Cancer-Related Health Disparities

Among our most vulnerable populations are racial and ethnic minorities. These groups suffer unequal premature cancer incidence, morbidity, and mortality. Racial and ethnic disparities are associated with various factors such as genetics/biology, culture, and health care delays or barriers. As ethnic minorities become an increasing proportion of cancer survivors, greater attention to the ethnic and cultural aspects of cancer care, outcomes, and survivorship is required.

Low-income populations experience unequal, premature morbidity and mortality.¹⁰ Low-income communities often struggle to meet basic needs and are at a disadvantage in obtaining necessary health services, quality care, and access to vital resources. They are likely to be uninsured or underinsured with limited capacity to pay for out-of-pocket expenses. This may hinder access to usual and trusted sources of care and/or discourage seeking care and medication adherence.

Sexual and Gender Minorities (SGM) are individuals that include lesbian, gay, bisexual, transgender, queer, intersex, gender non-conforming people, and other populations whose sexual orientation or gender identity and reproductive development are considered outside cultural, societal, or physiological norms.”

Compared to heterosexual and cisgender populations, SGM populations have a higher prevalence of selected health risk factors (smoking, alcohol consumption, substance use) and negative health outcomes (suicide, depression, selected cancers).2,3 They are also more likely to have poor access to health care and experience discrimination in health care settings. Regarding cancer disparities, the SGM population experiences higher cancer incidence, advanced stage of disease at diagnosis, and worse survival outcomes.

Cancers that disproportionately affect this community include HPV-related cancers (such as anal cancer, cervical, head, and neck cancers) and breast, colorectal cancer, and lung cancer.

A nationwide county-level study found that counties with a higher density of LGBT populations tend to have a higher incidence of colorectal cancer for both men and women. The SGM communities are at high-risk for cancer risk factors.

Smoking in the LGBT and Queer community, also known as LGBTQ, is twice as high as cisgender/heterosexual individuals, with rising rates among LGBT youth impacting lung cancer rates.

Also, this community experiences inequitable access to regular health services.

• Approximately 30% of LGBT adults do not seek health care services or lack a regular health care provider compared with 10% of age-matched heterosexual people. This has downstream effects on cancer prevention, early detection, and post-treatment follow-up care.

Racial and ethnic minority women have higher mortality rates and poorer cancer survival compared to non-Hispanic white women. Current research reveals how cancer burdens are also shaped by intersecting life course factors such as socioeconomic status, identity, and subordination.

Place of residence in California affects how individuals access and receive health resources and care. Rural communities in particular, often face greater challenges and fewer options for their health care.

They can be at a disadvantage with respect to:

• seeking care close to home;

• acquiring specialist advice and care;

• receiving advanced health care services;

• and accessing clinical trials, supportive services, and end-of-life care.

Many minority and marginalized groups are excluded from pertinent health care resulting in increased cancer and overall disease burdens. There are several cross-cutting factors that impact cancer burdens, requiring policies and interventions unique to specific groups and the California social-geographic contexts. Targeted interventions must address a wide range of issues, including but not limited to, socio-political environment, social cohesion and assets, immigration status, and various system-level factors-all critical for improving the overall well‑being of our diverse California.

The plan takes into account multiple factors influencing cancer-related disparities:

• The complex and interrelated social determinants of health that influence how people “are born, grow, live, work and age”.

• California’s residents include our society’s most diverse racial, ethnic, social, economic, cultural, and geographic populations.

• The environmental, institutional, and structural barriers/obstacles exist across the cancer control and care continuum.

• Ethnic minority and diversity inclusion must be incorporated into federal and state health policies and practices.

Challenges to contend with include a widening knowledge gap as well as an inadequate infrastructure for data collection, mining, functionality, and use on marginalized populations. Insufficient inclusion of representative populations remains detrimental to both optimal scientific advancements and equitable care. To significantly reduce the burden of cancer in California, all groups must be represented in cancer data, science, and medical care. While there is monumental importance to reduce statewide cancer incidence and mortality, it is essential to diminish persistent disparities towards sustaining a healthy, productive California.

Driven by CDPH’s CCR report, “Cancer Burden among Native Americans in California,” this section focuses on the cancer experiences of the American Indian Alaska Native (AIAN) population in California. The AIAN population is comprised of California-based Tribal people and AIANs who have relocated to California from other areas of the United States: it is a geographically, historically, and culturally diverse group.

The beliefs of AIANs are deeply rooted in tradition and culture. However, due to the physical relocations, lack of trust of medical professionals, and the current/historical trauma experienced by AIAN communities, they now suffer from more significant health disparities than the general population. They are also more likely to be of lower socioeconomic status.

Additionally, AIANs have much higher rates of tobacco use, obesity, diabetes, physical inactivity, heart disease, suicide, and many other chronic diseases compared to the general population.

In addition to the health disparities they face, AIANs are profoundly impacted by cancer; it is the second leading cause of death after heart disease. Limited access to healthcare contributes to a more significant state-wide systemic problem.

Addressing the unique health challenges of SGM communities will require a comprehensive approach that consists of improving the collection of SOGI data and enhancing the provision of care for SGM patients through an intersectional lens that acknowledges multiple intersecting identities that are related to one’s sexual orientation, socioeconomic status, gender identity, and other identities that indicate the sociocultural power and privilege in the community.

The following strategies are recommended to achieve broad gains in the health of the SGM communities:

1. Develop systematic and consistent methods of collecting SOGI information in health care settings and cancer registries (an objective in the Surveillance Chapter aims to include gender identity categories in order to enhance data capture in the California Cancer Registry).

2. Develop Continuing Medical Education courses that meet the Institute of Medicine’s Core Competency to “provide patient-centered care” focused on increasing awareness around cancer disparities in SGM populations, acknowledging the heterogeneity within the SGM populations, and recognizing the influence of multiple minority group identities on an individual’s health.

3. Create programs that provide free or low-cost prevention, screening, diagnostic and treatment services for the most significant cancers affecting SGM populations and design program evaluation to assess the impact of these programs.

4. Encourage the development of SGM-focused research programs within the University of California Office of the President.

1. A system of partners is necessary to assist this group in accessing prompt healthcare services, specifically cancer-related services.

2. Given their rural distribution, AIANs are typically required to travel long distances for screening and treatment services, which can be an obstacle to timely diagnosis and treatment of life-threatening cancers and diseases.

3. In both the short and long-term, these cultural, historical, and geographical disparities combined leave AIANs at an increased risk of late-stage cancer diagnoses, increased susceptibility to cancer-related deaths, and significantly lower cancer survival rates compared to other populations.

In addition to the CCCP, CDC also funds comprehensive cancer control efforts targeting Tribal communities in California. The California Tribal Comprehensive Cancer Control Program (CTCCCP) housed within the California Rural Indian Health Board, Inc. has supported California Tribal communities in implementing cancer control, prevention, and survivorship activities since 2017.

The CTCCCP strategically recruited members across California Tribal health programs, Tribes, Tribal organizations, and organizations serving Tribal communities to participate in the CTCCCP Coalition (Coalition). These members have a stake in improving the lives of AIANs across California. They have been especially important in identifying the most pressing needs of California Tribal communities and assessing the impact of cancer within tribal communities.

1. An important task of the Coalition is to develop and implement a tribal comprehensive cancer control plan (tribal cancer plan), formally The Cancer Control Plan. The tribal cancer plan includes objectives, evidence-based interventions, and activities that aim to meet the cancer prevention and survivorship needs of the AIAN communities in California. Like the state cancer plan, the goals are aligned with CDC’s NCCCP. The goals of the tribal cancer plan are to increase cancer prevention awareness among Tribal communities, increase prevention and screening efforts, improve cancer survivors’ quality of life, and increase health equity as it relates to cancer control.

2. California’s tribal cancer plan includes objectives that aim to strengthen Tribal communities with targets to be met by 2023. Although targets are to be met before set targets within this state cancer plan, interventions have already been initiated with opportunities for collaboration. The Coalition and its extended partners, the CCCP and CDOC, intend to continue supporting one another by sharing resources, services, and staff in order to meet the identified objectives, which were developed with the most common health disparities in mind. To review strategies for these objectives, other content, or to get involved with the implementation of the tribal cancer plan, please visit:

California’s Tribal Cancer Plan Objectives

1. By 2023, decrease the percent of AIAN adults who are current smokers, from the current baseline of 14.3% to 10%.

Data Source: Tribal Behavioral Risk Factor Survey, 2015

2. By 2023, decrease the percent of adult obesity prevalence, from 72.1% to 60%.

Data Source: Tribal Behavioral Risk Factor Survey, 2015

3. By 2023, increase the percentage of provider referrals for screening based on national guidelines.

4. By 2023, increase the percent of the public’s knowledge of the burden of cancer survivorship and issues faced by Native survivors.

5. By 2023, increase the percentage of access to quality care (including at cancer centers) for all, but especially underserved populations.

6. More Information and Resources - California Tribal Comprehensive Cancer Control Program

https://crihb.org/ctcccp/