1. Cancer Disparities: Overview, Emerging Research Issues and Models in Prevention, Diagnosis, and Treatment Claudia R. Baquet, MD, MPH Associate Professor Epidemiology/Preventive Medicine Director Cancer Disparities Research University of Maryland School of Medicine and Greenebaum Cancer Center Chair, Maryland Subcommittee on Cancer Disparities November 2003

2. HHS Overarching Goal  Healthy People 2010 Overarching Goal:  Elimination of Health Disparities

3. Disparity Definition  Health Disparity Definition “…differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the United States. Research on health disparities related socioeconomic status is also encompassed in the definition.”* *NIH Strategic Plan to reduce and ultimately eliminate health disparities. October 6, 2000

4. Disparity Classifications  Racial/ethnic  Geographic: urban and rural  Gender  Age  Socioeconomic groups  Other

5. Health Disparities Research  Definition is evolving  Multidisciplinary  Covers the continuous spectrum of: characterization, explanation intervention translation and application policy formulation* * Baquet C, et al: JAAMP

6. Cancer Disparities  Known for decades  Rates: Incidence Mortality Survival Stage distribution  Contributing factors  Access to quality care and treatment  Access to pain management and palliative care

7. Major Cancer Disparities Affecting African Americans  Cancer Incidence, Mortality and Survival Rates Female breast Colon-Rectum Lung Prostate Other tobacco related cancers: cervical, esophagus, oral, pancreas, stomach Multiple myeloma  Pain Management and Palliative Care

8. Incidence and death rates for all cancer sites and races, 1996–2000. Hispanic is not mutually exclusive from whites, blacks, Asian/Pacific Islanders, and American Indians/Alaska Natives. Incidence data for Hispanics excludes cases from Detroit and Hawaii. Mortality data for Hispanics excludes cases from Connecticut, Oklahoma, New York, and New Hampshire. Rates are per 100 000 persons and are age-adjusted to the 2000 U.S. standard population 5-year age groups. Incidence data are from the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program for 12 geographic areas and cover 14% of the U.S. population. Death data are from the Centers for Disease Control and Prevention’s National Vital Statistics System and cover the entire U.S. population. Data are adapted from http://www.seer.cancer.gov/csr/1975_2000/.http://www.seer.cancer.gov/csr/1975_2000/ Cancer Incidence and Mortality Rates

9. Cancer Survival Rates for Blacks and Whites

10. Contributing Factors  Major risk factors/markers and exposures Tobacco Alcohol Occupation Diet and nutrition Socioeconomic status and environment

11. Contributing Factors (continued)  Delay in seeking diagnosis and treatment  Access and availability of quality prevention, screening and follow up services  Disparities in cancer treatment and end of life care  Biology and other emerging factors

12. Contributing Factors (continued)  Access, availability, use and delivery of quality prevention, screening and follow up services Inadequate or no health insurance Delay in diagnosis and treatment Treatment disparities SES Low participation rates in clinical trials

13. Barriers to Participation in Clinical Research and Trials  Patient  Community  Health Care Professionals  Investigator  Research Institution  Health System

14. University of Maryland Models To Eliminate Cancer Disparities  University of Maryland Statewide Health Network (CRF)  “Maryland Special Populations Cancer Research Network” (NCI 5UO1CA-08624904)  UMES-UMB Comprehensive Cancer Research Planning Grant (U 56: NCI)  Comprehensive Health Disparities Research, Training and Outreach Center (P 60: NIH)

15. UMSHN Overview  Mission: To reduce morbidity and death resulting from cancer and tobacco-related diseases and to reduce the disparity in cancer deaths attributable to racial/ethnic, cultural, geographic, or socioeconomic barriers.

16. UMSHN  The statute states that the Network will support a wide variety of prevention and control activities related to cancer and tobacco-related diseases, including: Activities aimed at increasing participation of diverse populations in clinical trials; Development of “Best Practices Models”; and Coordination among local hospitals, community clinics, physicians, and other health care providers.

17. UMSHN Goals  To expand the University of Maryland’s efforts related to screening, early detection, follow-up and prompt treatment, pain management and palliative care for patients in Maryland’s urban and rural underserved regions  To reduce morbidity and death resulting from cancer and tobacco-related diseases and to reduce the disparity in cancer deaths attributable to racial/ethnic, cultural, geographic, or socioeconomic barriers.

18. Targeted Cancers  Lung  Colorectal  Breast  Cervical  Prostate  Skin  Oral  Other Tobacco- Related Cancers

19. Specific Areas of Accomplishment  Infrastructure Development  Leveraging Resources  Partnerships: Local Hospitals, Community organizations, Faith Based, Local health departments, Schools  Telemedicine Linkages Grand Rounds, Tumor Boards, Clinical Trials, Consults Community education Planned home telehealth pilot project “Chronic disease management in Rural Maryland”  Intensive Clinical Trials Awareness and Education  Clinical trials infrastructure support for local hospitals  Field Outreach Projects  Professional Education  Baseline Health Behavior Needs Assessment

20. Telemedicine Linkages  UMSHN has established 17 telemedicine linkages throughout Maryland.  Linkages provide rapid access to UM clinical and research resources.  Faculty Telemedicine Projects in Radiation Oncology, Home telehealth pilot project, Psychiatry, and Ophthalmology. Increases access to clinical care for urban and rural remote regions.

21. University of Maryland Statewide Health Network Sites and Telemedicine/Videoconference Linkages Cecil Kent Queen Anne’s Talbot Dorchester Wicomico Somerset Worcester Car- oline Garrett AlleganyWashington Frederick Carroll Howard Montgomery Baltimore Balt. City Anne Arundel St. Mary’s Harford Prince George’s Charles Cal- vert Garrett AlleganyWashington Garrett AlleganyWashington Cecil Kent Queen Anne’s Talbot Dorchester Wicomico Somerset Worcester Car- oline Cecil Kent Queen Anne’s Talbot Dorchester Wicomico Somerset Worcester Caroline Frederick Carroll Howard Baltimore Balt. City Anne Arundel St. Mary’s Harford Prince George’s Charles Cal- vert Frederick Carroll Howard Baltimore Balt. City Anne Arundel St. Mary’s Harford Prince George’s Charles Calvert Montgomery Baltimore City Regional Office Area Served Baltimore City Western Maryland Regional Office Area Served Garrett County Allegany County Washington County Eastern Shore Regional Office Area Served Caroline, Cecil, Dorchester, Kent, Queen Anne’s, Somerset, Talbot, Wicomico, and Worcester Counties UMSHN Sites UMSHN Offices – 1.Central Office 2.Baltimore City Regional Office 3.Chester (ES Office) 4.Salisbury (ES Office 5.Hagerstown (WM Office) 6.LaVale (WM Office) 5. 3. Telemedicine/Videoconference Linkages (17) 1. 4. 6. 2. (3) (7) (1)

22. Program Implementation  Sponsors a wide range of community education programs.  Focus on prevention, screening, early detection, and treatment of cancer and other tobacco-related diseases.  Programs are conducted at UMSHN offices, community-based organizations, churches, schools, Head Start programs, youth programs, health fairs, and worksites.

23. UMSHN Expansion  Additional counties Charles, St.Mary’s, Calvert Prince Georges (P 60) Montgomery (P 60) Frederick (MSPN) Baltimore metro region

24. Maryland Special Populations Cancer Research Network (MSPN) One of 18 Special Populations Cancer Research Network grants in the Nation funded by NCI to address cancer disparities in minority and underserved communities by:  Promoting awareness of cancer and clinical trials;  Increasing the pool of researchers working to address and eliminate cancer disparities

25. Overall Goal: To promote cancer disparities research, cancer awareness for minority and medically underserved communities, and increased participation in clinical trials. MSPN -- Goal

26. MSPN -- Initiatives Intensive Outreach Efforts for Consumers:  Faith – Based Ministerial Alliance Against Cancer  Community-Based Lay health workers Health Fairs, community workshops Focus Groups  Media-Based Baltimore Times, Shore Times, “Right on Time” Weekly Live Radio Program

27. MSPN – Initiatives Intensive Efforts To Reach Health Care Providers:  Clinical Trials Education and Recruitment  Lecture Series on Clinical Trials and Cancer  Pilot Project Initiatives  Grant Writing Workshops (NIH)

28. Resources  University of Maryland Statewide Health Network (CRF) www.mdhealthnetwork.org  Maryland Special Populations Cancer Research Network (NCI) http://mspn.umaryland.edu  cbaquet@som.umaryland.edu