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EDITORIAL |
Dr. Huerta is Director Cancer Preventorium, Washington Cancer Institute at Washington Hospital Center, Washington, DC.
In this issue of CA, Kathryn O’Brien of the American Cancer Society (ACS) and colleagues review cancer incidence, mortality, and selected cancer-related behaviors of Hispanic Americans and compare them with those of non-Hispanic Americans.1 The report is a classic example of a good news, bad news situation.
The good news is the lower rates of incidence and mortality from the four major cancer killers; the bad news is the higher incidence and mortality from several cancers in which infectious agents play a substantial etiologic role. The good news is the lower smoking rates among Hispanic adults and youth; the bad news is that much of this difference may be among immigrants, and that second- and third-generation Hispanic Americans remain vulnerable to tobacco marketing. The good news is that use of cancer screening tests and examinations has been increasing among Hispanics and that mammography use among Hispanic women exceeds the national average; the bad news is that prevalence of screening for colorectal, cervical, and prostate cancers among Hispanics remains considerably below average. The final bad news is higher rates of overweight and obese individuals and higher rates of physical inactivity. What is clear about this report is that patterns of cancer incidence, mortality, and behavioral risk factors for Hispanics differ sharply from the patterns of other racial and ethnic groups in the United States. Finally, it should be stated, the report raises many more questions than it answers.
We have to be careful when talking about Hispanics. Hispanics are a very diverse group of people with varying beliefs and identities. Hispanics are the fastest-growing and largest ethnic and minority group in the United States. Although Hispanics are united by ethnicity, language, music, culture, and traditions, they also retain some distinguishing customs from their individual homelands. Hispanics originate from 23 different countries and belong to all known human races. This reality needs to be taken into account when analyzing health-related data. It is possible that this enormous diversity may explain the different patterns of cancer incidence, mortality, and cancer-related behaviors.
The main problem is that Hispanics living in the United States are disproportionately affected by some disparities. Despite having the highest rate of labor force participation of all US population groups, Hispanics are the poorest minority group. In addition, they report the highest uninsured rate among all racial or ethnic groups. According to the US Census, there were 35.3 million Hispanics living in the United States in the year 2000. During the same year, 35% of Hispanics lacked health insurance.2 This represents more than 12 million people for whom going to see a doctor may constitute a financial hardship. In addition, the uninsured are less likely to get preventive care such as physical examinations and cancer screening.3 Other barriers to adequate access to quality health care include linguistic isolation, insufficient health information, scarcity of ethnically sensitive and culturally competent health facilities, and their lack of understanding of the US medical system.
The Hispanic community does not have access to the same quality of care as mainstream Americans. One fifth of this community lives in poverty (a figure twice the national average). Many do not understand the importance of early screening tests because they were not provided with linguistically and ethnically sensitive information. First-generation Hispanic migrants have higher rates of cancers etiologically related to infectious agents, again reflecting in part limited educational opportunities and public health/health care infrastructure in some of their home countries. Many Hispanic Americans, and first generation immigrants in particular, have a low awareness of services available to them; they fear the unknown, and the medical system can be seen as intimidating and impenetrable. The presence of Cancer Navigators (advocates that help patients navigate the medical system) have proven invaluable in cancer control among minority communities.4
Among all those barriers, the lack of awareness toward cancer prevention and early detection issues and the lack of access to quality health care are the predominant obstacles to achieving adequate cancer health outcomes. In addition, some cultural characteristics, such as fatalism, fear of cancer diagnoses, and preconceived ideas, also contribute to those disparities.
Despite all those problems, the overall news regarding cancer rates among Hispanics is encouraging. Hispanics have lower incidence and death rates from all cancers combined and from the four most common cancers (breast, prostate, lung, and colorectal) than non-Hispanic whites and blacks. They do, however, have higher incidence and mortality rates from cancers of the stomach, liver, uterine cervix, and gallbladder. What are the reasons for these patterns of occurrence? How can we explain lower rates for common cancers and higher rates for infection-related malignancies? Do these higher rates for infection-related malignancies reflect cases occurring largely among recent immigrants, infected in their home countries? Are Hispanics doing something to protect themselves from the most common malignancies? Do these protective behaviors persist in subsequent generations? What are the trends? What can we, as physicians, do to improve cancer statistics among the Hispanic community? These are some of the many questions that this report opens up for future research.
Assuming that stomach, cervix, and liver malignancies are very prevalent in Latin America, some innovative international collaborations may be necessary to respond to these questions. The ACS University, a capacity-building program of grants and professional education for international cancer control organizations and their leaders, represents one of the initiatives that may lead to the development of US-Latin American collaboration.5
The relatively low overall cancer incidence rate for Hispanics does not accurately reflect their actual burden of cancer, however, because cancers are typically diagnosed in Hispanics at a later stage than for non-Hispanic white Americans, allowing for lower cure rates. Why does this occur? Could only linguistic isolation and lack of awareness explain these rates? What role does the lack of insurance play? Do any successful programs exist to increase Hispanic access to medical care that can be tested and replicated? Again, there are more questions than answers.
There is no simple solution to these problems. But it seems to me that improving access to quality medical care and implementing targeted, ethnically sensitive educational programs may help to correct the disparities discussed in this report. What could be better than having an educated consumer who can easily find a provider to fulfill his or her needs? Changing the way Americans access the health care system is predominantly a political decision. Implementing education programs to increase patients’ knowledge of how to best access care and participate in treatment decisions is the obligation of the medical community.
Education works. We need to create innovative programs that will make health care and preventive medicine readily available to underserved communities, such as Hispanic Americans. We need to create media-based, consistent health education programs that offer easy to understand information about diet, healthier lifestyles, early screening, and prevention. We need to be ethnically sensitive when communicating cancer risks to a collectivist, fatalistic community.7 We need to provide assistance in navigating the health care system, bilingual services, and adequate health care at an affordable cost.
After 14 years of daily radio programs and weekly television shows, the Washington DC Hispanic community has overflowed the Cancer Preventorium, which was founded by the author at the Washington Hospital Center in 1994.6,8 The Preventorium (as opposed to the old sanatorium) was conceived as a health facility for asymptomatic people only. More than 12,000 men and women (90% Hispanics, 85% asymptomatic, 60% with less than a high school education, and 60% uninsured) have been served at the center. The Preventorium has a two-month waiting list. This experience proves that, for thousands of people, the health system has changed its paradigm. Instead of continuing to be an illness-based health system, the system is now a health promotion-based system for thousand of Hispanics. The media "sells" health promotion and disease prevention. The Preventorium delivers it. The recent introduction in the US Congress of the Patient Navigator, Outreach, and Chronic Disease Prevention Act of 20039 has demonstrated that a high degree of interest exists for the national replication of a program that combines the Preventorium and the Navigation programs. Increased awareness through consistent health education programs, and the provision of health facilities that encourage the presence of people without symptoms, are possible enterprises. It can be done. It is being done. It must be done.
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