Racial differences in the treatment of early-stage lung cancer

Pronostic des cancers colorectaux et inégalités socio-économiques

It is well established that socio-economic status is a major prognostic factor for many cancers, including colorectal cancer. The aims of this review are (i) to report epidemiological data showing how socio-economic status influences colorectal cancer survival, (ii) to attempt to describe the mechanisms underlying these survival inequalities, and (iii) to assess their impact on survival of colorectal cancer.

Meta-analysis of survival in African American and white American patients with breast cancer: ethnicity compared with socioeconomic status

PURPOSE

The extent to which socioeconomic disadvantages and inadequate health care access account for the disproportionately elevated mortality hazard observed in African American compared with white American patients with breast cancer is poorly defined.

METHODS

We identified 20 studies reported between January 1980 and June 2005 that provided survival analyses in patients with breast cancer after adjusting for ethnicity and some measurement of socioeconomic status. These studies also adjusted for age and stage of disease at time of diagnosis.

RESULTS

The pooled outcome data yielded estimates for the mortality hazard in 14,013 African American and 76,111 white American patients with breast cancer. Studies varied in their methods for assigning socioeconomic status, with most relying on area-wide measures such as census tract and census block data. The combined analysis (adjusted for age, stage, and socioeconomic status) revealed that African American ethnicity was associated with a statistically significant excess mortality risk in overall survival (mortality hazard, 1.27; 95% CI, 1.18 to 1.38) and in breast cancer-specific survival (mortality hazard, 1.19; 95% CI, 1.10 to 1.29).

CONCLUSION

Our pooled analysis demonstrated that African American ethnicity is a significant and independent predictor of poor outcome from breast cancer, even after accounting for socioeconomic status by conventional measures. These findings support the need for further investigation of the biologic, genetic, and sociocultural factors that may influence survival in African American patients with breast cancer.

Racial differences in trust and lung cancer patients' perceptions of physician communication

PURPOSE

Black patients report lower trust in physicians than white patients, but this difference is poorly studied. We examined whether racial differences in patient trust are associated with physician-patient communication about lung cancer treatment.

PATIENTS AND METHODS

Data were obtained for 103 patients (22% black and 78% white) visiting thoracic surgery or oncology clinics in a large Southern Veterans Affairs hospital for initial treatment recommendation for suspicious pulmonary nodules or lung cancer. Questionnaires were used to determine patients' perceptions of the quality of the physicians' communication and were used to assess patients' previsit and postvisit trust in physician and trust in health care system. Patients responded on a 10-point scale.

RESULTS

Previsit trust in physician was statistically similar in black and white patients (mean score, 8.2 v 8.3, respectively; P = .80), but black patients had lower postvisit trust in physician than white patients (8.0 v 9.3, respectively; P = .02). Black patients, compared with white patients, judged the physicians' communication as less informative (7.3 v 8.5, respectively; P = .03), less supportive (8.1 v 9.3, respectively; P = .03), and less partnering (6.4 v 8.2, respectively; P = .001). In mixed linear regression analysis, controlling for clustering of patients by physician, patients' perceptions of physicians' communication were statistically significant (P < .005) predictors of postvisit trust, although patient race, previsit trust, and patient and visit characteristics were not significant (P > .05) predictors.

CONCLUSION

Perceptions that physician communication was less supportive, less partnering, and less informative accounted for black patients' lower trust in physicians. Our findings raise concern that black patients may have lower trust in their physicians in part because of poorer physician-patient communication.

Understanding cancer patients' experience and outcomes: development and pilot study of the Cancer Care Outcomes Research and Surveillance patient survey

GOALS OF WORK

The National Cancer Institute's Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is conducting a population-based study of newly diagnosed patients with lung and colorectal cancer to describe the experience of persons living with cancer and to understand which barriers present the most significant obstacles to their receipt of appropriate care. The keystone to this effort is the baseline patient survey administered approximately 4 months after diagnosis.

PATIENTS AND METHODS

We developed a survey to obtain information from patients newly diagnosed with lung and colorectal cancer about their personal characteristics, decision making, experience of care, and outcomes. We conducted a pilot study to evaluate the feasibility of a lengthy and clinically detailed interview in a convenience sample of patients within 8 months of diagnosis (n=71).

MAIN RESULTS

The median length of the interviews was 75 min for patients with lung cancer (range 43-130) and 82 min for patients with colorectal cancer (range 46-119). Most patients had received some form of treatment for their cancer: 66.1% had undergone surgery, 28.2% had received radiation therapy, and 54.9% were treated with chemotherapy. In addition, 26.7% reported their overall health was less than 70 on a 0-100 scale, demonstrating that patients with substantial health impairment were able to complete the survey.

CONCLUSIONS

A clinically detailed survey of newly diagnosed lung and colorectal cancer patients is feasible. A modified version of this survey is being fielded by the CanCORS Consortium and should provide much needed population-based data regarding patients' experiences across the continuum of cancer care and their outcomes.

Surgical Outcomes Research Based on Administrative Data: Inferior or Complementary to Prospective Randomized Clinical Trials?

The importance of surgical research has gained new prominence over the past decades as the relevance of well designed and well conducted studies has become increasingly evident. There are two basic but diametrically different methods of conducting research: the prospective randomized clinical trial and the retrospective surgical outcomes study based on administrative data. Administrative databases contain data that were initially collected for purposes other than scientific research. Whereas the prospective randomized clinical trial is familiar to most surgeons, surgical outcomes research based on administrative data constitutes a genre of investigation that is often unfamiliar to and even disparaged by the surgical community. In the present article, the strengths and weaknesses of both prospective randomized clinical trials and retrospective surgical outcomes research are discussed. Specifically, the advantages and limitations of investigations based on large administrative databases are outlined. Because both study designs play an important role in surgical research, carefully designed and implemented surgical outcomes research based on administrative data should be viewed as being complementary and not inferior to prospective randomized clinical trials.

Racial differences in prenatal care of mothers delivering very low birth weight infants

OBJECTIVES

To determine whether there are any racial differences in the prenatal care of mothers delivering very low birth weight infants (VLBW).

STUDY DESIGN

Retrospective cohort study of infants cared for at a single regional level III neonatal intensive care unit over a 9-year period, July 1993-June 2002, N = 1234. The main outcome variables investigated included antenatal administration of steroids, delivery by cesarean section, and use of tocolytic medications. Both univariate and multivariate analyses were performed.

RESULTS

After controlling for potential confounding variables, white mothers delivering VLBWs had an increased odds of cesarean delivery (odds ratio 1.5, 95% confidence intervals (CI) 1.1-2.0), receiving antenatal steroids (1.3, CI 1.01-1.8), and tocolysis (1.4, CI 1.1-2.0) compared to black mothers. The models controlled for gestational age, multiple gestation, premature labor, clinical chorioamnionitis, maternal age, income, year of birth, and presentation.

CONCLUSIONS

In our population of VLBWs, white mothers are more likely to receive antenatal steroids, tocolytic medications, and deliver by cesarean section when compared to black mothers. From our data we cannot determine the reasons behind these racial differences in care of mothers delivering VLBWs.

Racial and ethnic disparities in survival in lung transplant candidates with idiopathic pulmonary fibrosis

Minority patients have worse outcomes than nonminority patients in a variety of pulmonary diseases. We aimed to compare the survival of Black and Hispanic patients to that of others with idiopathic pulmonary fibrosis (IPF). We performed a retrospective cohort study of patients with IPF who were evaluated for lung transplantation at our center. Kaplan-Meier survival curves and Cox proportional hazards models were used to compare survival between groups. Black and Hispanic patients had spirometry, lung volumes and diffusion capacity that were similar to others, but had worse exercise capacity. Minority patients had a significantly increased risk of death compared to others independent of transplantation status (hazard ratio = 3.3, 95% CI 1.2-8.9, p = 0.02). Differences in exercise capacity, pulmonary hemodynamics and socioeconomic factors appeared to account for some of the differences in survival. Black and Hispanic patients with IPF had an increased risk of death following referral for lung transplantation. This finding may be due to differences in disease progression and/or differences in access to medical care among minority patients. Future studies should confirm our findings in a larger cohort. The elimination of racial and ethnic disparities in outcome should be a priority for clinicians and researchers in this field.

Asian Americans and cancer clinical trials: a mixed-methods approach to understanding awareness and experience

Cancer clinical trials have been based on low accrual rates. Barriers to recruitment of minority populations affect the generalizability and impact of trial findings for those populations. The authors undertook a mixed-methods approach to understanding levels of awareness and experiences with cancer clinical trials. A survey was administered to new cancer patients and their caretakers (family, close friends, or other social support) at outpatient oncology clinics. Field observations of the trial accrual process also were conducted by employing the grounded theory approach in qualitative methods. Comparison of survey results for Asian-American respondents and non-Asian respondents indicated that Asians were less likely to have heard the term "clinical trial" and were more likely to define a clinical trial as "an experiment" or "a test procedure in a clinic" than non-Asians. Asians were more likely to have employer-based insurance and to report understanding issues related to cost reimbursement. Asians were less likely to have been involved in or to know someone in a trial and reported less willingness than white respondents to consider trial participation. Qualitative observations suggested that Asians who presented for a potential trial were interested in the availability of a novel cancer therapy but were not eligible for available trials. Multiple strategies will be necessary to enhance awareness of and experience with accrual to cancer clinical trials for Asians, including richer understanding and increased involvement of Asians in cancer clinical trials and greater attention to the location and diversity of the Asian population in structuring study centers and evaluating trial results.

Sociodemographic differences in quality of life in rheumatoid arthritis

Assessment of health-related quality of life (HR-QOL) in people with rheumatoid arthritis (RA) has become important in health research and can inform clinical care. Many studies have found sociodemographic differences in the HR-QOL of people with RA, and interpreting these differences can be challenging. Biological, health disparity, reporting and assessment instrument differences are a few of the possible explanations that should be considered when interpreting results. Our review of the evidence of sociodemographic differences in HR-QOL in people with RA produced 34 articles describing 49 studies.Typically, patients with RA who were older, female, less educated, non-employed and/or less affluent tended to have significantly lower HR-QOL than other groups. Some evidence also indicated that people with RA who are non-White or who live in rural settings may also tend to have lower HR-QOL scores, but the number of studies supporting these findings was sparse. Researchers and clinicians can optimise their assessment of HR-QOL by finding well validated instruments for the context they are working in. Additional research is needed to identify the exact causes of HR-QOL differences so that quality treatment can be provided to those in need.

Factors contributing to the racial differences in prostate cancer mortality

OBJECTIVE

To analyse, in a retrospective cohort study, differences in rates of surgical treatment for prostate cancer between African-Americans and White Americans, and to evaluate the extent to which these differences are associated with disparities in survival rates between these groups.

PATIENTS AND METHODS

Clinical, pathological, and demographic data from 4279 men diagnosed with clinically localized prostate cancer between 1980 and 1997 were used. The variables assessed included age, disease stage, tumour grade, comorbidities, treatment method, and socio-economic status (SES). Kaplan-Meier survival curves were generated and compared using log-rank tests. The Cox proportional hazards method was used for analyses involving adjustments for potential confounding factors.

RESULTS

The surgical treatment rate was 17% for African-American and 28% for White patients (P < 0.001). In those patients treated conservatively or by radiation therapy, both crude and cancer-specific survival rates were lower for African-Americans than for Whites (P < 0.001). However, for patients undergoing surgery, differences in survival between African-Americans and Whites were not statistically significant. According to our models, SES explained 50% and surgical treatment rates approximately 34% of the differences in survival between African-Americans and Whites.

CONCLUSIONS

This analysis suggests that the lower prostate cancer survival rates for the African-Americans in the present population can be largely explained by differences in SES and lower surgical treatment rates. Efforts to increase awareness of treatment options among African-American patients may be a way of improving survival in this group.

Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer

STUDY OBJECTIVES

Black patients undergo surgical treatment for early stage lung cancer less often than whites. We wanted to determine the causes for the racial difference in resection rates.

DESIGN

We studied a retrospective cohort of patients who presented to our institution with potentially resectable lung cancer (stage I or II) between the years 1995 and 1998, inclusive.

SETTING

A tertiary-referral hospital and clinic with a cancer database of all lung cancer patients seen.

PATIENTS

A total of 281 patients were included: 97 black patients (35%) and 184 white patients (65%).

MEASUREMENTS AND RESULTS

The surgical rate was significantly lower in blacks than in whites (56 of 97 patients [58%] vs 137 of 184 patients [74%], p = 0.004). We could not find evidence that the rate at which surgical treatment was offered was different between the two racial groups (68 of 97 black patients [70%] and 145 of 184 white patients [79%], p = 0.11). After controlling for preoperative pulmonary function, tumor stage, history of smoking, and significant comorbidities, we were unable to show that race was a predictor of being offered surgical treatment (odds ratio, 0.46; 95% confidence interval, 0.18 to 1.14; p = 0.09). The difference in surgical rates was mainly due to the fact that blacks were found to decline surgical treatment more often than their white counterparts (12 of 68 patients [18%] vs 7 of 145 patients [5%], p = 0.002).

CONCLUSIONS

Our analysis suggests that the lower surgical rate among black patients with early stage lung cancer is mainly due to low rates of acceptance of surgical treatment.

The effect of race on invasive staging and surgery in non-small-cell lung cancer

PURPOSE

Black patients with early-stage non-small-cell lung cancer (NSCLC) have worse overall survival than white patients. Decreased likelihood of resection has been implicated. To isolate the effect of decision making from access to care, we used receipt of surgical staging as a proxy for access and willingness to undergo invasive procedures, and examined treatments and outcomes by race.

PATIENTS AND METHODS

We examined registry and claims data of Medicare-eligible patients with nonmetastatic NSCLC in areas monitored by the Surveillance, Epidemiology, and End Results program from 1991 to 2001. Patients who obtained invasive staging, defined as bronchoscopy, mediastinoscopy, or thoracoscopy, were included. Logistic regression and Cox modeling calculated the odds of having staging and surgery, and survival outcomes.

RESULTS

A total of 14,224 patients underwent staging, and 6,972 had surgery for lung cancer. Black patients were less likely to undergo staging (odds ratio [OR] = 0.75; 95% CI, 0.67 to 0.83), and once staged, were still less likely to have surgery than whites (OR = 0.55; 95% CI, 0.47 to 0.64). Survival for blacks and whites was equivalent after resection (hazard ratio = 1.02; P = .06). Staged black patients were less likely to receive a recommendation for surgery when it was not clearly contraindicated (67.0% v 71.4%; P < .05), and were more likely to decline surgery (3.4% v 2.0%; P < .05).

CONCLUSION

Black patients obtain surgery for lung cancer less often than whites, even after access to care has been demonstrated. They are more likely not to have surgery recommended, and more likely to refuse surgery. Additional research should focus on the physician-patient encounter as a potential source of racial disparities.

Racial, Cultural, and Ethnic Factors Influencing End-of-Life Care

Past efforts in the palliative and end-of-life care field have been laudably directed at increasing the cultural competence of providers and institutions and improving outreach to multicultural communities. Today, however, we face new challenges with regard to racial, cultural, and ethnic factors at the end of life. We now have documented evidence of disparities in almost every area of health care. In addition, breakthroughs in genomics research, including "race-based therapeutics," have redefined the meaning of our human differences. These trends, unfolding in an increasingly polarized post-9/11 world, greatly challenge our understanding of concepts of race, culture, and ethnicity. By definition, when considering these concepts, our focus shifts from the individual to that of group membership. In turn, this suggests using a population-based or epidemiological approach, which at once reveals inequalities and inequities in mortality patterns across diverse groups. Understanding and serving the needs of specific populations requires us to apply a framework of equity and to consider strategies to eliminate disparities. These include identifying sources of bias and discrimination in health care; enhancing the collection of racial, ethnic, and other demographic data; and increasing the representation of a range of diverse population groups in well designed qualitative and quantitative research. Using an epidemiological framework does not suggest, however, that we lose sight of dying individuals and their families. At the end of life, an individualized approach to care with a focus on quality is paramount for any patient, regardless of racial, ethnic, or cultural background.

Predictors of outcomes for women with cervical carcinoma

BACKGROUND

To determine the impact of race and other factors on the management and outcomes of women treated for cervical cancer in a rural state.

METHODS

Following IRB approval, a retrospective review identified 434 eligible women treated for cervical cancer from 1994 to 2000. Collected data included: demographics, clinicopathologic data, primary and adjuvant therapy, recurrence, and survival. Statistical analyses were performed with the Chi-square test, Kaplan-Meier method, and Cox regression.

RESULTS

304 (70%) of the women were white and 130 (30%) were non-white. Non-whites were more likely to present with advanced stage disease [Stage IIB-IVB] (25% vs. 13%; P < 0.01). Whites were more likely to smoke, be married, be employed, and have private insurance. Non-whites were more likely to have medical co-morbidities such as diabetes and hypertension. Although whites with early stage disease were more likely to undergo surgery as their primary therapy than non-whites (93% vs. 84%; P < 0.01), survival was similar. Survival outcomes for advanced stage disease were similar between groups.

CONCLUSIONS

Non-whites diagnosed with cervical cancer are more likely to present with advanced stage disease than whites; however, overall survival was similar between groups. Non-whites with early stage disease were more likely to receive primary radiation therapy than whites. The decision to use radiation therapy vs. surgery does not appear to have a detrimental effect on overall survival, but may impact quality of life.

Cancer Surveillance Research: a Vital Subdiscipline of Cancer Epidemiology

Public health surveillance systems relevant to cancer, centered around population-based cancer registration, have produced extensive, high-quality data for evaluating the cancer burden. However, these resources are underutilized by the epidemiology community due, we postulate, to under-appreciation of their scope and of the methods and software for using them. To remedy these misperceptions, this paper defines cancer surveillance research, reviews selected prior contributions, describes current resources, and presents challenges to and recommendations for advancing the field. Cancer surveillance research, in which systematically collected patient and population data are analyzed to examine and test hypotheses about cancer predictors, incidence, and outcomes in geographically defined populations over time, has produced not only cancer statistics and etiologic hypotheses but also information for public health education and for cancer prevention and control. Data on cancer patients are now available for all US states and, within SEER, since 1973, and have been enhanced by linkage to other population-based resources. Appropriate statistical methods and sophisticated interactive analytic software are readily available. Yet, publication of papers, funding opportunities, and professional training for cancer surveillance research remain inadequate. Improvement is necessary in these realms to permit cancer surveillance research to realize its potential in resolving the growing cancer burden.

Annual report to the nation on the status of cancer, 1975-2002, featuring population-based trends in cancer treatment

BACKGROUND

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide information on cancer rates and trends in the United States. This year's report updates statistics on the 15 most common cancers in the five major racial/ethnic populations in the United States for 1992-2002 and features population-based trends in cancer treatment.

METHODS

The NCI, the CDC, and the NAACCR provided information on cancer cases, and the CDC provided information on cancer deaths. Reported incidence and death rates were age-adjusted to the 2000 U.S. standard population, annual percent change in rates for fixed intervals was estimated by linear regression, and annual percent change in trends was estimated with joinpoint regression analysis. Population-based treatment data were derived from the Surveillance, Epidemiology, and End Results (SEER) Program registries, SEER-Medicare linked databases, and NCI Patterns of Care/Quality of Care studies.

RESULTS

Among men, the incidence rates for all cancer sites combined were stable from 1995 through 2002. Among women, the incidence rates increased by 0.3% annually from 1987 through 2002. Death rates in men and women combined decreased by 1.1% annually from 1993 through 2002 for all cancer sites combined and also for many of the 15 most common cancers. Among women, lung cancer death rates increased from 1995 through 2002, but lung cancer incidence rates stabilized from 1998 through 2002. Although results of cancer treatment studies suggest that much of contemporary cancer treatment for selected cancers is consistent with evidence-based guidelines, they also point to geographic, racial, economic, and age-related disparities in cancer treatment.

CONCLUSIONS

Cancer death rates for all cancer sites combined and for many common cancers have declined at the same time as the dissemination of guideline-based treatment into the community has increased, although this progress is not shared equally across all racial and ethnic populations. Data from population-based cancer registries, supplemented by linkage with administrative databases, are an important resource for monitoring the quality of cancer treatment. Use of this cancer surveillance system, along with new developments in medical informatics and electronic medical records, may facilitate monitoring of the translation of basic science and clinical advances to cancer prevention, detection, and uniformly high quality of care in all areas and populations of the United States.

Racial Disparities in Treatment and Survival Among Women With Early-Stage Breast Cancer

Purpose

Black women with breast cancer are known to have poorer survival than white women. Suboptimal treatment may compromise the survival benefits of adjuvant chemotherapy. We analyzed the association of race and survival with duration of treatment and number of treatment cycles among women receiving chemotherapy for early-stage breast cancer.

Patients and Methods

Patients were women in the Henry Ford Health System tumor registry who were diagnosed with stage I/II breast cancer between January 1, 1996, and December 31, 2001, who received adjuvant chemotherapy. We calculated an observed/expected ratio of treatment duration and of completed chemotherapy cycles for each patient. Using Cox proportional hazards models, we analyzed the association of early treatment termination and treatment duration with all-cause mortality, controlling for age, race, stage, hormone receptor status, grade, comorbidity score, and doxorubicin use.

Results

Of 472 eligible patients, 28% (31% black, 23% white; P = .03) received fewer cycles of treatment than expected. Black race, receipt of ≤ 75% of the expected number of cycles, increasing age, hormone receptor negativity, and a comorbidity score of more than 1 were associated with poorer survival. Among the 344 patients receiving the expected number of cycles, 60% experienced delays. These delays did not reduce survival.

Conclusion

This study is the first to find that a substantial fraction of women with early-stage breast cancer terminated their chemotherapy prematurely and that early termination was associated with both black race and poorer survival. A better understanding of the determinants of suboptimal treatment may lead to interventions that can reduce racial disparities and improve breast cancer outcomes for all women.

Population-Based Assessment of Surgical Treatment Trends for Patients With Melanoma in the Era of Sentinel Lymph Node Biopsy

Purpose

The surgical staging of melanoma dramatically changed with the introduction of sentinel lymph node (SLN) biopsy. In this study, Surveillance, Epidemiology, and End Results (SEER) data were examined to determine how surgical treatment is being carried out and whether SLN biopsy is being performed in melanoma patients in conformance with National Comprehensive Cancer Network (NCCN) guidelines.

Patients and Methods

The SEER database (1998 to 2001) was searched for all patients with invasive melanoma. NCCN guidelines were used to define optimal stage-specific surgical treatment. Treatment trends in patients with stages I to III disease were summarized, and multivariate analyses were performed to identify factors associated with nonadherence with treatment guidelines.

Results

A total of 21,867 melanoma patients were identified; 18,499 of these patients met the inclusion criteria. The number of patients diagnosed with stage III melanoma increased by 55.7% over the study period, and this corresponded to a 53% increase in the number of SLN biopsies performed annually. The odds ratios for nonadherence were 2.32, 2.27, and 1.54 for stages IB, II, and III disease, respectively, compared with stage IA melanoma. Multivariate analyses revealed that age more than 65 years, marital status, minority populations, and primary tumor location were associated with nonadherence with guidelines. Treatment patterns among tumor registries also varied significantly.

Conclusion

Stage migration is evident in the SEER registries in consort with increasing use of SLN biopsy. Although treatment trends are improving, SLN biopsy continues to be underused, particularly in the elderly and minority populations, in patients with truncal and head/neck melanomas, and also in some geographic regions of the United States.

Radiation Therapy for the Treatment of Unresected Stage I-II Non-small Cell Lung Cancer

STUDY OBJECTIVES

Radiotherapy is considered to be the standard treatment for patients with stage I or II non-small lung cancer who refuse surgery or who are not surgical candidates because of significant comorbidities. To determine whether radiotherapy benefits these patients, we compared the survival of those treated with radiation alone to those left untreated.

METHODS

Using the Surveillance, Epidemiology, and End Results registry, we identified all patients in whom histologically confirmed, stage I and II non-small cell lung cancer had been diagnosed between 1988 and 2001. Among these patients, 4,357 did not undergo surgical resection. Kaplan-Meier survival curves were compared among patients who received and who did not receive radiation therapy. We used Cox regression analysis to evaluate the effect of radiation on survival after adjusting for potential confounders.

RESULTS

The survival of patients with lung cancer who did not undergo resection and had been treated with radiation therapy was significantly better compared to the untreated patients (stage I cancer, p = 0.0001; stage II cancer, p = 0.001). The median survival time of patients with stage I disease who underwent radiotherapy was 21 months compared to 14 months for untreated patients. Stage II patients who received and did not receive radiation therapy had median survival times of 14 and 9 months, respectively. The survival of treated and untreated patients was not significantly different approximately 5 years after diagnosis (stage I disease, 15% vs 14%, respectively; stage II disease, 11% vs 10%, respectively). In multivariate analysis, radiation therapy was significantly associated with improved lung cancer survival after controlling for age, sex, race, and tumor histology.

CONCLUSIONS

These results suggest that radiotherapy is associated with improved survival in patients with unresected stage I or II non-small cell lung cancer. The observed improvement in median survival time was only 5 to 7 months, and radiotherapy did not offer the possibility of a cure.

Racial disparities affecting the reproductive health of African-American women

Until African Americans make a conscious decision to gain control of the social and economic context in which they live, and assume primary responsibility for their health, the reproductive disparities and associated deaths experienced by African-American women will persist. There is truly a need for continued clinical, epidemiologic, and molecular investigations into the problems. Ultimately, however, the permanent elimination of reproductive health disparities will require a social movement, led by members of the target population, informed by the findings of evidenced-based medicine, and fueled by a desire to raise the standard of living of the African-American community. As this occurs, all women will benefit.

Explaining black-white differences in receipt of recommended colon cancer treatment

BACKGROUND

Black-white disparities exist in receipt of recommended medical care, including colorectal cancer treatment. This retrospective cohort study examines the degree to which health systems (e.g., physician, hospital) factors explain black-white disparities in colon cancer care.

METHODS

Data from the Surveillance, Epidemiology, and End Results program; Medicare claims; the American Medical Association Masterfile; and hospital surveys were linked to examine chemotherapy receipt after stage III colon cancer resection among 5294 elderly (> or = 66 years of age) black and white Medicare-insured patients. Logistic regression analysis was used to identify factors associated with black-white differences in chemotherapy use. All statistical tests were two-sided.

RESULTS

Black and white patients were equally likely to consult with a medical oncologist, but among patients who had such a consultation, black patients were less likely than white patients (59.3% versus 70.4%, difference = 10.9%, 95% confidence interval [CI] = 5.1% to 16.4%, P < .001) to receive chemotherapy. This black-white disparity was highest among patients aged 66-70 years (black patients 65.7%, white patients 86.3%, difference = 20.6%, 95% CI = 10.7% to 30.4%, P < .001) and decreased with age. The disparity among patients aged 66-70 years also remained statistically significant in the regression analysis. Overall, patient, physician, hospital, and environmental factors accounted for approximately 50% of the disparity in chemotherapy receipt among patients aged 66-70 years; surgical length of stay and neighborhood socioeconomic status accounted for approximately 27% of the disparity in this age group, and health systems factors accounted for 12%.

CONCLUSIONS

Black and white Medicare-insured colon cancer patients have an equal opportunity to learn about adjuvant chemotherapy from a medical oncologist but do not receive chemotherapy equally. Little disparity was explained by health systems; more was explained by illness severity, social support, and environment. Further qualitative research is needed to understand the factors that influence the lower receipt of chemotherapy by black patients.

Access to care for chronic pain: racial and ethnic differences

Access to medical care is a major national issue, and several surveys suggest that racial and ethnic differences influence access to care for chronic pain problems. To evaluate the influence of race and ethnicity on access to treatment for chronic pain, a cross-sectional telephone survey was performed in a nationally representative sample of 454 white, 447 African-American, and 434 Hispanic subjects with pain for > or =3 months. Questions explored demographics, pain and its treatment, and perceived access to care. A composite "access" variable combined actual consultation with perceived access. Hispanics were younger, least likely to be insured, and had the least education and lowest income; 61% spoke Spanish at home. Hispanics were significantly less likely to have consulted a primary care practitioner for pain (70%) than whites (84%) or African-Americans (85%). A lower likelihood of consultation also was associated with speaking Spanish, being male, being relatively young (18-34 years old) or single, having limited education, and not being employed. Low "access" to care was associated with being Hispanic and speaking Spanish, being younger or male, having low income or limited education, being employed, and agreeing that financial concerns prevented pain treatment. High "access" was associated with being white or African-American; being older or female or living in a suburban area; having insurance, higher income, or college education; and being unemployed. In multivariate models, low "access" was associated with Hispanic ethnicity and agreement that financial concerns prevented pain treatment. High "access" was associated with more severe pain, having insurance or an income of US 25,000 dollars to US 74,000 dollars, and agreeing that "A doctor or other health care provider is the first person I would go to to discuss my pain." These data suggest that race/ethnicity, other demographic characteristics, and socioeconomic factors influence access to pain care. Hispanic ethnicity predicts limited access.

PERSPECTIVE

The influence of race and ethnicity on access to health care is a major issue in the United States. A national telephone survey suggests that race and ethnicity, along with other demographic and socioeconomic factors, influence access to care for chronic pain.

New therapeutic approaches for early stage non-small cell lung cancer

Surgical resection remains the mainstay of therapy for early stage non-small cell lung cancer (NSCLC). Unfortunately, many patients present with advanced stage disease, and many with resectable early stage disease are unable to tolerate pulmonary resection because of compromised cardiopulmonary function. This article reviews the standard and some alternative therapies that are being introduced into clinical practice for early stage NSCLC. New therapies such as sublobar resection with brachytherapy, radiofrequency ablation and stereotactic radiosurgery offer some hope for those patients who are deemed poor candidates for curative resection.

Lung cancer in women

Lung cancer is the leading cause of cancer death in the United States and is responsible for 20,000 more deaths yearly in US women than breast cancer. Cigarette smoking is the major cause of lung cancer, and unfortunately, approximately 22 million US women smoke. Mounting evidence suggests that there are significant differences in lung cancer between the sexes. There is a difference in the histologic distribution of lung cancer, with glandular differentiation being more common in women. Genetic variation may account for differences in susceptibility, and hormonal and biologic factors may play a role in carcinogenesis. Lung cancer patients have few therapeutic options. A more thorough understanding of the heterogeneity of lung cancer across populations may lead to innovations in treatment and prevention strategies.

The role of the federal government in eliminating health disparities

Minorities live sicker and die sooner from too many acute and chronic illnesses. To eliminate racial and ethnic disparities in health, Congress and the Bush administration must address the serious challenge of increasing minorities' access to health care and improving the quality of care they receive. We clearly need to expand Medicaid and the State Children's Health Insurance Program (SCHIP), but we must also develop and train culturally competent providers, increase the diversity of the health care workforce, collect better race/ethnicity health data, and make a greater investment in public health.

Making health equality a reality: the Bronx takes action

In response to growing evidence of racial and ethnic disparities in health, Bronx Health REACH, a coalition of health care providers and community and faith-based organizations, is engaged in an effort to identify and eliminate the root causes of health disparities in their Bronx neighborhood. The group has gained a community perspective on health disparities that it has developed into a seven-point advocacy agenda: universal health insurance, an end to segregation in health facilities based on insurance status, accountability for state uncompensated care funds, culturally competent care for all, greater health workforce diversity, an expansion of public health education, and environmental justice.

Racial differences in attitudes regarding cardiovascular disease prevention and treatment: a qualitative study

The objective of this study was to explore coronary heart disease (CHD) health care experiences and beliefs of African-American and white patients to elicit potential causes of racial disparities in CHD outcomes. Twenty-four patients (14 white, 10 African-American) with established CHD participated in one of four focus groups. Using qualitative methods, verbatim transcripts of the groups were analyzed by independent investigators to identify key themes. We identified four themes: risk factor knowledge, physician--patient relationship, medical system access, and treatment beliefs. Racial differences were apparent in the experience of racism as a stress, knowledge of specifics of CHD risk factors, and assertiveness in the physician--patient relationship. These findings suggest that strategies to improve risk factor knowledge and to enable African-American patients to become active partners in their medical care may lead to improved CHD morbidity and mortality in this population. The efficacy of such interventions would need to be tested in further work.

Mortality From Lung Cancer and Tobacco Smoking in Ohio (U.S.): Will Increasing Smoking Prevalence Reverse Current Decreases in Mortality?

BACKGROUND

Despite significant changes in smoking patterns within the past few decades, lung cancer remains a major cause of cancer deaths in many developed countries in people of each sex, and one of the most important public health issues. The study aims to analyze the possible impact of changes in tobacco smoking practices in the state of Ohio (U.S.) on current and future trends and patterns of lung cancer mortality.

MATERIALS AND METHODS

Mortality rates from lung cancer were calculated for the period 1970 to 2001 on the basis of data from the National Center for Health Statistics. The Joinpoint regression approach was used to evaluate changes in time trends by sex, age, and race. Data on smoking prevalence in Ohio were retrieved from the Centers for Disease Control and Prevention website.

RESULTS

Lung cancer mortality rates in Ohio have declined among men of all ages as well as in specific age groups in the 1990s, and the rate of increase among middle-aged and elderly women has dropped over time. The mortality rate among young women (ages 20-44) began to increase during the early 1990s. The prevalence of smoking in Ohio has increased since the early 1990s, especially among young persons.

CONCLUSIONS

Recent trends in tobacco smoking in Ohio indicate that the declining trends in lung cancer mortality might be reversed in the future. An early indicator of possible change is the recent increase in mortality among young women. Implementation of the Ohio Comprehensive Tobacco Use Prevention Strategic Plan might help to disseminate proven prevention strategies among the inhabitants of Ohio and might thus prevent future increases in lung cancer mortality rates in the state.

Obesity and awareness of obesity as risk factors for breast cancer in six ethnic groups

OBJECTIVE

To document BMI and knowledge regarding obesity as a risk factor for breast cancer among subpopulations of African-, Caribbean-, and European-American women and to consider the variables predicting obesity in these diverse groups.

RESEARCH METHODS AND PROCEDURES

A stratified cluster-sampling plan was used to recruit 1364 older women from Brooklyn, NY, during 2000-2002. Two groups were born in the United States (African Americans and European Americans), whereas others were from the English-speaking Caribbean, Haiti, the Dominican Republic, and Eastern Europe. Participants provided demographics, height and weight measures, and estimates of the risk obesity posed for breast cancer.

RESULTS

Women from all groups were significantly overweight (BMI > 25 kg/m(2)), although European Americans were lowest, followed by Dominicans and Haitians; African-American and English-speaking Caribbean women fell into the obese range, even when background variables were controlled. Knowledge of obesity as a breast cancer risk factor was also poor across groups, but Dominicans and Haitians had the lowest scores on knowledge. Importantly, knowledge was not associated with BMI in the overall sample, even when controlling for demographics and ethnicity, although logistic regressions comparing normal weight women with overweight and obese groupings suggested some knowledge of breast cancer risk in the overweight, but not the obese, group.

DISCUSSION

The findings remind health professionals of the need to consider more specific ethnic groupings than has hitherto been the case, as well as consider how ethnic and cultural variables may influence perceptions of obesity and its relation to cancer risk.

Technology diffusion, hospital variation, and racial disparities among elderly Medicare beneficiaries: 1989-2000

BACKGROUND

Low rates of technology utilization in hospitals with high proportions of black inpatients may be a remediable cause of healthcare disparities.

OBJECTIVES

Our objective was to determine how differences in technology utilization among hospitals contributed to racial disparity and if temporal reduction in hospital procedure rate variation resulted in decreased racial disparity for these technologies.

METHODS

We identified 2,348,952 elderly Medicare beneficiaries potentially eligible for 1 of 5 emerging medical technologies from 1989-2000 and determined if these patients had received the indicated procedure within 90 days of their qualifying hospital admission. Initial multivariate regression models adjusted for age, race, sex, admission year, clinical comorbidity, community levels of education and income, and academic/urban hospital admission. The inpatient racial composition of each patient's admitting hospital and time-race interactions were added as covariates to subsequent models.

RESULTS

Blacks had significantly lower adjusted rates (P < 0.001) compared with whites for tissue replacement of the aortic valve, internal mammary artery coronary bypass grafting, dual-chambered pacemaker implantation, and lumbar spinal fusion. Hospitals with > 20% black inpatients were less likely to perform these procedures on both white and black patients than hospitals with < 9% black inpatients, and racial disparity was greater in hospitals with larger black populations. There were no temporal reductions in racial disparities.

CONCLUSIONS

Blacks may be disadvantaged in access to new procedures by receiving care at hospitals that have both lower procedure rates and greater racial disparity. Policies designed to ameliorate racial disparities in health care must address hospital variation in the provision of care.

Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities

PURPOSE

The use of do-not-resuscitate (DNR) orders may differ by sex or ethnicity, and DNR status may be associated with outcomes for hospitalized patients. Thus, we sought to determine whether differences in rates of DNR by sex and ethnicity influenced differences in mortality.

SUBJECTS AND METHODS

We included all patients admitted to nonfederal California hospitals in 1999 with stroke, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, chronic renal failure, angina, or diabetes mellitus. Rates of physician orders for DNR written within 24 hours of hospital admission and in-hospital mortality were compared between sexes and ethnicities after adjustment for age, admission source and diagnosis, payment type, and comorbidity scores in multivariable logistic regression models.

RESULTS

Of 327890 patients included, 25196 (7.7%) had DNR orders. In adjusted models, women were more likely to have DNR orders than men (odds ratio [OR] 1.19; 95% confidence interval 1.16-1.23; P <0.001) and non-Hispanic whites were more likely to have DNR orders than other ethnicities (OR 1.75; 1.69-1.82; P <0.001). Overall, 13549 (4.1%) patients died in the hospital. Risk of death was greater in those with a DNR order (OR 7.0; 6.7-7.3; P <0.001). Non-Hispanic whites appeared to have a greater risk of in-hospital death in adjusted models (OR 1.09; 1.04-1.12; P <0.001) when DNR status was ignored; however, the risk of death appeared to be lower in non-Hispanic whites in the complete model with DNR included (OR 0.94; 0.90-0.99; P = 0.01). A survival advantage for women was also more apparent after including DNR status in the adjusted model.

CONCLUSIONS

Women and non-Hispanic whites are more likely to have DNR orders. DNR status affected the measurement of sex-ethnic differences in mortality risk.

Testing for statistical discrimination in health care

OBJECTIVE

To examine the extent to which doctors' rational reactions to clinical uncertainty ("statistical discrimination") can explain racial differences in the diagnosis of depression, hypertension, and diabetes.

DATA SOURCES

Main data are from the Medical Outcomes Study (MOS), a 1986 study conducted by RAND Corporation in three U.S. cities. The study compares the processes and outcomes of care for patients in different health care systems. Complementary data from National Health And Examination Survey III (NHANES III) and National Comorbidity Survey (NCS) are also used.

STUDY DESIGN

Across three systems of care (staff health maintenance organizations, multispecialty groups, and solo practices), the MOS selected 523 health care clinicians. A representative cross-section (21,480) of patients was then chosen from a pool of adults who visited any of these providers during a 9-day period.

DATA COLLECTION

We analyzed a subsample of the MOS data consisting of patients of white family physicians or internists (11,664 patients). We obtain variables reflecting patients' health conditions and severity, demographics, socioeconomic status, and insurance from the patients' screener interview (administered by MOS staff prior to the patient's encounter with the clinician). We used the reports made by the clinician after the visit to construct indicators of doctors' diagnoses. We obtained prevalence rates from NHANES III and NCS.

FINDINGS

We find evidence consistent with statistical discrimination for diagnoses of hypertension, diabetes, and depression. In particular, we find that if clinicians act like Bayesians, plausible priors held by the physician about the prevalence of the disease across racial groups could account for racial differences in the diagnosis of hypertension and diabetes. In the case of depression, we find evidence that race affects decisions through differences in communication patterns between doctors and white and minority patients.

CONCLUSIONS

To contend effectively with inequities in health care, it is necessary to understand the mechanisms behind the problem. Discrimination stemming from prejudice is of a very different character than discrimination stemming from the application of rules of conditional probability as a response to clinical uncertainty. While in the former case, doctors are not acting in the best interests of their patients, in the latter, they are doing the best they can, given the information available. If miscommunication is the culprit, then efforts should be aimed at reducing disparities in the ways in which doctors communicate with patients.

Variation in Quality of Men??s Health Care by Race/Ethnicity and Social Class

BACKGROUND

Until recently, minority and poor men have been characterized as "an invisible population," overlooked by public and private efforts to improve the health status of women, children, and the elderly.

OBJECTIVE

This study compares the health care experiences of racial and ethnic minority men with that of white men, and low socioeconomic status with those of higher status. MEASURES/SUBJECTS: Quality-of-care measures in multiple clinical domains are evaluated. The authors use data from several databases, including the National Health Interview Survey, Medical Expenditure Panel Survey, and Health Care Cost and Utilization Project State Inpatient Database. The relative difference between each racial/ethnic and socioeconomic group and a fixed reference group is used to assess differences in use of services. Statistical significance is assessed using z tests.

RESULTS

Hispanic men were much less likely to receive colorectal cancer screening (relative risk [RR] range, 0.61-0.69), cardiovascular risk factor screening and management (RR, 0.84-0.88), and vaccinations (RR, 0.47-0.94). Black and Asian men were significantly less likely to have received selected preventive services (adult immunization and colorectal cancer screening). The differences in end-stage renal disease care that black and white men received were statistically significant (RR, 0.39-0.97), with black men consistently receiving worse care. For some measures of management of end-stage renal disease, Asian men received care that was similar to or better than that received by non-Hispanic whites.

CONCLUSION

Minority men are at a markedly elevated risk for the receipt of poor health care quality. However, generalizations about "minority" men are likely to be misleading and incomplete. There is a considerable variation in the magnitude, direction, and significance of these risks.

Ethnic disparities in the treatment of stage I non-small cell lung cancer

RATIONALE

Important variations exist in the treatment of non-small cell lung cancer. Because resection is the most effective treatment for patients with early disease, disparities in surgical rates can generate considerable differences in outcomes.

OBJECTIVE

We analyzed data from a national population-based registry to evaluate disparities in the treatment of Hispanic and white patients with stage I lung cancer and to assess the extent to which these inequalities explain survival differences.

METHODS

This study included 16,036 Hispanic and white patients with stage I lung cancer diagnosed between 1991 and 2000. Cases were identified from the Surveillance, Epidemiology, and End Results registry. Survival was compared among white and Hispanics using Kaplan-Meier curves. Stratified survival curves and Cox regression were used to evaluate whether inequalities in stage (IA vs. IB) and resection could explain survival differences.

RESULTS

Hispanics had worse overall and lung cancer-specific survival compared with whites (p = 0.04 and 0.008, respectively). Five-year lung cancer survival was 54% for Hispanics versus 62% for whites. Hispanics were more frequently diagnosed with stage IB disease (p = 0.0002) and less likely to undergo resection (p = 0.03). Among resected patients, survival was similar for the two groups, as it was among those who did not undergo unresection. After adjusting for surgery and stage, there was no difference in survival between groups.

CONCLUSIONS

Hispanics with stage I lung cancer had worse survival as compared with whites. These disparities are largely explained by lower rates of resection and higher probability of diagnosis at stage IB. Future work must delineate why Hispanics are receiving less surgery.

When Race Matters

Several widely held assumptions shape end-of-life discussion in the United States. They are embedded in mainstream bioethics and biomedical discourse, debate, and discussion, as well as in the popular media. We have come to regard them as the conventional wisdom. Despite their apparent reasonableness, the assumptions are not held universally by all US citizens, particularly those of color. They hold contradictions that partially explain why fewer African Americans than whites complete advance directives, and why African Americans tend to desire aggressive care at the end of life. This article considers some of these assumptions. It then considers a case and an approach to care that seeks to resolve potential conflicts proactively.

End-of-Life Hospitalization for African American and Non-Latino White Nursing Home Residents: Variation by Race and a Facility's Racial Composition

BACKGROUND

Hospitalization of nursing home residents at the end of life is common, more so among African Americans. Whether a nursing home's racial mix is associated with hospitalization is unknown.

OBJECTIVE

This study examined the association between race, a nursing home's racial mix, and end-of-life hospitalization.

DESIGN

This was a retrospective cohort study.

SETTING/SUBJECTS

Studied were nursing home residents in New York (n = 14,159) and Mississippi (n = 1481) who died in 1995-1996 and had a minimum data set (MDS) assessment within 120 days of death.

MEASUREMENTS

The outcome measure was the odds of hospitalization in the last 90 days of life. A variable reflecting a nursing home's proportion of African American residents (in 1995-1996) represented a nursing home's racial mix.

RESULTS

Forty-six percent of African Americans and 32% of whites were hospitalized in the last 90 days of life. After controlling for demographics, diagnoses, function, patient preferences (do-not-resuscitate [DNR]), and facility resources, nursing home residents in facilities having higher proportions of African American residents had greater odds of hospitalization (adjusted odds ratio [AOR] 1.14; 95% confidence interval [CI] 1.10, 1.18 in New York and AOR 1.35; 95% CI 1.24, 1.46 in Mississippi). Age and frailty interacted with race; older African Americans had a 16% greater likelihood (95% CI 1.08, 1.24) of hospitalization, and African Americans with more functional limitations had a 37% (95% CI 1.24, 1.51) greater likelihood of hospitalization than did comparable whites.

CONCLUSIONS

It appears higher end-of-life hospitalization rates for African American residents are attributable to the facilities where most reside, and to differential hospitalization of older or more functional limited residents.

The impact of comorbidity on outcomes

Patients often have other diseases, illnesses, or conditions in addition to the disease under study. These other medical conditions are referred to as comorbidity. Comorbidity can impact on diagnosis, prognosis, and selection of therapy. There are a variety of instruments available to measure the type and severity of comorbid ailments. Comorbidity information can be obtained from direct discussions with the patient, a review of the medical record, or from electronic databases that contain billing information. The method of comorbidity assessment can impact on the interpretation of results. Accurate comorbid information will improve the conduct of and generalizability of clinical trials, evaluation of outcomes from observational research, population-based epidemiological studies, and patient-physician communication.

Racial differences in surgical evaluation, treatment, and outcome of locoregional esophageal cancer: a population-based analysis of elderly patients

PURPOSE

We investigated racial disparities in access to surgical evaluation, receipt of surgery, and survival among elderly patients with locoregional esophageal cancer.

METHODS

We selected 2,946 white patients and 367 black patients who were older than 65 years and had clinically locoregional esophageal cancer in the Surveillance, Epidemiology, and End Results (SEER) registry (1991 to 1999). Treatment and outcome data were obtained from the linked SEER-Medicare databases. We used logistic regression analysis to estimate odds ratios (ORs) for being seen by a surgeon and for undergoing surgery. Cox proportional hazards analyses were performed to estimate hazard ratios (HRs) for survival adjusted for medical, nonmedical, and treatment characteristics.

RESULTS

The rate of surgery for black patients was half that of white patients (25% v 46%; OR, 0.38; P < .001), which was caused by both a lower rate of seeing a surgeon (70% v 78%; OR, 0.66; P < .001) and a lower rate of surgery once seen (35% v 59%; OR, 0.38; P < .001). These racial disparities were only partly explained by differences in patient and cancer characteristics, and not by nonmedical factors, such as socioeconomic status. The 2-year survival rate was lower for black patients (18% v 25%; HR, 1.18; P = .004), but this racial difference disappeared when corrected for treatment received (adjusted HR, 1.02; P = .80).

CONCLUSION

Underuse of potentially curative surgery is an important potential explanation for the poorer survival of black patients with locoregional esophageal cancer. Barriers to surgical evaluation and treatment need to be reduced, whether related to patient or healthcare system factors.

‘A little bitty spot and I'm a big man’: patients' perspectives on refusing diagnosis or treatment for lung cancer

Patient refusal of physicians' recommendations may partially account for variations in lung cancer treatment affecting survival. Reasons for refusal have not been well researched, and patients who refuse are often labeled derogatorily as irrational or enigmatically non-compliant. This study explored why patients refused recommendations for further diagnosis or treatment of lung cancer. We conducted in-depth interviews with nine patients, identified and recruited over a 2-year period, with documented refusal of doctors' recommendations. Recruiting was hampered by deaths, logistics, and refusal to participate. Questions focused on participants' understanding of disease, medical recommendations, and perceptions of decision-making. Transcripts were analyzed using a grounded theory approach. Participants emphasized self-efficacy, minimizing threat, fatalism or faith, and distrust of medical authority; explanations were often multi-dimensional. Comments included complaints about communication with physicians, health system discontinuities, and impact of social support. Explanations of participants' decisions reflected several ways of coping with an undesirable situation, including strategies for reducing, sustaining, and increasing uncertainty. Problematic Integration Theory helps to explain patients' difficulties in managing uncertainty when assessments of disease outcomes and treatment recommendations diverge. Implications for clinical communication include increasing trust while delivering bad news, understanding the source of resistance to recommendations, and discussing palliative care.

Race as biology is fiction, racism as a social problem is real: Anthropological and historical perspectives on the social construction of race

Racialized science seeks to explain human population differences in health, intelligence, education, and wealth as the consequence of immutable, biologically based differences between "racial" groups. Recent advances in the sequencing of the human genome and in an understanding of biological correlates of behavior have fueled racialized science, despite evidence that racial groups are not genetically discrete, reliably measured, or scientifically meaningful. Yet even these counterarguments often fail to take into account the origin and history of the idea of race. This article reviews the origins of the concept of race, placing the contemporary discussion of racial differences in an anthropological and historical context.

Differences in the quality of breast cancer care among vulnerable populations

BACKGROUND

It is unknown whether differences in the quality of breast cancer care among women from racial and ethnic minority groups, the elderly, and rural areas have changed over time across the continuum of care.

METHODS

The linked Surveillance, Epidemiology, and End Results-Medicare database identified 22,701 women ages 66-79 years diagnosed with early stage breast cancer from 1992-1999. Multiple breast cancer processes of care were measured, including breast-conserving surgery, radiation therapy, documentation of estrogen receptor status, surveillance mammography, and a combined measure of "adequate care".

RESULTS

African-American and Hispanic women were significantly less likely to receive adequate care than White women in unadjusted comparisons (54.7% and 58.0% vs. 68.4% for African-American and Hispanic vs. White women) and adjusted comparisons (adjusted odds ratio [AOR] 0.67; 95% confidence interval [95% CI] 0.59-0.76, and AOR 0.77; 95% CI 0.66-0.90 for African-American and Hispanic women, respectively). The proportion of Asian/Pacific Islander women receiving adequate care was similar to White women. When considering only women diagnosed with breast cancer from 1997-1999, African-American women remained less likely than White women to receive adequate care (AOR 0.63; 95% CI 0.50-0.79). Women ages 75-79 years were less likely to receive adequate care compared with women ages 66-69 years (AOR 0.74; 95% CI 0.69-0.80), and women from rural (vs. metropolitan) areas were less likely to receive adequate care (AOR 0.81; 95% CI 0.73-0.89).

CONCLUSIONS

The quality of breast cancer care is lower among vulnerable populations across the continuum of care, and many of these differences have not improved in more recent years.

A population-based study of lung carcinoma in Pennsylvania

BACKGROUND

Lung carcinoma remains the major cause of cancer death in North America and is even more common among military veterans. The objective of this study was to determine whether there were differences in the characteristics and survival of Pennsylvania patients with lung carcinoma in the Veterans Administration (VA) hospital system compared with patients in the rest of the state.

METHODS

The Pennsylvania Cancer Registry was used to identify all patients who were diagnosed with lung carcinoma in the State of Pennsylvania from 1995 to 1999. Patients who were treated within the Veterans Administration Health Care Network were identified by hospital code. Survival from the date of diagnosis of lung carcinoma was determined by using the Pennsylvania state mortality files from 1995 to 2001.

RESULTS

From 1995 to 1999, 48,994 patients were newly diagnosed with lung carcinoma in Pennsylvania (41.2% women), including 856 patients in the VA system (6 women). The current analysis was restricted to male patients (n = 28,798 men). There was no major difference in age of VA patients compared with non-VA patients, and the proportions of patients who had localized or regional stage disease were similar (49% of VA patients vs. 48% of non-VA patients). The proportion of black patients was much higher in the VA population (23%) compared with the non-VA population (9%). The median survival was 6.3 months for VA patients compared with 7.9 months for patients in the rest of the state, and the 5-year overall survival rate was 12% for VA patients compared with 15% for patients in the rest of the state. When survival was analyzed according to race, there was a significant difference in the age-adjusted survival of white patients in the VA system compared with patients in the rest of the state (P = 0.0007), but no significant difference was observed among black patients (P = 0.92).

CONCLUSIONS

The overall survival of VA patients with lung carcinoma in Pennsylvania was inferior to that of patients in the remainder of the state and this was due primarily to differences in survival among the white patients. Further investigation will be necessary to determine whether this disparity was caused by differences in socioeconomic status or comorbidities or whether there are systematic differences in the diagnosis, staging, or treatment of lung carcinoma between VA patients and civilian patients.

Factors influencing HIV-risk behaviors among HIV-positive urban African Americans

Urban African Americans are disproportionately affected by HIV, the virus associated with AIDS. Although incidence and mortality appear to be decreasing in some populations, they continue to remain steady among inner-city African Americans. A major concern is the number of HIV-positive individuals who continue to practice high-risk behaviors. Understanding factors that increase risks is essential for the development and implementation of effective prevention initiatives. Following a constructionist epistemology, this study used ethnography to explore social and cultural factors that influence high-risk behaviors among inner-city HIV-positive African Americans. Leininger's culture care diversity and universality theory guided the study. Individual qualitative interviews were conducted with HIV-positive African Americans in the community to explore social and cultural factors that increase HIV-risky behaviors. For this study, family/kinship, economic, and education factors played a significant role in risky behaviors. Reducing HIV disparity among African Americans is dependent on designing appropriate interventions that enhance protective factors. Clinicians providing care to HIV-positive individuals can play a key role in reducing transmission by recognizing and incorporating these factors when designing effective prevention interventions.

Hospital choice of rural Medicare beneficiaries: patient, hospital attributes, and the patient-physician relationship

OBJECTIVE

To examine how patient and hospital attributes and the patient-physician relationship influence hospital choice of rural Medicare beneficiaries.

DATA SOURCES

Medicare Current Beneficiary Survey (MCBS), Health Care Financing Administration (HCFA) Provider of Services (POS) file, American Hospital Association (AHA) Annual Survey, and Medicare Hospital Service Area (HSA) files for 1994 and 1995.

STUDY DESIGN

The study sample consisted of 1,702 hospitalizations of rural Medicare beneficiaries. McFadden's conditional logit model was used to analyze hospital choices of rural Medicare beneficiaries. The model included independent variables to control for patients' and hospitals' attributes and the distance to hospital alternatives.

PRINCIPAL FINDINGS

The empirical results show strong preferences of aged patients for closer hospitals and those of greater scale and service capacity. Patients with complex acute medical conditions and those with more resources were more likely to bypass their closest rural hospitals. Beneficiaries were more likely to bypass their closest rural hospital if they had no regular physician, had a shorter patient-physician tie, were dissatisfied with the availability of health care, and had a longer travel time to their physician's office.

CONCLUSIONS

The significant influences of patients' socioeconomic, health, and functional status, their satisfaction with and access to primary care, and their strong preferences for certain hospital attributes should inform federal program initiatives about the likely impacts of policy changes on hospital bypassing behavior.