Addressing Cancer Disparities in Minority Communities: Hispanics/Latinos Marielos L. Vega, BSN, RN; Stanley H. Weiss, MD; Ping-Hsin Chen, PhD; Jeanne Ferrante, MD; Ana Natale- Pereira, MD, MPH; Sue Rovi, PhD; Steven K. Keller, PhD; Mark S. Johnson, MD, MPH UMDNJ-New Jersey Medical School Dept. Family Medicine, Dept. Preventive Medicine & Community Health/Epidemiology, and Dept. Internal Medicine Newark, NJ ********

Who are the Hispanics/Latinos? As of March 2004, there were 40.4 million (1 of 9) Hispanics in the civilian non-institutional population of the United States By 2050, the Hispanic population is projected to number around 100 MILLION or 25% of the population (1 of 4) Four major geographical areas: Spain, Central America/Mexico, South America, and the Caribbean basin (Cuba, Dominican Republic, and Puerto Rico) The 14.4% of the U.S. population that are Hispanics make up 30.4% of the nation's uninsured In 2000, the median age for Hispanics was 25.9 years [35.3 white] In 2000 Hispanic educational benchmarks: - high school graduate 57.0% [88.4%] - college graduate 10.6% [ 28.1%] - < 9 th grade school 27.3% [4.2%] Source: Current Population Survey, US Census gov, PGP-4

Regional Population Distribution by Hispanic Origin:2002 Northeast Midwest South West Source: Current Population Survey, March 2002, PGP-5 14% of NJ population [2004] Census Bureau's March 2004 and 2005 Current Population Survey 14% of US population [2004]

Undocumented Number of Hispanics  Really Bad news: Who will pay to screen/diagnose/treat the Undocumented? Hispanic/Latino(a)? Source: Pew Hispanic Center estimates based on March 2002, 2003, and 2004 Passel, Jeffrey S., Randolph Capps, and Michael E. Fix Undocumented Immigrants: Facts and Figures. Urban Institute Fact Sheet. Urban Institute: Washington, DC. January 12. Also,

Barriers to Healthcare Access Lack of insurance Low income Lack of transportation Under-representation in healthcare fields Cultural factors Language differences Source: Morales LS., et al., Socioeconomic, cultural, and behavioral factors affecting Hispanic health outcomes.Journal of Health Care for the Poor & Underserved. 13(4): , 2002 Nov.

Incidence & Mortality Rates* by Site and Hispanic Ethnicity, US, LungCRCBreastProstate Incidence* Males n/a140.0 Females n/a Mortality* Males n/a23.5 Females n/a Source: American Cancer Society, Surveillance Research, 2005 * Per 100,000, age-adjusted to the 2000 US standard population

Cancer and Hispanics Leading cancer sites for Hispanic are the same as those for Whites: prostate, breast, lung, and colon and rectum Incidence rates among Hispanics for each of these cancers are at least 30% lower than rates for Whites However, Hispanic are diagnosed at later stages due to lack of access to care and low participation in pre-screening prevention programs Source: American Cancer Society, Surveillance Research, 2005 Redes en Acción, The National Hispanic/Latino Cancer Network

Cancer and Hispanics [cont..] The incidence rate of stomach cancer [28.6 vs whites] and mortality [15.0 vs. 8.6 whites] is highest among Hispanics/Latinos The incidence rate of liver cancer [19.3 vs whites] and mortality [15.7 vs. 8.8 whites] is highest among Hispanics/Latinos The incidence rate of cervical cancer [16.2 vs. 8.9 whites] and mortality [3.6 vs. 2.6 whites] is highest in Hispanic/Latina women Source: American Cancer Society, Surveillance Research, 2005

Cancer and Hispanics [cont….] However, there is evidence that high variation exists among Hispanics subgroups in terms of: - demographics, - socioeconomic status, - behavioral risks (smoking, diet, obesity, physical activity, etc), - access to, and use of, health care services, and - health status Length of stay within the US, also had an impact in relative risk of death – Acculturation - 23% to 45% lower for Hispanics who lived in the US for less than 15 year Source: Morales LS., et al., Socioeconomic, cultural, and behavioral factors affecting Hispanic health outcomes.Journal of Health Care for the Poor & Underserved. 13(4): , 2002 Nov.

Cancer and Hispanics [cont….] Differences also exist among Hispanics born in the US vs. Hispanics who are foreign-born Data available regarding incidence, morbidity, and mortality by Hispanic subgroup is scarce and incomplete It has been assumed that all Hispanic have same cancer risk factors, morbidity, and experience similar barriers to access health care - 23 different countries

Progress in Hispanic Cancer Prevention and Control Initiatives YearInitiative 1987The NCI establishes the first Hispanic Cancer Control Program 1988Three working groups assess needs – Experts working with Cuban, Mexican, and Puerto Rican communities 1989 *RFA for Hispanic intervention research – 5 studies funded 1990National Hispanic Cancer Control Research Network established – Primary objective to increase the pool of Hispanic cancer research investigators 1991North American Conference on Cancer in Hispanics & Grantsmanship Workshop for Hispanic Investigators 1992*Quick Guide for the Preparation of Grant Applications & RFA for National Hispanic Leadership Initiative on Cancer (NHLIC) issued 1993Preliminary findings of Hispanic intervention research projects presented at APHA in special session 1994Grantsmanship Workshop for Hispanic Investigators & NHLIC preliminary findings presented at APHA in special session 1995Cancer Research in Hispanic Populations, NCI monograph published The National Latino Cancer Research Network En Acción (In Action) Amelie G. Ramirez, Dr.P.H., M.P.H Redes en Acción (Networks in Action) Amelie G. Ramirez, Dr.P.H., M.P.H Redes en Acción (Networks in Action): Community Networks Program (CNP) initiative Amelie G. Ramirez, Dr.P.H., M.P.H. Other regional networks have been established: 1). Latin American Cancer Research Coalition (Huerta, 2000 Washington area), 2). The Latino Research and Policy Center (Flores, 1997 Denver area),3). Latinos in a Network for Cancer Control (Fernandez, Texas)

Hispanic/Latino Cancer Initiatives : En Acción- Amelie G. Ramirez Dr.P.H., [NCI funded] initiated the first comprehensive assessment of cancer risk factors among the major populations of Hispanic/Latino men and women in the United States - Sites: Brooklyn, NY, Miami, FL, San Francisco, CA, San Diego, CA San Antonio, TX, and Brownsville, TX Program activities included: - Recruitment of 955 community networkes & 399 role models - Distributed 768,000 monthly newsletters a year community partnerships developed - Mass media outreach – 900 stories - Expanding our knowledge cancer risk factors in diverse Hispanic populations

Hispanic/Latino Cancer Initiatives : Redes En Acción: The National Latino Cancer Research Network - Amelie G. Ramirez Dr.P.H., [NCI] Core activities include: Promoting training and research opportunities for Latino students and researchers, Generating research projects on key Latino cancer issues, Supporting cancer awareness activities within the Latino community 3 New Jersey Pilot Projects Funded 3 New Jersey Pilot Projects Funded

New Jersey Initiatives Through Redes en Acción “Improving Cultural Competency in a Medical Residency Program” PI: Debbie Salas-Lopez, MD MPH Aims of Study To develop a cultural competency cancer education program for medical residents that will promote equities in health care for Latinos in Newark, NJ To demonstrate that a cultural competency cancer education program developed for internal medicine residents will: Increase their Latino patients’ completion rate of cancer screening examination; Result in higher levels of patient satisfaction; and Improve their attitudes and knowledge of cancer in Latinos.

New Jersey Initiatives Through Redes en Acción “ Improving Colorectal Cancer Screening among Hispanics/Latinos ” PI: Ana Natale-Pereira, MD MPH Aims of Study To determine the factors that influence colorectal cancer (CRC) screening among Hispanics/Latinos To design a culturally and linguistically appropriate CRC multi- component educational module To evaluate the effectiveness of the CRC educational module in increasing screening rates among Hispanic/Latinos

New Jersey Initiatives Through Redes en Acción “ Barriers to Colorectal Screening among Hispanics/Latinos ” PI: Mark S. Johnson, MD MPH Aims of Study To evaluate cultural and linguistic barriers to colorectal cancer screening among Hispanics/ Latinos To design a survey that will help to improve our understanding of CRC among Hispanic/Latinos To translate into Spanish and pilot test the reading level, cultural sensitivity, and acceptability of two FOBT kits

Other Programs Addressing Cancer among Hispanics/Latinos in New Jersey New Jersey Cancer Education and Early Detection Screening Program (NJCEED) funded by the CDC. Provides comprehensive screening services for breast, cervical, prostate, and CRC cancers for many uninsured and under-insured Hispanics/Latinos in NJ New Jersey Cancer Connect Trial in Spanish allows no- English users to search for cancer clinical trials throughout the state Evaluation of reading level and cultural sensitivity of cancer educational materials distributed by Health Departments in New Jersey

Conclusion Collaboration & partnerships with Hispanic community members and researchers at the local, regional, statewide, and national level is what will help advance our understanding of Cancer among Hispanics/Latinos Cancer screening and prevention programs will not be successful to reach Hispanics/Latinos unless they are cultural and linguistically sensitive to meet their needs