The meaning of race in science--considerations for cancer research: concerns of special populations in the National Cancer Program

Asian American Pacific Islander Representation in Outcomes Research: NSQIP Scoping Review

BACKGROUND

If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research.

STUDY DESIGN

Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion.

RESULTS

In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p < 0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001).

CONCLUSIONS

Our study is the first to examine AAPI representation in surgical outcomes research. We found < 75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research.

Development and Validation of a Multivariable Prediction Model for Missed HIV Health Care Provider Visits in a Large US Clinical Cohort

Background

Identifying individuals at high risk of missing HIV care provider visits could support proactive intervention. Previous prediction models for missed visits have not incorporated data beyond the individual level.

Methods

We developed prediction models for missed visits among people with HIV (PWH) with ≥1 follow-up visit in the Center for AIDS Research Network of Integrated Clinical Systems from 2010 to 2016. Individual-level (medical record data and patient-reported outcomes), community-level (American Community Survey), HIV care site–level (standardized clinic leadership survey), and structural-level (HIV criminalization laws, Medicaid expansion, and state AIDS Drug Assistance Program budget) predictors were included. Models were developed using random forests with 10-fold cross-validation; candidate models with the highest area under the curve (AUC) were identified.

Results

Data from 382 432 visits among 20 807 PWH followed for a median of 3.8 years were included; the median age was 44 years, 81% were male, 37% were Black, 15% reported injection drug use, and 57% reported male-to-male sexual contact. The highest AUC was 0.76, and the strongest predictors were at the individual level (prior visit adherence, age, CD4+ count) and community level (proportion living in poverty, unemployed, and of Black race). A simplified model, including readily accessible variables available in a web-based calculator, had a slightly lower AUC of .700.

Conclusions

Prediction models validated using multilevel data had a similar AUC to previous models developed using only individual-level data. The strongest predictors were individual-level variables, particularly prior visit adherence, though community-level variables were also predictive. Absent additional data, PWH with previous missed visits should be prioritized by interventions to improve visit adherence.

How do we assess a racial disparity in health? Distribution, interaction, and interpretation in epidemiological studies

Identifying the exposures or interventions that exacerbate or ameliorate racial health disparities is one of the fundamental goals of social epidemiology. Introducing an interaction term between race and an exposure into a statistical model is commonly used in the epidemiologic literature to assess racial health disparities and the potential viability of a targeted health intervention. However, researchers may attribute too much authority to the interaction term and inadvertently ignore other salient information regarding the health disparity. In this article, we highlight empirical examples from the literature demonstrating limitations of overreliance on interaction terms in health disparities research; we further suggest approaches for moving beyond interaction terms when assessing these disparities. We promote a comprehensive framework of three guiding questions for disparity investigation, suggesting examination of the group-specific differences in (1) outcome prevalence, (2) exposure prevalence, and (3) effect size. Our framework allows for better assessment of meaningful differences in population health and the resulting implications for interventions, demonstrating that interaction terms alone do not provide sufficient means for determining how disparities arise. The widespread adoption of this more comprehensive approach has the potential to dramatically enhance understanding of the patterning of health and disease and the drivers of health disparities.

Community Development Model for Public Health Applications: Overview of a Model to Eliminate Population Disparities

For well over two decades, the public health community has undertaken a broad range of initiatives to identify and eliminate various health-related disparities among populations. The Centers for Disease Control and Prevention’s (CDC) Office on Smoking and Health (OSH), for example, has committed resources to help states eliminate population disparities related to tobacco use. These initiatives have enjoyed a degree of success and some measurable decreases in population disparities. However, traditional public health approaches that are overly influenced by reductionist paradigms more content with risk factor assessment of at-risk strata may not be sufficient to produce successful results when applied to more intractable disparities. The elimination of disparities will require a more encompassing and comprehensive approach that addresses both population strata at risk and the communities in which they reside. This article proposes a new, concentrated model to address the elimination of population disparities—a model that focuses on community as the critical unit of analysis and action to achieve success.

Self-reported race/ethnicity in the age of genomic research: its potential impact on understanding health disparities

This review explores the limitations of self-reported race, ethnicity, and genetic ancestry in biomedical research. Various terminologies are used to classify human differences in genomic research including race, ethnicity, and ancestry. Although race and ethnicity are related, race refers to a person's physical appearance, such as skin color and eye color. Ethnicity, on the other hand, refers to communality in cultural heritage, language, social practice, traditions, and geopolitical factors. Genetic ancestry inferred using ancestry informative markers (AIMs) is based on genetic/genomic data. Phenotype-based race/ethnicity information and data computed using AIMs often disagree. For example, self-reporting African Americans can have drastically different levels of African or European ancestry. Genetic analysis of individual ancestry shows that some self-identified African Americans have up to 99% of European ancestry, whereas some self-identified European Americans have substantial admixture from African ancestry. Similarly, African ancestry in the Latino population varies between 3% in Mexican Americans to 16% in Puerto Ricans. The implication of this is that, in African American or Latino populations, self-reported ancestry may not be as accurate as direct assessment of individual genomic information in predicting treatment outcomes. To better understand human genetic variation in the context of health disparities, we suggest using "ancestry" (or biogeographical ancestry) to describe actual genetic variation, "race" to describe health disparity in societies characterized by racial categories, and "ethnicity" to describe traditions, lifestyle, diet, and values. We also suggest using ancestry informative markers for precise characterization of individuals' biological ancestry. Understanding the sources of human genetic variation and the causes of health disparities could lead to interventions that would improve the health of all individuals.

Shoulder impairment before breast cancer surgery

OBJECTIVE

To compare pre- and post-operative shoulder active range of motion (AROM) values from female breast cancer survivors to population norm values for shoulder AROM; and to compare shoulder AROM differences pre- and post-surgery between female African American and White breast cancer survivors (BCA).

STUDY DESIGN

This pilot study used a convenience sample and longitudinal design measuring participants 2 times (T0 = baseline, after biopsy but within 2 weeks before BCA surgery; T1 = 2nd postoperative week).

BACKGROUND

The U.S. has the largest BCA survivor population in history and yet the mortality burden remains highest among AA BCA survivors. AAs may also have greater burden of physical and functional side effects compared to whites and the general population.

METHODS AND MEASURES

The data were collected from a convenience sample (n = 33; nAA = 9, nW = 24) and included data on shoulder AROM, medical chart review for pre- and co-morbid conditions, and self-reported demographics and medical history. We used t-tests to compare sample AROM means to population norms. We then compared our sample across 2 timepoints (T0 = pre-surgery; T1 = 2 weeks post-surgery) using independent samples t-tests and repeated measures analysis of variance (p < .05) to compare AA to White sub-samples AROM means.

RESULTS

African Americans had significantly less shoulder abduction (at T0) and flexion (at T1) than whites. However, 100% had significantly reduced AROM for all movements at T0 (prior to surgery but after biopsy) when compared to population norms.

CONCLUSIONS

The significant reduction in shoulder AROM after biopsy but before surgery points to a possible unmet need for early physical therapy intervention. Further research using randomized controlled trial design is recommended.

Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnic background: a cohort study

Objective

To evaluate surgical treatment delay disparities by race/ethnic group in a group of breast cancer patients treated in the New York region.

Design

Cohort study.

Setting

Two affiliated hospitals in the New York region.

Participants

Patients admitted at two affiliated hospitals in the New York region for breast cancer treatment during 2007–2011.

Main outcome measure

Time to receiving first surgery for breast cancer, defined as the time in days between initial diagnosis (biopsy) and definitive surgical treatment (lumpectomy or mastectomy). Predicted time to first surgery by race group was also analysed using a multivariate linear regression model with adjustments made for several demographic and clinical factors.

Results

Totally, 3071 patients who were first treated with surgery were identified. Racial background was classified as White, African American or Asian/other. Overall median time to surgery was 28 days: 28 days in whites, and 34 and 29 days in African Americans and Asian/others, respectively (p = 0.032). Multivariate analyses showed that only African Americans, not Asian/others, had significantly increased surgical delay compared to whites (p = 0.019).

Conclusions

This study demonstrates significant racial differences in surgical delay in a group of breast cancer patients treated in the New York region. These differences may reflect tacit attitudes of medical providers or processes insensitive to patient educational needs. Additional studies may improve our understanding of this delay.

Increased mortality among Hispanic testis cancer patients independent of neighborhood socioeconomic status: a SEER study

Testis cancer-specific survival (CSS) varies by Hispanic ethnicity. Our goal was to assess whether neighborhood socioeconomic status (SES) accounts for elevated testis CSS among Hispanic patients. We queried the Surveillance, Epidemiology, and End Results (SEER) database for Hispanic (HW) and Non-Hispanic white (NHW) patients. Multivariate Cox regression analyses evaluated Hispanic ethnicity's impact on tCSS while adjusting for neighborhood socioeconomic status (education and income levels). HWs constituted 14.3% of the 26,258 patients in the cohort. Neighborhood SES factors such as county income (P < 0.001) and education level (P < 0.001) were significant predictors of testis cancer-specific survival (tCSS). Controlling for SES and other variables, Hispanic ethnicity remained a significant predictor of tCSS. Compared to NHWs, HWs experienced a 41% greater cancer-specific mortality (HR: 1.406, 95% CI: 1.178-1.678, P < 0.001). The mechanism underlying the increased testis cancer mortality experienced by Hispanic patients remains unknown.

The racial disparity in breast cancer mortality

Black women die of breast cancer at a much higher rate than white women. Recent studies have suggested that this racial disparity might be even greater in Chicago than the country as a whole. When data describing this racial disparity are presented they are sometimes attributed in part to racial differences in tumor biology. Vital records data were employed to calculate age-adjusted breast cancer mortality rates for women in Chicago, New York City and the United States from 1980-2005. Race-specific rate ratios were used to measure the disparity in breast cancer mortality. Breast cancer mortality rates by race are the main outcome. In all three geographies the rate ratios were approximately equal in 1980 and stayed that way until the early 1990s, when the white rates started to decline while the black rates remained rather constant. By 2005 the black:white rate ratio was 1.36 in NYC, 1.38 in the US, and 1.98 in Chicago. In any number of ways these data are inconsistent with the notion that the disparity in black:white breast cancer mortality rates is a function of differential biology. Three societal hypotheses are posited that may explain this disparity. All three are actionable, beginning today.

Occult tumor burden contributes to racial disparities in stage-specific colorectal cancer outcomes

BACKGROUND

There are differences in outcomes in blacks compared with whites with lymph node-negative (pN0) colorectal cancer. Recurrence in pN0 patients suggests the presence of occult metastases undetected by conventional approaches. This study explores the association of racial differences in outcomes with occult tumor burden in regional lymph nodes.

METHODS

Lymph nodes (range, 2-159) from 282 prospectively enrolled pN0 colorectal cancer patients followed for a median of 24 months (range, 2-63 months) were subjected to molecular analysis. Occult tumor burden was estimated by quantifying the expression of GUCY2C, a biomarker for metastatic colorectal cancer cells. Risk categories defined using occult tumor burden was the primary outcome measure. Association of prognostic variables and risk were defined by multivariate polytomous logistic regression.

RESULTS

Occult tumor burden stratified this cohort of 259 whites and 23 blacks into categories with low (60%; recurrence rate [RR] = 2.3%; 95% confidence interval [CI], 0.1%-4.5%), intermediate (31%; RR = 33.3%; 95% CI, 23.7%-44.1%), and high (9%; RR = 68.0%; 95% CI, 46.5%-85.1%; P < .001) risk. Blacks compared with whites exhibited 4-fold greater occult metastases in individual lymph nodes (P < .001). Multivariate analysis revealed that race (P = .02), T stage (P = .02), and number of lymph nodes collected (P = .003) were independent prognostic markers of risk category. Blacks compared with whites were more likely to harbor levels of occult tumor burden, associated with the highest recurrence risk (adjusted odds ratio = 5.08; 95% CI, 1.69-21.39; P = .007).

CONCLUSIONS

Racial disparities in stage-specific outcomes in colorectal cancer are associated with differences in occult tumor burden in regional lymph nodes.

Marked variations in proximal colon cancer survival by race/ethnicity within the United States

GOALS

To investigate the race/ethnicity and sex-specific variations in proximal colon cancer survival within the United States.

BACKGROUND

Recent studies suggest a shift toward more proximal distributions of colon cancers. Survival benefits from screening colonoscopy may be limited to left-sided cancers. Identifying groups at greatest risk for mortality from proximal cancers will help to target health care resources to address these disparities.

STUDY

A retrospective cohort study from 1973 to 2004 using a large population-based cancer registry to investigate demographic variations in colon cancer survival.

RESULTS

Marked sex and race/ethnicity-specific variations in proximal colon cancer survival were observed. Overall 5-year survival was greatest in females (5-y survival, females: 44.5% and males: 41.7%, P<0.001) and in Asians (5-y survival, Asians: 50.4%, non-Hispanic whites: 43.1%, blacks: 39.7%, and Hispanics: 46.7%, P<0.001). Compared with females, males had significantly worse 5-year survival outcomes [odds ratios (OR), 0.77; 95% confidence intervals (CI), 0.75-0.79]. Compared with non-Hispanic whites, blacks had worse 5-year survival odds (OR, 0.74; 95% CI, 0.70-0.78) and Asians had better survival outcomes (OR, 1.16; 95% CI, 1.08-1.24).

CONCLUSIONS

There exists significant sex and race/ethnicity-specific disparities in 5-year survival from proximal colon cancer. These differences may be explained by variations in delivery of health care between demographic groups or differences in disease biology specific to each group.

One size does not fit all: differences in HPV knowledge between Haitian and African American women

BACKGROUND

Historically, all black persons, regardless of ancestry or country of origin, have been categorized as one group for cancer research and control efforts. This practice likely masks variability in exposure to determinants of disease, as well as in risk of cancer incidence and mortality. The current study examines potential differences in knowledge of human papilloma virus (HPV) between Haitian women living in Little Haiti, Miami, Florida, and a national sample of predominately African American women.

METHODS

Data for Haitian women were collected in 2007 as part of an ongoing community-based participatory research initiative in Little Haiti. For purposes of comparison, we used data from a largely African American subsample of the 2007 Health Information National Trends Survey (HINTS). These data sources used identical items to assess HPV knowledge, providing a unique opportunity to examine how this outcome may vary between two very distinct populations who are often grouped together for research and disease surveillance.

RESULTS

Relative to the HINTS sample, Haitian women were far less likely to have heard about HPV.

CONCLUSIONS

Study data highlight important differences in Haitian and African American women's knowledge of HPV, a known determinant of cervical cancer risk. Such findings suggest that continuing to classify persons of similar phenotype but different cultural backgrounds and lifetime exposures as one group may preclude opportunity to understand, as well as attenuate, health disparity.

Black-White health disparities in the United States and Chicago: a 15-year progress analysis

OBJECTIVES

In an effort to examine national and Chicago, Illinois, progress in meeting the Healthy People 2010 goal of eliminating health disparities, we examined whether disparities between non-Hispanic Black and non-Hispanic White persons widened, narrowed, or stayed the same between 1990 and 2005.

METHODS

We examined 15 health status indicators. We determined whether a disparity widened, narrowed, or remained unchanged between 1990 and 2005 by examining the percentage difference in rates between non-Hispanic Black and non-Hispanic White populations at both time points and at each location. We calculated P values to determine whether changes in percentage difference over time were statistically significant.

RESULTS

Disparities between non-Hispanic Black and non-Hispanic White populations widened for 6 of 15 health status indicators examined for the United States (5 significantly), whereas in Chicago the majority of disparities widened (11 of 15, 5 significantly).

CONCLUSIONS

Overall, progress toward meeting the Healthy People 2010 goal of eliminating health disparities in the United States and in Chicago remains bleak. With more than 15 years of time and effort spent at the national and local level to reduce disparities, the impact remains negligible.

Marked Variations in Colon Cancer Epidemiology: Sex-specific and Race/Ethnicity-specific Disparities

BACKGROUND

Recent studies have reported on the changing epidemiology of colon cancer. Given this cancer's high prevalence and mortality, defining high risk groups will be important to guide improvements in cancer screening programs.

METHODS

A retrospective cohort study of a large population-based cancer registry in the United States from 1973-2004 was performed to analyze the race and sex-specific disparities in colon cancer epidemiology.

RESULTS

Blacks and females demonstrated the greatest proportions of proximal cancers: the incidence rate of proximal cancers among black males was more than double that of Asian males (25.2 per 100,000/year vs 11.7 per 100,000/year, p < 0.0001) and the rate among black females was twice that of Asian females (21.9 per 100,000/year vs 11.4 per 100,000/year, p < 0.0001). Blacks as a group had the highest rates of advanced cancers: the rate among black males was nearly double that of Hispanic males (17.1 per 100,000/year vs 8.7 per 100,000/year, p < 0.0001) and the rate of advanced cancers among black females was twice that of Hispanic females (12.4 per 100,000/year vs 6.2 per 100,000/year, p < 0.0001).

CONCLUSIONS

This study demonstrates marked disparities in the sex-specific and race/ethnicity-specific epidemiology of colon cancer. These differences likely represent unequal access to health care resources and race and sex-specific variations in cancer biology. An individualized approach incorporating these disparities would benefit future research and guidelines for improvements in cancer screening programs.

Determinants of cancer health disparities: barriers to cancer prevention, screening, diagnosis and treatment

BACKGROUND

Many health disparities occur when beneficial medical interventions are not shared by all.

OBJECTIVE

To examine the barriers that cause the disparities.

METHODS

In terms of obtaining beneficial medical interventions, the individual with disparities is influenced by his/her community, healthcare provider and healthcare system. The determinants of cancer health disparities include cultural, socio-economic and environmental factors, and the effects of social injustice.

RESULTS/CONCLUSION

These factors create inadequate information and knowledge about cancer, risk-promoting behaviors, inadequate conditions for seeking medical procedures, diminished access to and use of healthcare and inadequate healthcare services. The use of patient navigators may serve to address many of these factors.

Patterns of leukemia incidence in the United States by subtype and demographic characteristics, 1997-2002

OBJECTIVE

Efforts to prevent leukemia have been hampered by an inability to identify significant risk factors. Exploring incidence patterns of leukemia subtypes by sex and race/ethnic group may generate new etiologic hypotheses and identify high-risk groups for further study.

METHODS

Data from the North American Association of Central Cancer Registries for 1997-2002 were used to assess patterns of leukemia incidence by subtype, sex, age, race and ethnicity.

RESULTS

A total of 144,559 leukemia cases were identified, including 66,067 (46%) acute and 71,860 (50%) chronic leukemias. The highest rates of acute myeloid leukemia with and without maturation were observed in Asian-Pacific Islanders (API). Hispanics had a higher incidence of acute lymphocytic leukemia, particularly in childhood, and promyelocytic leukemia than did non-Hispanics. African-Americans had the highest rates of HTLV-1 positive adult T-cell leukemia/lymphoma. A sharp increase in the incidence of chronic myeloid leukemia was observed for both APIs and Hispanics, 85 years and older.

CONCLUSION

Known risk factors are unlikely to explain the observed disparities in leukemia incidence. Further studies of differences in environmental and genetic risk factors in these populations by specific leukemia subtype may provide clues to the etiologies of these malignancies.

Racial categories in medical practice: how useful are they?

Is it good medical practice for physicians to "eyeball" a patient's race when assessing their medical status or even to ask them to identify their race?

The use of family health histories to address health disparities in an African American community

African Americans continue to suffer from health disparities. The Center for Minority Health (CMH) within the University of Pittsburgh has the mission to eliminate racial and ethnic health disparities. CMH has designed and implemented the Family Health History (FHH) Initiative. The FHH Initiative places genetic-counseling graduate students in the African American community to provide risk assessments and emphasize the importance of family history as it pertains to disease prevention. The FHH Initiative also allows participants to enroll into the Minority Research Recruitment Database (MRRD). This enables CMH to alert individuals to available research participation opportunities. In the first year of this program, 225 African Americans completed their family health histories. More than 60% of individuals enrolled in the MRRD. The authors report their initial successes and challenges of an initiative that incorporates awareness of family history information, proper screening guidelines, behavior-modification recommendations, and support for participation in clinical research.

The black:white disparity in breast cancer mortality: the example of Chicago

OBJECTIVE

The black:white disparity in breast cancer mortality has been increasing in the U.S. In order to gain insight into this disparity in Chicago, we examined mortality data together with other important measures associated with breast cancer.

METHODS

Trends in black:white female breast cancer mortality, incidence, stage at diagnosis, and mammography screening in Chicago were examined using data from the Illinois State Cancer Registry, Illinois Department of Public Health Vital Records, and the Illinois Behavioral Risk Factor Surveillance System.

RESULTS

The breast cancer mortality rate for black women in Chicago for 1999-2003 was 49% higher than that of white women, but the disparity is a recent phenomenon that is increasing rapidly. In 2003 the black rate was 68% higher than the white rate. Mortality rates were similar in the 1980's and only started to diverge in the 1990's as a result of a sharp improvement in mortality among white women contrasted with no improvement for black women. This lack of progress for black women is perplexing given that self-reported mammography screening rates have been the same for blacks and whites in Chicago since at least 1996 and that the early detection of breast cancer for black women has been increasing.

CONCLUSIONS

There has been no improvement in mortality from breast cancer for black women in Chicago in 23 years. This study, along with a review of the literature, lends support to the hypothesis that the disparities in breast cancer mortality are due to differential access to mammography, differential quality in mammography, and differential access to treatment for breast cancer. Fortunately, all three are amenable to intervention, which would help ameliorate this unacceptable disparity.

Reifying human difference: the debate on genetics, race, and health

The causes of racial and ethnic inequalities in health and the most appropriate categories to use to address health inequality have been the subject of heated debate in recent years. At the same time, genetic explanations for racial disparities have figured prominently in the scientific and popular press since the announcement of the sequencing of the human genome. To understand how such explanations assumed prominence, this essay analyzes the circulation of ideas about race and genetics and the rhetorical strategies used by authors of key texts to shape the debate. The authority of genetic accounts for racial and ethnic difference in disease, the author argues, is rooted in a broad cultural faith in the promise of genetics to solve problems of human disease and the inner truth of human beings that is intertwined with historical meanings attached to race. Such accounts are problematic for a variety of reasons. Importantly, they produce, reify, and naturalize notions of racial difference, provide a scientific rationale for racially targeted medical care, and distract attention from research that probes the complex ways in which political, economic, social, and biological factors, especially those of inequality and racism, cause health disparities.

The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates

OBJECTIVES

We sought to determine whether differences in the prevalences of 5 specific pregnancy complications or differences in case fatality rates for those complications explained the disproportionate risk of pregnancy-related mortality for Black women compared with White women in the United States.

METHODS

We used national data sets to calculate prevalence and case-fatality rates among Black and White women for preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage for the years 1988 to 1999.

RESULTS

Black women did not have significantly greater prevalence rates than White women. However, Black women with these conditions were 2 to 3 times more likely to die from them than were White women.

CONCLUSIONS

Higher pregnancy-related mortality among Black women from preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage is largely attributable to higher case-fatality rates. Reductions in case-fatality rates may be made by defining more precisely the mechanisms that affect complication severity and risk of death, including complex interactions of biology and health services, and then applying this knowledge in designing interventions that improve pregnancy-related outcomes.

Population science is science only if you know the population

BACKGROUND

Cancer control efforts have had limited effect in reducing the inequities for minorities and the medically underserved. One factor is the lack of theory-based conceptualization of the terms used to define race, ethnicity, and culture.

METHOD

Guidelines are provided to develop more accurate use of the terms race, ethnicity, and culture to determine standards of comparability across studies of cancer incidence, survival, and quality of life in diverse populations rather than stereotypes.

RESULTS AND CONCLUSIONS

Our ability to use theoretically based criteria to differentiate groups of people could increase our ability to more effectively eliminate these disparities.

Conceptualizing and categorizing race and ethnicity in health services research

OBJECTIVES

Veterans Affairs (VA) patient populations are becoming increasingly diverse in race and ethnicity. The purpose of this paper is to (1) document the importance of using consistent standards of conceptualizing and categorizing race and ethnicity in health services research, (2) provide an overview of different methods currently used to assess race and ethnicity in health services research, and (3) suggest assessment methods that could be incorporated into health services research to ensure accurate assessment of disease prevalence and incidence, as well as accounts of appropriate health services use, in patients with different racial and ethnic backgrounds.

DESIGN

A critical review of published literature was used.

PRINCIPAL FINDINGS

Race is a complex, multidimensional construct. For some individuals, institutionalized racism and internalized racism are intertwined in the effects of race on health outcomes and health services use. Ethnicity is most commonly used as a social-political construct and includes shared origin, shared language, and shared cultural traditions. Acculturation appears to affect the strength of the relationships among ethnicity, health outcomes, and health services use.

CONCLUSIONS

Improved and consistent methods of data collection need to be developed for use by VA researchers across the country. VA research sites with patients representing specific population groups could use a core set of demographic items in addition to expanded modules designed to assess the ethnic diversity within these population groups. Improved and consistent methods of data collection could result in the collection of higher-quality data, which could lead to the identification of race- and ethnic-specific health services needs. These investigations could in turn lead to the development of interventions designed to reduce or eliminate these disparities.

Cancer-related Disparities: Weathering the Perfect Storm Through Comprehensive Cancer Control Approaches

During the last two decades extraordinary progress in developing and using effective cancer prevention strategies, early detection interventions, and cancer treatments has been made. This progress has resulted in an overall decline in mortality rates for all cancers combined. Nonetheless, cancer is the second most common cause of death in the United States. Although cancer is a diagnosis that many survive, cancer experiences across populations may vary considerably. These differences in cancer experiences have created an unequal disease burden that presents distinct professional and moral challenges to our nation. Many cancer control plans suggest specific strategies that prioritize eliminating cancer-related disparities. This article describes certain cancer-related disparities in the United States and gives several examples of how communities and disenfranchised populations are using comprehensive cancer control (CCC) approaches to eliminate these disparities. One or two interventions are highlighted in each example.

Differences in colorectal carcinoma stage and survival by race and ethnicity

BACKGROUND

In the United States, blacks with colorectal carcinoma (CRC) presented with more advanced-stage disease and had higher mortality rates compared with non-Hispanic whites. Data regarding other races/ethnicities were limited, especially for Asian/Pacific Islander and Hispanic white subgroups.

METHODS

Using data from 11 population-based cancer registries that participate in the Surveillance, Epidemiology and End Results program, the authors evaluated the relation among 18 different races/ethnicities and disease stage and mortality rates among 154,103 subjects diagnosed with CRC from 1988 to 2000.

RESULTS

Compared with non-Hispanic whites, blacks, American Indians, Chinese, Filipinos, Koreans, Hawaiians, Mexicans, South/Central Americans, and Puerto Ricans were 10-60% more likely to be diagnosed with Stage III or IV CRC. Alternatively, Japanese had a 20% lower risk of advanced-stage CRC. With respect to mortality rates, blacks, American Indians, Hawaiians, and Mexicans had a 20-30% greater risk of mortality, whereas Chinese, Japanese, and Indians/Pakistanis had a 10-40 % lower risk.

CONCLUSIONS

The authors observed numerous racial/ethnic disparities in the risks of advanced-stage cancer and mortality among patients with CRC, and there was considerable variation in these risks across Asian/Pacific Islander and Hispanic white subgroups. Although the etiology of these disparities was multifactorial, developing screening and treatment programs that target racial/ethnic populations with elevated risks of poor CRC outcomes may be an important means of reducing these disparities.

Perception of health and quality of life in minorities after mild-to-moderate traumatic brain injury

Much has been reported of the influence of age, affective symptoms, and satisfaction on self-ratings of health functioning, but little is known about the extent that race-based perceptions may have on influencing behavior or adjustment after a mild-to-moderate traumatic brain injury (MTBI). We investigated differences in perception of health functioning by race for mental and physical functioning using a global measure of health functioning. MTBI (n = 135) and general trauma (GT, n = 83) patients recruited from an area Level-1 trauma center at 3 months after injury were administered the Medical Outcomes Study: Short Form (SF-36), Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994), Community Integration Questionnaire, Social Support Questionnaire (SSQ), Center for Epidemiological Studies-Depression, and the Visual Analogue Scale of Depression. A significant interaction for Race Group (p < .01) was found on the Physical Component Scale (PCS) of the SF-36. In the MTBI group, African Americans reported worse functioning (p < .04) on the PCS scale; they perceived functioning on subscales General Health Perception (p < .02) and Physical Functioning (p < .04) to be more limited. On the SSQ, Hispanic MTBI patients reported having fewer social supports available to them (p < .05), although the race groups were comparable for satisfaction with their support. Rate of depression across groups was comparable, although subjective reporting by minority MTBI patients indicated greater depressed feelings. Differences in perception of health functioning may be related to the unique interaction created between sustaining an MTBI and variations in cultural expression of disability. Manifestations of physical difficulties may be better accepted for some cultures than having mental illness.

Slave ethics and imagining critically applied anthropology in public health research

For several years I considered myself a resident enemy alien of public health research. This polemical article explores this enemy alien subjectivity by looking at an ethnographic case showing how race is figured in public health research, and it asks what this subjectivity might suggest for a medical anthropology struggling to be both more public and interdisciplinary, and more fundamentally ethnological. As I imbue my enemy alien subjectivity with uniquely anthropological images and references, I ask medical anthropologists to reflect upon the specialized nature of a contemporary anthropological imagination and, while doing this, to look to the Nietzschean notion of slave ethics in order to engage with questions of how we might use this self-awareness to create various modes of"postcritical"practice in public health.

Race and genetics: Controversies in biomedical, behavioral, and forensic sciences

Among biomedical scientists, there is a great deal of controversy over the nature of race, the relevance of racial categories for research, and the proper methods of using racial variables. This article argues that researchers and scholars should avoid a binary-type argument, in which the question is whether to use race always or never. Researchers should instead focus on developing standards for when and how to use racial variables. The article then discusses 1 context, criminology, in which the use of racial variables in behavioral genetics research could be particularly problematic. If genetic studies of criminalized behavior use forensic DNA databanks or forensic genetic profiles, they will be confounded by the many racial biases of the law enforcement and penal system.

Beyond race: towards a whole-genome perspective on human populations and genetic variation

The renewed emphasis on population-specific genetic variation, exemplified most prominently by the International HapMap Project, is complicated by a longstanding, uncritical reliance on existing population categories in genetic research. Race and other pre-existing population definitions (ethnicity, religion, language, nationality, culture and so on) tend to be contentious concepts that have polarized discussions about the ethics and science of research into population-specific human genetic variation. By contrast, a broader consideration of the multiple historical sources of genetic variation provides a whole-genome perspective on the ways i n which existing population definitions do, and do not, account for how genetic variation is distributed among individuals. Although genetics will continue to rely on analytical tools that make use of particular population histories, it is important to interpret findings in a broader genomic context.

[The relationship between oral habits, oronasopharyngeal alterations, and malocclusion in preschool children in Vitória, Espírito Santo, Brazil]

The objective of this study was to estimate the prevalence of malocclusion and associated variables such as deleterious habits (DH) and oronasopharyngeal alterations (OA), mouth breathing, atypical phonation, and atypical swallowing in three-year-old children in Vitória, Espírito Santo State, Brazil. The sample included 291 children of both sexes enrolled in a Children's Educational Center and selected through probability sampling by conglomerates. Logistic regression indicated a high relative risk (RR) in children with altered overjet, open bite, and cross-bite to present mouth breathing (RR = 1.89; CI: 1.56-2.03), (RR = 2.46; CI: 2.00-3.02), (RR = 1.45; CI: 1.23-1.72); atypical swallowing (RR = 2.57; CI: 1.87-3.52), (RR = 3.49; CI: 2.53-4.81), (RR = 1.86; CI: 1.46-2.39); and atypical phonation (RR = 2.25; CI: 1.66-3.05), (RR = 3.18; CI: 2.38-4.25), (RR = 1.71; CI: 1.32-2.22), respectively. An association was shown between finger or pacifier sucking and altered overjet (p < 0.001), and between pacifier sucking and open bite (p < 0.001). Such results indicate that the prevalence of malocclusions is associated with DH and OA.

Interpretations of 'appropriate' minority inclusion in clinical research

The range of possible interpretations of the phrase "appropriate representation" has left investigators struggling with the practical application of the National Institutes of Health guidelines on the inclusion of minorities in research. At least three goals might be reached by including minorities in clinical research: to test specific hypotheses about differences by race and ethnicity; to generate hypotheses about possible differences by race and ethnicity; and to ensure the just distribution of the benefits and burdens of participation in research, regardless of whether there are expected differences in outcome by race or ethnicity. In this paper, we describe possible interpretations of "appropriate representation," as well as provide a general approach that investigators might use to address this issue. To expand scientific knowledge about the health of minority populations, investigators should be expected to state which goal they have selected and why that goal is appropriate as compared with other possible goals.

Racial meanings and scientific methods: changing policies for NIH-sponsored publications reporting human variation

Conventional wisdom holds that race is socially constructed and not based on genetic differences. Cutting-edge genetic research threatens this view and hence also endangers the pursuit of racial equality and useful public health research. The most recent incarnation of racial genetics is not due to scientific discoveries about population differences per se, but follows from how the United States and other governments have organized racial categories. This article explains tensions in U.S. government guidelines and publications on the study of human genetic diversity, points out the absence of any compelling public health benefits that might justify this research, introduces conceptual tools for addressing the complicated heuristic and policy problems posed by medical population genetics, and offers two policy proposals to remedy the current problems.

Smoking: what does culture have to do with it?

In this commentary issues are raised relating to the role of ethnicity and "culture" as a context influencing adolescent smoking. A processual rendering of culture is encouraged, as is an appreciation of intraethnic diversity. The question posed is "what is cultural about particular patterns, transitions and trajectories of smoking?" Productive ways of investigating patterns of smoking which attend to class, ethnicity, gender norms, modernity and popular culture are focused upon as an ongoing project subject to both the identity needs of youth and the agenda of the tobacco industry. Promising areas of research are identified, as are the potential contributions of ethnographies of tobacco use.

Perda dentária precoce em adultos de 35 a 44 anos de idade: estado de São Paulo, Brasil, 1998

Dados secundários de condições de saúde bucal em adultos de 35 a 44 anos de idade foram analisados a fim de estimar a prevalência da perda dentária precoce e do ataque de cárie dentária. Uma amostra não probabilística, de exames epidemiológicos provenientes de 5.777 professores e funcionários de escolas públicas e particulares, aleatoriamente selecionadas em 131 cidades do estado de São Paulo foi utilizada. Os critérios de observação do ataque de cárie recomendados pela Organização Mundial da Saúde (1997) foram empregados. O índice CPOD, correspondendo ao número de dentes permanentes cariados, perdidos e restaurados, e a proporção de adultos com ao menos 20 dentes funcionais foram analisados de acordo com o sexo, a idade, o grupo étnico, acesso à água de abastecimento fluoretada, tipo de escola: rural e urbana e o tamanho da população da cidade. O censo de 1991 - na época a mais recente fonte disponível - ofereceu informação de base municipal do perfil sócio-econômico. Análise espacial foi empregada para avaliar associação entre o perfil de saúde bucal e os indicadores sócio-econômicos. O ataque de cárie na amostra de adultos foi 22,39 (6,24). Perda dentária foi responsável pela metade do valor do ataque. Taxas crescentes de perda dentária precoce foram observadas para adultos mais velhos, negros, que trabalhavam em escolas rurais, em cidades pequenas e áreas não fluoretadas. Indicadores sócio-econômicos municipais mostraram correlação com a proporção de adultos com ao menos 20 dentes funcionais. Estes resultados podem auxiliar na formulação de políticas públicas dirigidas à promoção da saúde bucal.

Cancer-related health disparities in women

OBJECTIVES

This article synthesizes information about cancer in 9 populations of minority women: Mexican American, Puerto Rican, Cuban American, African American, Asian American, Native Hawaiian, American Samoan, American Indian, and Alaska Native.

METHODS

Cancer registry data, social indicators, government sources, and published articles were searched for information on the background and cancer experience of these 9 racial/ethnic groups.

RESULTS

Approximately 35 million women in these racial/ethnic groups live in the United States, and their numbers are increasing rapidly. Since 1992, incidence rates for major cancer sites have slowed or decreased among these groups, but declines in mortality have not occurred or have been smaller than for Whites. Gaps in early detection have narrowed, but minority women still lag behind Whites. Smoking and obesity remain common in these populations.

CONCLUSIONS

More culturally appropriate interventions and research are needed, and these efforts must involve the community and raise the quality of health services.

Prevalência de oclusopatia na dentição decídua e permanente de crianças na cidade de São Paulo, Brasil, 1996

O objetivo deste estudo foi estimar a prevalência de oclusopatia na dentição decídua e permanente de crianças de escolas públicas e privadas do Município de São Paulo, SP, Brasil, em 1996. A condição oclusal foi classificada em três categorias: normal, leve e moderada/severa conforme os critérios da Organização Mundial da Saúde. Os resultados referem-se a 985 exames em crianças de 5 e 12 anos de idade. A prevalência das oclusopatias foi alta, aumentando de 48,97 ± 4,53% na dentição decídua a 71,31 ± 3,95% na dentição permanente, sendo que a proporção de oclusopatia moderada/severa foi quase duas vezes maior na dentição permanente (OR = 1,87; IC95% = 1,43-2,45; p < 0,001). Quanto ao sexo e ao tipo de estabelecimento de ensino, não foram observadas diferenças estatisticamente significativas nas idades estudadas. Diferenças estatísticas associadas aos grupos étnicos denotam a complexidade e diversidade da oclusão na população e sugerem que estudos longitudinais devem ser realizados.

Variations in breast carcinoma treatment in older medicare beneficiaries: is it black or white

BACKGROUND

To evaluate associations between race and breast carcinoma treatment.

METHODS

Data from 984 black and 849 white Medicare beneficiaries 67 years or older with local breast carcinoma and a subset of 732 surviving women interviewed 3-4 years posttreatment were used to calculate adjusted odds of treatment, controlling for age, comorbidity, attitudes, region, and area measures of socioeconomic and health care resources.

RESULTS

Sixty-seven percent of women received a mastectomy and 33% received breast-conserving surgery. The odds of radiation omission were 48% higher (95% confidence interval [CI] 1.01-2.19) for blacks than for whites after considering covariates, but the absolute number of women who failed to receive this modality was small (11%). In race-stratified models, the odds of having radiation omitted were significantly higher among blacks living greater distances from a cancer center (vs. lesser) or living in areas with high poverty (vs. low), but these factors did not affect radiation use among whites. Among those interviewed, blacks reported perceiving more ageism and racism in the health care system than whites (P = 0.001). The independent odds of receiving mastectomy (vs. breast conservation and radiation) were 2.72 times higher (95% CI 1.25-5.92) among women reporting the highest quartile of perceived ageism scores, compared with the lowest, and higher perceived ageism tended to be associated with higher odds of radiation omission (P = 0.06).

CONCLUSIONS

Older black women with localized breast carcinoma may have a different experience obtaining treatment than their white counterparts. The absolute number of women receiving nonstandard care was small and the effects were small to moderate. However, if these patterns persist, it will be important to evaluate whether such experiences contribute to within-stage race mortality disparities.

Efficacy of systemic adjuvant therapy for breast cancer in African-American and Caucasian women

Observed variations in breast cancer survival by racial/ethnic background have been attributed to many factors, including differences in clinical and pathologic disease features at diagnosis and economic resource inequities that may affect treatment access and quality. In this report, we examine outcomes for African-American and Caucasian breast cancer patients participating in selected randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP) to determine whether prognosis or efficacy of systemic adjuvant therapy differed between these groups. Randomized clinical trials offer the advantages of a similar disease stage and a uniform treatment plan for all participants. Patients from four NSABP trials enrolling patients from 1982 through 1994 with axillary lymph node-negative disease (543 African-American and 7582 Caucasian) and three trials enrolling patients from 1984 through 1991 with axillary lymph node-positive disease (548 African-American and 4986 Caucasian) were included. Disease-free survival (DFS), which was defined as time on study free of breast cancer recurrence, second primary cancer, or death preceding these events, and survival risk ratios (RRs) with two-sided 95% confidence intervals (CIs) for African-Americans versus Caucasians were computed from Cox proportional hazards models that included relevant prognostic covariates. Treatment benefits for the therapies evaluated in these trials were estimated separately for African-Americans and for Caucasians. Among patients with lymph node-negative disease, African-Americans had similar DFS rates to Caucasians (African-American/Caucasian RR = 1.06, 95% CI = 0.92 to 1.23) but had modestly greater mortality rates (RR = 1.21, 95% CI = 1.01 to 1.46). Among lymph node-positive patients, DFS was similar (RR = 1.04, 95% CI = 0.93 to 1.17) and survival was again less favorable for African-Americans (RR = 1.18 95% CI = 1.03 to 1.34). Survival excluding deaths most likely attributable to causes other than cancer was similar between African-Americans and Caucasians (RR = 1.08 [95% CI = 0.88 to 1.33] for lymph node-negative patients and RR = 1.09 [95% CI = 0.96 to 1.25] for lymph node-positive patients). Among lymph node-negative and lymph node-positive patients, African-Americans and Caucasians realized comparable benefit from either the addition of chemotherapy or tamoxifen to surgery alone or the addition of chemotherapy to tamoxifen. In summary, African-American women and Caucasian women who were diagnosed at a comparable disease stage and were similarly treated tended to experience similar breast cancer prognosis. However, a mortality deficit persisted for African-American women relative to Caucasian women, which may be in part due to greater mortality from noncancer causes among African-Americans. Benefit from systemic adjuvant therapy for recurrence and mortality reduction was comparable between African-Americans and Caucasians. This study and investigations in other health-care settings suggest that African-American women and Caucasian women with breast cancer derive a similar benefit from systemic adjuvant therapy when it is administered in accordance with their clinical and pathologic disease presentation.

How sociodemographics, presence of oncology specialists, and hospital cancer programs affect accrual to cancer treatment trials

PURPOSE

We chose to examine the impact of socioeconomic factors on accrual to National Cancer Institute (NCI)-sponsored cancer treatment trials.

PATIENTS AND METHODS

We estimated the geographic and demographic cancer burden in the United States and then identified 24,332 patients accrued to NCI-sponsored cancer treatment trials during a 12-month period. Next, we examined accrual by age, sex, geographic residence, health insurance status, health maintenance organization market penetration, several proxy measures of socioeconomic status, the availability of an oncologist, and the presence of a hospital with an approved multidisciplinary cancer program.

RESULTS

Pediatric patients were accrued to clinical trials at high levels, whereas after adolescence, only a small percentage of cancer patients were enrolled onto clinical trials. There were few differences by sex. Black males as well as Asian-American and Hispanic adults were accrued to clinical trials at lower rates than white cancer patients of the same age. Overall, the highest observed accrual was in suburban counties. Compared with the United States population, patients enrolled onto clinical trials were significantly less likely to be uninsured and more like to have Medicare health insurance. Geographic areas with higher socioeconomic levels had higher levels of clinical trial accruals. The number of oncologists and the presence of approved cancer programs both were significantly associated with increased accrual to clinical trials.

CONCLUSION

We must work to increase the number of adults who enroll onto trials, especially among the elderly. Ongoing partnership with professional societies may be an effective approach to strengthen accrual to clinical trials.

Pharmacogenetics, race, and ethnicity: social identities and individualized medical care

Social categories such as race and ethnicity have long been used in interpreting patient symptoms, diagnosing disease, and predicting therapeutic response. DNA-based diagnostic tests and pharmacogenetic screens could make these uses of social categories largely irrelevant by allowing clinicians to base diagnosis and treatment decisions on the unique genetic features of individual patients. Despite this attractive vision of individualized care, however, social categories are likely to continue playing a significant role in the coming era of genetic medicine. Current uses of social categories in pharmacogenetic research, for example, illustrate how drug development and marketing will perpetuate the use of social categories such as race and ethnicity. Those uses may unintentionally blunt the precision of genetic technologies and pose new threats to socially identifiable populations. These implications suggest the need for greater caution in using social categories as indicators for specific tests or therapies and for federal legislation to protect against discriminatory uses of individuals' genetic information. In addition, more precise social classifications than those presently in use may allow us to realize the full potential of DNA-based technologies, thus minimizing social disparities in health care. Those more precise social classifications should reflect extended patient pedigrees and not the self-reported claims of racial and/or ethnic affiliation.

Racial disparity in survival of patients with squamous cell carcinoma of the oral cavity and pharynx

BACKGROUND

This study was designed to determine if race and age are independent prognostic factors for survival in patients treated for squamous cell carcinoma of the oral cavity and pharynx.

METHODS

Retrospective study.

RESULTS

Out of 909 patients registered, 815 (90%) were white and 94 (10%) were African-American. The median age was 60 years (range 19-93). The African-American patients had a significantly lower 5 year survival rate of 27.6% (95% CI 19.9-38.3) compared with white patients with a survival rate of 52.0% (95% CI 48.7-55.6) (P < 0.001). The greatest racial disparities in survival were observed in patients under 60 years of age [29.2% (95% CI 19.5-43.6) vs 60.9% (95% CI 56.3-66.0) for African-American and white patients, respectively, P < 0.001], and in African-American men compared with white men [20.2% (95% CI 12.6-30.2) vs 51.0% (95% CI 46.7-53.0), P < 0.001]. A multivariate Cox model, stratified according to stage of disease, indicated that race, age, and type of treatment were statistically significant predictors of survival. After adjusting for race and treatment received, African-American patients had a relative risk of dying of 1.61 (95% CI 1.23-2.10) compared with white patients. All patients 60 years of age and older had a higher risk of dying 1.59 (95% CI 1.31-1.92). Compared with surgical treatment alone, radiotherapy and other treatments were both associated with increased risk of dying with respective relative risks of 1.34 (95% CI 1.01-1.76) and 1.94 (95% CI 1.52-1.48).

CONCLUSIONS

African-American patients had poorer survival outcomes, with race and age emerging as significant independent predictors of survival after treatment for oral and pharyngeal cancer, compared with their white counterparts. Primary and secondary prevention programs that target younger patients at high risk might reduce environmental risk factors such as smoking and alcohol consumption, which may play a greater role in the acquired susceptibility for oral and pharyngeal cancer in African-American males.

Impact of race in lung cancer: analysis of temporal trends from a surveillance, epidemiology, and end results database

STUDY OBJECTIVES

We analyzed data from a community-based cancer database over a 26-year period in order to characterize clinicopathologic differences between black and white patients with lung cancer, and to identify relevant temporal trends in incidence and survival.

DESIGN, SETTING, AND PATIENTS

Data on demographics, stage, histology, and survival were obtained on all black and white patients with primary bronchogenic carcinoma registered in the community-based metropolitan Detroit Surveillance, Epidemiology, and End Results database from 1973 to 1998.

RESULTS

Of 48,318 eligible patients, 23% were black. Lung cancer incidence rates decreased for men of both races from 1985 to 1998, with a greater decline occurring in black men (p < 0.0001). Although incidence rates declined over time for men of both races < 50 years of age, this decrease was greater in white men, resulting in an increase in the racial differential in younger men. Temporal trends in incidence rates were similar for women of both races. The incidence of distant-stage disease was higher among blacks throughout the study period. The incidence of local-stage disease decreased for both races, though this decline was greater in blacks. A significant racial difference in 2-year and 5-year survival rates developed during the study period, due to a distinct lack of improvement in black patients. In a multivariate model, the relative risks of death for black patients, relative to white patients, were 1.24 (p < 0.0001) for local stage, 1.14 (p < 0.0001) for regional stage, and 1.03 (p = 0.045) for distant stage.

CONCLUSION

Significant racial differences exist in the incidence and survival rates for lung cancer in metropolitan Detroit. Since 1973, several disturbing trends have developed, particularly with regard to the lack of improvement in overall survival in black patients. Further study is required to determine the factors responsible for these temporal trends.