Cancer Epidemiology in the United States: Racial, Social, and Economic Factors

  • Dana Sloane
Part of the Methods in Molecular Biology book series (MIMB, volume 471)


It is widely accepted that there is a differential burden of cancer in certain populations, including racial/ ethnic minorities, the medically underserved, and older adults. Differences in survival, stage at diagnosis, and risk of death have been identified in these populations for cancers of the lung, colon and rectum, prostate, and female breast. The factors that drive these disparities are not uniformly understood. Addressing the unique issue of racial differences in cancer epidemiology necessitates a discussion of the definitions of “race” and “ethniCity,” and an analysis of the validity of these concepts within the context of scientific study. Poor cancer-related health outcomes in groups of low socioeconomic status highlight issues of access to care and preventive care use. There is a scant amount of data on cancer in the elderly, and the special considerations that this group faces. A unique challenge facing cancer epidemiologists is suboptimal recruitment of members of these groups into clinical studies, which precludes a robust understanding of the existing disparities. It is critical to appreciate the overlap that exists between these populations, because this may complicate data interpretation. Legislative efforts that have, in part, been driven by the National Center on Minority Health and Health Disparities and by the Department of Health and Human Services, will continue to play an instrumental role in the identification and resolution of cancer disparities in these groups.

Key Words

Cancer disparity race ethnicity socioeconomic status elderly cancer survival stage at diagnosis cancer mortality 


  1. 1.
    Whaley AL. (2003) EthniCity/race, ethics and epidemiology. JNMA 95(8), 736– 742.Google Scholar
  2. 2.
    Smedley, A (ed.) (1999) R ace in North America: Origin and Evolution of a World-view, 2nd ed., Boulder, CO: Westview Press.Google Scholar
  3. 3.
    Smedley A, Smedley B. (2005) Race as biol ogy is fiction, racism as a social problem is real: anthropological and historical perspec tives on the social construction of race. Am Psych 60(1), 16–26.CrossRefGoogle Scholar
  4. 4.
    Williams DR. (1997) Race and health: basic questions, emerging directions. Ann Epidemiol 7(5), 322–333.CrossRefPubMedGoogle Scholar
  5. 5.
    Herman AA. (1996) Toward a conceptu alization of race in epidemiologic research. Ethn Dis 6, 7–20.PubMedGoogle Scholar
  6. 6.
    Bhopal R, Donaldson L. (1998) White, European, Western, Caucasian, or what? Inappropriate labeling in research on race, ethniCity, and health. Am J Public Health 88, 1303–1307.CrossRefPubMedGoogle Scholar
  7. 7.
    Fullilove MT. (1998) Comment: abandon ing “race” as a variable in public health research—an idea whose time has come. Am J Public Health 88(9), 1297–1298.CrossRefPubMedGoogle Scholar
  8. 8.
    U.S. Census Bureau. (2000) CensusScope. multiracial.html. Cited Jun 2007.
  9. 9.
    Hayes MA, Smedley BD (eds.) (1999) The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Medically Underserved. Washington, DC: National Academies Press.Google Scholar
  10. 10.
    Oppenheimer GM. (2001) Paradigm lost: race, ethniCity, and the search for a new population taxonomy. Am J Public Health 91, 1049–1055.CrossRefPubMedGoogle Scholar
  11. 11.
    Frost F, Taylor V, Fries E. (1992) Racial mis-classification of Native Americans in a surveil lance, epidemiology and end results cancer registry. J Nat Can Inst. 84(12), 957–62.CrossRefGoogle Scholar
  12. 12.
    Trans-HHS Cancer Health Disparities Progress Review Group (2004) Making Cancer Health Disparities History. Submit ted to the Secretary, U.S. Department of Health and Human Services, March 2004. Washington, DC: U.S. Department of Health and Human Services.Google Scholar
  13. 13.
    Thomson GE, Mitchell F, Williams M (eds.) (2006) Committee on the Review and Assessment of the NIH's Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities, Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business. Washington, DC: National Academies Press.Google Scholar
  14. 14.
    Krieger N. (2001) Theories for social epi demiology in the 21st century: an ecosocial perspective. Int J Epidemiol 30, 668–677.CrossRefPubMedGoogle Scholar
  15. 15.
    Vega J, Irwin A. (2004) Tackling health inequalities: new approaches in public policy. Bulletin of the World Health Organization, Geneva, Switzerland. http://www.who. int/bulletin. Cited Jun 2007.
  16. 16.
    Krieger N. (2005) Defining and investigating social disparities in cancer: critical issues. Cancer Causes Control 16(1), 5–14.CrossRefPubMedGoogle Scholar
  17. 17.
    Carter-Pokros O, Baquet C. (2002) What is a “health disparity”? Public Health Rep 117, 426–434.Google Scholar
  18. 18.
    Whitehead M. (1991) The concepts and principles of equity and health. Health Prom Int 6(3), 217–228.CrossRefGoogle Scholar
  19. 19.
    U.S. Census Bureau. (2000) The Hispanic population in the United States: 1999. Current Population Reports, Series P20-527. Washington, DC: U.S. Census Bureau ( p20-527.pdf). Cited Jul 2007.
  20. 20.
    Singh GK, Miller BA, Hankey BF, Edwards BK. (2003) Area Socioeconomic Varia tions in U.S. Cancer Incidence, Mortality, Stage, Treatment, and Survival, 1975– 1999. National Cancer Institute, Cancer Surveillance Monograph Series, Number 4. National Institutes of Health Publication No. 03–5417. Bethesda, MD: National Cancer Institute.Google Scholar
  21. 21.
    Miller B, Kolonel L, Bernstein L, et al. (eds.) (1996) Racial/Ethnic Patterns of Cancer in the United States 1988–1992. National Institutes of Health Publication No. 96–4104. Bethesda, MD: National Cancer Institute.Google Scholar
  22. 22.
    Wingo PA, Ries LA, Rosenberg HM, et al. (1998) Cancer incidence and mortality, 1973–1995: a report card for the U.S. Cancer 82, 1197–1207.CrossRefPubMedGoogle Scholar
  23. 23.
    Howe HL, Wu X, Ries LA. (2006) Annual report to the nation on the status of cancer, 1975–2003, featuring cancer among U.S. Hispanic/Latino populations. American Cancer Society. Published online September 2006 in Wiley InterScience ( Cited Jul 2007.
  24. 24.
    Piffath TA, Whiteman MK, Flaws JA, et al. (2001) Ethnic differences in cancer mortal ity trends in the U.S., 1950–1992. Ethn Health 6(2), 105–119.CrossRefPubMedGoogle Scholar
  25. 25.
    Landis SH, Murray T, Bolden S, et al. (2000) Cancer statistics, 2000. CA Cancer J Clin 50(1), 2398–2424.Google Scholar
  26. 26.
    Clegg LX, Li FP, et al. (2002) Cancer sur vival among US Whites and minorities. Arch Int Med 162, 1985–1993.CrossRefGoogle Scholar
  27. 27.
    Haddock RL, Naval CL. (1996) Cancer in Guam: a review of death certificates from 1971–1995. Pac Health Dial 4(1), 66–75.Google Scholar
  28. 28.
    Nasca PC, Pastides H (eds.) (2001) Funda mentals of Cancer Epidemiology. Sudbury, MA: Jones and Bartlett Publishers.Google Scholar
  29. 29.
    Ni H, Cohen R. (2002) Trends in health insurance coverage by race/ethniCity among persons under 65 years of age: United States, 1997–2001. National Center for Health Statistics Health E-Stats. http://www.cdc. gov/nchs/products/pubs/pubd/hestats/ healthinsur.htm. Cited Jul 2007.
  30. 30.
    Grann VR. (2003) Health insurance and can cer survival. Arch Int Med. 163, 2123–2124.CrossRefGoogle Scholar
  31. 31.
    Schwartz KL, Crossley-May H, Vigneau FD, et al. (2003) Race, socioeconomic status and stage at diagnosis for five common malignan cies. Cancer Causes Control 14, 761–766.CrossRefPubMedGoogle Scholar
  32. 32.
    Watlington AT, Byers T, Mouchawar J, et al. (2007) Does having insurance affect differences in clinical presentation between Hispanic and non-Hispanic white women with breast cancer? Cancer 109(10), 2093–2099.CrossRefPubMedGoogle Scholar
  33. 33.
    Du XL, Meyer TE, Franzini L. (2007) Meta-analysis of racial disparities in survival in association with socioeconomic status among men and women with colon cancer. Cancer 109, 2161–2170.CrossRefPubMedGoogle Scholar
  34. 34.
    Doubeni CA, Field RS, Buist DS, et al. (2007) Racial differences in tumor stage and survival for colorectal cancer in an insured population. Cancer 109, 612–620.CrossRefPubMedGoogle Scholar
  35. 35.
    Williams DR, Jackson PB. (2005) Social sources of racial disparities in health. Health Aff 24(2), 325–334.CrossRefGoogle Scholar
  36. 36.
    Roetzheim RG, Pal N, Tennant C, et al. (1999) Effects of health insurance and race on early detection of cancer. J Nat Canc Inst. 91(16), 1409–1415.CrossRefGoogle Scholar
  37. 37.
    Lantz PM, Mujahid M, Schwartz K, et al. (2006) The influence of race, ethniCity, and individual socioeconomic factors on breast cancer stage at diagnosis. Am J Public Health 96(12), 2173–2178.CrossRefPubMedGoogle Scholar
  38. 38.
    Hetzel L, Smith A (eds.) (2001) The 65 Years and Over Population: 2000. Report No. C2KBR/01–10. Economic and Statis tic Administration, Bureau of the Census. Washington, DC: U.S. Department of Commerce.Google Scholar
  39. 39.
    U.S. Census Bureau. (1993) We the Ameri can Elderly. Washington, DC: U.S. Depart ment of Commerce.Google Scholar
  40. 40.
    American Cancer Society. (2002) Cancer facts and figures. Washington, DC: American Cancer Society.Google Scholar
  41. 41.
    Best A, Hiatt RA, Cameron R, et al. (2003) The evolution of cancer control research: an international perspective from Canada and the United States. Cancer Epidemiol Biomark Prev 12, 705–712.Google Scholar
  42. 42.
    Thun EE, Jemal AM. (2006) Cancer epi demiology. In: Cancer Medicine, 7th ed. Kufe DW, Bast RC, Hait WN, et al. (eds.) London, UK: BC Decker, pp. 339–353.Google Scholar
  43. 43.
    Zahm SH, Pottern LM, Lewis DR, et al. (1994) Inclusion of women and minorities in occupational cancer epidemiology research. J Occ Med 36, 842–847.CrossRefGoogle Scholar
  44. 44.
    Henderson C. (1997) Meeting planned to encourage minority involvement in trials. Can Wkly Plus 2, 10.Google Scholar
  45. 45.
    Shavers VL, Lynch CF, Burmeister LF. (2002) Racial differences in factors that influence the willingness to participate in medical research studies. Ann Epidemiol 12, 248–256.CrossRefPubMedGoogle Scholar
  46. 46.
    Goldberg KB, Goldberg P (eds.) (1997) Minority accrual low in prevention trials: NCI plans programs to boost enrollment. Cancer Lett 22, 1–4.Google Scholar
  47. 47.
    Coleman EA, Tyll L, LaCroix AZ, et al. (1997) Recruiting African American older adults for a community health promotion intervention: which strategies are effective? Am J Prev Med 13(Suppl 6), 51–56.PubMedGoogle Scholar
  48. 48.
    Harris Y, Gorelick PB, Samuals P, et al. (1996) Why African Americans may not be participating in clinical trials. J Nat Med Assoc 88, 630–634.Google Scholar
  49. 49.
    Shavers-Hornaday VL, Lynch CF, Bur meister LF, et al. (1997) Why are African Americans under-represented in medical research studies? Impediments to participa tion. Ethn Health 2, 31–46.CrossRefPubMedGoogle Scholar
  50. 50.
    Brandon, D.T., L.A. Isaac, and T.A. LaVeist. (2005) The legacy of Tuskegee and trust in medical care: is Tuskegee responsible for race differences in mistrust of medical care? J Natl Med Assoc 97(7), 951–956.PubMedGoogle Scholar
  51. 51.
    Comis, R., et al. (2000) A Quantitative Survey of Public Attitudes Towards Can cer Clinical Trials. http://www.cancer Cited Mon 2008
  52. 52.
    Wendler, D., et al. (2006) Are racial and ethnic minorities less willing to participate in health research? Public Lib Sci Med 3(2), e19.Google Scholar
  53. 53.
    National Cancer Institute (2002). States That Require Health Plans to Cover Patient Care Costs in Clinical Trials. Cited Jun 2007.
  54. 54.
    Intercultural Cancer Council: Cancer Fact Sheets (2004) Cited Jul 2007.
  55. 55.
    Baquet CR, Horn JW, Gibbs T, et al. (1991) Socioeconomic factors and cancer incidence among blacks and whites. J Natl Can Inst 93, 551–557.CrossRefGoogle Scholar
  56. 56.
    Frank-Stromberg M, Olsen SJ (eds.) (2001) Cancer Prevention in Diverse Populations: Cultural Implications for the Multidiscipli nary Team, 2nd ed. Pittsburgh, PA: Oncology Nursing Society.Google Scholar
  57. 57.
    Brunner WF. (1915) The Negro health problem in southern cities. Am J Public Health 5(3), 183–190.CrossRefGoogle Scholar
  58. 58.
    Shavers VL, Shavers BS. (2006) Racism and health inequity among Americans. JNMA 98(3), 386–393.Google Scholar
  59. 59.
    Burhansstipanov L. (1996) Overcoming psycho-social barriers to Native American cancer screening research. In: Conferences Summary: Recruitment and Retention of Minority Participants in Clinical Cancer Research. National Cancer Advisory Board, National Cancer Institute. U.S. Depart ment of Health and Human Services. NIH 96-4182, pp. 109–127.Google Scholar
  60. 60.
    Borrayo EA, Lawsin C, Coit C. (2005) Latinas' appraisal of participation in breast cancer prevention clinical trials. Cancer Control 12(Suppl 2), 107–110.PubMedGoogle Scholar
  61. 61.
    Nguyen TT, Somkin CP, Ma Y. (2005) Participation of Asian-American women in cancer chemoprevention research: physi cian perspectives. Cancer 104(12 Suppl), 3006–3014.CrossRefPubMedGoogle Scholar
  62. 62.
    Giuliano AR, Mokuau N, Hughes C, et al. (2000) Participation of minorities in cancer research: the influence of structural, cultural, and linguistic factors. Ann Epidemiol 10(8) Suppl 1, S22–S34.CrossRefPubMedGoogle Scholar
  63. 63.
    National Cancer Institute Cancer Clinical Trials: The Basic Workbook. (2002) NIH Publication no. 02-5050. http://www. m.pdf. Bethesda, MD: National Institutes of Health. Cited Jul 2007.
  64. 64.
    Schenck AP, Klabunde CN, Davis WW. (2006) Racial differences in colorectal cancer test use by Medicare consumers. Am J Prev Med 30(4), 320–326.CrossRefPubMedGoogle Scholar
  65. 65.
    O'Malley AS, Forrest CB, Feng S, et al. (2005) Disparities despite coverage: gaps in colorectal cancer screening among Medi care beneficiaries. Arch Int Med. 165(18), 2129–2135.CrossRefGoogle Scholar
  66. 66.
    Burhansstipanov L, Olsen S. (2001) Cancer prevention and early detection in American Indian and Alaska Native populations. In: Cancer Prevention in Diverse Populations: Cultural Implications for the Multidiscipli nary Team, Frank-Stromborg M, Olsen SJ (eds.). St. Louis, MO: Mosby Publishers.Google Scholar
  67. 67.
    American College of Physicians—American Society of Internal Medicine. (2000) No health insurance? It's enough to make you sick. Latino community at great risk. Philadelphia: College of Physicians—American Society of Internal Medicine; White Paper. Philadelphia, PA: American College of Physicians—American Society of Internal Medicine.Google Scholar
  68. 68.
    Ponce NA, Hays RD, Cunningham WE. (2006) Linguistic disparities in health care access and health status among older adults. J Gen Int Med. 21(7), 786–791.CrossRefGoogle Scholar
  69. 69.
    Centers for Disease Control and Preven tion. (2000) National Center for Chronic Disease Prevention and Health Promo tion. Tobacco information and preven tion source (Tips)-Hispanics and tobacco. statistics/sgr/sgr_1998/sgr-min-hsp.htm. Cited July 2007.
  70. 70.
    U.S. Department of Health and Human Serv ices. (1998) Tobacco use among US racial/ ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispan ics: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.Google Scholar
  71. 71.
    Friedell G, Brown P. (2000) Report of the data working group meeting—issues for rural, poor White, medically underserved (Appalachian) populations. Intercultural Cancer Council Report, 26 Sep 2000.Google Scholar
  72. 72.
    Fernandez ME, DeBor M, Candreia MJ, et al. (1999) Evaluation of ENCOREplus. A community-based breast and cervical cancer screening program. Am J Prev Med 16(3 Suppl), 35–49.CrossRefPubMedGoogle Scholar
  73. 73.
    Tangka FK, Dalaker J, Chattopadhyay SK, et al. (2006) Meeting the mammography screening needs of underserved women: the performance of the National Breast and Cervical Cancer Early Detection Program in 2002–2003 (United States).Cancer Causes Control 17(9), 1145–1154.CrossRefPubMedGoogle Scholar
  74. 74.
    Ross JS, Bradley EH, Busch SH. (2006) Use of health care services by lower-income and higher-income uninsured adults. JAMA 295(17), 2027–2036.CrossRefPubMedGoogle Scholar
  75. 75.
    Rosenberg L, Wise LA, Palmer JR, et al. (2005) A multilevel study of socioeco nomic predictors of regular mammography use among African-American women. Cancer Epidemiol Biomark Prev 14(11 Pt 1), 2628–2633.CrossRefGoogle Scholar
  76. 76.
    McAlearney AS, Reeves KW, Tatum C, et al. (2005) Perceptions of insurance coverage for screening mammography among women in need of screening. Cancer 103, 2473–2480.CrossRefPubMedGoogle Scholar
  77. 77.
    Giacomini M, Miller F, O'Brien BJ. (2003) Economic considerations for health insur ance coverage of emerging genetic tests. Community Genet 6(2), 61–73.CrossRefPubMedGoogle Scholar
  78. 78.
    Hodgson, DC, Fuchs, CS, Ayanian, JZ. (2001) Impact of patient and provider char acteristics on the treatment and outcomes of colorectal cancer. J Natl Canc Inst 93(7), 501–515.CrossRefGoogle Scholar
  79. 79.
    Centers for Disease Control and Prevention. (2003) The National Breast and Cervical Cancer Early Detection Program: Reduc ing Mortality through Screening. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion.Google Scholar
  80. 80.
    Mandelblatt J, Gold K, O'Malley A, et al. (1999) Breast and cervix cancer screening among multiethnic women: role of age, health, and source of care. Prev Med 28, 418–425.CrossRefPubMedGoogle Scholar
  81. 81.
    Federal Interagency Forum on Aging-Related Statistics. (2000) Older Americans 2000: Key Indicators of Well-Being. Hyat tsville, MD: U.S. Government Printing Office.Google Scholar

Copyright information

© Humana Press a part of Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Dana Sloane
    • 1
  1. 1.Division of GastroenterologyWashington Hospital CenterWashingtonUSA

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