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Journal of Clinical Oncology, Vol 24, No 14 (May 10), 2006: pp. 2135-2136 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.06.7918
Disparities in Cancer Care: A Worldwide Perspective and Roadmap for ChangeUniversity of Chicago Medical Center, Chicago, IL
Federal University of Rio Grande do Sul, Porto Alegre, Brazil
National Cancer Center Hospital, Chiba, Japan
Oregon Health & Science University, Portland, OR The primary objective of this issue of the Journal of Clinical Oncology's Special Series is to address health disparities from a global perspective. We elected to move past an exhaustive recitation of statistics, but charge the contributors to develop ideas around achievable practical solutions to reduce health disparities and to identify opportunities for research. Furthermore, we felt that it was imperative that this issue reflect a worldwide perspective because some of the major disparities are, in part, strongly related to geography, culture, and socioeconomic status. Health disparities are present and well documented among poor and rich countries and within poor and minority populations in the same country. We hope this issue of the Journal will galvanize health care providers, industry, and policy makers in all regions of the world to work cooperatively on developing novel strategies to reduce global cancer disparities. The first article, by Kamangar, Dores, and Anderson,1 attempts to put into perspective the most recent observations pertaining to the geographic epidemiologic patterns in cancer incidence, mortality, and prevalence using the GLOBOCAN (2002) and Cancer Incidence in Five Continents (CI5-VII) databases. This comprehensive summary serves as a platform on which to prioritize interventions to address the matrix of contributing factors in the development of the most common malignancies worldwide. One of the challenges inherent in sorting through the literature, as it pertains to disparities across any of a number of diseases, is the imperfect definition of how individuals are routinely categorized in research studies. For example, most clinicians and researchers understand that the concept of race, is a rather complex social construct that incorporates nonbiologic effects that have been poorly delineated in the United States. With completion of the Human Genome Project (http://www.genome.gov/10001772) comes an understanding that human beings are 99.9% identical, but that the 0.1% difference may explain individual differences in cancer risk and response to therapy. To this end, Rebbeck, Halbert, and Sankar2 present a concise discussion of a major variable that has yet to be clearly defined: race and/or ethnicity. Using self-identified race or ethnicity as a variable in research studies that identify genetic differences with respect to disease status or outcomes without a proper definition of SIRE could lead to spurious results that have the potential to propagate stereotypes. Researchers are admonished to properly consider the meaning, definitions, and use of race, ethnicity, and ancestry in molecular epidemiologic studies. Differences in the pharmacogenetics and pharmacokinetics (ie, ethnopharmacology) of certain systemic antitumor agents and/or inherent mutations within the tumor, within certain identifiable patient groups may help molecular cancer epidemiologists to further elucidate the complex relationships that presently complicate the clinician's understanding of determinants of treatment response. Calvo and Baselga3 discuss the very interesting observations that certain somatic mutations within domains of the epidermal growth factor receptor in non–small-cell lung cancer patients from the East are correlated with response to small-molecule tyrosine kinase inhibitors. Maitland, DiRienzo, and Ratain4 describe differences in toxicity and response to systemic therapeutic agents, as well as the emerging role of pharmacogenomics in cancer treatment. The authors aptly point out that personalized medicine of the future will require knowledge of functional polymorphisms that confer variability in drug toxicity and tumor responsiveness. Breast, gastric, and colorectal cancers are common malignancies for which disparities in incidence and outcome have been documented. The four disease-specific contributions to this issue of the JCO (Blackman and Masi5; Hall and Olopade6; Ohtsu, Yoshida, and Saijo7; and Polite and Dignam8) provide insight and propose strategies to address the disparities observed. Blackman and Masi5 look serially at patient, provider, health care system, and the myriad socioeconomic factors that contribute to breast cancer disparities in the United States. In some instances, physician attitudes contribute to disparities in cancer mortality, and the fragmentation of health care can be particularly challenging for low-literacy persons without health insurance. Polite and Dignam8 reviewed many of the major factors that contribute to disparate outcomes in cancer of the colon and rectum. Most importantly, the authors present an oncology health disparities model that may have applicability across other tumor types. This model outlines the interplay between the variables contributing to pretreatment stage, the type of therapy recommended and received, and the effectiveness of received treatment—all which contribute to overall cancer-specific mortality. Identifying high-risk individuals and developing strategies to reduce risk have been shown to be an effective cancer control approach, yet Hall and Olopade6 provide insight into the global disparities that exist in the use of cancer genetic services. To realize the promise of genetics in cancer care, there is an urgent need to develop genetic testing services beyond BRCA1 and BRCA2 and to expand services to underserved minority populations from the United States and abroad.6 There exist risk factors pertaining to the disparities in exposure to carcinogens that may impact the incidence of certain tumor types (ie, Heliobacter pylori leading to gastric cancer or hepatitis C virus contributing to the development of hepatocellular carcinoma). Ohtsu, Yoshida, and Saijo7 characterize the differences in incidence, mortality, and response to treatment for gastric cancer that have been observed between predominately Asian (Eastern) and non-Asian (Western) countries. Intercountry, multi-institutional clinical trials, may begin to identify variables that contribute to the inferior outcome of gastric cancer across stage in Western societies, for example. Access to the latest technologic advanced in prevention, diagnosis, and treatment of cancer exist, in part, because of disparities in socioeconomic status both between different regions of the globe and among different areas within a given country. Bruner et al9 have aggressively outlined a research strategy to address cancer disparities within a major North American city with the promise of applicability across some other societies. Such targeted intervention can serve as a roadmap to policy makers when making recommendations on how to best utilize the precious resources that are available. No one model can serve as an adequate template for most societies. It is paramount that myriad coordinated, validated, and tailored strategies be developed. Jones et al,10 have outlined how national and international cancer-focused organizations (both within and outside of government) have prioritized their respective resources throughout the world. The authors propose that a better utilization of resources within certain countries may begin to address, in part, some of the underlying causes of cancer disparities that have been observed. In aggregate, the contributors have proposed roadmaps to guide future prioritization of resource allocation on the macro and micro levels. A multifaceted and -staged approach will likely be required to address many of the present disparities in cancer outcome. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. Author Contributions
REFERENCES
1. Kamangar F, Dores GM, Anderson WF: Patterns of cancer incidence, mortality, and prevalence across five continents: Defining priorities to reduce cancer disparities in different geographic regions of the world. J Clin Oncol 24:2137-2150, 2006 2. Rebbeck TR, Halbert CH, Sankar P: Genetics, epidemiology, and cancer disparities: Is it black and white? J Clin Oncol 24:2164-2169, 2006 3. Calvo E, Baselga J: Ethnic differences in response to epidermal growth factor receptor tyrosine kinase inhibitors. J Clin Oncol 24:2158-2163, 2006 4. Maitland ML, DiRienzo A, Ratain MJ: Interpreting disparate responses to cancer therapy: The role of human population genetics. J Clin Oncol 24:2151-2157, 2006 5. Blackman DJ, Masi CM: Racial and ethnic disparities in breast cancer mortality: Are we doing enough to address the root causes? J Clin Oncol 24:2170-2178, 2006 6. Hall MJ, Olopade OI: Disparities in genetic testing: Thinking outside the BRCA box. J Clin Oncol 24:2197-2203, 2006 7. Ohtsu A, Yoshida S, Saijo N: Disparities in gastric cancer chemotherapy between the East and West. J Clin Oncol 24:2188-2196, 2006 8. Polite BN, Dignam JJ: A colorectal cancer model of health disparities: Understanding mortality differences in minority populations. J Clin Oncol 24:2179-2187, 2006 9. Bruner DW, Jones M, Buchanan D, et al: Reducing cancer disparities for minorities: A multidisciplinary research agenda to improve patient access to health systems, clinical trials and effective cancer therapy. J Clin Oncol 24:2209-2215, 2006 10. Jones LA, Chilton JA, Hajek RA, et al: Between and within: International perspectives on cancer and health disparities. J Clin Oncol 24:2204-2208, 2006
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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