ways to prevent the development of PrCA, other cancers, and other health outcomes. Implementing diet and nutrition programs in rural parts of the state, possibly through schools or churches, offer benefit to both youth and adults alike. So, it would be possible, indeed it would be desirable, to create programs that may be used for research in one part of the population (e.g., men with PrCA), but are equally beneficial for others (e.g., their spouses and children). Organizing studies that can focus on promising new areas of research and changing the paradigms under which the research community currently operates probably will require re-conceptualizing research strategies employing methods that entail CBPR approaches. Because much of South Carolina's African-American population resides in rural parts of the state, outreach presents a challenge for both researchers and clinicians. Individuals living in rural areas are more likely than urban residents to live in poverty, report poorer health status, and not have private health insurance. Americans living in rural areas face disparities in access to basic public health services compared to those living in metropolitan areas. In very practical ways, local public health departments are absent in many rural communities, and rural hospitals continue to close, removing needed services. Closing of public hospitals has been shown to significantly increase the percentage of people without a primary health care provider as well as the percentage of people denied care. Public health departments are of particular importance to rural residents as they serve as the main avenue for public health and clinical care for this group. Issues such as access to care, lack of frequent physician's visits and quality of medical care have a negative impact on outcomes for men with PrCA, particularly in relationship to staging. If better outcomes are to be achieved in South Carolina, then more must be done to reach the community and provide better access to care in more rural areas of the state. Small media interventions, such as those presented in churches and barbershops may be an effective means for reaching the rural AA population. Our ability to reach out to and interact with the high-risk pockets in the state will be necessary for screening, treatment, and research (which, if conducted competently, will affect screening efficacy, treatment effectiveness, and primary prevention). It is believed that currently available decision-making materials for PrCA screening may not be appropriate due to socioeconomic as well as health literacy differences present in all male groups. It is unclear whether men in the lower socioeconomic groups are given appropriate information that allows them to make educated, informed decisions around PrCA screenings. Considering the number of males in the lower socioeconomic groups in South Carolina and the large AA male population, research evaluating the appropriateness of the existing materials could have an impact --both within the state and in national efforts. Patient education is a promising strategy, but educating the patient in the context of his family seems to be a more effective strategy for this population. Family networks and faith-based networks offer a strong support base for the patient when making health-related decisions, particularly for the African-American male. In collaboration with the SCCDCN, the South Carolina Cancer Alliance (SCCA) is currently developing a proposal to create a decision guide for prostate screening that is targeted toward the African-American male. The SCCA plans to pilot test new, culturally appropriate materials in the Low Country of South Carolina because of its comparatively large African-American population and its high rate of residential stability. South Carolina is one of only a few states to adopt expanded Medicaid coverage for the treatment of breast cancer. PrCA needs to receive equal recognition. This year alone in South Carolina 3,290 women will be diagnosed with breast cancer and 630 will die from the disease. Likewise, the American Cancer Society estimated 3,770 men in South Carolina would be diagnosed with prostate cancer and 440 will die from the disease in 2006. The 1 million dollars set aside in South Carolina budget by lawmakers for treatment of breast and cervical cancer patients makes no mention of prostate cancer, which is an unfair omission. Finally, there currently exists a number of high-quality PrCA treatment, research, and referral resources in the state. Collaborations across agencies, institutes and organizations throughout South Carolina would prove to be beneficial in reaching the most rural (and therefore hardest to reach) populations. Collaborative arrangements will be pursued to increase positive outcomes and better futures for South Carolinians.