when reducing cancer risk in our population, let’s not exacerbate disparities

When reducing cancer risk in our population, let’s not exacerbate disparities

Graham A Colditz, MD DrPHNiess-Gain Professor

Department of SurgeryDivision of Public Health Sciences


Goals of talk§ Highlight how epidemiology and population

research can mistakenly leave gaps in knowledge § This can exacerbate disparities, or invent them§ Priority should be to refocus on prevention and

control research approaches to preempt worsening disparities and equitable access to prevention

§ Lets’ not make disparities while we focus on “incremental precision”


Know my background• Born Sydney, Australia• Came into the country in 1981• Have a convict in my family tree

But…• Australia has generated many public health and

prevention researchers, without known causal origin


Our findings suggest that false positivereports are an important and perhaps underappreciatedcomponent of the “genotype-positive–phenotype-negative” subgroup of tested persons.These findings show how health disparities mayarise from genomic misdiagnosis. Disparitiesmay result from errors that are related neither toaccess to care nor to posited “physiological differences”but, rather, to the historical dearth ofcontrol populations that include persons of diverseracial and ethnic backgrounds. NEJM Aug 16, 2016


Definition of precision medicineNIH:

“Precision medicine is an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.”

Personalized medicine à similar but need to be careful§ “Personalized” implies that treatments and preventions developed

uniquely for each individual

https://www.nih.gov/precision-medicine-initiative-cohort-program


All of UsPrecision Medicine Initiative (PMI)President Obama announced in January 2015 in State of the Union address$215 million in 2016

§ $130 million allocated to NIH to build cohort§ $70 million allocated to NCI to lead efforts in cancer genomics as part

of PMI for Oncology

Goal: to extend precision medicine to all diseases by building national research cohort of 1 million or more U.S. participants

https://www.nih.gov/precision-medicine-initiative-cohort-program


https://www.nih.gov/precision-medicine-initiative-cohort-program/infographics


Precision Medicine - Oncology• Initial: targeted therapy in late 90s, early 2000s• Not all individuals benefit equally from current cancer

prevention strategies§ Biologic differences in risk and response to preventive modality§ Response to environmental influences

Precision prevention = broader conceptual framework§ Involves use of biologic, behavioral, socioeconomic, and epidemiologic data to

devise and implement strategies tailored to reducing cancer incidence and mortality in a specific individual or group of individuals

• “Prevention is better than cure.”-Desiderius Erasmus (1466-1536)

http://cebp.aacrjournals.org/content/cebp/23/12/2713.full.pdfhttps://www.cancer.gov/news-events/cancer-currents-blog/2016/precision-prevention-chanock


Framework for precision prevention of cancer

Figure 1.http://cebp.aacrjournals.org/content/cebp/23/12/2713.full.pdf

Rebbeck CEBP 2014


Precision treatment vs. Precision preventionPrecision treatment = focus on treating existing disease

§ Most efficacious and least harmful pharmaceutical treatments to prevent relapse or death (e.g. cancer)

§ “Below the skin” à emphasizes the “what” more than the “how”

Precision prevention = tailoring behavioral interventions to individual’s characteristics

§ Overcome psychosocial barriers, emphasize achievable goals, adapt to families’ differing economic or cultural circumstances

§ “Above the skin” à emphasizes the “how” as much as the “what” or the “why”

Gillman and Hammondhttp://jamanetwork.com/journals/jamapediatrics/fullarticle/2472719


Disparities…


COLON CANCER


Mortality: maleCross over -Made an excess in blackmen


Mortality” femaleFrom equal morality delayin decline leads to blackexcess


Delivering evidence based care: CRC California

Integrated health system Non-integrated health system

Rhoads et al JCO 2015


Delivering evidence based care: CRC California

Integrated Non-integrate health system


But, treatment effectiveness can lead to disparitiesReview shows effective treatment can make disparities• See Tehranifar P à SEER 1995-99

http://cebp.aacrjournals.org/content/cebp/18/10/2701.full.pdf

• Define cancer as:§ Mostly amenable to treatment; § Partly, or § Non-amenable to treatment


SEER cancer specific survival by amenable to medical intervention

TehranifarCEBP 2009

1.05 (1.03-1.07

1.38 (1.34-1.41)

1.41 (1.37-1.46)


Access and treatment matter• Also note social support, income, and costs of

care each impact completion of therapy, bankruptcy, risk of death

Studies within the USA show that patients with cancer, especially those younger than 65 years without access to Medicare and social security protection, are more than twice as likely as their same-aged peers to file for bankruptcy.

§ See Ramsey Health Aff (Millwood) 2013; 32: 1143–52Colditz & Emmons Lancet 2016


Are the colorectal disparities due to incidence?


Incidence: Male Cross over of Black – White Incidence rates


Incidence: femaleSubstantial delay in declineIn ind=cidence


What is this Massachusetts drop?• Massachusetts colorectal cancer work group

formed in 1997§ Academic medical/public health centers§ State department of public health § ACS (New England Region)

• Undertook broad range of education and outreach to providers and the public to facilitate CRC screening in primary care


Siegel et al CEBP 2015


66.4%

2014

56.9%

Wyoming

76.5%

Massachusetts

Behavioral Risk Factor Surveillance System (BRFSS), Centers for Disease Control and Prevention, 2014. (Ages 50-75 met the USPSTF recommendation)

Colon Cancer ScreeningNational av. Lowest Highest


2008 – 2010 up to date CRC screening Missouri

Based on 37 counties in Missouri with at least 30 respondents


Example – HPV VaccineAccepted as precision medicine• Racial differences for completing vaccine series

§ In the U.S. in 2014, for girls age 13-17§ 70% of whites and Hispanics completed 3 doses§ 62% of blacks completed 3 doses

African American women are also more likely to be diagnosed with cervical cancer at later stages and die at almost twice the rate compared to non-Hispanic white women

Reagan-Steiner, S., Yankey, D., Jeyarajah, J., Elam-Evans, L. D., Singleton, J. A., Curtis, C. R., . . . & Stokley, S. (2015). National, regional, state, and selected local area vaccinationcoverage among adolescents aged 13-17 years–United States, 2014. MMWR Morb Mortal Wkly Rep, 64(29), 784-792.


HPV vaccination 2015 CDC data3 dose completion, 13-17 US pop percentage

Overall US population 70.3%At or above poverty 72.6%Below poverty 66.4%Black 64.6%White 71.5%Urban 74.2%Non metro 66.9%

2015 Adolescent HPV vaccination coverage dashboard, CDC


Other contributing factorsLow literacy levels

§ ↑ interest in receiving genomic info but ↓ intentions to change health habits as a result of genomic info

§ ↓ genetic knowledge but ↑ perceived importance of genetic info

§ ↓ awareness of family health history (FHH) and ↓ perceived importance of FHH but ↑ communication with doctor about FHH

Kaphingst, Kimberly A., et al. "Relationships between health literacy and genomics-related knowledge, self-efficacy, perceived importance, and communication in a medically underserved population." Journal of health communication 21.sup1 (2016): 58-68.

Kaphingst, Kimberly A., et al. "Effects of racial and ethnic group and health literacy on responses to genomic risk information in a medically underserved population." Health Psychology 34.2 (2015): 101.


What will we need to avoid exacerbating disparities?• Consider that race/ethnicity and health literacy

levels may affect responses to genomic risk info• Individual-level factors

§ Awareness, knowledge, attitudes, and beliefs§ Culture

• System-level factors§ Providers’ perceptions of genetic counseling and testing§ Healthcare system barriers (e.g. insurance barriers)§ Levels of trust in healthcare system

§ Generally low among minorities

Kaphingst, Kimberly A., and Melody S. Goodman. "Importance of race and ethnicity in individuals' use of and responses to genomic information." Personalized Medicine 13.1 (2016): 1-4.Kaphingst, Kimberly A., et al. "Effects of racial and ethnic group and health literacy on responses to genomic risk information in a medically underserved population." Health Psychology 34.2 (2015): 101.


Next step prioritiesAvoid inducing disparities

Build platform for effective implementation of precision prevention, if new indications and technologies arise.

Collaborate with diverse partners to improve communication and use of our findings.


SITEMAN CANCER CENTER


SITEMAN CANCER CENTER

DESCRIBE

SOLVE

CHANGE

Data: Record review of stage at diagnosisExcessbreastcancermortality

FQHCsengagedScreening/referralrevisedandimplemented

BreastcancermortalitydecreaseMammographyaccessimprovedNavigatornetworkestablished

Reducing Disparities PECaD at WUSTL: Breast Cancer

Significant increase in situ disease in AA women over decade 16% (2000) to 24%

(2013)4 deaths/100k Black

vs. 3 deaths/100k White

Stage IV diseasedecrease to 6% cases


SITEMAN CANCER CENTERPartnership with the St. Louis American –

Missouri’s largest African American newspaper with over 244,000 readers


SITEMAN CANCER CENTERRedPlum inserts providing cancer information

to over 124,000 household in high risks zip codes


SITEMAN CANCER CENTER10 week billboard campaign in high

risks targeted areas to increase cancer awareness -12 million impressions


SITEMAN CANCER CENTERPartnership with the St. Louis Public Libraries providing educational materials and DVDs on cancer prevention


SITEMAN CANCER CENTERCertificate Ceremony & Reception

Honoring our 45 community research fellow graduates

August 8, 2013 Eric P. Newman Education Center Auditorium


Addressing cancer health disparities

Cancer ContinuumPrevention DetectionDiagnosisTreatment

Survivorship

Access issues

Participation in research

Community Outreach & Training

Rural populations


Implementation Outcomes

FeasibilityFidelity

PenetrationAcceptabilitySustainability

UptakeCosts

*IOM Standards of Care

Conceptual Model for Implementation Research

What?

EvidenceBased Interventions

How?

ImplementationStrategies

Implementation Research Methods

ServiceOutcomes*

EfficiencySafety

EffectivenessEquity

Patient-centeredness

Timeliness

PopulationOutcomes

Health statusSymptomsFunction

Satisfaction

Proctor et al 2009 Admin. & Pol. in Mental Health Services

CONTEXT

CONTEXT

CO

NTE

XT

CO

NTE

XT


Key prevention questions:• Which lifestyle/system component to change?• At what age?• By how much?• For how long?• When will benefit be observed, and how long will

benefit last?• Will it reduce not exacerbate disparities?

See Colditz, Cancer Causes and Control 2010Colditz and Taylor, Ann Rev Public Health 2010


Cancer Prevention Gaps to Fill• Where do we strengthen science?• How do we sharpen focus: on

individual/community/broader public health programsHigh risk vs. population-wide programs

• Increase translation and delivery to all members of society

• Even when program implemented, research & implementation gaps remain to achieve full population coverage and health benefits


Conclusions…If we are to benefit as a nation from our investment in cancer research, it is imperative that we focus research on strategies to reduce variation in implementation of effective cancer prevention programs, in clinical and other settings that provide broad population reach, as well as through state and federal policy.

Emmons and Colditz 2017, in press


We have a great deal to learn from studying settings that have higher uptake and implementation of prevention-focused policies, and understanding the social, political and environmental factors that lead to increased implementation of evidence-based programs.

If our efforts to reduce the cancer burden are to go beyond rhetoric, they simply must address implementation factors that influence cancer disparities and have the biggest impact on populations carrying the largest cancer burden.

Emmons and Colditz 2017, in press


When we implement evidence-based prevention and screening programs correctly and at scale, we achieve substantial population benefits.

We can achieve reductions in the cancer burden right now by doing what we already know.

Our moonshot is right here—ready for the taking. Emmons and Colditz 2017, in press


QUESTIONS?

when reducing cancer risk in our population, let’s not exacerbate disparities

Health & Medicine