When reducing cancer risk in our population, let’s not exacerbate disparities

When reducing cancer risk in
our population, let’s not
exacerbate disparities
Graham A Colditz, MD DrPH
Niess-Gain Professor
Department of Surgery
Division of Public Health Sciences

Goals of talk
§ Highlight how epidemiology and population
research can mistakenly leave gaps in knowledge
§ This can exacerbate disparities, or invent them
§ Priority should be to refocus on prevention and
control research approaches to preempt
worsening disparities and equitable access to
prevention
§ Lets’ not make disparities while we focus on
“incremental precision”

Know my background
• Born Sydney, Australia
• Came into the country in 1981
• Have a convict in my family tree
But…
• Australia has generated many public health and
prevention researchers, without known causal
origin

Our findings suggest that false positive
reports are an important and perhaps underappreciated
component of the “genotype-positive–
phenotype-negative” subgroup of tested persons.
These findings show how health disparities may
arise from genomic misdiagnosis. Disparities
may result from errors that are related neither to
access to care nor to posited “physiological differences”
but, rather, to the historical dearth of
control populations that include persons of diverse
racial and ethnic backgrounds. NEJM Aug 16, 2016

Definition of precision medicine
NIH:
“Precision medicine is an emerging approach for
disease treatment and prevention that takes
into account individual variability in genes,
environment, and lifestyle for each person.”
Personalized medicine à similar but need to be careful
§ “Personalized” implies that treatments and preventions developed
uniquely for each individual
https://www.nih.gov/precision-medicine-initiative-cohort-program

All of Us
Precision Medicine Initiative (PMI)
President Obama announced in January 2015 in
State of the Union address
$215 million in 2016
§ $130 million allocated to NIH to build cohort
§ $70 million allocated to NCI to lead efforts in cancer genomics as part
of PMI for Oncology
Goal: to extend precision medicine to all diseases
by building national research cohort of 1 million or
more U.S. participants
https://www.nih.gov/precision-medicine-initiative-cohort-program

https://www.nih.gov/precision-medicine-
initiative-cohort-program/infographics

Precision Medicine - Oncology
• Initial: targeted therapy in late 90s, early 2000s
• Not all individuals benefit equally from current cancer
prevention strategies
§ Biologic differences in risk and response to preventive modality
§ Response to environmental influences
Precision prevention = broader conceptual framework
§ Involves use of biologic, behavioral, socioeconomic, and epidemiologic data to
devise and implement strategies tailored to reducing cancer incidence and
mortality in a specific individual or group of individuals
• “Prevention is better than cure.”
-Desiderius Erasmus (1466-1536)
http://cebp.aacrjournals.org/content/cebp/23/12/2713.full.pdf
https://www.cancer.gov/news-events/cancer-currents-blog/2016/precision-prevention-chanock

Framework
for precision
prevention
of cancer
Figure 1.
http://cebp.aacrjournals.org/content/cebp/23/12/2713.full.pdf
Rebbeck CEBP 2014

Precision treatment vs. Precision prevention
Precision treatment = focus on treating existing
disease
§ Most efficacious and least harmful pharmaceutical treatments to
prevent relapse or death (e.g. cancer)
§ “Below the skin” à emphasizes the “what” more than the “how”
Precision prevention = tailoring behavioral
interventions to individual’s characteristics
§ Overcome psychosocial barriers, emphasize achievable goals, adapt
to families’ differing economic or cultural circumstances
§ “Above the skin” à emphasizes the “how” as much as the “what” or
the “why”
Gillman and Hammond
http://jamanetwork.com/journals/jamapediatrics/fullarticle/2472719

Disparities…

COLON CANCER

Mortality: male
Cross over -
Made an excess in black
men

Mortality” female
From equal morality delay
in decline leads to black
excess

Delivering evidence based care:
CRC California
Integrated health system Non-integrated health system
Rhoads et al JCO 2015

Delivering evidence based care:
CRC California
Integrated Non-integrate health system

But, treatment effectiveness can
lead to disparities
Review shows effective treatment can
make disparities
• See Tehranifar P à SEER 1995-99
http://cebp.aacrjournals.org/content/cebp/18/10
/2701.full.pdf
• Define cancer as:
§ Mostly amenable to treatment;
§ Partly, or
§ Non-amenable to treatment

SEER cancer specific survival by
amenable to medical intervention
Tehranifar
CEBP 2009
1.05 (1.03-1.07
1.38 (1.34-1.41)
1.41 (1.37-1.46)

Access and treatment matter
• Also note social support, income, and costs of
care each impact completion of therapy,
bankruptcy, risk of death
Studies within the USA show that patients with
cancer, especially those younger than 65 years
without access to Medicare and social security
protection, are more than twice as likely as their
same-aged peers to file for bankruptcy.
§ See Ramsey Health Aff (Millwood) 2013; 32: 1143–52
Colditz & Emmons Lancet 2016

Are the colorectal disparities due
to incidence?

Incidence: Male
Cross over of Black – White
Incidence rates

Incidence: female
Substantial delay in decline
In ind=cidence

What is this Massachusetts drop?
• Massachusetts colorectal cancer work group
formed in 1997
§ Academic medical/public health centers
§ State department of public health
§ ACS (New England Region)
• Undertook broad range of education and
outreach to providers and the public to facilitate
CRC screening in primary care

Siegel et al CEBP 2015

66.4%
2014
56.9%
Wyoming
76.5%
Massachusetts
Behavioral Risk Factor Surveillance System (BRFSS),
Centers for Disease Control and Prevention, 2014.
(Ages 50-75 met the USPSTF recommendation)
Colon Cancer Screening
National av. Lowest Highest

2008 – 2010 up to date CRC screening Missouri
Based on 37 counties in Missouri with at least 30 respondents

Example – HPV Vaccine
Accepted as precision medicine
• Racial differences for completing vaccine series
§ In the U.S. in 2014, for girls age 13-17
§ 70% of whites and Hispanics completed 3 doses
§ 62% of blacks completed 3 doses
African American women are also more likely to be
diagnosed with cervical cancer at later stages and
die at almost twice the rate compared to non-
Hispanic white women
Reagan-Steiner, S., Yankey, D., Jeyarajah, J., Elam-Evans, L. D., Singleton, J. A., Curtis, C. R., . . . & Stokley, S. (2015). National, regional, state, and selected local area vaccination
coverage among adolescents aged 13-17 years–United States, 2014. MMWR Morb Mortal Wkly Rep, 64(29), 784-792.

HPV vaccination 2015 CDC data
3 dose completion, 13-17 US pop percentage
Overall US population 70.3%
At or above poverty 72.6%
Below poverty 66.4%
Black 64.6%
White 71.5%
Urban 74.2%
Non metro 66.9%
2015 Adolescent HPV vaccination coverage dashboard, CDC

Other contributing factors
Low literacy levels
§ ↑ interest in receiving genomic info but ↓ intentions to
change health habits as a result of genomic info
§ ↓ genetic knowledge but ↑ perceived importance of genetic
info
§ ↓ awareness of family health history (FHH) and ↓ perceived
importance of FHH but ↑ communication with doctor about
FHH
Kaphingst, Kimberly A., et al. "Relationships between health literacy and genomics-related knowledge, self-efficacy, perceived importance, and communication in a medically underserved
population." Journal of health communication 21.sup1 (2016): 58-68.
Kaphingst, Kimberly A., et al. "Effects of racial and ethnic group and health literacy on responses to genomic risk information in a medically underserved population." Health Psychology 34.2 (2015): 101.

What will we need to avoid
exacerbating disparities?
• Consider that race/ethnicity and health literacy
levels may affect responses to genomic risk info
• Individual-level factors
§ Awareness, knowledge, attitudes, and beliefs
§ Culture
• System-level factors
§ Providers’ perceptions of genetic counseling and testing
§ Healthcare system barriers (e.g. insurance barriers)
§ Levels of trust in healthcare system
§ Generally low among minorities
Kaphingst, Kimberly A., and Melody S. Goodman. "Importance of race and ethnicity in individuals' use of and responses to genomic information." Personalized Medicine 13.1 (2016): 1-4.
Kaphingst, Kimberly A., et al. "Effects of racial and ethnic group and health literacy on responses to genomic risk information in a medically underserved population." Health Psychology 34.2 (2015): 101.

Next step priorities
Avoid inducing disparities
Build platform for effective implementation of
precision prevention, if new indications and
technologies arise.
Collaborate with diverse partners to improve
communication and use of our findings.

SITEMAN CANCER
CENTER

SITEMAN CANCER
CENTER
DESCRIBE
SOLVE
CHANGE
Data: Record review
of stage at diagnosisExcess breast cancer mortality
FQHCs engaged
Screening/referral revised
and implemented
Breast cancer mortality decrease
Mammography access improved
Navigator network established
Reducing Disparities PECaD at WUSTL: Breast Cancer
Significant increase
in situ disease in AA
women over decade
16% (2000) to 24%
(2013)
4 deaths/100k Black
vs. 3 deaths/100k
White
Stage IV disease
decrease to 6% cases

SITEMAN CANCER
CENTER
Partnership with the St. Louis American –
Missouri’s largest African American newspaper with over 244,000
readers

SITEMAN CANCER
CENTER
RedPlum inserts providing cancer information
to over 124,000 household in high risks zip
codes

SITEMAN CANCER
CENTER
10 week billboard campaign in high
risks targeted areas to increase cancer
awareness -12 million impressions

SITEMAN CANCER
CENTER
Partnership with the St. Louis Public Libraries
providing educational materials and DVDs on
cancer prevention

SITEMAN CANCER
CENTER
Certificate Ceremony & Reception
Honoring our 45 community research fellow graduates
August 8, 2013 Eric P. Newman Education Center Auditorium

Addressing cancer health
disparities
Cancer
Continuum
Prevention
Detection
Diagnosis
Treatment
Survivorship
Access
issues
Participation
in research
Communit
y Outreach
& Training
Rural
populations

Implementatio
n Outcomes
Feasibility
Fidelity
Penetration
Acceptability
Sustainability
Uptake
Costs
*IOM Standards of Care
Conceptual Model for Implementation Research
What?
Evidence
Based
Interventions
How?
Implementation
Strategies
Implementation Research Methods
Service
Outcomes*
Efficiency
Safety
Effectiveness
Equity
Patient-
centeredness
Timeliness
Population
Outcomes
Health status
Symptoms
Function
Satisfaction
Proctor et al 2009 Admin. & Pol. in Mental Health Services
CONTEXT
CONTEXT
CONTEXT
CONTEXT

Key prevention questions:
• Which lifestyle/system component to change?
• At what age?
• By how much?
• For how long?
• When will benefit be observed, and how long will
benefit last?
• Will it reduce not exacerbate disparities?
See Colditz, Cancer Causes and Control 2010
Colditz and Taylor, Ann Rev Public Health 2010

Cancer Prevention Gaps to Fill
• Where do we strengthen science?
• How do we sharpen focus: on
individual/community/broader public health
programs
High risk vs. population-wide programs
• Increase translation and delivery to all members
of society
• Even when program implemented, research &
implementation gaps remain to achieve full
population coverage and health benefits

Conclusions…
If we are to benefit as a nation from our
investment in cancer research, it is imperative that
we focus research on strategies to reduce variation
in implementation of effective cancer prevention
programs, in clinical and other settings that
provide broad population reach, as well as through
state and federal policy.
Emmons and Colditz 2017, in press

We have a great deal to learn from studying
settings that have higher uptake and
implementation of prevention-focused policies, and
understanding the social, political and
environmental factors that lead to increased
implementation of evidence-based programs.
If our efforts to reduce the cancer burden are to go
beyond rhetoric, they simply must address
implementation factors that influence cancer
disparities and have the biggest impact on
populations carrying the largest cancer burden.

When we implement evidence-based prevention
and screening programs correctly and at scale, we
achieve substantial population benefits.
We can achieve reductions in the cancer burden
right now by doing what we already know.
Our moonshot is right here—ready for the taking.

QUESTIONS?

When reducing cancer risk in our population, let’s not exacerbate disparities

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When reducing cancer risk in our population, let’s not exacerbate disparities