Racial/Ethnic Racial/Ethnic Disparities in Disparities in

Cancer Incidence, Cancer Incidence, Survival and Survival and TreatmentTreatmentLinda C. Harlan, PhD, MPHLinda C. Harlan, PhD, MPH

National Cancer InstituteNational Cancer InstituteDivision of Cancer Control and Division of Cancer Control and

Population SciencesPopulation Sciences

Disparities in CancerDisparities in Cancer

Age Age GenderGender Marital StatusMarital Status IncomeIncome EducationEducation InsuranceInsurance Health System CharacteristicsHealth System Characteristics Geographic Geographic Race/EthnicityRace/Ethnicity

Age-Adjusted US Mortality Rates Age-Adjusted US Mortality Rates for the Most Common Cancers by for the Most Common Cancers by

Race/Ethnicity for 2000-2003Race/Ethnicity for 2000-2003

0

10

20

30

40

50

60

70

Prostate Colorectal Lung Breast

pe

r/1

00

,00

0

NH White Hispanic Black A/PI

Source: US population NCHS

Racial/Ethnic Disparities Along Racial/Ethnic Disparities Along the Cancer Continuumthe Cancer Continuum

IncidenceIncidence ScreeningScreening Stage at DiagnosisStage at Diagnosis TherapyTherapy SurvivalSurvival

Age-Adjusted Incidence Rates for Age-Adjusted Incidence Rates for the Most Common Cancers by the Most Common Cancers by

Race/Ethnicity for Race/Ethnicity for 2000-20032000-2003

0

20

40

60

80

100

120

Prostate Colorectal Lung Breast

pe

r 1

00

,00

0

White Hispanic NH Black A/PI

Source: SEER

Percentage of Women Age 40 and Percentage of Women Age 40 and Older Reporting Having Older Reporting Having

Mammography in the Past Two Mammography in the Past Two YearsYears

0

10

20

30

40

50

60

70

80

1987 1992 1998 2000 2003 2005

Per

cent

NHWhite Hispanic NHBlack

Source: NCHS

Documented Time Elapsed Since Documented Time Elapsed Since Last Mammogram for Women Last Mammogram for Women

Age 40 and Older by Age 40 and Older by Racial/Ethnic Group*Racial/Ethnic Group*

0

10

20

30

40

50

60

1 2 3 4 First Never

Time Elapsed Since Last Mammogram in Years

Per

cent

NHWhite Hispanic NHBlack A/ PI

Source: Smith-Bindman, 2006

*Adjusted for age and registry

SEER DataSEER Data Population-Based RegistriesPopulation-Based Registries Register all cancer cases within a Register all cancer cases within a

geographic areas geographic areas 26% of the US population26% of the US population Detailed data on Detailed data on

DemographicsDemographics Tumor characteristic Tumor characteristic TreatmentTreatment Active follow-up of casesActive follow-up of cases

Public use files, available to researchersPublic use files, available to researchers Analysis program associated with dataAnalysis program associated with data

Stage at Diagnosis of In Situ and Stage at Diagnosis of In Situ and Invasive Breast Cancer by Invasive Breast Cancer by Race/Ethnicity for Cases Race/Ethnicity for Cases Diagnosed in 2000-2003Diagnosed in 2000-2003

0%

10%

20%

30%

40%

50%

60%

In situ Stage I Stage II Stage III Stage IV

NH White Hispanic NH Black A/PI

Source: SEER

5-year Cancer-Specific Survival by 5-year Cancer-Specific Survival by Race/Ethnicity and Stage for Invasive Breast Race/Ethnicity and Stage for Invasive Breast Cancer Patients Diagnosed Between 1990 -Cancer Patients Diagnosed Between 1990 -

20022002

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Stage I Stage II Stage III Stage IV

NH White Hispanic NH Black A/PI

Source: SEER

Percentage of Women Receiving Percentage of Women Receiving Radiation Following Breast Conserving Radiation Following Breast Conserving Surgery by Racial/Ethnicity and Year Surgery by Racial/Ethnicity and Year

of Diagnosisof Diagnosis

50%

55%

60%

65%

70%

75%

80%

00 01 02 03

Year of Diagnosis

NHwhite Hispanic NHblack A/PI

Tumor < 5cmSource: SEER

Percent of Breast Cancer Cases Percent of Breast Cancer Cases Receiving Radiation Following BCS by Receiving Radiation Following BCS by

Race/Ethnicity and County Family Race/Ethnicity and County Family Poverty Rate 2000-2003Poverty Rate 2000-2003

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-10% >10-20% >20%

NH White Hispanic NH Black A/PI

Source: SEER Families at or Below Poverty Level

Use of Adjuvant Chemo/Hormonal Use of Adjuvant Chemo/Hormonal Therapy for Early Stage, Node Therapy for Early Stage, Node

Negative Breast Cancer by Negative Breast Cancer by Race/Ethnicity, and ER status 2000Race/Ethnicity, and ER status 2000

01020

3040506070

8090

100

NH White Hispanic NH Black NH White Hispanic NH Black

Per

cent

Chemotherapy Both Tamoxifen

ER negative ER positiveSource: Harlanunpublished

Adjusted* Percentage of Patients Adjusted* Percentage of Patients Diagnosed 1995 through 1999 Receiving Guideline Diagnosed 1995 through 1999 Receiving Guideline

Therapy by Insurance Status and Race/EthnicityTherapy by Insurance Status and Race/Ethnicity

40

45

50

55

60

65

70

75

No Insurance Any Private Any Medicaid Medicare only

Per

cen

t

NH White Hispanic NH Black

*Charlson score, stage, number of positive lymph nodes, residency training program, hospital bed size, age, marital status, % high school diploma, gender, geographic region

Source: Harlan, 2005

SummarySummary

Racial/ethnic disparities occur across the Racial/ethnic disparities occur across the cancer continuumcancer continuum ScreeningScreening Stage at diagnosisStage at diagnosis TreatmentTreatment Survival Survival

Data SourcesData Sources Surveillance, Epidemiology and End-Results DataSurveillance, Epidemiology and End-Results Data

http://seer.cancer.gov/seerstat/http://seer.cancer.gov/seerstat/ Demographic, tumor characteristic, surgery and radiationDemographic, tumor characteristic, surgery and radiation Active follow-up for vital statusActive follow-up for vital status

SEER-Medicare linked fileSEER-Medicare linked file http://http://healthservices.cancer.gov/seermedicare/obtainhealthservices.cancer.gov/seermedicare/obtain// Cancer cases age 65+ and a 5% sample of non-cancer patientsCancer cases age 65+ and a 5% sample of non-cancer patients SEER data + SEER data + Treatment data, long-term medical follow-up, proceduresTreatment data, long-term medical follow-up, procedures

Breast Cancer Surveillance ConsortiumBreast Cancer Surveillance Consortium Mammography registries Mammography registries http://http://

breastscreening.cancer.gov/work/proposal_data.htmlbreastscreening.cancer.gov/work/proposal_data.html