Keywords

Introduction

The second ASCL conference was held in February 2020, about 1 month after the first case of coronavirus disease 2019 (COVID-19) was documented in the United States and before evidence of community spread. Since then, COVID-19 has become a global pandemic that has disproportionately infected, hospitalized, and killed ethnic and racial minorities in the United States [1,2,3,4]. According to a report of provisional life expectancy estimates from the National Center for Health Statistics, the life expectancy for US Hispanics decreased 3 years (81.8–78.8) between 2019 and 2020. As a result, the life expectancy advantage held by Hispanics over non-Hispanic whites narrowed by 60%, suggesting poorer health and mortality outcomes for the US Hispanic population. It is estimated that 90% of this decline in the life expectancy gap is the result of mortality caused by COVID-19 [5]. Some speculate that this disease disparity exists because Hispanics and other underrepresented groups receive the greatest exposure to the virus. They are more likely to live in densely populated areas and multigenerational households; use public transportation; and have essential public-facing jobs in the service and healthcare sectors, where working from home is not an option [4, 6, 7]. If infected, they are also more likely to experience severe symptoms of COVID-19 because of comorbidities such as diabetes, obesity, cardiovascular disease, asthma, and other chronic conditions [6].

The pandemic’s disproportionate burden of disease on Hispanics and other vulnerable populations highlights health inequities in the United States, including cancer disparities. Worrisome effects of the pandemic have been delays along the cancer care continuum and increased barriers to healthcare access, which exacerbate disparities already experienced by Hispanics and other racial/ethnic groups. Early in the pandemic, the healthcare system was mobilized to care for the surge of COVID-19 patients and to prevent further spread of the disease. Non-urgent healthcare, including elective surgeries, preventive care, and cancer screening were postponed, and it is feared that delays in cancer screening will result in later-stage diagnosis and poorer outcome down the road [4]. Further, cancer patients already in treatment may have experienced less than optimal treatment because of delays in cancer surgery, chemotherapy, and radiation therapy [4, 7, 8].

Hispanic and other disparity populations are likely to experience additional pandemic-related delays in cancer screening, diagnosis, and treatment because of inequities in social determinants that create barriers to healthcare access. For example, the COVID-19 pandemic has caused economic hardship through the loss of employment and employer-based health insurance, leaving many under- and uninsured. The resulting lack of insurance and increased poverty may lead some to delay or forgo cancer care to pay for food or housing [4, 6, 7]. Secondly, health providers have turned to virtual care through telemedicine to minimize exposure to coronavirus; however, ethnic and racial barriers to the access of telemedicine put vulnerable disparity populations at risk of receiving interrupted care or of being lost to follow-up [4, 7, 9, 10]. A recent multicenter, prospective cohort study examined the effects of COVID-19 on the delivery of cancer care. While they found no significant changes in in-person visits by ethnicity or race, they found Hispanic (aOR 0.71; 95% CI, 0.51–0.98) and non-Hispanic black (aOR 0.69; 95% CI, 0.50–0.94) patients were less likely than other groups to use telemedicine during the pandemic [9]. Further, they found that Hispanic patients were more likely to experience treatment delays (aOR 1.53; 95% CI, 1.03–2.26) than non-Hispanic white patients.

The COVID-19 pandemic has worsened existing cancer disparities, so advancing the science of cancer in Latinos is now a tougher challenge. Going forward, how can we mitigate the detrimental effects of COVID-19 on cancer care? The most urgent needs are to address near-term consequences of the pandemic, such as postponements in screening and subsequent delays in diagnosis; delays and interruptions in treatment; loss to follow-up; financial hardship from job and insurance loss; and increased barriers to healthcare access. This will require redoubling outreach efforts and bolstering pre-pandemic community infrastructure and relationships, encouraging their continued partnerships with health providers, researchers, and healthcare systems (Chap. 15: Torrez-Ruiz et al.). While the pandemic’s mid- and long-term consequences on Latino cancer disparities are still unknown, future research should document and evaluate these changes as they unfold [11]. The next ASCL conference in 2022 will provide an opportunity for collaboration and identification of new research opportunities to address Latino cancer disparities in the face of the COVID-19 pandemic and beyond.

Vulnerable Populations and Health Threats in the Latino Community

One aim of the ASCL conference was to identify opportunities for future research that will advance the science of cancer in Latinos. The authors made recommendations in their papers that are excerpted and offered as a resource in this and the following two sections.

  • Investigate the adverse effects of treatment for acute lymphoblastic leukemia (ALL) in Latino children. CNS-directed ALL therapy causes acute and subacute neurotoxicity and may cause long-term neurocognitive impairment, profoundly affecting quality of life in survivors. Latino pediatric patients with ALL experience these neurotoxic events at a rate far exceeding their non-Latino counterparts, and yet current research on neurotoxicity of pediatric ALL therapy largely neglects Latino populations. There is a need for well-designed studies that account for factors linked to disparities in cognitive performance, such as SES, acculturation, inherited genetic variation, clinical characteristics, and sociocultural differences. The association between local Native American genetic ancestry and neurotoxic effects of methotrexate should be examined, and novel approaches such as admixture mapping could identify susceptibility loci responsible for ethnic disparities in the risk of neurotoxic effects of CNS-directed therapy. (Chap. 4: Brown et al.)

  • Revise the Patient Protection and Affordable Care Act (ACA) to be more inclusive of vulnerable Latino subgroups. The ACA has improved insurance coverage and primary healthcare access and utilization across all racial and ethnic groups in the United States. Disparities remain, however, especially for Latinos in states that have not expanded Medicaid; for Mexican and Central American subgroups; and for non-citizen and undocumented immigrants. Revisions in implementing the ACA must address these disparities and include non-citizens who have been in the country for less than 5 years and undocumented immigrants (Chap. 3: Ortega).

  • Implement food insecurity screening and prevention programs in community oncology practice. Cancer-related financial hardship and food insecurity disproportionately affects Hispanic cancer survivors, and thus there is a need for food insecurity screening and prevention programs in community oncology practice. Strategies to address food insecurity will benefit from community-based approaches that seek to understand the lived experience of food insecurity in Hispanic households. The strong relationship between food insecurity and access to cancer care points to the need for further research to address this social determinant of health and to achieve health equity (Chap. 11: McDougall et al.).

Disparities Research Along the Cancer Control Continuum

Cancer Prevention and Screening

  • Develop behavioral cancer interventions that capitalize on the strengths of Latinx culture. US Latinos overall have a lower cancer burden than other groups; however, as Latinos become acculturated to the United States, their health behavior changes and their risk for cancer rises. Studying the cultural and behavioral patterns of recent immigrants may help identify protective behavioral practices and explain the better-than-expected health outcomes in this community. The negative change in cancer risk associated with acculturation might be mitigated by promoting healthy protective behaviors through culturally appropriate interventions that leverage aspects of Latino culture, such as collectivism, personalismo, and familismo. Research studies should integrate cultural beliefs and values to increase relevancy for Latino participants and contribute to compliance and long-term participation for improved population health (Chap. 15: Torrez-Ruiz et al.).

  • To eliminate cervical cancer, promote three existing and effective tools—HPV vaccination, Pap smear screening, and timely treatment for abnormal cervical dysplasia. Most cancers caused by HPV (cervical, vulvar, vaginal, anal, oropharyngeal, and penile) can be prevented with these three existing tools. Even though cervical cancer incidence has declined in the United States since 1975, Hispanic women continue to have significantly higher rates of cervical cancer than non-Hispanic white and black women. The fastest way to achieve the goal of cervical cancer elimination is to screen at least 93% of age-eligible women. Only 80% now follow this recommendation, with lower percentages among Hispanic women (70–78%). Health providers must deliver strong and linguistically/culturally relevant recommendations for both HPV vaccination and cancer screening and ensure that those who are diagnosed with precancerous lesions are actually treated (Chap. 17: Giuliano).

Cancer Treatment

  • Identify and assess determinants of delays in breast cancer treatment among ethnic and racial populations. Breast cancer incidence among Hispanic women is lower than non-Hispanic white women, but Hispanic women are more likely to be diagnosed with more aggressive disease and to experience treatment delays that contribute to worse outcome. Disparities in social determinants contribute to this outcome disparity; therefore, to improve cancer care delivery and long-term breast cancer outcomes, we must expand culturally effective health education programs and social assistance alongside research of biological differences in Hispanic tumor characteristics. Future research should focus on expanding breast cancer patient narratives to enrich qualitative understanding of treatment delays among racial and ethnic populations to develop a culturally effective framework for reducing health disparities (Chap. 6: Malinowski and Chavez Mac Gregor).

Genetic Ancestry and Precision Medicine Approaches

  • Improve understanding of subtype-specific breast cancer risk in admixed minority populations. Hispanic women have a higher risk than non-Hispanic white women of developing ER–/PR– HER2+ and ER–/PR– HER2– breast cancer—intrinsic subtypes that have fewer treatment options and poorer prognosis than others. Research suggests there are associations between degree of Indigenous American ancestry and HER2+ tumors and between degree of African Ancestry and ER– tumors. Only a few breast cancer studies have analyzed the correlation between individual genetic ancestry proportion and tumor subtype in Hispanics. Thus, further studies are needed to find more precise tumor subtype-specific risk assessment, treatment efficacy, and outcome prognosis in US Hispanics/Latinas and Latin American women (Chap. 7: Tamayo et al.).

  • Develop novel risk-stratification strategies and targeted therapies for lung cancer that consider genetic admixture and health disparities among Latin(x) populations. Genetic admixture creates a broad spectrum of lung cancer susceptibility among Latin(x) subgroups, and a large component of African ancestry is associated with worse clinical outcome. Targeted approaches must consider these differences in susceptibility to increase the number of lung cancer patients who may benefit from precision therapies. Lung cancer in all racial/ethnic groups is often diagnosed too late for curative surgical intervention; thus, there is a need for precise identification of individuals who are at risk for lung malignancy, such as those with chronic obstructive pulmonary disease. Development of non-invasive, early biomarkers of lung cancer is also needed, as is research to uncover molecular pathways of malignant conversion that can be targeted for therapeutic intervention (Chap. 8: Ramos, Guerra, and El-Zein).

Outcomes and Survivorship

  • Investigate how genetic ancestry, obesity phenotypes, and related comorbidities affect aggressive breast cancer presentation, treatment, and survivorship by race/ethnicity. Hispanics are a genetically admixed population with European, Indigenous American, and African ancestry, and there is a need to collect data on Hispanic breast cancer survivors to determine if the way breast cancer affects patient-reported outcomes and prognosis differs by Hispanic subgroup. Among Hispanic and black populations, genetic ancestry has been correlated with adiposity and obesity-related physiologic measurements (e.g., BMI and waist-to-hip ratio) and comorbidities (e.g., diabetes and hypertension). Hispanic breast cancer survivors are a growing and vulnerable population; to address their needs, we must have a better understanding of the complex interactions between race/ethnicity, culture, and ancestry (Chap. 14: Bandera, Hong and Qin).

  • Address the unique supportive-care needs of Hispanic men cancer survivors. Hispanic men not only experience disproportionate cancer disparities, but they also have unique supportive care needs as cancer survivors. To reduce their illness burden, researchers should develop culturally competent care delivery; transcreate existing interventions that engage and meet psychosocial needs; and disseminate research findings to the Latino community, providing health information to survivors and their families. Further, new interventions should build on the strengths of the Latino community and help survivors connect with one another, relieving the burden of isolation frequently experienced by this population (Chap. 5: Martinez Tyson and Ruiz).

  • Develop and assess e-health interventions tailored for Hispanic breast cancer survivors. Hispanic breast cancer survivors experience worse health-related quality of life (HRQOL) and symptom burden than non-Hispanics, and their highest expressed unmet needs exist in the psychosocial domain. E-health interventions such as smartphone applications can deliver accessible, culturally tailored psychosocial interventions that may improve patient engagement and patient-reported outcomes. Future studies should include a social networking component to fulfill the desire for social support and should integrate evidence-based, patient-centered tools into electronic health records. Given the multiple components of psychosocial interventions, the effect of each component should be separately evaluated to identify the most effective elements on study outcomes (Chap. 13: Baik et al.).

Cross-Cutting Research and the Future of Cancer Care

  • Engage the Latino community in cancer research. The lack of Latinos and other racial/ethnic groups in clinical trials hinders the development of precision medicine that can benefit these vulnerable populations. There is thus a need to optimize Latino participation in research so that researchers can develop tailored therapeutics and deliver more effective public health educational interventions. One recommendation is to use community-based participatory research approaches in designing studies to optimize Latino participation and retention. Recommended communication strategies are to: (1) transfer knowledge to the community in a timely way with messages designed for different levels of acculturation and language preference; (2) deliver information using preferred social media platforms, Spanish language TV, and radio; and (3) include traditional written formats and interpersonal communication, which work well in the Latino community. To engage stakeholders in responsive communication and consultation efforts, researchers can develop community advisory boards, patient advocates, and citizen scientists. They can also widen the net of partners by collaborating and developing coalitions with community opinion leaders (Chap. 9: Baezconde-Garbanati et al.).

  • Make clinical trials more inclusive to overcome research disparities. Clinical research should reflect demography to capture differences among underrepresented populations, making personalized healthcare available to everyone. Hispanics are underrepresented in clinical trials, so many Hispanic communities do not have equal opportunities to access investigational medicines and contribute to medical progress. Strategic priorities for the biotechnology industry are to develop more inclusive practices, increasing the amount of genomic data and scientific insights from underrepresented populations. Improving health outcomes for vulnerable communities must be a coordinated effort; the entire healthcare ecosystem must work together to increase participation of underrepresented groups in clinical trials, improve patient access to clinical research, elevate patient-centric development, and enrich the quality of clinical information available in the development of personalized healthcare (Chap. 16: Gonzales).

  • Use an exposome-wide approach to study Latino cancer disparities. The underlying causes of Latino cancer disparities are varied and complex, and conducting exposome-wide association studies can provide the conceptual framework to help explain the role of multiple environmental exposures in the etiology and progression of cancer among Latinos. Further, much remains unknown about how social determinants in the Latino community actually cause cancer and lead to disparate outcomes; the exposome can be a model for understanding the biological mechanisms and pathways through which non-chemical stressors, such as social factors, can lead to cancer. Using prognostic and diagnostic biomarkers based on “omics” technologies holds the promise of linking measured environmental exposures to biochemical and molecular changes. Also, much of cancer disparities research does not account for subgroup heterogeneity among Latinos; an added advantage to the trans-omics approach is that it has the potential to yield robust information addressing variation among this genetically admixed group (Chap. 2: Juarez et al.).

  • Use implementation science to bridge the research to practice gap. Translating recent research evidence into adopted medical practice often takes too long, especially for Latino populations. To ensure that new cancer discoveries reduce the cancer burden for Latinos, researchers must focus not only on what evidence-based interventions improve outcomes but also on how those interventions can be adopted, implemented, and sustained. To ensure that new and effective evidence-based interventions can be adopted, researchers should: (1) determine whether the intervention is feasible for the relevant populations; (2) train practitioners to deliver the intervention; (3) provide support and technical help to trained practitioners to offer the intervention through their routine practice; and (4) ensure the intervention can potentially reach any patient who could benefit (Chap. 12: Neta).

  • Revise public healthcare policy to reflect the predicted shift in the demography of cancer resulting from Latino population growth. Latinos account for the majority of growth in the United States today and will in the coming decades. Even though Latinos have lower age-adjusted cancer incidence and death rates than other groups, their disproportionate growth is likely to contribute to the shifting demography of cancer and have implications for public policy. Because of the growing presence of Latinos, cancer researchers and healthcare providers must better understand the diversity that characterizes this population. It is also expected that inequities in access to affordable healthcare and lack of health insurance will increase the risk of Latinos having cancer and of dying from the disease. Finally, public policy that discourages migration from Mexico to the United States could erode Latino morbidity and mortality advantages that have existed for decades (Chap. 10: Sáenz).

Conclusion

The second ASCL conference brought together over 250 participants from 25 states and Puerto Rico to collaborate on the science of Latino cancer disparities. The papers published in this volume showcase the breadth of topics presented and describe research dedicated to improve the understanding of cancer in the Latino population. Recommendations from the conference participants provide direction for future research that will advance science and eventually save lives. Given the scope and urgency of the problem, we must work together throughout the cancer continuum to reach populations with needed screening, treatment, and improved quality of life for cancer survivors to improve long-standing inequities and reduce the cancer burden among Latinos.