Janice A. Chilton

Between and Within: International Perspectives on Cancer and Health Disparities

The purpose of this article is to compare reasons for cancer health disparities in developing and developed countries. By 2010, approximately 60% of new cancer cases will occur in the developing world, higher than rates developed countries. However, disparities exist not only between countries but also within countries. Cancer epidemiology in developing countries is paradoxical: Increased incidence is partially due to increased development resulting in longer life expectancy and unhealthy lifestyle behaviors. Reduced mortality from infectious diseases results in relatively greater mortality from chronic diseases. However, infectious diseases are also risk factors for the leading causes of cancer mortality in these countries. While health disparities in developing versus developed countries are quantitatively worlds apart, they are qualitatively rather similar. They share common causes, such as environmental pollution, the need for social justice, large gaps between the rich and the poor, lack of access to cancer resources, and health services that are available to some but not to all. While industrialization and urbanization elevate a countrys economic base while contributing to cancer incidence and mortality. Strategies to reduce international cancer disparities include country- and regional-level interventions, utilizing nongovernmental organizations, and developing long-term inter-institutional partnerships. Although economic aid is undoubtedly necessary, it is not sufficient to control cancer in the developing world. To address these problems, it will be necessary to focus attention on what can be done locally-within countries, not only between countries.

Declines in sex ratio at birth and fetal deaths in Japan, and in U.S. whites but not African Americans

Background The expected ratio of male to female births is generally believed to be 1.05, also described as the male proportion of 0.515. Objectives We describe trends in sex ratio at birth and in fetal deaths in the United States, in African Americans and in whites, and in Japan, two industrial countries with well-characterized health data infrastructures, and we speculate about possible explanations. Methods Public health records from national statistical agencies were assembled to create information on sex ratio at birth and in fetal deaths in the United States (1970–2002) and Japan (1970–1999), using SPSS. Results Sex ratio at birth has declined significantly in Japan and in U.S. whites, but not for African Americans, for whom sex ratio remains significantly lower than that of whites. The male proportion of fetal death has increased overall in Japan and in the United States. Conclusions Sex ratio declines are equivalent to a shift from male to female births of 135,000 white males in the United States and 127,000 males in Japan. Known and hypothesized risk factors for reduced sex ratio at birth and in fetal deaths cannot account fully for recent trends or racial or national differences. Whether avoidable environmental or other factors—such as widespread exposure to metalloestrogens or other known or suspected endocrine-disrupting materials, changes in parental age, obesity, assisted reproduction, or nutrition—may account for some of these patterns is a matter that merits serious concern.

Young Asian Americans' knowledge and perceptions of cervical cancer and the human papillomavirus.

Cervical cancer is a major health disparity among Asian Americans, with cervical cancer rates of Vietnamese women being significantly higher than for the general US female population and low screening rates reported for Asian American females. Focus groups and interviews were conducted with young Vietnamese, Filipino, and Korean adults (ages 18–29) to collect information on knowledge, perceptions and sources of information regarding cervical cancer, Pap tests and the human papillomavirus. 16 Korean, 18 Vietnamese, and 18 Filipino (50% female) adults participated in the study. Many participants had never heard of HPV, cervical cancer and Pap testing. Cervical cancer screening rates were low for Korean and Vietnamese females and were influenced by moral beliefs and lack of awareness. Culturally relevant education materials that consider specific Asian ethnicity and language are needed to increase awareness of cervical cancer, Pap testing, and HPV among Asian American young adults

Impact of Breast Cancer on African American Women: Priority Areas for Research in the Next Decade

Despite all the gains that have been made in the area of breast cancer research, African American women suffer disproportionately from the effects of the disease. Breast cancer is the second leading cause of cancer death among African American women, exceeded only by lung cancer. Improvements in cancer incidence, mortality, and survival rates among populations are undoubtedly the outcome of quality research. Therefore, there is a need to identify and discuss issues regarding breast cancer among African American women and to determine whether these issues should be a part of the nations breast cancer research agenda. This commentary summarizes the results of the Summit Meeting Evaluating Research on Breast Cancer in African American Women, which was held September 8-11, 2000, in Washington, DC. Listed are priority areas and some of the questions that fueled this 2-day discussion among 130 participants, including health advocates, cancer survivors, and experts representing various areas of cancer research.

Increase in cruciferous vegetable intake in women previously treated for breast cancer participating in a dietary intervention trial.

Abstract Consumption of cruciferous vegetables has been associated with reduced breast cancer risk mechanistically and in population-based studies, although evidence has been inconsistent. This inconsistency may be related to limitations in quantifying and qualifying cruciferous vegetable exposure using standard instruments for dietary assessment (for example, food-frequency questionnaires, FFQs) or due to low levels of intake demonstrated among U.S. population samples. Cruciferous vegetable intake data are presented from a longitudinal study of a high-vegetable dietary intervention to reduce breast cancer recurrence among breast cancer survivors (n = 1,156; 536 intervention and 620 comparison group subjects). Intake was assessed using repeat administration of an FFQ and cross-sectional administration of a cruciferous vegetable–specific FFQ (CVFFQ). Mean intake in the intervention group assessed using the standard FFQ was 37.7 g/day at baseline and increased to 57.1 g/day at 12 mo (P = 0.0001) and was sustained through 48 mo. Broccoli and cabbage were the most commonly consumed cruciferous vegetables, regardless of the instrument used to assess intake. Differences in intake by group assignment were shown for raw cruciferous vegetables (30.2 g/day vs. 24.6 g/day, assessed using the CVFFQ), suggesting increased exposure to biologically active, cancer-preventive food constituents. These data suggest that this study population will be the first U.S. population sample to provide ample quantity and variety in cruciferous intake to examine whether these vegetables are protective against breast cancer recurrence.

Addressing cancer health disparities using a global biopsychosocial approach.

The Center for Research on Minority Health has translated the biopsychosocial framework to address global cancer health disparities through the integration of biological (eg, endogenous steroids, genetic susceptibility, and pesticide levels) and behavioral (eg, dietary interventions) determinants, along with community‐based research (eg, comprehensive involvement of community advisory boards) and educational approaches (eg, kindergarten through postgraduate training). Evidence of successful implementation of this framework includes health disparities training for >2000 individuals ranging from elementary to the postgraduate level, and conducting transdisciplinary projects that incorporate traditional and nontraditional health professionals to examine associations between biological and nonbiological determinants of health. Examples and recommendations for implementation of the biopsychosocial approach as it applies to cancer health disparities research are described. Cancer 2010.

On the importance of using multiple methods of dietary assessment.

Background: Plasma carotenoid concentrations reflect intake of vegetables and fruits, the major food sources of these compounds. This study compared the ability of 2 measures of dietary intake (24-hour diet recalls and food frequency questionnaires [FFQs]) to corroborate plasma carotenoid concentrations in a subset of women participating in a diet intervention trial. Methods: Plasma carotenoid concentrations and dietary intakes, estimated from 24-hour diet recalls and FFQs, were examined at baseline and 1 year later in a subset of 395 study participants (197 intervention and 198 comparison group). We used longitudinal models to examine associations between estimated intakes and plasma carotenoid concentrations. These analyses were stratified by study group and adjusted for body mass index (BMI), plasma cholesterol concentration, and total energy intake. We conducted simulations to compare mean-squared errors of prediction of each assessment method. Results: In mixed-effects models, the estimated carotenoid intakes from both dietary assessment methods were strongly associated with plasma concentrations of α-carotene, β-carotene, and lutein. Furthermore, modeling the 2 sources of intake information as joint predictors reduced the prediction error. Conclusion: These findings underscore the importance of using multiple measures of dietary assessment in studies examining diet–disease associations.

Circle of sisters: Raising awareness of native American women to breast cancer

The Circle of Sisters is a breast cancer education initiative that incorporates free mammography for American Indian women. In two separate but similar initiative-sponsored one-day events, 37 American Indian women underwent screening mammography and experienced a full day of culturally tailored educational activities. Women observed a cooking demonstration, participated in moderate exercise activity, strung beads to learn about the dimensions of breast tumors, and listened to an American Indian breast cancer survivor recount her story of diagnosis and treatment. Significant shifts in opinion included an increase in the understanding that a woman’s chances of being diagnosed with breast cancer increase with age (p=.015) and with never bearing children (p <.001) and that breast cancer can be detected early (p=.043). The percentage of those expressing an intention to get a mammogram every year grew from 81.1% to 94.6%.

Ambivalence: A Key to Clinical Trial Participation?

Trust exerts a multidimensional influence at the interpersonal level in the clinical trials setting. Trust and distrust are dynamic states that are impacted, either positively or negatively, with each participant-clinical trials team interaction. Currently, accepted models of trust posit that trust and distrust coexist and their effects on engagement and retention in clinical trials are mediated by ambivalence. While understanding of trust has been informed by a robust body of work, the role of distrust and ambivalence in the trust building process are less well understood. Furthermore, the role of ambivalence and its relationship to trust and distrust in the clinical trials and oncology settings are not known. Ambivalence is a normal and uncomfortable state in the complex decision making process that characterizes the recruitment and active treatment phases of the clinical trials experience. The current review was conducted to understand the constructs of ambivalence as a mediator of trust and distrust among vulnerable, minority participants through different stages of the oncology clinical trials continuum, its triggers and the contextual factors that might influence it in the setting of minority participation in oncology clinical trials. In addition, the researchers have sought to link theory to clinical intervention by investigating the feasibility and role of Motivational Interviewing in different stages of the clinical trials continuum. Findings suggest that ambivalence can be processed and managed to enable a participant to generate a response to their ambivalence. Thus, recognizing and managing triggers of ambivalence, which include, contradictory goals, role conflicts, membership dualities, and supporting participants through the process of reducing ambivalence is critical to successfully managing trust. Contextual factors related to the totality of ones previous health-care experience, specifically among the marginalized or vulnerable, can contribute to interpersonal ambivalence. In addition, changes in information gathering as a moderator of interpersonal ambivalence may have enormous implications for gathering, assessing, and accepting health information. Finally, motivational Interviewing has widespread applications in healthcare settings, which includes enabling participants to navigate ambivalence in shared-decision making with their clinician, as well as executing changes in participant behavior. Ultimately, the Integrated Model of Trust can incorporate the role of therapeutic techniques like Motivational Interviewing in different stages of the clinical trials continuum. Ambivalence is a key component of clinical trial participation; like trust, ambivalence can be managed and plays a major role in the management of trust in interpersonal relationships over time. The management of ambivalence may play a major role in increasing clinical trial participation particularly among the marginalized or the vulnerable, who may be more susceptible to feelings of ambivalence.

Training the Mind’s Eye

The article profiles a program called Images of Health, a program for Native American women within a program called Circle of Sisters which was established to encourage breast cancer awareness, screening and early detection and features program activities which include having women string beads the size of tumors that are typically detected by different detection methods. The views that the U.S. Preventive Services Task Force and the American Cancer Society have about self breast examinations for women are discussed.