Cancer Disparities in SC

The Journal Cancer Disparities in South Carolina

The Journal since 1905

VOLUME 102 NUMBER 7 August 2006 PAGES 171-262

Volume 102 , Number 7 Pages 171-262

Cancer Disparities in SC

Epidemiology and prevention of the seven cancers of most critical importance in South Carolina: Breast, Cervix, Colon, Esophagus, Lung, Oral Cavity, and Prostate.

August 2006

This issue presents results of collaborations among the SC Statewide Cancer Prevention and Control Program at the University of South Carolina, the SC Cancer Disparities Community Network, the SC Central Cancer Registry, the SC Cancer Alliance, and their partners.

President’s Page Physicians Can Close the Gaps in Healthcare For thirty plus years as a private practitioner of general surgery, I did not consider ethnic disparities in health. When I saw a patient who needed care, he or she was given the best I had to give without any consideration of ethnic origin, ability to pay, or cultural differences. Recently, disparities in health care has become frequently discussed in the medical world and numerous studies have shown significant disparities in health care delivery and outcomes. I would like to think this is not the result of deliberate discrimination. There are some people with cultural differences who approach health care in unorthodox ways which may cause them to become disenfranchised. More often, access to care becomes a large problem for patients who cannot afford a family doctor, do not have a medical home, and, therefore, are often diagnosed much later in the course of their disease. Treatment and outcome are often adversely affected by the delay. The illiterate and poorly educated are also at risk for disparity in health care because they are unable to read about and understand their signs and symptoms. The current health care system is so complex that even highly educated people are often unable to deal with it efficiently. The complexities of dealing with bureaucracy and rushed physicians who speak “doc talk” could certainly drive away some patients who most need our help. I am happy to report that great effort is being put forth to alleviate this problem. The American Medical Association has joined with more than 45 organizations in the Commission to End Health Care Disparities. The SCMA is addressing the problem in this and past issues of The Journal. I am proud to say that AnMed Health (where I work), in conjunction with Clemson University, has obtained a grant to work with community leaders to list and define health care needs and priories in two low income areas in Anderson County. Much is being done; more needs to be done. We must keep this problem in our sights. I remind all physicians in South Carolina of the need to be involved in and take responsibility for the health care of ALL South Carolinians. We must be sensitive to the fact that some patients are less able to access our health care system because of language, illiteracy, culture, economics, etc. That being said, we must also work to provide patients with the tools necessary to become more responsible for their own health. Spending time with our patients, educating our staffs, and providing written materials are very basic steps we can all take to educate our patients and empower them to feel ownership in their health care decisions.

Jerry Powell, MD SCMA President

Volume 102 • August 2006

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The Journal

of the South Carolina Medical Association

The mission of The Journal is to advance the art and science of medicine; to promote the ideals of the South Carolina Medical Association; to encourage scholarship and good will among South Carolina physicians; and to disseminate information specifically applicable to the health care of South Carolinians. EDITOR Charles S. Bryan, M.D., Columbia

The Journal of the South Carolina Medical Association (ISSN 0038-3139) and The eJournal (ISSN 1544-4910) are published by the South Carolina Medical Association business office: 132 Westpark Blvd., Columbia, SC 29210.

ASSOCIATE EDITOR FOR ELECTRONIC PUBLISHING Lawrence B. Afrin, M.D., Charleston MANAGING EDITOR Jeanette Mangels DESIGN EDITOR Jenny Anderson EDITORIAL BOARD Jeff Z. Brooker, M.D., Columbia T. Edwin Evans, M.D., Seneca Ivar Frithsen, M.D., Charleston Robert Gifford, M.D., Columbia John Hayslip, M.D., Goose Creek Edgar O. Horger, III, M.D., Columbia William H. Hunter, M.D., Clemson Neil L. Kao, M.D., Greenville Melanie A. Lobel, M.D., Columbia James Majeski, M.D., Ph.D., Mount Pleasant

E. Conyers O’Bryan, Jr., M.D., Florence J. David Osguthorpe, M.D., Charleston Robert M. Sade, M.D., Charleston I. David Schwartz,, M.D., Columbia Gregory T. Squires, M.D., Charleston Hunter R. Stokes, M.D., Florence A. Weaver Whitehead, M.D., Florenc W. Curtis Worthington, Jr., M.D., Charleston James L. Young, M.D., Greenville Deyi Zheng, M.D., Lexington

SCMA OFFICERS Jerry R. Powell, M.D., President Gerald E. Harmon, M.D., President-Elect Gerald A. Wilson, M.D., Immediate Past President John G. Black, M.D., Secretary Oswald L. Mikell, M.D., Treasurer Richard A. Schmitt, M.D., Chairman of the Board; Trustee, Sixth District Gregory Tarasidis, M.D., Vice Chairman of the Board; Trustee, Third District Gary A. Delaney, M.D., Executive Committee Member-at-Large; Trustee, Eighth District Andrew J. Pate, M.D., Speaker of the House Patrick J. Kelly M.D., FACEP, Vice Speaker of the House

TRUSTEES Thaddeus Bell, M.D., First District H. Timberlake Pearce, Jr., M.D., First District Vincent J. Degenhart, M.D., Second District Dale R. Gordineer, M.D., Second District Marshall L. Meadors, III, M.D., Fourth District Bruce A. Snyder, M.D., Fourth District Terry L. Dodge, M.D., Fifth District Tallulah F. Holmstrom, M.D., Fifth District William Dean Lorenz, M.D., Sixth District James Roper Ingram, M.D., Seventh District William Warren Kerfoot, M.D., Ninth District Kenneth F. Hill, M.D., Ninth District Jennifer R. Root, M.D., Young Physicians Section Garry Martin, II, Medical Student Section Adrienne Coopey, D.O., Resident Physician Section

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DELEGATES TO THE AMA J. Chris Hawk, M.D., Delegate William H. Hester, M.D, Delegate Stephen A. Imbeau, M.D., Delegate Carol S. Nichols, M.D., Delegate Boyce G. Tollison, M.D., Delegate John P. Evans, M.D., Alternate Gerald E. Harmon, M.D., Alternate J. Capers Hiott, M.D., Alternate Jerry R. Powell, M.D., Alternate Gerald A. Wilson M.D., Alternate

CHIEF EXECUTIVE OFFICER Mr. Todd K. Atwater

Beginning in 2002, publication of The Journal alternates monthly between printed (even months) and electronic (odd months as needed) formats. All issues are available for download via www.scmanet.org/scma/journal.aspx. Subscription price for the printed issue to non-members is $25.00. SCMA members’ subscription cost is $15.00 (included with payment of annual dues). To advertise in the printed issue: Contact the managing editor via [email protected]. SCMA Address 132 Westpark Blvd, Columbia, SC 29210 Mailing Address: P. O. Box 11188 Capitol Station, Columbia, SC 29211. Phone: (803) 798-6207 or (800) 327-1021 Website: www.scmanet.org E-mail: [email protected]

Periodicals postage paid at Columbia, SC. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, SC 29211 Copyright© 2006 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

The Journal of the South Carolina Medical Association

The Journal


Volume 102 August 2006 Number 7

Scientific articles 183

Lung and Bronchus Cancer Disparities in South Carolina: Epidemiology and Strategies for Prevention Anthony J. Alberg, PhD, MPH; Marie-Josephe D. Horner, MSPH; Virginie G. Daguise, PhD; Matthew J. Carpenter, PhD; Catishia M. Mosley, MSPH; Brad Vincent, MD; Gerard Silvestri, MD, MS; Carolyn E. Reed, MD; James R. Hebert, MSPH, ScD

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Head and Neck Cancer Disparities in South Carolina: Descriptive Epidemiology, Early Detection, and Special Programs K. Lawrence Yen, MD; Marie-Josephe D. Horner, MSPH; Susan G. Reed, DDS, MPH, DrPH; Virginie G. Daguise, PhD; Susan W. Bolick-Aldrich, MSPH, CTR; M. Rita I. Young, PhD; Terry A. Day, MD; Patricia A. Wood, M.D, PhD; James R. Hebert, MSPH, ScD

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Esophageal Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology James R. Hebert, MSPH, ScD; Swann Arp Adams, PhD; Virginie G. Daguise, PhD; Deborah Hurley, MSPH; Eric W. Smith, PhD; Carryn Purdon, PhD; Andrew Lawson, PhD; Michael Mitas, PhD; Carolyn E. Reed, MD

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Colorectal Cancer Disparities in South Carolina: Descriptive Epidemiology, Screening, Special Programs, and Future Direction Virginie G. Daguise, PhD; James B. Burch, MS, PhD; Marie-Josephe Horner, MSPH; Catishia Mosley, MSPH; Lorne J. Hofseth, PhD; Michael J. Wargovich, PhD; Stephen C. Lloyd, PhD, MD, James R. Hebert, MSPH, ScD

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Cervical Cancer Disparities in South Carolina: An Update of Early Detection, Special Programs, Descriptive Epidemiology, and Emerging Directions Heather M. Brandt, PhD; Mary V. Modayil, MSc; Deborah Hurley, MSPH; Lucia A. Pirisi-Creek, MD; Mary G. Johnson, MSPH; Jennifer Davis, BS; Subbi P. Mathur, PhD; James R. Hebert, MSPH, ScD

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Breast Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology Swann Arp Adams, PhD; James R. Hebert, MSPH, ScD; Susan Bolick-Aldrich MSPH, CTR; Virginie G. Daguise, PhD; Catishia M. Mosley, MSPH; Mary V. Modayil, MSc; Sondra H. Berger, PhD; Jane Teas, PhD; Michael Mitas, PhD; Joan E. Cunningham, PhD; Susan E. Steck, PhD; James Burch, MS, PhD; William M. Butler, MD; Marie-Josephe D. Horner, MSPH; Heather M. Brandt, PhD

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Prostate Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology Bettina F. Drake, MPH, PhD; Thomas E. Keane, MD; Catishia M. Mosley, MSPH; Swann Arp Adams, PhD; Keith T. Elder, PhD; Mary V. Modayil, MSc; John R. Ureda, DrPH; James R. Hebert, MSPH, ScD

ON THE COVER

The imbalance in the caduceus scales held in the hands of an African American and a European-American represents the racial imbalances that exist in cancer rates in South Carolina and the many partners that made this special issue of The Journal of the South Carolina Medical Association possible. Read more on page 262.

FEATURES 262 Classifieds 262 On the Cover

ASSOCIATION 260

Alliance Page

258

AMA Annual

Meeting Report

256

CME Calendar

105

President’s Page

253

SCMA Updates

continued→


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The Journal

Volume 102 August 2006 Number 7


Community perspectives 210

Tobacco Related Cancer Disparities: Community Perspective Ruby F. Drayton, MBA, LPN; Marc Gardner, MHA, CHES; Dianne Wilson, BA

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Community Perspective: Colorectal Cancer Disparities in South Carolina Deloris G. Williams, RN, MSN, PhD; Dolores B. Scott, MEd

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Breast and Cervical Cancer Disparities in SC: African-American Perspective Tracy R. Powell, MSW

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Prostate Cancer Disparities in South Carolina: Two Generations Talking from a Male Community Perspective Lee H. Moultrie II; Justin H. Smith

EDITORIALS 175

Cancer Prevention in South Carolina: Will You Join the Cause? John E. Vena, PhD

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The Greatest Benefit to Our Patients: Understanding the Emotions of Cancer Gerald A. Wilson, MD

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Meeting the Challenges of Cancer Prevention and Control in South Carolina: Focusing on Seven Cancer Sites, Engaging Partners James R. Hebert, MSPH, ScD; Keith Elder, Ph.D., MPA, MPH; John R. Ureda, DrPH

special issue 261 Acknowledgments

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Editorial Cancer Prevention in South Carolina: Will You Join the Cause? John E. Vena, PhD

Cancer affects all of us; it has a tremendous impact on physician practices and families dealing with the many related issues that cancer raises. This special issue of The Journal of the South Carolina Medical Association offers you a unique opportunity to learn and then spread the word about the challenges and opportunities to tackle cancer as a clinical and public health issue in South Carolina. Primary prevention of cancer can happen through better understanding of the etiologies of these diseases. It can also occur through screening for cervical, colorectal, and oral cancers, which allows for detecting and removing or treating precancerous lesions. Secondary prevention through early diagnosis and prompt treatment can be targeted toward special populations at risk. Supportive care and tertiary prevention form an important safety net, certainly affect quality of life, and may lead to increases in disease-free survival. This Journal issue presents a series of articles on the epidemiology and prevention of the seven cancers of most critical importance in South Carolina; Breast, Cervix, Colon, Esophagus, Lung, Oral Cavity, and Prostate. Data presented are from the excellent resources of the South Carolina Central Cancer Registry (SCCCR). Prior to 1996, South Carolina had no registry of new cancer cases, so there wasn’t any way to grasp a better understanding of the population dynamics of the impact of cancer. The SCCCR data is certified for completeness, timeliness, and quality by the North American Association of Central Cancer Registries and the Centers for Disease Control and Prevention. Having participated in this certification process for seven years (since 1997, the first year it was eligible) the SCCCR has been awarded five Gold and two Silver ratings. This year the South Carolina Cancer Registry, under the leadership of Susan Bolick-Aldrich, received another Gold Certification for the quality of their work. This means that the

SC Registry is ranked as one of the best in the country and the world! I serve on the SC Cancer Prevention Advisory Board and the Cancer Surveillance Subcommittee and have observed firsthand the importance of the registry as a resource for cancer research. This special issue is yet another example. The citizens of South Carolina can be assured that the Statewide Cancer Prevention and Control Program (CPCP), which was organized in 2003 under the leadership of Dr. James Hebert, is conducting a world-class effort aimed at reducing cancer-related health disparities and preventing cancer at all levels. Dr. Hebert and the great team of interdisciplinary scientists who have been recruited to the program have articulated a focused and targeted mission to prevent and control the leading cancers in SC. CPCP faculty members partner with physicians, concerned citizens, and state public health officials to implement a comprehensive plan to address the disparities in cancer incidence and mortality in this state. As part of that effort, the partners developed the reports that comprise this special issue. Such a comprehensive and insightful treatise with input from all the partners is indeed unique. This was repeatedly mentioned to me by the world-class scientists who served as reviewers of the articles. I urge each of you to take the time to read this unprecedented issue, to get involved, and to spread the word to your colleagues and patients. Partners have come forward from all sectors of South Carolina who are passionate about eliminating cancer health disparities. Please support them and their efforts. Collaborate on their outreach, community education, and research activities and share and disseminate information to your patients. Working together, we can make cancer prevention in South Carolina a reality. n

Dr. John E. Vena is a professor and chair of the Department of Epidemiology and Biostatistics at the Arnold School of Public Health in Columbia, South Carolina. Address correspondence to: Dr. Vena, Department of Epidemiology and Biostatistics Arnold School of Public Health University of South Carolina, 800 Sumter Street Columbia, SC 29208-0001. Email:[email protected].


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Editorial Wilson Editorial Gerald A. Wilson, MD

There are few words in the English language that can elicit more human emotion than that of the word Cancer. In the care of our patients, when such a diagnosis is considered or made, subjective variables often introduce considerable entropy in the patient-physician relationship and can impair orderly, scientific discussion and management. In the course of my practice, there have been many instances where it has been necessary to remain mindful that the human element can bring challenges in diagnosing, discussing and treating cancer. There are two examples that specifically come to mind. I was fortunate enough to treat a high school classmate of mine for breast cancer. She presented at age 42 with a baseball-sized mass in her right breast which had been palpable to her for at least 2 years. This proved to be positive with wide-spread metastases. Her explanation for why she presented at such an advanced stage: she was afraid the lump might be cancer. Her sixteen year-old daughter was dismayed that she would allow her fear to delay therapy for so long and result in her ultimate demise.

a partial colectomy for a large polyp. I was discussing the pathology report with her and informed her that there was invasive cancer in the polyp but that the stage was early and the lymph node status revealed none positive for cancer. I asked if she understood or had any questions and she affirmed that she understood. Upon leaving the patient’s room, the nurse assisting me told me (from her personal experience) that after my patient heard me say the word “Cancer,” she didn’t hear another thing that I said. She assured me that she would go back in later and discuss this to her “in her own words.” These examples demonstrate where we, as health care professionals, often find ourselves. It is required that we be knowledgeable about cancer, understanding of our patients’ concerns and willing to learn about impediments to the delivery of care due to biases, racial and cultural differences. The importance of this issue of the Journal rests not only in the research information that is transmitted to physicians, but in recognizing that advances in cancer research, diagnosis and treatment are accomplished with basic science, clinical medicine and public health working in a collaborative manner. The result can only be of greatest benefit to our patients.

I had another patient who was post-op and recovering from

Dr. Wilson is a general surgeon in Columbia, SC. He is the Immediate Past President of the South Carolina Medical Association and the founder of the SCMA’s HealthWatch program. The HealthWatch program disseminates information on health-related topics of specific concern to people in South Carolina from SCMA member physicians. Address Correspondence to Dr. Wilson,

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Overview Meeting the Challenges of Cancer Prevention and Control in South Carolina: Focusing on Seven Cancer Sites, Engaging Partners James R. Hebert, MSPH, ScD 1,2,3 Keith Elder, Ph.D., MPA, MPH 3,4 John R. Ureda, DrPH 3,5 Cancer is a set of diseases that affects everyone, though the incidence and severity of specific cancers varies considerably (sometimes several hundred-fold) from place to place and across populations. A little over a year ago, the South Carolina Medical Association set a national precedent by devoting an entire special issue of The eJournal to cancer prevention and control.1 At that time, we challenged our colleagues, community activists, cancer survivors, and others to respond to those articles that comprised the July 2005 special issue. The current issue reflects the very careful response of individuals from many constituencies who have an interest in cancer prevention and control, and the thoughtful peer review of the seven cancer site-specific articles by scientists around the country and the world. This Journal issue consists of these seven research papers and four articles by community partners speaking from a variety of constituent perspectives. Although we have made considerable progress in the past year, South Carolinians continue to experience some of the highest cancer incidence rates in the world.2,3 Relative to other populations, our mortality rates are even more striking.2,4 Marked disparities in cancer incidence and mortality rates in African Americans drive the overall high rates of cancer in South Carolina.2 While some of the differences, especially in mortality, are related to socioeconomic factors that determine access to care, we are pretty much in the dark regarding many of the underlying causes.5-8 Despite that racial designations are far from perfect, the epidemiologic evidence is consistent with race (geographic origin), rather than skin color, being related more strongly to known or suspected cultural and biological determinants of cancer.8-12 In the US as a whole, as in South Carolina, the designations “White” and “Black” are used when collecting data for purposes of cancer registration. The reality is that the vast majority of Blacks are of predominantly African origin (African American) and the vast majority of Whites are of predominantly European origin (European American). So, when we are focusing on underlying causes of disease and discussing conceptual issues around research and care we use the more


accurate, if still imperfect, terms “African American” and “European American.” When we refer specifically to registry data we use the terms employed by the registries (i.e., Black and White). The seven scientific articles that form the basis of this special issue of The Journal highlight the most significant of South Carolina’s cancer disparities. In 2003, we began a process of very actively engaging the community in research related to cancer disparities. This began by bringing the Cancer Research Needs Report of the South Carolina Cancer Research Network (CRN)13 to the attention of activists in the community. This method of active engagement has continued to expand through the South Carolina Cancer Disparities Community Network (SCCDCN – http://sccdcn.sph.sc.edu), one of 25 centers funded through the NCI’s Community Networks Program. The seven scientific articles and the four pieces by community partners reflect the dialogue that has continued to develop across our various constituencies. While each of the relevant constituencies might be inclined to focus on a single aspect of prevention, the Community Network defines the scope of cancer prevention and control very broadly, to include: • Primary prevention (i.e., focusing on factors such as diet and physical activity that may modify the probability of getting cancer and therefore would have a direct effect on incidence). For some cancers, including three on which we focus here (i.e., cervical, colorectal, and oral), screening is a primary preventive and not just a method of early detection (as the detected lesion may be precancerous). • Secondary prevention (i.e., directing attention toward issues such as early detection to downstage disease at the time of diagnosis, and factors that may modify the likelihood of survival and recurrence and therefore have an effect on prevalence) • Tertiary prevention (i.e., examining factors that would influence quality of life, but not necessarily change either incidence or prevalence) The SCCDCN (Community Network) defines its scope and

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Overview direction in very broad terms. Its predominant theme is community-based participatory research (CBPR) designed to encompass a broad array of community, consumer, clinical, basic science, and public health perspectives. We intend to serve the broad constituencies who diagnose and treat people with cancer, those who are in high-risk groups or already have been diagnosed with a cancer, and researchers who are charged with understanding the full range of cancer prevention and control issues. The main focus is on research, but this is defined in the broadest terms possible to include studies ranging from gene-environment interactions to health policy-related issues. Given the discordance between real and perceived risk across an array of public health issues,14-17 we also define education as fundamental to our purpose. Furthermore, we see education as something from which any and all of the constituencies may benefit. Each of the seven cancer site-specific articles presents the descriptive epidemiology of the cancer, discusses issues around screening, and describes special cancer prevention and control activities and programs that exist in South Carolina. While the articles stop short of proposing advocacy and public policy positions, there are clear implications for what we know and should do something about. Likewise, areas for future research are outlined – and these range from understanding basic disease etiology to educational programs and interventions to health policy research. One of our goals is to engage the broad range of our constituencies in thinking in creative ways about tackling the cancer problem. An important constituency is the readership of The Journal of the South Carolina Medical Association. As a member of the National Cancer Institute’s Community Networks Program, the Community Network was designed specifically to address South Carolina’s cancer problem by engaging those individuals and communities at greatest risk of getting and dying of cancer. The community-based participatory research (CBPR) approach it uses involves community members in understanding the problem and in defining the scope of the research question.18,19 These community members work with academic researchers and health-care providers in the design and implementation of research studies; and indeed in setting the research agenda. Their input, which reflects a desire to be partners, ensures that we pose the best questions to move us along in addressing cancer disparities. Because many of the underlying causes of specific cancers are causally related to other cancers and disorders that disproportionately affect racial, ethnic, and underserved minorities, this work holds great promise for having positive impacts on people’s lives.

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While many South Carolinians know that rates of most chronic diseases, including many cancers, are elevated in our state, few understand just how little our understanding may be advanced by findings obtained from research conducted in other parts of the country or the world. Good scientific research is designed to produce results that can be generalized beyond the populations in which the studies were conducted (hence, the rationale for doing research in animals). However, it is clear from reading the articles in this issue that findings from these studies often fall short of the goal of being applicable everywhere. Research conducted elsewhere – or spearheaded by scientists based elsewhere – runs the risk of not leading to practical advancement of knowledge as to why rates of these cancers are so much higher in South Carolina. Although there are some surprises in terms of what is happening in South Carolina, these articles will reinforce what wellinformed researchers and practitioners know. The cancers of the upper aerodigestive tract (oral, esophagus, and lung) are strongly associated with tobacco use. From professional, personal, and political perspectives we know that we should limit and discourage tobacco use. However, what seems to be true for European or European American populations may not hold as well for African Americans, especially in our state. For example, in South Carolina the incidence rate of squamous cell carcinoma of the esophagus, a particularly deadly cancer, is six times higher in African Americans than in European Americans.20 Based on studies conducted elsewhere, predominantly in European or European American populations, the conventional thinking is that more than 95 percent of variability in this particular cancer is attributable to the combination of smoking and drinking.21,22 It is indeed curious and troublesome that African Americans and European Americans drink at about the same rate and that African Americans actually have lower smoking rates,23-26 especially in South Carolina.27 Clearly, there is something unusual about the underlying causes of this cancer in this population. It is equally clear that research conducted elsewhere has missed the mark in terms of explaining risk and in providing complete information about what people can do to protect themselves. For strongly hormone-sensitive cancers (prostate and breast) striking disparities also exist. Prostate cancer rates continue to be extraordinarily high among African American men in comparison to their European American counterparts. While there is about a 55 percent elevation in prostate cancer incidence in African Americans nationally, in South Carolina the difference is close to 80 percent - about a 50 percent increase in the racial disparity seen nationally.2,28 Mortality rates are about 2.5 times higher in African Americans.28 There is no good explanation


Overview for why this large disparity exists, and the hardship this creates is staggering. The incidence of breast cancer, the major hormone-sensitive cancer affecting women, is about 15% lower in African Americans.29 However, for a given stage of breast cancer, African American women have much more aggressive (higher grade and lower probability of hormone receptivity) disease than do European American women. Therefore, even with reasonable access to screening (and, thanks to some excellent programs, screening rates are not very much different by race in this state), African American women would be expected to do worse. Indeed, the upshot is that the breast cancer mortality rate in African American women is about 60 percent higher than what we would expect based on incidence alone. The race-by-gender anomalies in rates also are striking – and something we would know little about without access to the superb data of the South Carolina Central Cancer Registry (SCCCR). The articles on colorectal, oral, lung, and esophageal cancers illustrate that for most cancers that afflict both genders women have lower incidence rates of disease. However, African American women have a proportionately higher incidence of cancer relative to European American women; whereas African American men tend to have rates that are more similar to their European American counterparts. Much of what we already know in order to prevent and control human cancers has emerged from health care environments. Competent research in this arena can occur only in well-organized clinical settings that understand, appreciate, and support research. Through a process of productive engagement, clinicians and consumers help to ensure that important questions are asked; with the consequence that the findings from relevant research improve care. The levels of prevention outlined by the NCI,30-34 beginning with basic science (encompassing both “wet lab” and epidemiologic research) and culminating with health policy research, can and should be integrated with clinical and public health practice. In fact, the full range of such activities can be incorporated into single programs, and often single studies. By working together we greatly limit the likelihood of working in the “silo” mentality that characterizes much of the War on Cancer.35 In this way we can work so that we: • avoid “exquisitely irrelevant” results on the basic science side of things, • obtain important etiologic clues that can be gleaned in clinical practice, • place our work in the proper personal and public health contexts, and • address the complex array of community factors that determine the occurrence and outcomes of cancer.


Ultimately, failures in any of these cause us to waste precious human resources. Cancer research in South Carolina should not be limited to etiologic studies. However, given the provocative findings of the descriptive epidemiologies of these cancers presented in this issue, conducting well-designed analytic epidemiologic studies must be one of our priorities. Other kinds of studies, including dissemination of smoking cessation, cancer screening, and community-based dietary and physical activity programs need to be undertaken. Also, competent evaluation and health services research can (and should) be conducted as part of outreach and access to care. Our goal, of course, is to address the full range of prevention (from primary prevention to palliation of symptoms and reduction of suffering) and to go beyond outreach. The South Carolina Cancer Disparities Community Network’s intention is to engage. We begin from an understanding that no one person or group has all the answers. It is our collective intelligence and wisdom that will meet the challenge of these cancer disparities. We must create a dialogue that addresses cancer from all of its many facets. We are grateful to have the will and perspectives of the community expressed in this special issue of The Journal – another precedent for which the South Carolina Medical Association can be justifiably proud. While the primary interest of many readers of The Journal is focused on the health of individuals, the remarkable improvements in longevity and quality of life that humans have experienced in the past century and a half have come from a collective commitment to improve population health.36,37 Although physicians and other health care providers are probably the single most important constituency in changing individuals’ health-related behaviors and attitudes about those behaviors,38-41 there is only so much any individual can do to create durable change in communities and the larger populations they comprise. Long-term change in the health status of populations must combine personal and institutional accountability.42 As health professionals, we need to remind ourselves of how the people we serve lead their lives. People live in families and larger communities – workplaces, schools, community organizations, and places of worship, among others. The willingness to seek medical care or enroll in a research study is conditioned by interactions with you, physicians and other health care providers, and the barriers that exist in communities at all levels. About half of all cancer patients want the opportunity to participate in research studies, especially intervention trials that may either increase survival or improve quality of life, or both.43-49 Even more people (including both cancer patients and disease-

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Overview free subjects) are willing to participate in observational studies. These studies can help answer the kinds of questions that address our high cancer rates. Despite this, few adult cancer patients actually participate.50-52 Even fewer African American cancer patients choose to participate.53 Therefore, we all must be engaged in cancer prevention and control efforts, including designing studies that are seen by potential participants as desirable and relevant to their lives. South Carolina stands ready to make a significant contribution to cancer research locally, as well as regionally, nationally, and internationally. We all need to work together to make sure that those who are at highest risk of getting cancer and who will suffer the most once they get the disease are being served. We need to encourage dialogue and involvement. We are making progress, but we have a long way to go. Context and collaboration are crucial to addressing the many dimensions and facets of cancer prevention and control and the research needed to drive progress. Founded in 2003, the South Carolina Cancer Alliance (SCCA) is an organization of nearly 900 members, including more than 140 institutional members, and many individual members who are also SCMA members. The SCCA (www.sccanceralliance.org) has been instrumental in acting as an umbrella for many of the cancer prevention and control activities in the state. Unlike any other organization in the US, the SCCA creates a real, statewide focus for cancer prevention and control activities. It is with a sense of appreciation and gratitude that we acknowledge the work of the SCCA and its many affiliates. In particular, we would like to point out work by the South Carolina Department of Health and Environmental Control (DHEC) and its South Carolina Central Cancer Registry (SCCCR). The SCCCR has consistently received the highest ratings from the North American Association of Central Cancer Registries and the National Program of Cancer Registries. Without the dedication of the SCCCR staff and their commitment to excellence, this special issue of The Journal would not have been possible. Besides their work in supporting rigorous use of the registry data by academicians, the SCCCR has a wonderful interface accessible to both health professionals and the lay public who wish to query cancer-related facts. In 2005, we pointed to the South Carolina Cancer Report Card as an example of the kind of excellent collaboration that exists in few, if any, places in the US.54 In developing the 2005 Report Card (see www.sccanceralliance.org), which focused largely on cancer rate differences, the SCCA epidemiologist (Dr. Virginie Daguise) acted as the SCCA liaison to the registry for data requests. This year’s Report Card, which focuses on mortality-to-incidence ratios to identify areas of particularly

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virulent disease and examines policies that have a direct impact on cancer rates, represents an attempt to move beyond mere description of the “cancer problem.” The SCCA is the major partner with DHEC in the development of the new Comprehensive Cancer Control Plan for South Carolina (CCCPSC – also see www.sccanceralliance.org). Our intention for the current plan is to create a living document that can change easily as our knowledge base increases and as we improve in primary prevention, screening, and treatment of cancer. It also is intended that this plan emphasize implementation and be very accessible to researchers, health-care providers, and the general population. Public awareness lays the foundation for accountability in effecting health policy change and, as noted, progress is being made on various fronts in community engagement in South Carolina. However, moving to health policy formulation at a state level is problematic. While state health policies often do have a significant impact on the health of its residents, state policymaking is not highly interactive.55 Public input and awareness tends to be lower at the state level than the federal level and policymaking at the state level is more strongly influenced by special interest groups. African Americans are less likely to participate in the political process than European Americans at both the federal and state levels. Also, the majority of European Americans (67%) are not aware of racial and ethnic health disparities.56 So, to the extent that the clinicians and researchers are willing to create awareness and advocate for those in greatest need of services, we can help to fill the obvious gap. Examples of effective bridging include: 1) the agreement of The Black Caucus of South Carolina Legislators to partner with the SCCDCN (Community Network) to look at ways to reduce cancer health disparities; and 2) South Carolina’s adoption of expanded Medicaid coverage for the treatment of breast cancer; and 3) setting aside $1 million dollars in the state budget for the treatment of breast and cervical cancer. Challenges for the future include moving South Carolina out of the group of 31 states that do not require health insurance companies to pay for colorectal cancer screening (one of three cancers for which we can screen for primary prevention) and having South Carolina become one of the majority of states that have legislation or special agreements requiring health plans to pay for medical care received by clinical trial participants. To our knowledge, a complete analysis of all such policies and programs has never been completed. Just as medical practice is best conducted when based on strong scientific evidence, we believe an assessment of this kind will equip the public and policy-makers with evidence-based in-


Overview formation to inform policy and program directions aimed at reducing cancer disparities in South Carolina. The findings are of some importance because over half of African Americans are poor or near poor, 20% have no health insurance, and inefficiently delivered health care is very expensive.57 This special issue of The Journal of the South Carolina Medical Association represents a major step forward in our commitment to work collectively on a major issue of clinical and public health importance. Along with the South Carolina Cancer Alliance and its affiliates and members (especially SC DHEC) this places us in the vanguard of cancer research and treatment in the United States.

Acknowledgements We would like to acknowledge: • Funding of the South Carolina Cancer Disparities Community Network (SCCDCN) through grant number 1 U01 CA114601-01 from the National Cancer Institute (Community Networks Program); and • The South Carolina Central Cancer Registry (SCCCR) for the state cancer incidence and mortality data provided. The SCCCR is funded by the CDC National Program of Cancer Registries, cooperative agreement number U55CCU421931, and SCDHEC.

References 1. Hebert JR, Ureda JR. Meeting the challenges of cancer prevention and control in South Carolina: Focus on seven cancer sites. J South Carolina Med Assoc 2005;101:e183-e187. 2. US Cancer Statistics Working Group. United States Cancer Statistics: 2001 Incidence. Atlanta (GA): DHHS/CDC/NIH-NCI; 2004. 3. Ferlay J, Bray F, Pisani P, Parkin DM. Cancer Incidence, Mortality and Prevalence Worldwide: International Agency for Research on Cancer, World Health Organization; 2001. 4. Ferlay J, Bray F, Pisani P, Parkin DM. Globocan 2002: Cancer Incidence, Mortality and Prevalence Worldwide. IARC Cancer Base 2004;5(2.0). 5. Madigan MP, Ziegler RG, Benichou J, Byrne C, Hoover RN. Proportion of breast cancer cases in the United States explained by wellestablished risk factors. J Nat Cancer Inst 1995;87(22):1681-1685. 6. Mezzitti M, La Vecchia C, Decarli A, P. B, Talamini R, Franceschi S. Population attributable risk for breast cancer: diet, nutrition and physical exercise. J Natl Cancer Inst 1998;90:389-394. 7. Ward E, Jemal A, Cokkinides V, Singh GK, Cardinez C, Ghafoor A, Thun M. Cancer disparities by race/ethnicity and socioeconomic status. Ca: A Cancer J Clin 2004;54(2):78-93. 8. Schwartz KL, Crossley-May H, Vigneau FD, Brown K, Banerjee M. Race, socioeconomic status and stage at diagnosis for five common malignancies. Cancer Causes Control 2003;14(8):761-766. 9. Chlebowski RT, Chen Z, Anderson GL, Rohan T, Aragaki A, Lane D, Dolan NC, Paskett ED, McTiernan A, Hubbell FA, AdamsCampbell LL, Prentice R. Ethnicity and breast cancer: factors influencing differences in incidence and outcome. J Natl Cancer Inst 2005;97(6):439-448. 10. Krieger N, Chen JT, Waterman PD, Rehkopf DH, Subramanian SV. Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures--the


public health disparities geocoding project. Am J Public Health 2003;93(10):1655-1671. 11. Gordon NH. Socioeconomic factors and breast cancer in black and white Americans. Cancer Metastasis Rev 2003;22(1):55-65. 12. Gadgeel SM, Kalemkerian GP. Racial differences in lung cancer. Cancer Metastasis Rev 2003;22(1):39-46. 13. Harris JR, Brown PK, Coughlin S, Fernandez ME, Hebert JR, Kerner J, Prout M, Schwartz R, White C, Wilson K. The Cancer Prevention and Control Research Network. Prev Chronic Dis 2005;2(1):A21. 14. Freudenburg WR. Perceived risk, real risk: social science and the art of probabilistic risk assessment. Science 1988;242(4875):44-49. 15. Weinstein ND, Nicolich M. Correct and incorrect interpretations of correlations between risk perceptions and risk behaviors. Health Psychol 1993;12(3):235-245. 16. Graham GN, Leath B, Payne K, Guendelman M, Reynolds G, Kim S, James B, Ware D, Hunter M, Burwell A, Buggs G. Perceived versus actual risk for hypertension and diabetes in the African American community. Health Promotion Practice 2006;7(1):34-46. 17. Mullin S. Communicating risk: closing the gap between perception and reality. Journal of Urban Health 2002;79(3):296-297. 18. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Ann Rev Public Health 1998;19:173-202. 19. Lasker RD, Weiss ES. Broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research. J Urban Health 2003;80(1):14-47. 20. Hebert JR, Horner MJD, Adams SA, Daguise VG, Smith EW, Mosley CM, Johnson MG, Reed CE. Esophageal cancer disparities in South Carolina: Early detection, special programs, and descriptive epidemiology. J South Carolina Med Assoc 2005;101:e212-e217. 21. Nguyen AM, Luke CG, Roder D. Comparative epidemiological characteristics of oesophageal adenocarcinoma and other cancers of the oesophagus and gastric cardia. Asian Pacific Journal of Cancer Prevention: APJCP 2003;4(3):225-231. 22. Pera M. Recent changes in the epidemiology of esophageal cancer. Surg Oncol 2001;10(3):81-90. 23. Hebert JR, Kabat GC. Menthol cigarette smoking and esophageal cancer. Am J Public Health 1988;78:986-987. 24. Hebert JR, Kabat GC. Menthol cigarette smoking and Oesophageal cancer: results of a case-control study. Int J Epidemiol 1989;18:3744. 25. Hebert JR, Miller DR, Toporoff ED, Teas J, Barone J. Black-white differences in U.S. cancer rates: a discussion of possible dietary factors to explain large and growing divergencies. Cancer Prev 1991;1:141-156. 26. Hebert JR. Invited commentary: menthol cigarettes and risk of lung cancer. Am J Epidemiol 2003;158(7):617-620. 27. South Carolina Behavioral Risk Factor Surveillance System. South Carolina Department of Health and Environmental Control, 2005. (Accessed 8 August, 2006, at http://www.scdhec.gov/hs/epidata/ BRFSS/2005/_rfsmok3.html.) 28. US Cancer Statistics Working Group. United States Cancer Statistics: 2002 Incidence and Mortality. Atlanta (GA): US DHHS/CDC/ NIH-NCI; 2005. 29. Adams SA, Modayil MV, Daguise VG, Berger SH, Horner MJD, Teas J, Brandt HM, Mitas M, Mosley CM, Johnson MG, Cunningham JE, Butler WM, Hebert JR. Breast cancer disparities in South Carolina: Early detection, special programs, and descriptive epidemiology. J South Carolina Med Assoc 2005;101:e188-e194. 30. Greenwald P. Keynote address: cancer prevention. J Natl Cancer Inst Monogr 1992;12:9-14. 31. Greenwald P. NCI cancer prevention and control research. [Review] [89 refs]. Prev Med 1993;22(5):642-660. 32. Greenwald P, Cullen JW. The new emphasis in cancer control. J Natl Cancer Inst 1985;74(3):543-551. 33. Greenwald P, Sondik E, eds. Cancer Control Objectives for the Nation: 1985-2000, Monograph 2, Publication (PHS) 86-1880. Bethes-

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Overview da, MD: National Cancer Institute; 1986. 34. Greenwald P, Cullen JW, McKenna JW. Cancer prevention and control: from research through applications. J Natl Cancer Inst 1987;79(2):389-400. 35. Bailar JC, Gornick HL. Cancer undefeated. N Engl J Med 1997;336:1569-1574. 36. Rosenkrantz B. Public Health and the State: Changing Views in Massachusetts, 1842-1936. Cambridge, MA: Harvard University; 1972. 37. Palladino P. Discourses of smoking, health, and the just society: yesterday, today, and the return of the same? Soc History Med 2001;14(2):313-335. 38. Kottke TE, Foels JK, Hill C, Choi T, Fenderson DA. Nutrition counseling in private practice: attitudes and activities of family physicians. Prev Med 1984;13:219-225. 39. Hebert JR, Kristeller J, Ockene JK, Landon J, Luippold R, Goldberg RJ, Kalan K. Patient characteristics and the effect of three physiciandelivered smoking interventions. Prev Med 1992;21:557-573. 40. Ockene IS, Hebert JR, Ockene JK, Saperia GM, Stanek E, Nicolosi R, Merriam PA, Hurley TG. Effect of physician-delivered nutrition counseling training and an office support system on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH). Arch Intern Med 1999;159:725-731. 41. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: does it work? Arch Intern Med 1999;159:2198-2205. 42. Neighbors H, Braitwaite R, Thompson E. Health promotion and African Americans: from personal empowerment to community action. Am J Health Promotion 1995;9(4):281-287. 43. Clemow L, Hebert J, Massion A, Fowke J, Druker S, Kabat-Zinn J. A meditation-based stress reduction intervention for women with breast cancer: outcome and 1-year follow-up. Ann Behav Med 1998;20:52S. 44. Merzel C, D’Afflitti J. Reconsidering Community-Based Health Promotion: Promise, Performance, and Potential. Am J Public Health 2003;93:557-574. 45. Motzer SA, Moseley JR, Lewis FM. Recruitment and retention of families in clinical trials with longitudinal designs. West J Nurs Res 1997;19(3):314-333. 46. Sheppard VB, Cox LS, Kanamori MJ, Canar J, Rodriguez Y, Goodman M, Pomeroy J, Mandelblatt J, Huerta EE, Latin American Can-

cer Research C. Brief report: if you build it, they will come: methods for recruiting Latinos into cancer research. J Genl Intern Med 2005;20(5):444-447. 47. Donovan J, Mills N, Smith M, Brindle L, Jacoby A, Peters T, Frankel S, Neal D, Hamdy F. Quality improvement report: Improving design and conduct of randomised trials by embedding them in qualitative research: ProtecT (prostate testing for cancer and treatment) study. Commentary: presenting unbiased information to patients can be difficult. BMJ 2002;325(7367):766-770. 48. Adams-Campbell LL, Ahaghotu C, Gaskins M, Dawkins FW, Smoot D, Polk OD, Gooding R, DeWitty RL. Enrollment of African Americans onto clinical treatment trials: study design barriers. J Clin Oncol 2004;22(4):730-734. 49. Zhu K, Hunter S, Bernard LJ, Payne-Wilks K, Roland CL, Levine RS. Recruiting elderly African American women in cancer prevention and control studies: a multifaceted approach and its effectiveness. J Natl Med Assoc 2000;92(4):169-175. 50. Clinical Trials Program Review Group. Report of the National Cancer Institute Clinical Trials Program Review Group. Bethesda, MD: National Cancer Institute, National Institutes of Health; 1997. 51. Cancer clinical trials: A resource guide for outreach, education, and advocacy. National Cancer Institute, National Institutes of Health, 2001. (Accessed at www.cancer.gov/clinicaltrials/resources/outreach-education-advocacy.) 52. Boosting cancer trial participation. National Cancer Institute, National Institutes of Health, 2002. (Accessed at http://cancer.gov/clinicaltrials/digestpage/boosting-trial-participation.) 53. Christian MG, Trimble EL. Increasing participation of physicians and patients from underrepresented racial and ethnic groups in National Cancer Institute-sponsored clinical trials. Cancer Epidemiol Biomark Prev 2003;12:277-283. 54. South Carolina Cancer Alliance. South Carolina Cancer Report Card, 2004. Columbia, SC; 2005. 55. Weissert C, Weissert W. Governing Health: The Politics of Health Policy. Baltimore: John Hopkins Press; 1996. 56. Race, Ethnicity, and Medical Care: Public Perceptions and Experiences. Menlo Park, CA: Henry J. Kaiser Family Foundation; 1999. 57. Lillie-Blanton M, Rushing O, Ruiz S. Key Facts: Race, Ethnicity & Medical Care. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2003. n

Author Affiliations 1. 2. 3. 4. 5.

Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC Department of Family and Community Medicine, School of Medicine, University of South Carolina, Columbia, SC Statewide Cancer Prevention and Control Program, South Carolina Cancer Center, Columbia, SC Department of Health Services, Policy, and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC Insights Consulting, 2728 Wilmot Ave., Columbia, SC 29205

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The Journal


Lung and Bronchus Cancer Disparities in South Carolina: Epidemiology and Strategies for Prevention Anthony J. Alberg, PhD, MPH 1,2 Marie-Josephe D. Horner, MSPH 3 Virginie G. Daguise, PhD 4,5 Matthew J. Carpenter, PhD 6 Catishia M. Mosley, MSPH 7 Brad Vincent, MD 8 Gerard Silvestri, MD, MS 8 Carolyn E. Reed, MD 1,9 James R. Hebert, MSPH, ScD 1,2,10,11 Cancers of the lung and bronchus are by far the leading cause of cancer death in the United States (U.S.). According to 2006 estimates, the number of deaths from lung cancer will soon surpass the combined total of the next four leading causes of cancer death.1 The projected number of new cases of lung and bronchus cancer in 2006 is 162,460 nationally, with 2,830 of these occurring in South Carolina.1 These 2,830 lung cancer deaths make lung cancer by itself the third leading cause of death in South Carolina, after heart disease and deaths from all other malignancies.3 In the U.S. in 2006, cancers of the lung and bronchus are expected to account for an estimated 29% of all deaths from cancer: 31% among men and 26% among women.2 The proportionate mortality from lung cancer in South Carolina was slightly higher, 31% of overall cancer deaths, 36% in men and 25% in women.2

Address correspondence to: Dr. Alberg, Cancer Prevention and Control Program, Hollings Cancer Center, 96 Jonathan Lucas St., Charleston, SC 29425. Email: [email protected]


The substantial contribution of lung cancer to the overall mortality burden is due to the combined effects of a disease that has a high incidence rate and a poor overall fiveyear relative survival rate of 16%.5 The five-year relative survival rate varies markedly depending on the stage at diagnosis, from 49% to 16% to 2% for local, regional, and distant disease, respectively.5 Stage at diagnosis accounts for the most marked variation in prognosis, but patient characteristics associated with poorer survival also include being older, male, and African American (AA).5 Of South Carolina lung cancer patients who were staged in 2002, approximately 30% were diagnosed with regional disease and 50% were diagnosed with distant disease.2 The distribution of lung cancer by stage at diagnosis does not show marked variation across gender-race subgroups.2 Due to the fact that most lung cancers are diagnosed in late stages and the survival rate for late-stage disease is so poor, lung cancer incidence rates closely parallel mortality rates. Nationally, lung cancer incidence and mortality rates are currently much higher in men than women, but the gap is narrowing as the rates in men have decreased during the past 15 years, whereas the rates in women rose steadily during the past five decades.6 Nationally, the age-adjusted lung cancer incidence rates are 61% higher in men than women (86.4 versus 53.7 per 100,000/year), but this differential is even more pronounced in South Carolina, where the rates in males exceed those in females by 106% (103.1 versus 50.2 per 100,000/ year).2,7 Men in South Carolina have the ninth highest lung cancer incidence rates in the U.S., whereas SC females rank 35th.1

A troubling aspect of the occurrence of lung cancer in South Carolina is that the favorable downward trend in men seen nationally during the past 15 years is not yet discernable. In South Carolina men, there is no evidence of a monotonic downward trend from 1997 through 2002, with the age-adjusted incidence rates (per 100,000) during this period of 107.0, 108.5, 115.6, 107.8, 110.5, and 103.1, respectively.2 Based on historical smoking patterns, the downward trend in nationwide data in men can be expected to continue for approximately another 20 years. Conversely, the epidemic of lung cancer in women has only recently crested, with a decline in lung cancer incidence rates in women anticipated in the coming decades. Lung cancer is the leading cause of cancer death across gender and racial groups, both nationally and in South Carolina (SC). However, the rates vary markedly between population subgroups (Figure 1). In South Carolina in 2002, the highest age-adjusted lung cancer incidence rates were in AA men (107.9 per 100,000/year), with rates in EuropeanAmerican (EA) men, EA women, and AA women that were 6%, 51%, and 63% lower, respectively. The 6% higher ageadjusted lung cancer incidence rates in SC AA than SC EA men (107.9 versus 101.8 per 100,000 per year)2 is narrower than the 24% differential seen nationally (105.7 AA versus 85.6 EA per 100,000 per year in 2002).7 However, while the racial/ethnic disparity among men in South Carolina is less, this is due to higher rates in SC EA than US EA men (not lower rates in SC AA men than US AA men). Nationwide in 2002, the age-

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Lung and Bronchus Cancer Disparities in South Carolina: Epidemiology and Strategies for Prevention

140 Men

Women

Age-Adjusted Incidence Rates per 100,000

120

100

80

60

40

20

0 SC White

US White

SC Black

US Black

Figure 1. Lung and Bronchus Cancer Age-Adjusted Incidence Rates (1998-2002) per 100,000 by Race and Gender in SC, US (2002)

proximately 85% of the lung cancer burden.8 On average, a patient’s individual risk of lung cancer is largely determined by smoking history and age. The smokingassociated risk of lung cancer is extremely strong and follows clear-cut dose-response gradients, increasing with the number of cigarettes smoked per day and the number of years of smoking.8 A current smoker benefits from quitting smoking at any age. Compared to persistent smokers, the risk of lung cancer decreases after smoking cessation and continues to decrease further with longer duration of sustained cessation.9 However, compared to never smokers, the residual risk of lung cancer in quitters lasts many decades,10 indicating the powerful carcinogenic effects of cigarette smoke are exerted broadly across the multi-step pathway of lung carcinogenesis.

adjusted lung cancer incidence rates in AA women were 8% less than in EA women (50.3 versus 54.9 per 100,000 persons/year).7 A greater difference exists in South Carolina, where AA women had rates 24% lower than EA women (40.3 versus 53.0 per 100,000/year);2 the wider gap in SC was a consequence of markedly lower lung cancer incidence rates in SC AA women compared to US AA women. A comparison of age-adjusted lung cancer mortality rates during 2000-2004 in South Carolina yields patterns very similar to the incidence patterns noted above, with a mortality rate 10% higher in AA men than in EA men, whereas the mortality rate in AA women was 30% lower than in EA women. As noted above, mortality rates are a function of both the incidence rates and survival from lung cancer. Nationally during 1995-2001, the five-year relative survival rate was lower in AA compared to EA; 11% lower in men and 15% less in women, and this racial gap persisted across diagnostic stage.5

9% of counties and greater AA mortality rates in 17% of counties (Figure 2 and Figure 3). Among women, compared to state rates for EA women, AA women had significantly lower incidence and mortality rates of lung cancer in approximately 40% of SC counties.

Comparing the county-specific age-adjusted lung cancer rates for SC AA males to the state EA rate revealed a statistically significantly greater AA incidence rate in

Cigarette Smoking: The Predominant Cause

Epidemiology of Cigarette Smoking

The predominant cause of lung cancer is cigarette smoking, which accounts for ap-

In 2004,15 nationwide prevalence of cigarette smoking was 24% in AA males,

184

In summary, a comparison of the patterns of occurrence of lung cancer in South Carolina to the U.S. as a whole reveals three notable features of the SC rates among males: 1) the rates in SC are much higher than the overall national rate; 2) the absence of the downward trend in rates over time, which has been clear and pronounced for over 15 years in the U.S.; and 3) the rates in African Americans are as high as national rates, but the racial disparity in male lung cancer rates in South Carolina (6%) is less pronounced than nationally (24%) due to the very high rates in SC EA men. Among women, in South Carolina the incidence rate in AA women was 24% lower than EA women, considerably less than the 8% difference in rates seen nationally.

The link between cigarette smoking and lung cancer is so strong that population patterns in the historical prevalence of cigarette smoking can be used to predict the future occurrence of lung cancer.11 The epidemic rise in lung cancer rates is closely linked with a two- to three-decade lag in the population prevalence of cigarette smoking.11 Thus, assessing raceand sex-specific smoking prevalence can assist in developing strategies to reduce the burden of disease and can deepen our understanding of racial disparities in lung cancer incidence and mortality. Active cigarette smoking accounts for most of the lung cancer burden, but secondhand smoke exposure is estimated to cause an additional 3,000 lung cancer deaths nationally per year.12 Cigar smoking also is an established cause of lung cancer.13 The lung cancer risks associated with cigar smoking are substantial, but less than the risks observed for cigarette smoking due to differences in smoking frequency and depth of inhalation. The same pattern holds true for pipe smoking.14



24% in EA males, 20% in EA females, and 17% in AA females. National Health Interview Survey data show that among males, AA and EA were equally likely to be daily smokers (21%) but AA males smoked one-third fewer cigarettes per day than EA (14 versus 21 cigarettes per day).16 A similar pattern is evident among women, as only 16% of AA were daily smokers compared to 19% of EA. As in men, AA women who smoked daily smoked fewer cigarettes than their EA counterparts: 12.3 versus 17.0 cigarettes smoked per day, respectively.16 In South Carolina, as in the nation as a whole, it is not understood why the incidence of lung cancer in AA men is higher than in EA men given that the overall daily number of cigarettes smoked is actually lower in AAs. The rates in AA men are higher than would be expected if one were to predict cancer outcomes based on cigarette smoking prevalence and intensity of smoking alone. Results from the Multi-Ethnic Cohort Study provide strong evidence that AA smokers are more susceptible to smoking-induced lung carcinogenesis.17 The reasons underlying this enhanced susceptibility are not known, but research has focused on two different lines of inquiry: 1) the type of cigarettes smoked and 2) intrinsic host factors affecting inter-individual susceptibility to carcinogens in cigarette smoke. With respect to the type of cigarettes smoked, the prevalence of smoking mentholated cigarettes is 69% among African Americans compared to 22% among EA smokers.18 The hypothesis has been proposed that menthol cigarettes may increase the risk of lung cancer even more than non-menthol cigarettes; if so, the greater prevalence of menthol cigarette use in AAs compared to EAs may contribute to the racial disparity in lung cancer incidence rates.18,19 Menthol cigarettes could be associated with greater risk, for example, if smokers of menthol cigarettes inhaled more deeply than smokers of nonmenthol cigarettes because of the local anesthetic effects of menthol.20 Another


Significantly Higher* No Difference Significantly Lower* 1998-2002 SC Rate for White Men = 107.2/100,000 *95% CIs Disjoint

Map Produced by South Carolina Central Cancer Registry PHSIS, SC DHEC (C.M.M.) February 2006

Figure 2. South Carolina Lung Cancer: Comparison of the Age-Adjusted, CountySpecific Incidence Rate for Black Males vs. the Age-Adjusted, State-Specific Incidence Rate for White Males (1998-2002)

Significantly Higher* No Difference Significantly Lower* 1999-2003 SC Rate for White Women = 89.2/100,000 *95% CIs Disjoint


Figure 3. South Carolina Lung Cancer: Comparison of the Age-Adjusted, CountySpecific Mortality Rate for Black Males vs. the Age-Adjusted, State-Specific Mortality Rate for White Males (1999-2003)

mechanistic pathway may be by menthol stimulating an increase in membrane permeability to carcinogens.21 Furthermore, menthol cigarette smokers may have a greater potential for nicotine dependence that undermines successful quitting.19,20 AA smokers are less likely than EA smokers to successfully quit smoking.22 This is despite several lines of evidence showing that AA smokers are more motivated to quit than are EA smokers.16,22 However, the evidence to date suggests that menthol

cigarette smokers do not have a greater risk of lung cancer than non-menthol smokers,23-26 regardless of racial/ethnic group.23,24 Gaps in the evidence have been identified, including that evidence is lacking on this topic from studies conducted in the rural south, where the majority of AAs reside.27 With respect to inter-individual differences in susceptibility, few studies have been designed specifically to make comparisons

185


60

Caucasian

African American

% Ex-Smokers/Ever Smokers

50

40

30

20

10

0 1965

1970

1974

1979

1983

1988

1992

1993

1994

1995

1997

1998

1999

2000

Source: www.cdc.gov/tobacco Note: Years Reflect NHIS Survey Years

Figure 4. Quit Ratio by Race. Source: www.cdc.gov/tobacco. Note: Years reflect NHIS survey years.

between AA and EA. Biomarkers of tobacco carcinogens have been observed to be present in higher concentrations in AA male smokers compared to EA male smokers per unit exposure.28 In a casecontrol study, stronger risks of lung cancer in AA than EA have been observed for phenotypic markers such as mutagen sensitivity and cell cycle arrest.29,30 Despite intensive study of lung cancer risk in relation to polymorphisms in genes, which encode proteins involved in DNA repair and carcinogen metabolism and detoxification,31,33 few studies have made comparisons of these associations in AA compared to EA. In comparison to EA, AA smokers report greater motivation to quit as demonstrated through both self-report and behavioral data. AA smokers are more likely to want to quit smoking and are more likely to make a quit attempt.16,22 Results from the National Health Interview Survey16 show that 45% of AA male smokers vs. 40% of EA male smokers made a quit attempt in the past 12 months. For women, the equivalent rates were 47% vs. 43%. However, although motivation to quit appears to be higher among AAs, this does not translate to successful quitting. In fact, the quit ratio (proportion of ever smokers who have

186

quit) has been consistently lower among AA smokers (Figure 4). The most recent data indicate that 37% of AA smokers have quit, compared to 49% of EAs. Thus, it appears AA smokers may be more motivated to attempt to quit, but less likely to successfully do so. Results of some case-control studies have suggested a potentially higher risk of smoking-associated lung cancer in women compared to men.34 However, the evidence from prospective cohort studies fails to support the notion of a sex-differential in susceptibility to lung cancer from smoking.35 Equal rates of lung cancer mortality exists between younger U.S. men and women, and these rates correspond to a time of equal smoking prevalence. This provides evidence against an important gender difference in susceptibility to smoking-induced lung cancer.36 Current evidence against the gender difference hypothesis outweighs the evidence in favor. This evidence primarily comes from studies demonstrating similar associations between relative risk estimates for men and women for a specific degree of smoking history.35

Additional Risk Factors In addition to tobacco smoke exposure,

many other factors are established causes of lung cancer. A number of agents have been identified as lung carcinogens based on evidence obtained from workers exposed to these substances at relatively high concentrations. These include chromium, nickel, arsenic, asbestos, and radon.37-39 The relative contribution of occupational exposures to the lung cancer burden, though substantial at approximately 10%,6 is diminishing over time. This recent trend is due to steps being taken to minimize workplace exposures as agents are identified as lung cancer risk factors.37 Radon is an inert gas produced naturally from radium in the decay series of uranium. Because it enters buildings in soil gas, it is a common indoor air pollutant. The U.S. Environmental Protection Agency estimates approximately 15,000 to 20,000 lung cancer deaths per year in the United States are caused by radon.40 Studies of radon exposures in residential settings indicate a level of lung cancer risk associated with indoor radon exposure is consistent with this prediction.41 In addition to the known, established causes of lung cancer, many other factors have been studied in relation to risk. The evidence is solidifying that outdoor air pollution contributes to lung cancer risk, and may be responsible for 1-2% of the overall lung cancer burden.42 The identification of lifestyle factors other than cigarette smoking that affect lung cancer risk could expand the menu of options for the primary prevention of lung cancer. Diet and physical activity are examples of factors that have been studied in this regard. The results of case-control and prospective cohort studies have tended to show that individuals with high dietary intake of fruits or vegetables have a lower risk of lung cancer than those with low fruit or vegetable intake.43 Behavioral Risk Factor Surveillance System (BRFSS) survey data reveal that in South Carolina in 2003, the prevalence of eating five or more fruits and vegetables per day was 13% lower in



Table 1. South Carolina 2000 BRFFS data by race and gender: How old were you when you first started smoking cigarettes regularly?* Never Smoked (%)

Ever Smoked (%) < 14 years

15-16 years

17-18 years

>19 years

48

12.8

20.8

25.5

36.2

Male

55

14.7

22.4

25.5

31.9

Female

39

10.8

19.1

25.4

40.8

White

46

13.4

22.4

25.8

33.8

Black

58

6.3

13.0

22.3

52.6

Others

51

28.9

20.4

28.0

17.6

Total Gender

Race

*This question was asked of all respondents who reported smoking 100+ cigarettes in his/her lifetime.

AA than EA,44 documenting a difference between racial/ethnic groups with respect to this potentially protective health behavior. Although protective associations have been observed with increased fruit and vegetable consumption, the specific constituents of fruits and vegetables that might confer protection are unknown. For example, the results of large-scale randomized primary prevention trials now clearly indicate that regular use of dietary supplements containing beta-carotene45-47 or vitamin E48,49 does not protect against lung cancer. In fact, in high-intensity smokers, beta-carotene supplements increased lung cancer risk.45,47 Several studies have reported that more physically active individuals have a lower risk of lung cancer than those who are more sedentary,50 even after adjustment for cigarette smoking. Physical activity has yet to be studied in relation to lung cancer risk in an AA population. To the extent physical activity is relevant to lung cancer, it is worth noting BRFSS survey data indicate that among adults in South Carolina in 2003, the prevalence of getting 20 minutes or more of physical activity on three or more days per week was 18% less in AA than EA.44 As with the assessment of any lifestyle factor other than smoking with lung cancer risk, potential


residual confounding by cigarette smoking must be considered a viable explanation until proven otherwise.

Screening for Lung Cancer Screening for lung cancer has been controversial for over three decades. Early large randomized controlled trials (RCTs) of screening sponsored by the National Cancer Institute (NCI) as well as a Czechoslovakian study tested chest roentgenograms and sputum cytopathologic examination in various combinations. None demonstrated a decrease in lung cancer-related mortality,51-55 the ultimate goal of any lung cancer screening program. It follows from this finding that increased detection of early-stage, resectable lung cancer does not prolong life. Factors such as inadequate statistical power and choice of a control arm are cited as limitations of these trials. Consequently, no cancer-related organization recommends screening for lung cancer. In general, the effectiveness of a lung cancer screening program is enhanced by minimizing the number of invasive tests for confirming a lung cancer diagnosis and by targeting a high-risk population. These steps decrease the unnecessary testing on those without cancer and increasing the yield of the screening program. Advancements in imaging technology

have spurred a renewed interest in lung cancer screening. Low-radiation-dose CT (LDCT) imaging techniques use low levels of ionizing radiation to generate a low-resolution image. This technique is faster and less costly than standard helical CT scanning, but it is approximately four times more sensitive than a standard chest roentgenogram. The hypothesis is that LDCT will detect a lung malignancy at an earlier, and therefore more treatable, stage than the standard chest radiograph. Two observational studies evaluated LDCT in persons who were at high risk of lung cancer due to significant smoking histories. Of all suspicious nodules detected by LDCT, 10-13% were biopsyconfirmed as cancer, and most (53-81%) were stage I.56-59 The detection of a significant number of stage I cancers is a promising finding, but the mortality benefit is currently unknown.60 An important consideration regarding LDCT as a screening tool is that its high sensitivity will result in many false positive test results, leading to the downstream effects of unnecessary invasive testing and surgical procedures. Furthermore, some detected cancers would never have progressed to clinical disease (i.e. overdiagnosis). Whether or not the aggregate morbidity and mortality associated with detecting lung cancers at an early stage with LDCT will be outweighed by reduced lung cancer mortality rates remains to be seen. These questions will be resolved by the NCI-sponsored National Lung Screening Trial (NLST), in which more than 50,000 persons were randomized to either chest radiograph or LDCT for three annual screens. Preliminary results are expected in 2009. The Medical University of South Carolina is a participating site in this study.61 Other screening modalities for lung cancer are under investigation. In one study, lesions over 7mm in size were evaluated with positron-emission tomography (PET) scanning plus LDCT; this combination successfully identified 90% of cancers, but also resulted in biopsies of 50% of false-positive tests.62 Screening with molecular markers, such as volatile

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organic acids and microsatellite DNA alterations detected in exhaled condensate, has recently been tested.63-65 The application of proteomics could potentially generate a specific blood and tissue-specific antibody profile that mirrors the natural history of lung cancer at a molecular level.66,67 The expression pattern of specific microRNAs have been observed to be able to distinguish lung tumors from adjacent normal tissue; if these findings are replicated, this could potentially provide a new strategy for the early detection of lung cancer.68

Conclusions The optimal strategy to bring South Carolina’s epidemic of lung cancer under control is an effective cigarette smoking control program. Because approximately 85% of all lung cancer is attributable to cigarette smoking, lung cancer prevention strategies need to focus on preventing initiation of cigarette smoking among youths and young adults and assisting cessation efforts among current smokers. As seen in Table 1, a substantial proportion (36%) of all smokers and especially African American smokers (53%) in South Carolina began smoking after they turned 19 years old. This indicates a need to target smoking prevention intervention toward young adults. Smoking cessation guidelines outlined by the U.S. Public Health Service identify several tools for quitting.69 Pharmacotherapy, in the form of nicotine replacement therapy (NRT) or non-nicotine products (e.g., bupropion) have been observed to double a smoker’s chance of quitting successfully. The use of NRT is based on the rationale that it reduces withdrawal by supplying nicotine via a less toxic delivery system. NRT products include nicotine patch, gum, lozenge (all available over-the-counter), inhaler, and nasal spray (available through prescription only). Behavior therapy, with or without pharmacotherapy, is also effective for smoking cessation.69 However, use of these cessation aids remains low. Data from the 2000 NHIS indicate that

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78% of smokers who tried to quit in the previous year did not use any of these cessation methods,70 a finding that has been replicated by others.71,72 It is unclear if there is differential use or knowledge of effective cessation aids between AA and EA smokers. Moreover, there is a paucity of studies among AA smokers testing intervention strategies that reflect current state-of the-art techniques.73 For all smokers, quitting results in considerable health benefits in addition to the reduced risk of lung cancer.9 Clinicians must be willing to assist patients with quitting and be actively engaged in preventing young patients from starting to smoke. Unfortunately, evidence suggests that AA smokers are less likely than other racial/ethnic groups to be advised to quit smoking by a physician.74 This is particularly disconcerting because AAs have a more difficult time quitting once they are dependent smokers, and also have a higher risk of cancer for a given exposure to tobacco.17 The potential role of socioeconomic status cannot be overlooked in considering racial/ethnic disparities in the lung cancer burden. Lung cancer is more likely to occur in the poor and less educated, a pattern that has been observed in diverse geographic locations.75-77 Lower socioeconomic status has also been observed to be associated with later stage at diagnosis.78 Socioeconomic status is associated with a constellation of interacting determinants of lung cancer risk, such as smoking, diet, and exposures to inhaled carcinogens in the workplace and general environment. Lower socioeconomic status is associated with an unfavorable profile for all of these factors. Advancing our understanding of the complex linkages between components of socioeconomic status and lung cancer risk is essential to effectively addressing this social class disparity, and reducing lung cancer rates in the poorer segments of society. The central role of cigarette smoking prevention and control efforts to lung cancer

prevention is clear. The evidence to date on the role of other lifestyle factors such as diet and physical activity suggests these may also play a role in affecting lung cancer risk, but the magnitude of the impact is not only less compared to cigarette smoking but it is presently much less well-defined. Achieving a more precise understanding of the role of diet and physical activity in the etiology of lung cancer should be a priority, as these would open up new avenues for prevention. For example, dietary modification could potentially be used to help prevent lung cancer in nonsmokers and help former smokers to further reduce their lung cancer risk. Healthy lifestyle behaviors tend to be correlated, so healthful dietary modifications in smokers could even have downstream effects by increasing the likelihood of smoking cessation attempts. In contrast with other regions in the U.S., in the Southeast, AAs constitute a very high proportion of rural residents. South Carolina is a relatively rural state; over 40% of rural residents are AA. It also is a relatively poor state, with the average personal income only approximately fourfifths of the national average.79 These factors converge to create racial and geographic disparities in health care, which may at least partly explain the disproportionately high cancer rates of AAs, who represent 31% of South Carolina’s total population.80 Tobacco control strategies must be developed for South Carolina’s substantial rural population. Compared to the urban population, South Carolina’s rural population tends to be older, less educated, poorer, receive less preventive care, and have fewer physician visits.81,82 Rural residents tend to adopt a more fatalistic outlook toward developing cancer than their urban counterparts.83,84 Racial disparities in prognosis and late stage at diagnosis of lung cancer may be magnified by these characteristics associated with residing in rural areas. Rural and urban populations in the Southeast have been observed to differ with regard to higher smoking rates and their knowledge as well as attitudes about the dangers of sec-



ondhand smoke.85 Also, rural populations are less likely to participate in smoking cessation programs because of the lack of community-based health resources and programs.85 Establishing culturally sensitive tobacco control interventions within minority communities in general, and specifically in rural minority communities, will be pivotal to effective control of cigarette smoking in South Carolina. Examples of strategies are those designed to develop a minority lay health educator network, church-based cessation programs, and culturally appropriate self-help materials. Lung cancer accounts for such a large proportion of the overall burden of cancer mortality in South Carolina that lung cancer control efforts need to be the centerpiece of South Carolina’s overall cancer control strategy. Among males, lung cancer rates in AAs exceed those in EAs, and the reasons for this disparity are not understood. Research is needed to test new hypotheses to help better understand the persistent excess in lung cancer rates in AAs compared to other racial/ethnic groups so that this disparity can be eliminated. Substantially reducing the high rates of lung cancer in South Carolina will require preventing youths from starting to smoke cigarettes and effectively promoting smoking cessation among dependent smokers.

Acknowledgement We acknowledge the South Carolina Central Cancer Registry (SCCCR) for the state cancer incidence and mortality data provided. The SCCCR is funded by the CDC National Program of Cancer Registries (cooperative agreement U55CCU421931) and SCDHEC. We also acknowledge funding of the South Carolina Cancer Disparities Community Network (SCCDCN) through grant number 1 U01 CA114601-01 from the National Cancer Institute (Community Networks Program), and grant R01 CA105069 from the National Cancer Institute, and grant H75/CCH424532 from the CDC. The


contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the agencies that have funded this work. The authors also wish to thank the peer reviewers of an earlier version of this manuscript for their valuable comments.

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Author Affiliations

1. Statewide Cancer Prevention and Control Program, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 2. Department of Biostatistics, Bioinformatics, and Epidemiology, Medical University of South Carolina, Charleston, SC 3. Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD. *Work carried out while at the South Carolina Cancer Center, Columbia, SC 4. South Carolina Cancer Alliance, Columbia, SC 5. SC Department of Health and Environmental Control, Bureau of Community Health and Chronic Disease. Prevention, Columbia, SC 6. Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 7. South Carolina Central Cancer Registry, South Carolina Department of Health and Environmental Control, Columbia, SC 8. Department of Medicine, Division of Pulmonary and Critical Care Medicine, Division of Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC 9. Department of Surgery, Medical University of South Carolina, Charleston, SC 10. South Carolina Cancer Center/University of South Carolina, Columbia, SC 11. Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC


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The Journal


Head and Neck Cancer Disparities in South Carolina: Descriptive Epidemiology, Early Detection, and Special Programs Carolina, the most common of the OPCA K. Lawrence Yen, MD 1,2 sites in 2002 was the tongue (27.1%), alMarie-Josephe D. Horner, MSPH 3 though cancers occurring on the gums Susan G. Reed, DDS, MPH, DrPH 4 (15.9%) and the tonsils (12.4%) are also quite common.2 Virginie G. Daguise, PhD 5,6 Susan W. Bolick-Aldrich, MSPH, CTR 7 Descriptive Epidemiology Oral cancer is the fifth common canM. Rita I. Young, PhD 8,9 cer in the world,3 culminating in over 9,10 Terry A. Day, MD 600,000 new patients annually. Its inciPatricia A. Wood, M.D, PhD11,12 dence is particularly high in many counJames R. Hebert, MSPH, ScD 2,10,13 tries in Asia, such as India, Papua New Head and neck cancer includes mainly squamous cell carcinomas of the upper aerodigestive tract. These are usually sub-classified into multiple site groupings including the two most prevalent, oral and pharyngeal cancer (OPCA) and laryngeal cancer (LCA). OPCA comprises the majority of head and neck cancers, while LCA comprise approximately one-third of cases. In the United States (U.S.), these cancers account for three percent of all cancers diagnosed annually.1 OPCA is a generic term that applies to cancers diagnosed on lip, mouth (including tongue, buccal, upper and lower gums, hard palate, and floor of mouth), and pharynx (including oropharynx and hypopharynx; generally including nasopharynx, although nasopharyngeal cancer is not tobacco-related); while LCA is further divided into cancers of the supraglottis, glottis, and subglottis. In South Address correspondence to: Dr. Day, Department of Otolaryngology-Head and Neck Surgery, Hollings Cancer Center, Medical University of South Carolina, 86 Jonathan Lucas St., Charleston, SC 29425. Email: [email protected].

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Guinea and Taiwan, and certain places in the Western hemisphere, including parts of France and Brazil. Like lung cancer, head and neck cancers are traceable primarily to tobacco use. However, for these sites, smokeless tobacco (e.g., chewing) are also important, as studies in Asian populations clearly indicate.4-9 Chewing of tobacco products, in addition to smoking in various forms, is primarily responsible for the high incidence in India.10,11 By contrast, in the Western hemisphere, tobacco smoking and alcohol drinking are major risk factors. In the U.S., the way the tobacco is chewed predisposes to cancer of the floor of mouth, or “snuff dipper’s cancer.” Relative to the other regions in the nation, cancer of this site is particularly prevalent in the Southern states.12 Also in contrast to lung cancer, the combined carcinogenic effect of alcohol drinking with tobacco smoking has been well established from a variety of epidemiologic studies and reviews.1317 Therefore, in addition to chewing betel quid with tobacco and tobacco smoking, the International Agency for Research on Cancer (IARC) identifies alcoholic beverages as human carcinogens that target the oral cavity and pharynx.13-15 In the US, about three-quarters of the risk for

OPCA can be attributed to alcohol and tobacco use.16 Nutritional risk factors also have been implicated in cancers of the oral cavity. A number of studies have indicated that the consumption of vegetables and fruits reduces risk. These relationships may be independent of other risk factors and often evince a dose-response pattern.1720 Studies have reported that low intake of fruits and vegetables are associated with increased risk of OPCA.21-23 The positive association of low serum levels of B-vitamins, including folate, with oral lesions has also been studied.24 However, there is considerable potential for confounding, and this may be difficult or impossible to control in most epidemiologic studies on the subject.25 Work previously conducted in India was able to overcome some of these methodological difficulties and has shown that dietary factors can modify risk – often by antagonizing the effect of tobacco.26-28 Taken together, tobacco use, alcohol consumption, and poor diet probably account for over 90% of cases of OPCA cases worldwide.29 Diet clearly has an impact on oral health. It is believed that dietary intervention strategies may be effective in the prevention of OPCA. The role of diet needs to be further explored in the context of OPCA incidence in South Carolina. In addition, viruses may also play an etiological role. For example, human papillomavirus (HPV) is considered an independent risk factor associated with some of the incidence of OPCA, especially those of tonsillar origin.30-32 Work is needed to


Head and Neck Cancer Disparities in South Carolina: Descriptive Epidemiology, Early Detection, and Special Programs

Age is a non-modifiable risk factor for OPCA and LCA. There is an increased incidence rate in people over 40 years of age. Genetics is another non-modifiable risk factor. However, there is less research available about the genetics of OPCA than there is for many other cancer sites. On-going research may help to shed light on this.33 Additionally, there is interest in a possible molecular link to P53 isoforms.34 Clearly, we need to understand much more about the etiology of these cancers, while at the same time intervening on factors that we know can affect disease outcome. Over 30 years ago, men were five times as likely as women to be diagnosed with OPCA. However, as with lung cancer, with the rise in the consumption of tobacco by women in this country, this gap has diminished to the point where OPCA is now only twice as common in men as in women.35 OPCA is the eleventh most commonly diagnosed cancer among South Carolinians. During the period 1997 – 2002, the overall age-adjusted incidence rate for men was 19.6 per 100,000 persons/year, while in women it was 6.8 per 100,000. Similarly, age-adjusted rates for LCA in men are far higher than those in women (men = 10.4 per 100,000, women = 1.8 per 100,000). There also is a large disparity between races in the incidence of OPCA. In 1997-2002 the age-adjusted incidence rate in Black or African American (AA) men was 44.5% higher than the rate in White or European American (EA) men.2 Nationally, this disparity is around 18%. Although smaller in absolute terms than the esophageal cancer disparity (80% in South Carolina vs. 55% nationally),36 it is larger in proportional terms (i.e., 44.5% is about 2.5 greater than 18%). As seen


30 White

25.69


define the basic epidemiology and etiology of this category of disease in order to develop optimally effective prevention strategies, such as HPV vaccines.

Black

25

20 17.78

15

10 6.83

6.3

5

0 Men

Women

Figure 1. OPCA Age-Adjusted Incidence (1997-2002) Rates per 100,000 in SC by Race and Gender

in Figure 1, from 1997-2002, OPCA incidence rates were far greater in AA men than any other group. This large differential exists in South Carolina despite the relatively low rate of tobacco use in AA men in this state.37-41 The age-adjusted incidence rates in women are similar and considerably lower for women of both races, standing at 6.8/100,000 for EA women and 6.3/100,000 for AA women. Laryngeal cancer incidence follows the same trend, with AA men having the highest age-adjusted incidence (14.6/100,000) followed by EA men (9.2/100,000) and women, who have much lower incidence rates (AA women 1.8/100,000, EA women 1.8/100,000). Additionally, by stage at diagnosis, a larger proportion of newly diagnosed EA cases present at early local stages compared to AA (Figures 2-5). Similarly, EA men (37%) are more likely to be diagnosed at early local stages of OPCA than AA men (20%), and EA women (48%) are more often diagnosed at early stages than AA women (29%). The OPCA incidence rates by county seem to be evenly distributed geographically for both AA and EA men when

county rates were compared to their respective national average rates (Figures 6-7). However, mortality rates differed widely by county. The highest are in Kershaw (6.7 per 100,000), Sumter (6.5 per 100,000) and Orangeburg counties (5.9 per 100,000). As can be seen in Figure 8, for EA men, the mortality rates are quite comparable to the national average for EA men; while the mortality burden carried by AA men in several South Carolina counties far exceeds that of AA men in the rest of the nation (Figure 9). In the United States, the overall five-year survival rate during the years 1995 to 2001 is 59.4%. For localized disease, the five-year survival is 82.1% (83.9% for EA men, 59.8% for AA men), and 51.3% (53.1% for EA men, 31.3% for AA men) in regional disease; the five-year survival rates drops dramatically for distant disease to 27.6% (25.2% for EA men, 22.5% for AA men).35 In South Carolina, the incidence rate of patients diagnosed in late stages is 7.1 per 100,000 for OPCA and 2.0 per 100,000 for LCA. These numbers are more dramatic when comparing AA men who have an incidence rate of 18.0 per 100,000 for OPCA and 6.6 per 100,000 for LCA presenting in late stages.

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Distant 6%

Unstaged 7%

Unstaged 9%

Local 20%

Distant 11% Local 37%

Regional 60%

Regional 50%

Figure 2. OPCA Stage at Diagnosis in SC among White Men, 1997-2002

Unstaged 10% Distant 6%

Local 48%

Regional 36%

Figure 3. OPCA Stage at Diagnosis in SC among Black Men, 1997-2002

Unstaged 10% Distant 8%

Local 29%

Regional 53%

Figure 4. OPCA Stage at Diagnosis in SC among White Women, 1997-2002

Figure 5. OPCA Stage at Diagnosis in SC among Black Women, 1997-2002

The South Carolina OPCA mortality rates have been on a steady decline for EA men, EA women, and AA women since 1978. However, the mortality rate for AA men in the same period remained relatively constant. Over this period, men were more than twice as likely to die from one of these cancers as women. Mortality rates from OPCA and LCA show similar racial disparities.

est oral and pharyngeal cancer mortality rate with 11.8 deaths per 100,000/year, nearly three times greater than the rate in EA men (4.2 per 100,000/year). No doubt, the observed mortality disparities are partly explained by the stage distribution at the time of resection. However, it is not clear how much of the mortality difference would remain after taking this into account.

Overall, South Carolina ranks third in the nation in oral and pharyngeal cancer mortality;2 the 1999-2004 age-adjusted rate of 3.6 per 100,000/year is 29% higher than the national average. There were a reported 517 incident cases that occurred in 2002 and 158 deaths in 2004. In 2002 there were 223 incident cases and 64 deaths in 2004 from LCA in South Carolina. AA men have the high-

Clearly, there is a need for additional research to understand why incidence and mortality rates are higher in AAs than in EAs, given the difference in exposure types and overall lower exposure to known agents in AAs. The high rates in our state compared to other states along with the unexplained differences, underline the need for increased research in this area.

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Recommendations for Oral/ Pharyngeal Cancer Screening Oral and pharyngeal cancer often is preceded by asymptomatic oral precancerous lesions and conditions.4 Moreover, the risk of oral cancer in individuals with oral precancerous lesions has been demonstrated to be very high relative to those without such lesions, even after controlling for the use of tobacco.5 The association of oral precancerous lesions with tobacco habits follows a pattern similar to that of oral cancer.6 Because the prevalence of oral precancerous lesions is much higher than that of oral cancer, these lesions provide useful surrogate markers for oral cancer in the clinical setting. As such, they are very useful for screening and have been used in largescale intervention trials.10 The oral cavity is one of few sites where screening is both an effective secondary preventive measure (i.e., where cancerous lesions detected can be treated at an early stage) and as a true primary preventive measure (i.e., where lesions can be detected in the precancerous stage and an incident cancer can be prevented altogether). The extent of tumor involvement at diagnosis is a strong predictor of survival. The five-year relative survival rates for OPCA are three times greater when diagnosed in the early stages than late stages (81.5% for localized disease patients vs. 27.6% for patients with distant disease).35 Unlike many cancers for which simple visual examination is impossible and palpation may be difficult, cancers of the oral and pharyngeal regions are relatively accessible. Indeed, the accessibility of the sites formed the basis for work conducted in very high-risk populations in India, which described both the epidemiology of oral cancer and the process of malignant transformation.5-9 Despite the accessibility of the oral cavity to visual inspection and sample collection, according to the most recent Surveillance, Epidemiology, and End Results (SEER) report for the years 1995-2001, only 34% of oral and pharyngeal can-



cers are diagnosed in the localized stage. Once the patient experiences symptoms from the cancer, such as pain, bleeding, ulceration, a mass or dysphagia, it usually heralds a more advanced stage of disease. These patients are then deprived of the optimal survival and minimal dysfunction that is awarded in clinical scenarios when early-stage disease is diagnosed. The discouraging fact is that the proportion of localized disease at diagnosis has not changed since 1973, indicating that efforts at early detection have not been successful or have been targeted inappropriately.42 Systematic review of the literature has failed to find conclusive evidence to support or refute the use of visual examination as a method of screening for oral cancer in the general population. Other adjunctive methods of screening, including toluidine blue, fluorescence imaging, or brush biopsy also failed to demonstrate either benefit or harm.43 Review of community-based screening programs also has failed to demonstrate the effectiveness of such endeavors. Low general population prevalence of oral premalignant and malignant lesions has been cited as a possible reason.44 However, programs that target high-risk populations and obtain good compliance from the selected individuals suggest that oral cancer screening can result in improved survival.45,46 Opportunistic screening in high-risk groups, particularly heavy drinkers and smokers, may result in down-staging of disease. In one study on opportunistic screening, the proportion of stage I cancers increased from 22.8% to 48.2% of cases while stages II, III, IV decreased from 77.2% to 58.8% of cases.47 Another explanation for the discrepancy in the evidence for visual screening may be due to the commitment and motivation of the examiners, physicians, and dentists. Underlining some of the difficulties in screening, it has been found that some clinicians consistently find early asymptomatic cancers while others examining the same population do not.48


Significantly Higher* No Difference Significantly Lower* US Rate (2002) = 15.3/100,000 *95% CIs Disjoint


Figure 6. South Carolina Oral and Pharyngeal Cancer: Comparison of Age-Adjusted Rates, County-Specific Incidence Rates per 100,000 (1998-2002) in White Males, Compared to the US Rate Among White Males (2002)

Significantly Higher* No Difference Significantly Lower* US Rate (2002) = 17.5/100,000 *95% CIs Disjoint Map Produced by South Carolina Central Cancer Registry PHSIS, SC DHEC (C.M.M.) February 2006

Figure 7. South Carolina Oral and Pharyngeal Cancer: Comparison of Age-Adjusted Rates, County Specific Incidence Rates per 100,000 (1998-2002) in White Males, Compared to the US Rate Among White Males (2002)

Precancerous lesions have been found to outnumber frank oral cancers up to several hundred-fold in screened populations.26-28 Individuals diagnosed with precancerous oral lesions would have a special incentive for quitting, although they may require more intensive, specialized help for successful cessation. The effectiveness of community-based screenings may be enhanced if early detection of premalignant lesions could be coupled with treatment to prevent malignant transformation.44 Chemoprevention

is the use of pharmacologic or natural agents that inhibit the development of invasive cancer. These agents function by preventing the transformation of premalignant leukoplakia into malignant lesions. There is growing interest in chemoprevention because of the severe morbidity and mortality associated with invasive head and neck cancer. Presently, no effective chemo-protective treatments have been established from randomized clinical trials.49 Non-steroidal anti-inflammatory drugs (NSAID) are

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cancer detection; however, it encourages primary care physicians to perform an examination of the whole mouth as part of a routine cancer-related checkup.1

Significantly Higher* No Difference Significantly Lower* No Deathc

US Rate (2002) = 3.9/100,000 *95% CIs Disjoint


Figure 8. South Carolina Oral and Pharyngeal Cancer: Comparison of Age-Adjusted Rates, County-Specific Mortality Rates per 100,000 (1998-2002) in White Males, Compared to the US Rate Among White Males (2002)

The American Dental Association (ADA) conducted a public service campaign in late 2001 to raise the awareness of oral cancer in U.S. adults and the role of the dentist in early detection.52 In 2003, the ADA launched a campaign urging dentists to examine patients for signs of early cancer. In tandem, a fiveyear, $1.2 million grant from the National Cancer Institute was awarded to train dentists in oral cancer screening.53 The NIH National Institute of Dental and Craniofacial Research currently supports research on salivary biomarkers for early detection of OPCA.54

Special Projects Addressing Screening in South Carolina

Significantly Higher* No Difference Significantly Lower* US Rate (2002) = 6.3/100,000 *95% CIs Disjoint Map Produced by South Carolina Central Cancer Registry PHSIS, SC DHEC (C.M.M.) February 2006

Figure 9. South Carolina Oral and Pharyngeal Cancer: Comparison of Age-Adjusted Rates, County-Specific Mortality Rates per 100,000 (1998-2002) in Black Males, Compared to the US Rate Among Black Males (2002)

a promising class of chemopreventive agents that act on the COX-2 pathway in several cancers, but further research is needed to understand the molecular mechanisms of action in oral premalignant lesions.50 Clearly, because the main risk factors for cancer are well known, there is good scope for prevention simply by encouraging cessation of tobacco use and reducing or eliminating the consumption

196

of alcoholic beverages. The U.S. Preventive Services Task Force (USPSTF) states that there is insufficient evidence to recommend for or against routine screening for OPCA for low-risk individuals but advocate educational programs directed towards reducing the use of tobacco and alcohol.51 For individuals at high risk of oral cancer, the USPSTF recommends regular dental examinations. The American Cancer Society (ACS) has no official guidelines for oral

Through efforts supported by the Centers for Disease Control, South Carolina Department of Health and Environmental Control-South Carolina Central Cancer Registry (DHEC-SCCCR), South Carolina Cancer Alliance (SCCA), and the Head and Neck Tumor Program at the Medical University of South Carolina (MUSC) Hollings Cancer Center, a statewide collaborative was initiated in 2001 to improve the prevention and early detection of oral cancers in South Carolina. South Carolina was one of two states awarded funds for the Cancer Surveillance Research Oral/Pharynx Cancer Project (U58/CCU420312 – Part IV of PA 01102). The purpose of this threeyear study was to assess the completeness, timeliness, and quality of the registry’s oral and pharyngeal cancer surveillance data. It is suspected that oral and pharyngeal cancer diagnoses may be routinely underreported. Preliminary analyses of South Carolina data using standardized incidence/mortality ratios points to under-ascertainment of cases in South Carolina border counties. Special focus was given to these counties



as well as those categorized as medically underserved in the state. The SCCCR selected and applied methods to assess and improve data collection, reliability, and validity that will accommodate any distinct attributes of oral/pharyngeal cancer data. Methods included audits for coding reliability and validity across all hospital cancer registries in the state, reabstracting and case-finding audits. Results thus far reveal that problems with missed cases arise from diagnoses and treatments provided in physician offices and not reported to the cancer registry, miscoding of cases by physicians and registrars resulting in inaccurate case counts, and possible missed diagnoses in rural populations. In response, the SCCCR established an Oral Cancer Advisory Team (OCAT) to guide the study efforts and provide support for the applied improvements in the clinical community. Dr. Terry Day at MUSC chairs this group of clinicians and epidemiologists. Pathology laboratories specializing in oral /maxillofacial pathology that were not routinely reporting their cases to the cancer registry have been identified both in and out of South Carolina. The study was completed in September 2004. Additional results are expected when the case-finding audits are completed and final analyses are done. However, the OCAT is seeking alternate funding in order to further improve on the data quality of the registry. In 2002, with the support of MUSC Hollings Cancer Center and assistance of the South Carolina DHEC, a study to assess the self-reported baseline rates of oral cancer examinations of the adults of South Carolina was conducted using the cross-sectional South Carolina Behavioral Risk Factor Surveillance System (SC BRFSS) mechanism.55 The oral cancer examination questions were those used in previous national surveys. The prevalence for having had an oral cancer screening in the past twelve months for those 40 years and older, was 14.5% for South Carolina compared to 13% in the


U.S.56 The U.S. Healthy People 2010 Objective 21-7 is to have an annual oral cancer examination for at least 20% of adults aged 40 years and older.57 South Carolina’s results also showed that increasing income was directly related to having had an oral cancer examination and to having had the oral cancer examination within the past year. When asked what type of medical care personnel performed the examination, 70% reported “dentist,” followed by 20% reporting “doctor/physician”, and 5% reporting “dental hygienist.” One of the conclusions was that intervention is necessary to increase the proportion of South Carolina adults who, in the past 12 months, receive an examination to detect oral cancers. We also note that special measures may be needed to reach the population at highest risk of oral cancer. To assess the quality of training of future health care professionals in this state receive, studies were performed on South Carolina dental58 and medical59 students, focusing on students’ knowledge of signs and symptoms of oral cancer, tobacco cessation techniques, and the ability to perform oral cancer examinations. These studies have suggested a need for further improvements on the curriculum pertaining to oral cancer early detection and prevention. South Carolina medical and dental students need additional training to increase knowledge of risk factors, knowledge of signs and symptoms and to improve examination skills to improve oral cancer detection and prevention. It has also been suggested that dental students be required to conduct oral examination as part of their certification.

Special Projects on Epidemiology Research in South Carolina In 2004, the Centers for Disease Control awarded the MUSC Hollings Cancer Center a grant to reduce the impact of tobacco-related malignancies in South Carolina, including oral and oropharyngeal cancer. This grant includes statewide

collaboration, combining groups at the Medical University of South Carolina, the University of South Carolina, and DHECSCCCR to further expand existing efforts. Epidemiology and health services delivery research addressing health disparities are currently in progress. A statewide rapid case ascertainment (RCA) system to identify new patients quickly is being implemented at the SCCCR in order to facilitate patient recruitment for future statewide population-based research. The long-term goal is to conduct a cross-site case-control study that examines sections of tumors and looks at biological differences in the case series. This may provide some explanation for the differences in incidence rates between EAs and AAs, and the factors that negatively influence incidence. A better understanding of the biologic and genetic contributions to the racial disparity in incidence and mortality would allow for more precise adjustments in future disparity research in the social context. As noted for prostate cancer,60 South Carolina provides an ideal context to examine heretofore neglected factors that may have an impact on oral cancer incidence. The possible interaction of geological factors with underlying biological factors, such as metal transporter gene expression by race, needs to be explored in South Carolina.61,62 Much of South Carolina’s AA population resides in rural areas that contain unique water and mineral concentrations. A population-based study that examines these regions in South Carolina will allow testing of novel hypotheses connecting high concentrations of zinc, iron and copper with oral cancer incidence. This will allow us to bring together considerable expertise ranging from geography information system (GIS) surveillance mapping and spatial statistics to basic biology and genetics.

Innovative Treatment/ Basic Science Research Treatment for early-stage tumors typically involves surgery or radiation, whereas advanced-stage disease requires combi-

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nation therapy. As with many cancers, OPCA is highly curable if the disease is treated in the early stages of development. The addition of radiation-sensitizing chemotherapy drugs during radiotherapy, otherwise known as concomitant chemo-radiotherapy (CCRT), have shown marked improvements in survival of head and neck cancer patients when compared with radiotherapy alone.63-65 Several new drugs have been developed that show promise utilizing this multidisciplinary approach. One such agent is cetuximab, a monoclonal antibody antagonist of the epidermal growth factor receptor (EGFR), which showed significant locoregional control and survival advantages in a recent large scale clinical trial.66 Unfortunately, most patients continue to be diagnosed in advance stages, resulting in poor survival rates. Extent of treatment is typically stage related and thus, treatment-related morbidity including problems with speech, swallowing, chewing and cosmetic deformities are aggravated with advanced disease stage. Novel therapeutic approaches such as immune therapy have gained recent interest as a possible alternative treatment. OPCA patients have profound immune defects that are associated with increased recurrence. A reduced T-cell proliferative capability to mitogenic stimulation have been associated with a poorer outcome for OPCA patients.67 While OPCA cells are able to directly inhibit anti-tumor immune defenses, they also induce the appearance of immune inhibitory cells. Studies from the laboratory of Young et al.68 examining South Carolina patients have shown that the OPCA can skew immune responses towards less effective anti-cancer reactivity. Their studies have also shown that OPCA stimulate an increase in the number of bone marrowderived progenitor cells having immune inhibitory activity.69 Clinical trials using vitamin D3 analogs in patients with late-

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stage OPCA showed the feasibility of diminishing the levels of these immune inhibitory cells and restore immune competence by inducing differentiation of these cells into immune stimulatory cells.70 Trials are currently open to determine if treatment with vitamin D3 analogs can stimulate immune reactivity against the OPCA within the tumor mass. In the clinical arena, the Head and Neck Tumor Program at MUSC Hollings Cancer Center has a group of over 100 clinicians as members that provide a comprehensive multidisciplinary program aimed at improving the surgical, radiation, chemotherapy, speech, swallowing, dental, and many other important aspects of head and neck cancer care. Other centers of excellence for multidisciplinary care include the Dorn VA Medical Center in Columbia, the Cancer Center of the Carolinas in Greenville and the Gibbs Regional Cancer Center in Spartanburg. Clinical trials are also available at most of these sites. OPCA survival rates have not improved significantly in decades, despite many advances in surgical techniques, technology, radiation therapy, and chemotherapy. In recent years, research into the causes of racial differences in treatment suggests that more equitable receipt of cancer treatment may help reduce racial disparities in cancer morbidity, and survival from OPCA.71

Summary Recognizing that relatively easily detected precancerous lesions precede many cancers, there is a need to investigate the effectiveness of early interventions on the reduction of incidence rates in welldesigned large randomized control trials. If early detection can reduce mortality rates of OPCA, evaluation of the capacity of dentists and physicians to screen or detect precancerous lesions related to oral cancers may have merit. Presently, there is a paucity of research regarding ecological barriers in the healthcare sys-

tem, and improving access to adequate dental and medical care among the rural minority population in South Carolina certainly deserves emphasis. Additional research, specific to South Carolina, which includes comprehensive assessment of multiple social, behavioral, and biological factors, is needed. Interdisciplinary collaboration will be particularly important to dissect key factors contributing to the racial disparities observed in South Carolina. These differences should be taken into account while recommending and implementing public health strategies for the control of these cancers.

Acknowledgement We would like to acknowledge funding of the South Carolina Cancer Disparities Community Network (SCCDCN) through grant number 1 U01 CA11460101 from the National Cancer Institute (Community Networks Program), grant H75/CCH424532 from the CDC, and the South Carolina Central Cancer Registry for the state cancer incidence and mortality data provided. The SCCCR is funded by the CDC National Program of Cancer Registries, cooperative agreement number U55CCU421931, and SCDHEC. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the agencies that have funded this work.

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Head and Neck Cancer Disparities in South Carolina: Descriptive Epidemiology, Early Detection, and Special Programs precancerous lesions in India with special reference to nodular leukoplakia. Cancer 1989;63:2247-52. 6. Gupta PC, Mehta FS, Daftary DK, Pindborg JJ, Bhonsle RB, Jalnawalla PN, et al. Incidence of oral cancer and natural history of oral precancerous lesions in a 10-year follow-up study of Indian villagers. Community Dent Oral Epidemiol 1980;8:287333. 7. Mehta FS, Gupta PC, Daftary DK, Pindborg JJ, Choksi SK. An epidemiologic study of oral cancer and precancerous conditions among 101,761 villagers in Maharashtra, India. Int J Cancer 1972;10:134-41. 8. Mehta FS, Pindborg JJ, Gupta PC, Daftary DK. Epidemiologic and histologic study of oral cancer and leukoplakia among 50,915 villagers in India. Cancer 1969;24:832-49. 9. Murti P, Bhonsle R, Pindborg J, Daftary D, Gupta P, Mehta F. Malignant transformation rate in oral submucous fibrosis over a 17 year period. Community Dent Oral Epidemiol 1985;13:340-1. 10. Gupta PC, Mehta FS, Pindborg JJ, Bhonsle RB, Murti PR, Daftary DK, et al. Primary prevention trial on oral cancer in India: a 10-year follow-up study. J Oral Pathol Med 1992;21:433-9. 11. Gupta PC, Ray CS. Smokeless tobacco and health in India and South Asia. Respirology 2003;8:419-31. 12. Winn DM, Blot WJ, Shy CM, Pickle LW, Toledo A, Fraumeni JF. Snuff dipping and oral cancer among women in the southern United States. N Eng J Med 1981;304:745-9. 13. IARC Monograph. Alcohol drinking. Lyon: International Agency for Research on Cancer; 1989. 14. IARC Monograph. Betel-quid and arecanut chewing. Lyon: International Agency for Research on Cancer; 2004. 15. IARC Monograph. Tobacco and involuntary smoking. Lyon: International Agency for Research on Cancer; 2004. 16. Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston-Martin S, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res 1988;48:3282-7. 17. Franco EL, Kowalski LP, Oliveira BV, Curado MP, Pereira RN, Silva ME, et al. Risk factors for oral cancer in Brazil: a case-control study. Int J Cancer 1989;43:992-1000. 18. Marshall J, Graham S, Mettlin C, Shedd D, Swanson M. Diet in the epidemiology of oral cancer. Nutr Cancer 1982;3:145-9. 19. McLaughlin JK, Gridley G, Block G, Winn DM, Preston-Martin S, Schoenberg JB, et al. Dietary factors in oral and pharyngeal cancer. J Natl Cancer Inst 1988;80:1237-43. 20. Winn D, Ziegler R, Pickle L, Gridley G, Blot W, Hoover R. Diet in the etiology of oral and pharyngeal cancer among women from the Southern United States. Cancer Res 1984;44:1216-22. 21. La Vecchia C, Negri E, D’Avanzo B, Boyle P, Franceschi S. Dietary indicators of oral and pharyngeal cancer. Int J Epidemiol 1991;20:39-44. 22. Oreggia F, De Stefani E, Correa P, Fierro


L. Risk factors for cancer of the tongue in Uruguay. Cancer 1991;67:180-3. 23. Franceschi S, Barra S, La Vecchia C, Bidoli E, Negri E, Talamini R. Risk factors for cancer of the tongue and the mouth. A case-control study from northern Italy. Cancer 1992;70:2227-33. 24. Ramaswamy G, Rao VR, Kumaraswamy SV, Anantha N. Serum vitamins’ status in oral leucoplakias--a preliminary study. Eur J Cancer B Oral Oncol 1996;32B:120-2. 25. Marshall JR, Boyle P. Nutrition and oral cancer. Cancer Causes Control 1996;7:101-11. 26. Gupta PC, Hebert JR, Bhonsle RB, Sinor PN, Mehta H, Mehta FS. Dietary factors in oral leukoplakia and submucous fibrosis in a population-based case-control study in Gujarat, India. Oral Dis 1998;4:200-6. 27. Gupta PC, Hebert JR, Bhonsle RB, Murti PR, Mehta H, Mehta FS. Influence of dietary factors on oral precancerous lesions in a population-based case-control study in Kerala, India. Cancer 1999;85:1885-93. 28. Hebert JR, Gupta PC, Bhonsle RB, Mehta H, Zheng W, Sanderson M, et al. Dietary exposures and oral precancerous lesions in Srikakulum District, Andhra Pradesh, India. Public Health Nutr 2002;5:303-12. 29. Johnson N. Tobacco use and oral cancer: a global perspective. J Dent Educ 2001;65:328-39. 30. Smith EM, Ritchie JM, Summersgill KF, Hoffman HT, Wang DH, Haugen TH, et al. Human papillomavirus in oral exfoliated cells and risk of head and neck cancer. J Natl Cancer Inst 2004;96:449-55. 31. Mork J, Lie AK, Glattre E, Hallmans G, Jellum E, Koskela P, et al. Human papillomavirus infection as a risk factor for squamous-cell carcinoma of the head and neck. N Engl J Med 2001;344:1125-31. 32. Gillison ML, Koch WM, Capone RB, Spafford M, Westra WH, Wu L, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. J Natl Cancer Inst 2000;92:709-20. 33. Leethanakul C, Knezevic V, Patel V, Amornphimoltham P, Gillespie J, Shillitoe EJ, et al. Gene discovery in oral squamous cell carcinoma through the Head and Neck Cancer Genome Anatomy Project: confirmation by microarray analysis. Oral Oncol 2003;39:248-58. 34. Watling DL, Gown AM, Coltrera MD. Overexpression of p53 in head and neck cancer. Head Neck 1992;14:437-44. 35. Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al. SEER Cancer Statistics Review, 1975-2002. (Accessed February 28, 2006, at http://seer. cancer.gov/csr/1975_2002/) 36. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 2002 Incidence and Mortality. Atlanta: US DHHS/ CDC/NIH-NCI; 2005. 37. U.S. Department of Health and Human Services. National Survey on Drug Use and Health.; 2002. (Accessed January 4, 2006, at http://oas.samhsa.gov/nhsda.htm.) 38. U.S. Surgeon General. Tobacco Use Among

U.S. Racial/Ethnic Minority Groups - African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Bethesda, MD: U.S. Department of Health and Human Services, Centers for Disease Control, Center for Chronic Disease and Health Promotion, Office on Smoking and Health; 1998. 39. Schoenborn CA, Adams PF, Barnes PM, Vickerie JL, Schiller JS. Health behaviors of adults: United States, 1999-2001. Vital Health Stat 10 2004:1-79. 40. South Carolina behavioral risk factors surveillance system report: 2001 survey results. Columbia: Office of Public Health Statistics and Information Systems, Department of Health and Environmental Control, 2001. 41. Hebert JR. Invited commentary: menthol cigarettes and risk of lung cancer. Am J Epidemiol 2003;158:617-20. 42. Swango PA. Cancers of the oral cavity and pharynx in the United States: an epidemiological overview. J Public Health Dent 1996;56:309-18. 43. Kujan O, Glenny AM, Duxbury AJ, Thakker N, Sloan P. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev 2003: CD004150. 44. Patton LL. The effectiveness of community-based visual screening and utility of adjunctive diagnostic aids in the early detection of oral cancer. Oral Oncol 2003;39:707-23. 45. Mignogna MD, Fedele S. Oral cancer screening: 5 minutes to save a life. Lancet 2005;365:1905-6. 46. Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet 2005;365:1927-33. 47. Santana JC, Delgado L, Miranda J, Sanchez M. Oral Cancer Case Finding Program (OCCFP). Oral Oncol 1997;33:10-2. 48. Mashberg A, Samit A. Early diagnosis of asymptomatic oral and oropharyngeal squamous cancers. CA A Cancer J Clin 1995;45:328-51. 49. Lodi G, Sardella A, Bez C, Demarosi F, Carrassi A. Systematic review of randomized trials for the treatment of oral leukoplakia. J Dent Educ 2002;66:896-902. 50. Mulshine JL, Atkinson JC, Greer RO, Papadimitrakopoulou VA, Van Waes C, Rudy S, et al. Randomized, double-blind, placebo-controlled phase IIb trial of the cyclooxygenase inhibitor ketorolac as an oral rinse in oropharyngeal leukoplakia. Clin Cancer Res 2004;10:1565-73. 51. Screening for Oral Cancer., 2005. (Accessed June 10, 2005, at http://www.ahrq. gov/clinic/uspstf/uspsoral.htm.) 52. Stahl S, Meskin LH, Brown LJ. The American Dental Association’s Oral Cancer Campaign: The impact on consumers and dentists. J Am Dent Assoc 2004;135:1261-7. 53. American Dental Association. ADA news: $1 Million NCI grant targets oral cancer. (Accessed July 5, 2005, at http://www.ada.

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Head and Neck Cancer Disparities in South Carolina: Descriptive Epidemiology, Early Detection, and Special Programs org/public/media/releases/0310_release06asp.) 54. Pihlstrom BL, Tabak L. The National Insitute of Dental and Craniofacial Research, research for the practicing dentist. J Am Dent Assoc 2005;136:728-37. 55. Reed SG, Dong B, Cannick GF, Nickerson BC, Day TA. Oral cancer examinations: findings using the SC BRFSS. J Dent Res 2004;83A:1976. 56. National Center for Health Statistics. National Health Interview Survey, 1998. (Accessed February 28, 2005, at http://www. cdc.gov/nchs/nhis.htm.) 57. Healthy People 2010. (Accessed July 5, 2005, at http://www.health.gov/healthypeople.) 58. Cannick GF, Horowitz AM, Drury TF, Reed SG, Day TA. Assessing oral cancer knowledge among dental students in South Carolina. J Am Dent Assoc 2005;136:373-8. 59. Reed SG, Duffy NG, Walters KC. Oral cancer knowledge and experience: a survey of South Carolina medical students in 2002. J Cancer Educ 2005;20:125-42. 60. Drake BF, Keane TE, Donald CD, Modayil MV, Daguise VG, Johnson MG, et al. Prostate cancer disparities in South Carolina: Early detection, special programs, and descriptive epidemiology. J South Carolina

Med Assoc 2005;101:e225-30. 61. Blackshear PJ, Phillips RS, Vazquez-Matias J, Mohrenweiser H. Polymorphisms in the genes encoding members of the tristetraprolin family of human tandem CCCH zinc finger proteins. Prog Nucleic Acid Res Molec Biol 2003;75:43-68. 62. Vassella E, Kramer R, Turner CM, Wankell M, Modes C, van den Bogaard M, et al. Deletion of a novel protein kinase with PX and FYVE-related domains increases the rate of differentiation of Trypanosoma brucei. Molec Microbiol 2001;41:33-46. 63. Fountzilas G, Ciuleanu E, Dafni U, Plataniotis G, Kalogera-Fountzila A, Samantas E, et al. Concomitant radiochemotherapy vs radiotherapy alone in patients with head and neck cancer: a Hellenic Cooperative Oncology Group Phase III Study. Med Oncol 2004;21:95-107. 64. Gilbert J, Forastiere AA. Organ preservation for cancer of the larynx: current indications and future directions. Semin Radiat Oncol 2004;14:167-77. 65. Vokes E. Current treatments and promising investigations in a multidisciplinary setting. Ann Oncol 2005;16 Suppl 6:vi25-vi30. 66. Bonner JA, Harari PM, Giralt J, Azarnia N, Shin DM, Cohen RB, et al. Radiotherapy plus cetuximab for squamous-cell carci-

noma of the head and neck. N Engl J Med 2006;354:567-78. 67. Heimdal JH, Aarstad HJ, Olofsson J. Peripheral blood T-lymphocyte and monocyte function and survival in patients with head and neck carcinoma. Laryngoscope 2000;110:402-7. 68. Lathers DM, Young MR. Increased aberrance of cytokine expression in plasma of patients with more advanced squamous cell carcinoma of the head and neck. Cytokine 2004;25:220-8. 69. Pandit R, Lathers DM, Beal NM, Garrity T, Young MR. CD34+ immune suppressive cells in the peripheral blood of patients with head and neck cancer. Ann Otol Rhinol Laryngol 2000;109:749-54. 70. Lathers DM, Clark JI, Achille NJ, Young MR. Phase 1B study to improve immune responses in head and neck cancer patients using escalating doses of 25-hydroxyvitamin D3. Cancer Immunol Immunother 2004;53:422-30. 71. Shavers VL, Harlan LC, Winn D, Davis WW. Racial/ethnic patterns of care for cancers of the oral cavity, pharynx, larynx, sinuses, and salivary glands. Cancer Metastasis Rev 2003;22:25-38. n

Author Affiliations

1. Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC 2. South Carolina Cancer Center, Columbia, SC 3. Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD. *Work carried out while at the South Carolina Cancer Center, Columbia, SC 4. Department of Stomatology, College of Dental Medicine, Medical University of South Carolina, Charleston, SC 5. South Carolina Cancer Alliance, Columbia, SC 6. SC Department of Health and Environmental Control, Bureau of Community Health and Chronic Disease Prevention, Columbia, SC 7. South Carolina Central Cancer Registry, South Carolina Department of Health and Environmental Control, Columbia, SC 8. Ralph H. Johnson Veteran Affairs Medical Center, Charleston, SC 9. Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 10. Statewide Cancer Prevention & Control Program, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 11. Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC 12. Division of Oncology/Hematology, Dorn Veterans Affairs Medical Center, Columbia, SC 13. Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC

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The Journal


Esophageal Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology James R. Hebert, MSPH, ScD 1,2,3,4 Swann Arp Adams, PhD 1,2 Virginie G. Daguise, PhD 5,6 Deborah Hurley, MSPH 7 Eric W. Smith, PhD 2,8 Carryn Purdon, PhD 2,8 Andrew Lawson, PhD 1,2,3 Michael Mitas, PhD 3,9 Carolyn E. Reed, MD 3,9 Cancers of the esophagus represent an important public health problem. In the United States an estimated 14,520 new cases were diagnosed in the year 2005, and 13,570 deaths resulted from the disease.1 The mortality rate approximates that of pancreatic cancer and is more than four times that of rectal cancer.2 In excess of 90% of individuals diagnosed with an incident cancer of the esophagus die within five years of diagnosis, underlining the need for strategies to prevent this disease.3 Unfortunately, the measures needed for primary prevention are not as clear-cut as they seemed even a half a generation ago. For squamous cell carcinoma, by far the dominant type of esophageal cancer in the United States until the mid-1990s, conventional epidemiologic evidence indicates that tobacco and alcohol account for the vast majority of variability in incidence of this cancer.4,5 However, most of these studies were conducted in European American populations. For those Address correspondence to: Dr. Hebert, Department of Epidemiology and Biostatistics, 2221 Devine Street, Columbia, SC, 29208. Email: [email protected].


populations at highest risk of developing this disease (e.g., African Americans, who tend to participate at a much lower rate in epidemiologic studies), tobacco and alcohol use explains much less of the variability.6,7 Thus, recommendations to quit or reduce smoking and drinking, while effective at preventing many other health problems, may not be as effective for preventing squamous cell carcinoma of the esophagus in African Americans (AAs) as they would be in European Americans (EAs).8,9 While the epidemiology of squamous cell carcinoma has gone unresolved in AAs, a relative epidemic of adenocarcinoma of the esophagus has begun4,5 and it appears to be concentrated almost exclusively in EAs.4,6,10 The association between esophageal adenocarcinoma and gastroesophageal reflux disease (GERD) is unequivocal.11 The dose- and time-response association of GERD and esophageal adenocarcinoma and its biologic plausibility suggest causality. However, the epidemiologic observations made thus far do not help identify individuals who, among those patients suffering from GERD, are likely to develop adenocarcinoma.

Descriptive Epidemiology Esophageal cancers are relatively uncommon. However, as noted, they tend to be fatal. For example, based on the combined data of the Surveillance Epidemiology and End Results (SEER) Program of the National Cancer Institute and the National Program of Cancer Registries of the Centers of Disease Control and Prevention the mortality to incidence ratio for esophageal cancer is 0.92

as compared to 0.20 for breast cancer and 0.17 for prostate cancer.12 Cancers of the esophagus account for ≈1.5% of total cancer incidence in the US males, but they account for ≈1.9% of incidence in AA men.12 These cancers account for a higher percentage of cancer deaths; 3.2% and 3.4% in Black and White men, respectively. In women, esophageal cancers account for only ≈.5% of total cancer incidence. However, the rate is twice as high (≈1.0% of incidence) in AA women. As in men, esophageal cancers account for proportionally more of cancer mortality (i.e., for ≈1.0% overall and ≈1.5% in AA women).12 Esophageal cancers fall into two histologic categories. Squamous cell carcinomas, which are conventionally thought to be more strongly associated with tobacco and alcohol, tend to arise from the body of the proximal esophagus.13-15 Adenocarcinomas generally arise from the distal esophagus, near its junction with the stomach, and are strongly associated with GERD. Esophageal cancer incidence and mortality rates among Blacks (i.e., primarily AAs) were over three times those of Whites (i.e., primarily EAs) in the late 1980’s.16,17 This large differential emerged between 1950 and 1977, when the age-adjusted esophageal cancer incidence rate approximately doubled in AAs. Thereafter, the incidence increased slightly until leveling off in the mid 1980’s.16,17 During the same period, the rates of squamous cell cancers remained virtually unchanged in EA, and rates of adenocarcinomas remained relatively constant in both

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Esophageal Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology

10 Squamous Cell Carcinoma

Adenocarcinoma

9


8 7 6 5 4 3 2 1 0 White

Black

All Races

Figure 1. Esophageal Cancer Age-Adjusted Incidence Rates (1997-2002) per 100,000 in SC by Histologic Type and Race

races.4,6 Reflecting these epidemiologic facts, until the early 1990s the literature did not distinguish esophageal cancers by histologic type.17-20 Because of the much higher incidence and relatively large increases in incidence rates of squamous cell carcinoma of the esophagus over the ≈40 years after World War II, most findings were driven by the preponderance of squamous cell cancers. Since the early 1980s, rates of squamous cell carcinomas have remained approximately constant in both races. However, AAs remain at a distinct disadvantage in relation to EAs, owing to the large increases in incidence prior to the mid 1980s. In contrast, adenocarcinoma rates began increasing markedly from the late 1980s, rising about 3 to 4% per year, with the increase being confined almost entirely to EAs.4,6 There is marked geographic variability in the incidence of squamous cell esophageal cancer. Washington, D.C. and coastal South Carolina have the highest incidence in the United States, more than twice the national average.12,21,22 The racial disparity in this disease is among the most pronounced of any illness in the U.S., and is especially evident in South Carolina, where the incidence among AA men is 7.63 times that observed in EA men.22

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which is defined as an abnormal change in the growth of cells of the esophagus. It is generally accepted that this condition is a precursor to adenocarcinoma.5, 28 The role of infectious agents, most notably Helicobacter pylori, is much less certain and more complicated.

As shown in Figure 1, in South Carolina, squamous cell esophageal cancer incidence in AAs is currently about six times higher than that observed in EAs. This racial disparity is considerably larger than the ≈four-fold difference observed nationally,22,23 even though AAs have much lower rates of exposure to tobacco products,1,24 as we will discuss in the next section. As is true for the nation as a whole, rates of adenocarcinoma of the esophagus are higher in EAs than AAs in South Carolina (Figure 1). Men’s rates are about four to eight times higher than those of women, a gender difference about as extreme as that observed for squamous cell cancers. Esophageal adenocarcinomas are thought to be less strongly associated with tobacco than is squamous cell carcinoma.4,6,25,26 In the United States, increasing obesity is a possible contributing factor to the rising incidence of adenocarcinoma.27 One of the strongest risk factors for adenocarcinoma is GERD,5 the backflow of acid from the stomach into the esophagus, which irritates and sometimes damages the delicate lining on the inside of the esophagus. If this condition remains untreated in an individual, it can lead to Barrett’s esophagus,

Esophageal incidence and mortality rates are consistently at least twice as high for all types of esophageal cancer combined for AAs than for EAs.29 This disproportionate cancer burden in South Carolina does not appear to be merely an issue of access to care. For example, mortality and incidence track similarly by race, indicating that incident cancers are not going undetected in AAs due to lack of care. Additionally, there is little disparity by race in stage at diagnosis of squamous cell cancers within categories of gender (Figures 2-5). Therefore, this disproportionate cancer burden does not appear to be merely an issue of decreased access to care leading to delayed diagnosis. There do appear, however, to be some interesting disparities by gender and stage, with women (especially White women) being diagnosed at an earlier stage than their male counterparts. The very small numbers of adenocarcinomas in Blacks precludes comparisons similar to those shown in Figures 2-5 for squamous cell carcinomas. However, it does appear that the same general race-gender pattern would be seen for adenocarcinoma if the numbers were more robust.22 Men are more likely to be diagnosed with and die from esophageal cancer, as is clearly evident in both U.S.12,30 and South Carolina29,31 data. In South Carolina from 1997 to 2002, the overall incidence rate of esophageal cancer was over four times higher in men than women [10.43 vs. 2.31 /100,000/year].22 Differences in stage at diagnosis by gender may help to explain some of this disparity.29,31 The racial disparity, however, is not as large (4.45/100,000 in EA vs. 10.84/100,000 in AA); in large part due to large increases in adenocarcinoma in EAs.



As expected, mortality rates follow essentially the same pattern as incidence, but are more extreme. In South Carolina, from 1999 to 2004, the overall mortality rate of esophageal cancer was over four-and-half times higher in men than women (9.01 vs. 1.99 /100,000).22 Again, stage at diagnosis by gender may help to explain some this disparity.29,31 The racial disparity, however, is not as large (3.96/100,000 in EA vs. 8.64/100,000 in AA). Gender differences within race followed a similar pattern; i.e., were similar in relative terms (7.12/100,000 in White men vs. 1.49 in White women; and 16.05/100,000 in Black men vs. 3.41 in Black women). In addition to overall statewide differences by race, we also looked carefully at the 46 counties to see if there might be smaller foci of racial differences in rates. In order to present this in the most descriptive way, we used the mapping capability of SAS/STAT® software, Version 9.1 so as to locate and map statistical differences in incidence and mortality rates by race for both men and women.32 The statewide rates for South Carolina Whites are used as the comparison. As expected, we see large differences when comparing the incidence rates of squamous cell cancers in Blacks to those of Whites (see Figures 6 and 7). For men (Figure 6), all but eight counties had significantly higher rates in Blacks. The fact that the rates are higher in AAs is not surprising. What is remarkable is that the rate differences were statistically significant in such small geographical units, despite the general tendency for the 95% confidence limits to be very large with small sample sizes (which results in a lower probability of detecting a real difference). Among women (Figure 7), where the overall rates are just a fraction of those of men, statistically higher rates also were seen in twelve of the 46 counties. Mortality rates for all esophageal cancers (i.e., all histologic types combined)


Distant 6%

Unstaged 7%

Unstaged 9%

Local 20%

Distant 11% Local 37%

Regional 60%

Regional 50%

Figure 2. Esophageal Cancer Stage at Diagnosis in SC among White Men, 1997-2002 (Squamous Cell) Unstaged 10% Distant 6%

Local 48%

Regional 36%

Figure 3. Esophageal Cancer Stage at Diagnosis in SC among Black Men, 1997-2002 (Squamous Cell) Unstaged 10% Distant 8%

Local 29%

Regional 53%

Figure 4. Esophageal Cancer Stage at Diagnosis in SC among White Women, 1997-2002 (Squamous Cell)

Figure 5. Esophageal Cancer Stage at Diagnosis in SC among Black Women, 1997-2002 (Squamous Cell)

are shown in Figures 8 (for men) and 9 (for women). Figure 8 shows that the very high rates of squamous cell cancers in AA men coupled with the very high lethality of this cancer results in an overall esophageal cancer death rate that is significantly higher in AA than EA men in about half (22 of 46) of South Carolina’s counties. Again, owing primarily to small numbers, the pattern, though evident, was much less pronounced in AA women relative to their EA counterparts (Figure 9).

holic beverages, and especially the combination of the two, account for >95% of all squamous cell carcinomas of the esophagus.4,5 What is both puzzling and fascinating is that AAs drink at about the same rate as EAs, that they actually smoke less than EAs,16,17,33-35 and their smoking rate is especially low in South Carolina.36 Despite this, their rates for this cancer are much higher16,17 (see Figure 1 for a depiction of rates by histologic type and race in South Carolina). So, an estimate of increased risk due to heavy consumption of alcohol or tobacco (or both) accounting for approximately 14.9 excess cases of squamous cell carcinoma per 100,000 per year in AA than EA37 adds even more to the confusion. Clearly, the descriptive data on tobacco and alcohol are not explaining the elevated rates

Analytic Epidemiology Studies Squamous Cell Carcinomas Analytic epidemiologic studies conducted in the West, and predominantly in Europeans or EAs, indicate that tobacco smoking and the consumption of alco-

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liquors, and hard liquor. However, when they examined this issue, Brown et al. found no significant difference in risk by type of alcoholic beverage consumed. Rather, the total amount alcohol consumed played the largest role in determining risk.42 Given the work conducted to date, and the confusion about the role of dietary risk factors (including alcoholic beverages), future studies should focus on very careful measurement of this set of factors.

Significantly Higher* No Difference Significantly Lower* 1997-2002 (Sqamous Cell) SC Rate for White Men = 2.3/100,000 *95% CIs Disjoint


Figure 6. South Carolina Squamous Cell Esophageal Cancer: Comparison of AgeAdjusted, County-Specific Incidence Rates in Black Males vs. the Age-Adjusted, State-Average Rate in White Males (1997-2002)

Significantly Higher* No Difference Significantly Lower* 1997-2002 (Squamous Cell) SC Rate for White Women = 1.0/100,000 *95% CIs Disjoint


Figure 7. South Carolina Squamous Cell Esophageal Cancer: Comparison of AgeAdjusted, County-Specific Incidence Rates in Black Females vs. the Age-Adjusted, State-Average Rate in White Females (1997-2002)

of squamous cell esophageal cancers in AAs in South Carolina (and probably in the rest of the rural Southeast). In more recent work by this same group, Brown et al, it was found that, along with moderate/heavy alcohol intake and tobacco use, low income and infrequent consumption of raw fruits and vegetables explained 99% of the excess incidence among AA men.38 It would be interesting to see if careful measurement of these two other categories of “risk factors” would help

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to explain the anomalously high rates of squamous cell cancers of the esophagus here in South Carolina, and more generally in the American South. Although overall rates of exposure to alcohol are not much different in AAs than EAs, differences exist in the type of alcoholic beverages consumed.3941 It has been found that EAs tend to consume greater amounts of beer while AAs tend to consume more wine, malt

In contrast to the confusion about actual dietary exposures, we know much more about differences in the types of cigarettes smoked by AAs and EAs. It is a curious historical fact that when menthol brands were first introduced before World War II, AAs and women of all ethnicities evinced a preference for these brands.43 In a classic example of the interaction between marketing and product preference, menthol brands were targeted specifically at African Americans.44, 45 From their introduction in the 1920s through 1955, mentholated brands represented about 3% of all cigarette sales, with AAs and women accounting for a disproportionate share of purchases.43 From 1956 to the middle of the 1970s, menthol cigarettes increased in popularity.43,44,46 After achieving about 29% of market share in the late 1970s, their share of the market began falling in the late 1980s. They now account for just under 26% of total sales.9,44,47 Currently, about 75% of AA smokers use mentholated brands (vs. 23% of Whites), with three brands available only in mentholated form (Newport™, Kool™, and Salem™) accounting for 55% of total AA tobacco consumption.9 The close association between changes in consumption of menthol cigarettes and rates of change in esophageal cancer rates formed the basis for the hypothesis that exposure to mentholated cigarettes might explain some of the discrepancy between overall tobacco exposure and rates of esophageal cancer (and other cancers of the upper aerodigestive tract)



in AAs.16,17 These observations and the formulation of a hypothesis linking mentholated cigarettes to esophageal cancer led to a number of studies in the late 1980’s,17,48,49,50,51 and is currently a focus of renewed research in South Carolina.52 Due to the dominance of the mentholated cigarette market by three major brands, assessment of use of menthol cigarettes has become simpler compared to the situation a couple of decades ago when many more brands were available. This circumstance will benefit future epidemiologic studies. While smoking and alcohol are acknowledged to be the strongest risk factors for squamous cell carcinoma of the esophagus, surprisingly little is documented on other potential risk factors. Of all cancer sites, esophagus evinces the largest international variation in rates of disease.4,18,53,54 Until recently, most of the variation in rates of esophageal cancer could be assumed to be due to squamous cell cancers; however, that has begun to change.26 Consequently, the vast majority of literature from the more “distant past” (i.e., from before the 1990s) that has not differentiated between histologic types can be assumed to reflect mainly the epidemiology of squamous cell esophageal cancers. Despite the dominant focus on tobacco and, to a lesser extent alcohol, evidence has existed for some time to suggest that there are other lifestyle-related behaviors, especially those related to diet, that may be associated with esophageal cancer risk.55-59 In general, fruits and vegetables have been shown to be inversely related to esophageal cancer.55-57 More specifically, there is some evidence that cruciferous vegetables (e.g., broccoli, cauliflower, and brussel sprouts) protect against esophageal cancer. Heterocyclic amines, by-products from charred meat, have been linked with squamous cell carcinoma.58,59 Selected micronutrients such as antioxidants, folate, and selenium also have shown an inverse association with squamous cell carcinoma.60-63 Still other




Figure 8. South Carolina County-Specific Comparisons of Black vs. White Male Age-Adjusted Esophageal Cancer Mortality Rates (1998-2003; all histologic types combined)



Figure 9. South Carolina Esophageal Cancer: Comparison of Age-Adjusted, County-Specific Mortality Rates for Black Females vs. the Age-Adjusted, StateAverage Mortality Rate for White Females (1998-2003)

potential risk factors for squamous cell carcinoma are Helicobacter pylori infection (the common cause of stomach ulcers) and decreased use of non-steroidal anti-inflammatory drugs.63-66 African Americans in South Carolina are not the only population at unusually high risk of esophageal cancer. Some of the most intriguing data on the role of nontobacco/non-alcohol-related risk factors comes from the Caspian Littoral (i.e.,

Azerbaijan, the Islamic Republic of Iran, Kazakhstan, Turkmenistan, the Russian Federation, and neighboring Uzbekistan). There, in alcohol- and tobacco-abstinent populations, we find some of the highest rates of esophageal cancer in the world.67 In these regions it is customary to drink very hot beverages (usually teas) by pouring the scalding fluid onto the surface of the proximal esophagus.68,69 This is consistent with findings from other parts of the world,57,70,71 including some

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interesting findings from France showing an interaction between the alcoholic content of one beverage (Calvados) and the tendency to drink it hot.72 Evidence of a role of thermal damage and its interaction with other factors provides a possible connection to the mentholated cigarette hypothesis because prolonged use of menthol is known to attenuate sensations of heat, thereby allowing exposures of longer duration and greater heat intensity.17 Through work conducted at the University of South Carolina, we have found that menthol appears to have additional adverse effects such as: increasing the permeability of the esophageal membrane to tobacco carcinogens, influencing the amount of the carcinogen penetrating through the membrane, and increasing the amount of carcinogens forming a reservoir within the membrane.52 So, the interaction among these various factors, including the direct effect of menthol, the influence of thermal damage, and the effect of dietary factors appears to be a fruitful area to explore in order to reconcile the discrepancy between the descriptive epidemiology of squamous cell cancers of the esophagus and findings from studies of humans available in the literature.

Adenocarcinomas While squamous cell carcinoma of the esophagus is more common among AAs, adenocarcinoma is more common among EAs. It is estimated that incidence of this disease has increased on the order of 300% to 500% within the last 40 years.28 Adenocarcinoma also appears to be much more common among men than women, with the latest ratios showing about seven men diagnosed to every one woman nationally;5 and about 8.5:1 in South Carolina.22 It is very interesting to note that the pattern of incidence of adenocarcinoma very closely resembles that of the obesity epidemic seen in the United States, especially among individuals 40% of all rural residents are African-American). It is also a poor state, where the average personal income is about 81% of the national average.100 These factors make access to educational and health care resources and to research programs difficult. Speaking to the success of the BCN at reaching minority communities, approximately 60% of enrollees are African-American and an estimated 60% reside in a county classified as rural by the U.S. Census Bureau. Consequently, this program offers the ideal environment to examine ethnic differences in breast cancer among economically disadvantaged women, especially those residing in rural settings. With the passage of the Breast & Cervical Cancer Treatment Act in 2000, South Carolina has now been able to provide treatment for BCN participants who are diagnosed with breast cancer. Since 2001, South Carolina has offered treatment coverage under Medicaid through an agreement with the Department of

Most recently, the DHHS, in partnership with DHEC and community advocates, worked successfully to obtain one million dollars in state funds towards cervical and breast cancer treatment. These funds, which became available beginning on July 1, 2005, have been earmarked for breast and cervical cancer treatment under the Breast & Cervical Cancer Treatment Act. With this new funding, women with breast cancer or pre-cancerous conditions such as atypical hyperplasia, will qualify for Medicaid to pay for their treatment if they are younger than 65 years of age; do not have insurance coverage that covers breast cancer treatment; and have a family income that is at or below 200% of the federal poverty level. Furthermore, by receiving treatment for breast cancer under Medicaid, women receive full Medicaid benefits for the duration of the cancer treatment. One example of a medical system-based program is Palmetto Health’s Certificate of Public Advantage (COPA). This hospital-funded program, which was developed to initiate community health outreach within the immediate service area, has generated several other programs, including the Cancer Health Initiative. One component of Palmetto Health’s COPA Cancer Health Initiative is to provide breast cancer screenings to women 35 years of age and above who are uninsured or underinsured and live in Richland, Lexington, and Fairfield counties. Women who qualify receive screening mammograms and clinical breast examinations. If abnormal test results occur, women are notified by mail or phone and referred to Palmetto Health’s Breast Center for additional follow-up. The Cancer Health Initiative makes financial arrangements with the Breast Center to ensure that the patient is not billed at the time of follow up.


Breast Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology

Descriptive Epidemiology

Incidence rates in South Carolina are shown in Figure 1. In 2002, there were 3,350 new cases of breast cancer diagnosed in South Carolina. Of these, 77% occurred in European-American women. Incidence rates from 1996-2001 have remained stable with a somewhat higher age-adjusted incidence among EuropeanAmerican women than among AfricanAmerican women (129.8/100,000 in European-Americans, and 111.6/100,000 in African-Americans). There were 566 deaths among women in South Carolina from breast cancer in 2004, underlining that breast cancer is not a very deadly cancer (i.e., mortality is relatively low in comparison to incidence). However, mortality as a function of incidence disfavors African-American women in South Carolina (see Figure 2), whose incidence is lower than that of European-American women but whose mortality rate (33.2 deaths/100,000/year) is 42% higher than European-Americans (23.3 deaths/100,000/year). Nationally this difference is about 32%.1,4,101 This is due entirely to the difference between African-American rates in SC versus the US rate for African Americans. Rates in South Carolinians of European descent are virtually identical to those seen nationally.101 Furthermore, for the past


450

White

Black

400

Incidencee Rates per 100,000

Nationally, African-Americans have an overall lower incidence (12%) of breast cancer than do European-Americans, African-American women are more likely to die of invasive breast cancer than are European-American women (34.5 vs. 25.4 per 100,000 women).1 Additionally, trends in breast cancer incidence and mortality over time evince patterns that vary markedly by ethnicity. From 1975 to 2002, Surveillance, Epidemiology, & End Results (SEER) data indicate that European-American women had a 29% increase in breast cancer incidence and a 22% decrease in mortality.4 While African-American women experienced an identical 29% increase in incidence, they had a 16% increase in mortality during that time.4

350 300 250 200 150 100 50 0 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84

85+

5-year Age-Group

Figure 7. Female Breast Cancer Age-Specific Incidence (1998-2002) Rates per 100,000 in SC by Race and 5-year age-groups

several years mortality rates among African-American women have remained relatively constant, while they have been falling among European-American women.4 Not only does this significant difference suggest interesting and important research possibilities, it causes tremendous hardship in the AfricanAmerican community. Early detection through mammograms and clinical breast exams is known to reduce the risk of mortality from breast cancer.94,102 One potential explanation for the observed racial disparity is that African-American women may be less likely to be screened than EuropeanAmerican women in South Carolina. However, as demonstrated in Figures 3 and 4, the prevalence of mammography and self breast examination is similar among European-American and African-American women, at least among a random sample of women who have a telephone and have participated in the Behavioral Risk Factor Surveillance System (BRFSS) survey. Both in South Carolina and in the U.S. as a whole, African-American women are more likely to be diagnosed at late stages than European-American women.77,93,103

As shown in Figures 5 and 6, 27% of European-American women compared to 37% of African-American women are diagnosed with regional stage breast cancers. In addition, only 4% of European-American women present with distant stage disease versus 7% of African American women. Further research has shown that African-American women in South Carolina are more likely to have more aggressive disease within the same age range and tumor size category.76 Across racial groups, there is a steady increase in breast cancer incidence which peaks at 65 to 79 years of age and then the rates begin to decline (see Figure 7). Although this pertains to both racial groups, it also is obvious that the relative rate at young ages (when disease tends to be much more aggressive) disfavors African-American women as their rates of disease are slightly higher in the 25 to 39 age groups. In addition to overall state comparisons between racial groups, it is also useful to examine geographic trends in incidence and mortality by ethnicity within the state. Figures 8 and 9 provide a graphical representation of incidence and mortality in African-Americans compared

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factors that might facilitate the detection of tumors at an earlier stage and the development of more effective therapies. The most important of our goals is to design studies to reduce the incidence of the disease and interventions to improve survival and quality of life. The importance of participation in research cannot be overstated.



Figure 8. South Carolina Female Breast Cancer: Comparison of the Age-Adjusted, County-Specific Incidence Rate for Black Women vs. the Age-Adjusted, State-Specific Incidence Rate for White Women (1998-2002)



Figure 9. South Carolina Female Breast Cancer: Comparison of the Age-Adjusted, County-Specific Mortality Rate for Black Women vs. the Age-Adjusted, State-Specific Mortality Rate for White Women (1999-2003)

to the state rate for European-Americans. The areas of significantly lower incidence rates among African-American women are found in the coastal and central state regions while areas of significantly higher mortality rates among African-American women are found in the northern regions. It is interesting to note the single county (Florence - indicated by ‘X’) overlap between the two maps (i.e. counties with significantly lower incidence that also have significantly higher mortality).

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Summary A discrepancy exists between mortality and incidence rates between AfricanAmerican and European-American women in South Carolina. The relationship between tumor grade and the estrogen/ progesterone receptor status is different in African-American and European American women.77,79,104 African-American women with breast cancer should be encouraged to participate in clinical trials, with the goal of identifying biological

Reproductive factors such as early pregnancy and multiple pregnancies are strongly related to breast cancer risk, however, promotion of these factors as a “prevention strategy,” clearly does not lead to cogent, comprehensive public health messages. Data from ecological and migrant studies point clearly to other factors that may be important such as diet. Additional research around primary prevention strategies is needed. In addition, yearly mammograms (secondary prevention) are recommended for women over 50 years old or those with relatives who have developed breast cancer.94 The Best Chance Network, as a provider of screenings to low-income, uninsured women, has helped to narrow the racial gap in screening that otherwise might exist (see Figures 3 and 4) to a large extent. The determination for timing of surgery after diagnosis needs additional consideration. For example, factors such as effective screening in younger women, timing of screening and surgery in relationship to the ovulatory cycle, and season of screening and surgery may have a great impact on outcomes and may offer some insight105-107 into the process of carcinogenesis and therapeutic efficacy. Research into this area is so novel that the impact on possible ethnic disparities is completely unknown. The South Carolina Cancer Disparities Community Network (SCCDCN) has identified the following areas as potential research foci: • Identification of small media interventions as an effective strategy to motivate targeted populations, especially those least likely to seek screening for



breast cancer and those least likely to participate in research programs (African-Americans). • Utilization of breast cancer survivors, self-identified as community natural helpers can share their experiences with their church congregation. A replication of such a program in South Carolina has great potential because of the strong presence of the church, especially in rural parts of the state. Programs that closely integrate religion with screening women for breast cancer are promising in this state. • Development of a mammography registry whereby information on all mammography procedures would be collected within a single database system (much like a central cancer registry). This would aid in identifying population groups that could be targeted for special programs and in the examination and exploration of the most appropriate modalities of detection. Such a resource could also be a useful tool to encourage screening. Thus, this focus area has the potential to benefit epidemiologic and health promotion research on many different levels. Additional breast cancer screening methods should not be overlooked as a potential research focus. Mammography is not the only valid screening method for breast cancer. Magnetic resonance imaging has shown some promise for screening among women with a genetic predisposition for cancer.108 Another promising avenue is thermography. Because detection rates may depend on age, ethnicity, and breast mammographic characteristics, women for whom regular screening methods do not detect their cancers (e.g. older age, AfricanAmerican ethnicity, dense breasts) must be identified and other screening methods promoted within these populations. The above-mentioned mammography registry would support this type of research.

Acknowledgement We would like to acknowledge the South


Carolina Central Cancer Registry (SCCCR) for the state cancer incidence and mortality data provided. The SCCCR is funded by the CDC National Program of Cancer Registries, cooperative agreement number U55CCU421931, and SCDHEC. We would also like to acknowledge funding of the South Carolina Cancer Disparities Community Network (SCCDCN) through grant number 1 U01 CA114601-01 from the National Cancer Institute (Community Networks Program). The authors wish to thank Dr. Leslie Bernstein of the University of Southern California for her insightful review of this manuscript.

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Med Screen 2005; 12:43-49. 97. Ringash J, Canadian T. Preventive health care, 2001 update: screening mammography among women aged 40-49 years at average risk of breast cancer. CMAJ 2001; 164:469476. 98. de K. Mammographic screening: evidence from randomised controlled trials. Ann Oncol 2003; 14:1185-1189. 99. Miller AB. Is mammography screening for breast cancer really not justifiable?. Recent Results Cancer Res 2003; 163:115-128. 100.US Department of Commerce. Personal Income By State. Washington, DC: Bureau of Economic Analysis, 2003. 101.Sanders L, Hardy W, Ashford-Carroll T, Bolick-Aldrich S. South Carolina Cancer Facts and Figures: 2001-2002. 2001. South Carolina Central Cancer Registry,Office of Public Health Statistics and Information Services,South Carolina Department of Health and Environmental Control; American Cancer Society,Southeast Division. 102. Srivastava S, Rossi SC. Early detection research program at the NCI. Int J Cancer 1996; 69:35-37. 103. Harris DM, Miller JE, Davis DM. Racial differences in breast cancer screening, knowledge and compliance. J National Med Assoc 2003; 95:693-701. 104. Gordon NH. Socioeconomic factors and breast cancer in black and white Americans. Cancer Metastasis Rev 2003; 22:55-65. 105.Hrushesky WJ, Bjarnason GA. Circadian cancer therapy. J Clin Oncol 1993; 11:14031417. 106.Hrushesky W, Lester B, Lannin D. Circadian coordination of cancer growth and spread. Int J Cancer 1999; 83:365-373. 107. Retsky M, Demicheli R. Wounding from biopsy and breast-cancer progression. The Lancet North Am Ed 2001; 357:1048. 108.Warner E, Plewes DB, Hill KA, Causer PA, Zubovits JT, Jong RA, Cutrara MR, DeBoer G, Yaffe MJ, Messner SJ, Meschino WS, Piron CA et al. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA 2004; 292:1317-1325. n

Author Affiliations 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC South Carolina Cancer Center, Columbia, SC Cancer Prevention and Control Program, University of South Carolina, Columbia, SC Statewide Cancer Prevention & Control Program, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC South Carolina Central Cancer Registry, South Carolina Department of Health and Environmental Control, Columbia, SC South Carolina Cancer Alliance, Columbia, SC SC Department of Health and Environmental Control, Bureau of Community Health and Chronic Disease. Prevention, Columbia, SC Department of Basic Pharmaceutical Sciences, College of Pharmacy, University of South Carolina Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC Department of Surgery, Medical University of South Carolina, Charleston, SC Department of Obstetrics and Gynecology, School of Medicine, University of South Carolina, Columbia, SC South Carolina Oncology Associates, Columbia, SC Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD. *Work carried out while at the South Carolina Cancer Center, Columbia, SC


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PERSPECTIVES Breast and Cervical Cancer Disparities in SC: African-American Perspective Tracy R. Powell, MSW As the articles on breast and cervical cancer point out in detail, African-Americans suffer from high death rates in both of these cancers.1,2 According to the National Cancer Institute (NCI), disparities are determined and measured by three health statistics: incidence, mortality, and survival rates. Health disparities occur when one group of people has a higher incidence rate (e.g., in cervical cancer), when the mortality rate is higher, or the survival rate is lower than for another group. As in the case of breast cancer, health disparities are found in a variety of other health outcomes that include: infectious diseases, asthma, infant mortality, cardiovascular disease, diabetes, and HIV/AIDS. These diseases, and their causes, tend to cluster. Therefore, when a community has a high rate of one disease it tends to have high rates of the others, too. Many African-Americans are unfamiliar with the term “health disparities,” but the impact that health disparities have on their communities is dramatically evident. While the most common types of cancer among African-American women are breast and cervical cancer, these cancers are not talked about around the dinner table or during family functions. Many African-American women falsely believe they are at lower risk for getting cancer than European-Americans.3 These beliefs, along with personal fears and attitudes about cancer, prevent African-American women from being screened and treated. While progress has been made in the areas of cancer prevention, detection, treatment, and palliation, perceptions among AfricanAmericans remain the same.4 The mere thought of cancer continues to evoke visions of pain, mutilation, suffering, and death among African-Americans.4 Guidry et al., stated, “In order to address the role of culture and psychosocial issues that affect African-American women, we must address the following key psychosocial and cultural issues: fear, distrust, fatalism, anxiety, faith in God, lack of empowerment, real or perceived racial discrimination, putting one’s family needs above one’s own needs, the role of the extended family, and various other factors.”2 Until psychosocial and cultural issues are addressed in health promotion programs, health disparities will continue to merely be “buzz words” among researchers; no real change will be realized. We need to adapt educational programs to meet the specific needs of African-American women. Currently, SC Team Up is moving in that direction. Team Up is a national partnership to increase

breast and cervical cancer screening among rarely/never screened individuals. The national partners include the American Cancer Society (ACS), Center for Disease Control and Prevention (CDC), NCI, and the United States Department of Agriculture (USDA). Local partners include the Institute for Partnerships to Eliminate Health Disparities and South Carolina Cancer Disparities Community Network. SC Team Up is conducting breast and cervical cancer educational presentations in churches and communities centers in Orangeburg County, one of the largest concentrations of African-Americans in the state. These educational programs will address the role of cultural and psychosocial issues that affect African-American women. The goal of the partnership is to reduce cancer-related fear and anxiety in Orangeburg County and to increase breast and cervical cancer screening for women who are rarely/never screened. Researchers in SC are interested to discover breast cancer is much more lethal in African-American women and to establish a mammography registry in Orangeburg. With these programs, the community is recognized as an important partner. The final stage of translating new knowledge into practice requires that communities use their unique knowledge to guide the process. Engaging the community is an important component in overcoming disparities. Researchers and health professionals should be encouraged to utilize organizations such as the NCI Cancer Information Service (CIS), and the South Carolina Cancer Alliance (SCCA) with the goal of increasing cancer prevention over time. Such change could significantly decrease cancer rates. These organizations can be used as vehicles to develop and deliver culturally appropriate messages to African-American women.

References: 1. Adams, S, Hebert, J, Aldrich, S et. al. Breast Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology. Journal of the South Carolina Medical Association. 2006;102:230238. 2. Brandt H, Modayil M, Hurley, D et al. Cervical cancer disparities in South Carolina: Early Detection, Special Programs, Descriptive Epidemiology, and Emerging Directions. Journal of the South Carolina Medical Association. 2006;102:222-229. 3. Swinney, J.E. African Americans with Cancer: The Relationship Among Self-Esteem, Locus of Control, and Health Perception.2002; 25: 371-82. 4. Guidry, J.J, Matthew-Juarez, P., & Copeland, V. Barriers to Breast Cancer Control for African American Women. 2003; 97 (1Suppl):318-23. ■

Ms. Powell is the Community Liaison Director for the Institute for Partnerships to Eliminate Health Disparities at the University of South Carolina’s Arnold School of Public Health. Address correspondence to: USC Institute for Partnerships to Eliminate Health Disparities, 220 Stoneridge Drive, Suite 208 Columbia, South Carolina 29212. Email: [email protected].

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The Journal


Prostate Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology Bettina F. Drake, MPH 1,2,3 Thomas E. Keane, MD 4 Catishia M. Mosley, MSPH 5 Swann Arp Adams, PhD 1,2 Keith T. Elder, PhD 1,2 Mary V. Modayil, MSc 1,2 John R. Ureda, DrPH 6 James R. Hebert, MSPH, ScD 1,2,7 Cancer of the prostate (PrCA) is the most commonly diagnosed cancer among men in the United States, accounting for 30% of all male cancer diagnoses. The American Cancer Society predicts that one out of five men will develop PrCA sometime during his life.1 Based primarily on autopsy results, PrCA appears to be much more common than published incidence data would indicate.2,3 In fact, if screening continued past age 74 years, virtually all men in the US would be found to have pathological/ histological evidence of the disease.2-4 Despite the relative indolence of the disease, especially in older men, PrCA is a major cause of cancer-related deaths, second only to lung cancer among men in South Carolina5 and in the U.S. as a whole.6 PrCA rates have declined slightly in recent years among all groups; however, South Carolina’s PrCA mortality rate ranks consistently among the highest in the nation.6 African-American (AA) men in South Carolina have the highest age-adjusted death rate for PrCA in the nation.1 The problem may be exacerAddress correspondence to: Bettina Drake, MPH, Department of Epidemiology and Biostatistics, 2221 Devine Street, Columbia, SC, 29208. Email: [email protected].


bated in AAs for characteristics related to socio-economic status, among others. Two of these factors—over half of AAs are poor or almost poor and 20% have no health insurance—are predictors of health care utilization and health status.7

Recommendations for Early Detection Over the past few decades there have been modest advances in our capacity to treat prostate cancer.2,8,9 Therefore, it is disappointing that only 50% of patients are curable at diagnosis.1 Epidemiologic evidence suggests that men who have had their PrCA detected in the early stages have markedly better five-year survival rates (94%) compared to men who have their cancer diagnosed at more advanced stages (30%).10 Although PrCA tends to be a relatively indolent disease, studies also have shown that AA men are at significantly higher risk for being diagnosed with advanced-stage prostate cancer than European-American (EA) men. AA men also tend to be diagnosed with more aggressive disease at younger ages.11 Given the higher rates of PrCA, the migration toward lower ages, and the related tendency to be diagnosed with later-stage disease, efforts aimed at early detection may be a better strategy in AA men in relation to their EA counterparts. According to the South Carolina Behavioral Risk Factor and Surveillance System data there is no significant change over time in the number of individuals receiving a prostate-specific antigen (PSA) test or a significant difference in the percentage of EAs (69% in 2001; 66% in 2004) vs. AAs (64% in 2001; 66% in 2004) receiving the PSA test.

Conversely, a larger percentage of EA men report having received a digital rectal exam (DRE) than AA men (84.5% vs. 75.0% for years 2001-2004).12 There is a lack of convincing data of a mortality benefit associated with prostate cancer screening. However, there are some groups for whom more aggressive screening beginning at younger ages may be a practical means of reducing PrCA mortality, such as AA men and others with a family history of the disease. There are currently substantial differences of opinion regarding prostate cancer screening. Essentially, the debate revolves around issues of disease aggressiveness and its relationship to age—essentially the tension between over-treatment of indolent disease and under-treatment of aggressive disease.13-15 In general, PrCA screening efforts have resulted in a stage migration to more organ-confined tumors at the time of diagnosis, and have been temporally associated with a slight decrease in PrCA mortality. It is well known, however, that the screening methods currently in widespread use are far from perfect.16 Whenever we increase the rate of screening without changing the specificity (and therefore the false positive rate) of the test we are simply encouraging the identification of cancers that would not shorten the man’s life or detract from his quality of life if left undetected (and therefore untreated).13,17-19 The argument against PSA screening among asymptomatic men is that clinically localized prostate cancer usually progresses slowly, and most men with PrCA will die of other causes,13,17,20 without any deleterious effects resulting from never really knowing if he had the

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Prostate Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology

300


Incidence (1998-2002) 272.97Mortality (2000-2004) 250

200 150.91

150

100 71.96

50 25.59

0 White

Black

Figure 1. Prostate Cancer Age-Adjusted Incidence (1998-2002) and Mortality (2000-2004) Rates per 100,000 in SC by Race

disease. Underlining the problems with PSA screening, only one man out of three with a PSA level > 4.0 ng/mL will be found to have PrCA, and the remaining three will endure an unnecessary biopsy.16 Conversely, there will be a small fraction of men with very aggressive disease who may present with a PSA level < 4.0 ng/mL.2,17,21 In the early 1990s, the American Cancer Society and the American Urological Association advocated that all men over 50 years of age receive PSA tests annually.22 This recommendation was opposed by specialty groups of primary care physicians (American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP)), as well as the United States Preventive Service Task Force (USPSTF).23 The majority of physician organizations oppose routine prostate cancer screening, whereas most community-based organizations such as the Prostate Cancer Foundation and the American Foundation for Urologic Disease have recommendations for screening that include modifications for differences in age, race/ethnicity, and family history.22,23 Somewhat less controversial is the rec-

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ommendation in most guidelines; i.e., that PSA be used in combination with DRE as an aid to diagnosis.22 For the majority of these guidelines, the target population are men 50 years of age or older with a life expectancy of at least ten years. Early detection may start at the age of 45 years in African-American men or in men with a positive family history.22 Given the consequences of either over-treating indolent PrCA or under-treating aggressive disease, patients (and their family members) should be well informed about the potential consequences prior to PSA testing. This is difficult under any circumstance, but perhaps especially so in a high-incidence,24 high-mortality,6 low-literacy area such as South Carolina.25-26 Most organizations, including USPSTF, ACP and AAFP, recommend that healthcare providers discuss testing and arrive at informed decisions with their male patients. Despite the lack of recommendations for or against routine screening for prostate cancer in these organizations, family practitioners and general practitioners in internal medicine have been ordering PSA tests frequently for their asymptomatic patients over 50 years of age. Studies have shown that some of

these tests are ordered without discussing the benefits and limitations with the patient; in some instances tests have been ordered even without his consent.23,27,28 Informed decision-making (IDM) is an important component in prostate cancer screening and may reduce the stress and anxiety that may accompany decisions involved in this controversial screening process. Understanding the issues involved is one of the centerpieces of community-based participatory research (CBPR), which is a focal point of the South Carolina Cancer Disparities Community Network (SCCDCN). Not only will IDM lead to a better result for individual men and their families, but it may help to engage the community in both understanding the issues around prostate cancer screening and in both designing and in encouraging participation in PrCA research programs.

Special Programs Addressing Screening in South Carolina A number of PrCA programs in South Carolina focus on both screening and education. As mentioned earlier, most organizations recommend education with an option for screening. South Carolina organizations (civic, medical and governmental) are collaborating to develop and implement a number of communitybased programs to reduce PrCA mortality overall and among the most affected subgroup, African-American men. In this population it may be especially useful to engage the community in existing community-based programs as well as CBPR. Some of the available programs and collaborations are described below. The South Carolina Department of Health and Environmental Control Office of Minority Health (SC DHEC-OMH) received funding from the U.S. Department of Health and Human Services in 1998 to develop a program called “Real Men Checkin’ It Out.” This initiative is a community-driven, culturally appropriate education and communication prototype that addresses PrCA in the AA community and is implemented in various community/



White Age-Adjusted Incidence Rate per 100,000

SC DHEC awarded two cancer control mini-grant projects related to PrCA in 2005. One was given to SC DHEC Region II and the other award was to a partnership between Region IV and the McLeod Health Cancer Care and Research Center. The Region II project, Prostate Cancer Education, Screening & Referral project, uses an American Cancer Society Prostate Cancer Awareness Program to institute a “train the trainer” method in barbershops, salons and members of the faith community to allow the community at large to be informed by their peers. The trainers then recruit men for free community-wide screenings to include a PSA test and digital rectal exams. The Pee Dee Cancer Awareness Prevention & Early Detection project in Region IV, focuses on cancer awareness and prevention education is provided to the African-American population through 18 churches and civic organizations in addition to screenings and follow-up referrals provided by McLeod Health at no cost to the patients.

350

250

200

150

100

50

1996

1997

1998

1999

National cancer prevention organiza-


2000

2001

2002

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Figure 2. Prostate Cancer Age-Adjusted Incidence Rates per 100,000 in SC by Race & Year of Diagnosis, 1996-2002 35

33.2

30

25

23.3

20

15

10

5

0 White

Charged with addressing the racial and ethnic disparities in PrCA in South Carolina, a group of public health professionals, researchers, and community members formed the South Carolina African American Prostate Cancer Network. This network serves as a resource for promoting, developing and implementing culturally competent strategies to address prostate cancer, prevention, screening and treatment for AfricanAmerican males.

Black

300

0

Age-Adjusted Mortality Rates per 100,0000

faith-based organizations. SC DHECOMH partnered with the Palmetto Health Richland hospital system in 2000 to educate 5,500 men and women. Through this program, 5,356 men received screening and 48 prostate cancers were diagnosed between 2000 and 2004. These results were the efforts of Palmetto Health’s Grant Awards Program. Over, 157 churches in the Lexington, Fairfield, Richland and Pickens counties participate.

Black

Figure 3. Prostate Cancer Age-Adjusted Mortality Rates per 100,000 in SC by Race & Year of Death, 1994-2004

tions that have local chapters in South Carolina also promote education and raise prostate cancer awareness. Such examples are the National Black Leadership Initiative on Cancer II: Network Project and UsTOO’s Minority and Underserved Populations Prostate Cancer Awareness Program. Additionally, the social fraternity, Phi Beta Sigma has established a collaborative partnership with the American Cancer Society to

develop and implement Sigma’s Waging War against Cancer to reduce PrCA incidence through fundraising, advocacy, and community service.

Descriptive Epidemiology Most recent South Carolina data indicate that 3,304 new cases of PrCA were diagnosed in 2002 and 495 men died of the disease in 2004. Data over six years (1996-2002) indicates that, on average,

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Unstaged 10%

Distant 8%

Distant 3%

Unstaged 13%

Regional 9%

Regional 9%

Local 70%

Local 78%

Figure 4. Prostate Cancer Stage at Diagnosis in SC among White Men, 1998-2002

Figure 5. Prostate Cancer Stage at Diagnosis in SC among Black Men, 1998-2002

67% of new cases and 57% of deaths occur among EA men (despite their much higher representation in the population).29 Statistics in relative incidence and mortality reflect a large racial disparity between AA and EA men. Nationally, AA men have about 55% higher incidence of PrCA than EA, while in South Carolina the differential is about 80%. This is exclusively due to the higher rates of cancer in AA men, as the EA rates in South Carolina are identical to those of the nation as a whole.24 During the period 1998-2002, the invasive PrCA incidence rate for White (primarily EA) men in South Carolina was 150.9 per 100,000 compared to 272.9 per 100,000 among Black (primarily AA) men (see Figure 1). Mortality rates are even more divergent; AA men are over two-and-ahalf times more likely to die of PrCA.6,24 Over the five-year period from 2000 to 2004 in South Carolina, AAs had almost three times greater mortality (71.9 deaths per 100,000/year) than EAs (25.6 per 100, 000) (see Figure 1). The trend in incidence rates does not correspond to the mortality rate trend for AAs and EAs. Though incidence has decreased over the period of 1996 to 2002 for both AAs and EAs, the difference between the two groups has remained fairly consistent (see Figure 2). However, the same relationship is not seen among mortality rates. The total percent reduction from 1994 to 2003 in mortality is over oneand-a-half time greater among EA than

AA men (see Figure 3).

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Differences in disease virulence have important implications for screening and treatment decisions by race and age.4, 13-15,29 As noted, AA men develop PrCA at earlier ages; at younger ages prostate cancer tends to be a much more virulent disease than that observed in older men.13,14 It is equally important to understand that across racial groups, most men are likely to have PrCA detected after 60 years of age. Screening at older ages will tend to increase apparent incidence rates to a very large extent. Indeed, examination of incidence rates over the period that PSA screening became popular (i.e., in the early to mid 1990s) indicates a large increase in overall incidence.6 Therefore, age differences in incidence by race may have more to do with screening practices and differences in disease virulence than real differences in incidence rates. While incidence rates appear to decrease after 70 years of age in EAs, these rates remain significantly higher in older AA men. As for many types of cancer, the prognosis of PrCA is related to the stage and grade of disease at diagnosis. Stage refers to the anatomic spread of the cancer; i.e., ranging from being confined to the prostate gland to having spread outside the gland to nearby regions or to distant locations within the body.18 Both in South Carolina and in the U.S. as a

whole, AA men are more likely to be diagnosed at later stages (i.e., with regional and distant spread) than EA men.29,30 As shown in Figures 4 and 5, 17% of AA men compared to 12% of EA men are diagnosed at regional and distant stages. Grade, expressed in four levels, refers to the histo-pathologic characterization of the cancer and is a measure of disease severity.18 Although AA men have higher rates of PrCA across all grades of disease, they tend to have the largest proportional increases in Grade III (poorly differentiated) disease, which is associated with much poorer prognoses than more well-differentiated disease (see Figure 6). In addition, a comparison of incidence and mortality rates by county among AA men compared to the state rate for EA men shows the dramatic racial disparity that exists in South Carolina (see Figures 7 and 8). PrCA incidence in AA men is significantly higher than in EA in 40 of 46 counties in South Carolina. Similarly, the PrCA mortality rate in AA men is significantly higher than in EA men in 38 of 46 counties. Furthermore, African-American men in a majority of South Carolina counties have a significantly greater risk of dying from PrCA than their counterparts in the nation as a whole.6,29,31

Disparities in Prostate Cancer Risk Factors The reasons for the large disparities we have presented are not yet understood, although factors ranging from socioeconomic status to lifestyle factors32-37 to genetics38-40 have been invoked. As we have noted earlier, comparing withincountry rates of disease to across-country rates can help broaden and deepen our understanding of the causes of many cancers, including PrCA.41-43 Dramatic international variations in age-adjusted incidence and mortality rates provide clues to the etiology of prostate cancer. Qidong County in China, for example, has an incidence rate of only 0.5 per 100,000 men, whereas the rate in the



Epidemiologic studies that have used different study designs suggest that, among environmental influences, dietary factors constitute the most important of modifiable risk factors. Total fat and meat consumption is associated with overall increased incidence of prostate cancer as well as with incidence of more aggressive tumors.52,53 Saturated fat, primarily from meat and dairy intake, is the most strongly associated fat subtype.42,54,55 Conversely, intake of whole grains and soy products is associated with decreased mortality.42 In cross-national comparison studies of both prostate and breast cancers, we can use “disappearance data” (i.e., the difference between population-level estimates of production +imports –exports –estimates of food wastage) to estimate populationlevel estimates of food intake. Using these data, which are available from UN sources, we have been able to explain up


180 164.3

White

Black

160


U.S. is >150 per 100,000.24,44,45 Japanese men, like Chinese men, also have much lower PrCA incidence and mortality rates than Americans. However, upon migration to the U.S., their rates increase four- to nine-fold within one generation and approximate American rates by the second generation.44,46,47 This suggests that environmental (non-genetic), rather than genetic, factors appear to account for most of these differences in incidence. The clear dominance of environmental factors in “explaining” rapid changes in incidence should not, however, lead one to underestimate the role of genetic factors in determining risk profiles —either individually or across races (or other identifiable population subgroups). There may very well be subsets of the population who are particularly sensitive to the influences of environmental factors because of their genetic constitution. Indeed, a major frontier in cancer epidemiology is the search for gene-environment interactions that can help explain risk and thereby help to identify individuals who are sensitive to particular lifestyle and other environmental influences.44,46,47

140 120 102.0 100 80 56.6

60

37.1

40 26.2 14.8

20 7.3

13.2 0.7

1.9

0 Well differentiated; Grade I

Moderately differentiated; Grade II

Poorly differentiated; Grade III

Undifferentiated; anaplastic; Grade IV

Unknown

Figure 6. Prostate Cancer Age-Adjusted Incidence Rates (1998-2002) per 100,000 in SC by Race & Grade

to 90% of variability in PrCA mortality with dietary factors accounting the vast majority of the variation.42,56 In contrast to mortality differences within the U.S., which are about 2.5 times higher in AA than EA men, mortality rates ranged over 100-fold from the country with the highest mortality rate to the one with the lowest rate. Results from laboratory animal experiments are consistent with the findings of the international studies: fat restriction has been shown to inhibit growth of transplanted prostate cancer cells in rodents.42,57,58 Both fat restriction59 and feeding of genistein,60 a soy isolate, inhibit growth of the LNCaP human prostate cancer cell line. Preliminary evidence also suggests that PrCA may continue to be sensitive to dietary factors even after development of metastases. Substantive dietary changes, marked by adoption of plant-based diets, have been associated with prolonged survival and instances of remission of bone metastases in men with advanced disease,61 findings which may be explained in part by the demonstrated ability of very low-fat, high-fiber diets to modulate circulating androgen levels.62,63 Unlike dietary factors, there is no reposi-

tory of physical activity “disappearance” data that can be used to exploit the huge variations in cancer rates observed across countries of the world. Recent reviews of the physical activity (PA) and PrCA association have therefore had to rely exclusively on results of studies conducted at the level of the individual. Findings from such studies have been divergent.64,65 Friendenreich65 concluded, using criteria previously used to assess diet - cancer relationships,66 that the association was “probable,” based on findings that 15 of 26 published studies demonstrating that higher levels of activity are associated with reduced risk and that nine of 19 reported a dose-response effect. However, a more recent review by Lee64 has found that favorable results for an association between PA and PrCA have not been replicated in recent studies. This may be due to the increasing use of the PSA test and its more frequent use by men with more positive healthseeking behaviors. Therefore, epidemiologic data do not support a role of PA in preventing PrCA.64 Also, the American Cancer Society’s Guidelines on Nutrition and Physical Activity for Cancer Prevention, reviewing the same evidence, suggested that the epidemiologic evidence for a beneficial effect of

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improved quality of life following treatment.73 In a review of studies that have assessed obesity with PrCA mortality, higher grade and advanced stage disease have consistently produced results showing that obesity may not increase the risk of PrCA, but rather promote growth of the tumor once established. Biologically active polypeptides, called adipokines have been linked to a number of carcinogenic mechanisms, such as cell proliferation, metastasis and alterations in sex-steroid hormone levels.74



Summary Figure 7. South Carolina Prostate Cancer: Comparison of the Age-Adjusted, County-Specific Incidence Rate for Black Men vs. the Age-Adjusted, State-Specific Incidence Rate for White Men (1998-2002)



Figure 8. South Carolina Prostate Cancer: Comparison of the Age-Adjusted, County-Specific Mortality Rate for Black Men vs. the Age-Adjusted, State-Specific Mortality Rate for White Men (1999-2003)

physical activity was “insufficient.”67 While the interpretation of available evidence is inconsistent, our knowledge of the biologic mechanisms linking PA to PrCA needs to be strengthened. A leading biological mechanism is the effect of PA on endogenous androgens or on Sex Hormone Binding Globulin (SHBG), or both.68 However, much less is known about the effects of regular physical activity participation on important emo-

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tional, physical, and survival outcomes following the diagnosis of PrCA.69,70 even though regular participation in PA is thought to enhance emotional (e.g., depression, anxiety) and physical functioning following diagnosis and treatment,71 and many patients are interested in lifestyle interventions at this time in their lives.72 Accordingly, more welldesigned studies are urgently needed to enhance our understanding of the biological link between PA and PrCA and

Available evidence suggests that there may be qualitative differences in the natural history of PrCA by race.30,75-77 If this is true then additional etiologic research is needed to identify places in the causal chain where we can intervene to lower PrCA rates in AA men. South Carolina may prove to be a useful context in which to study prostate cancer etiology, because of the presence of unique environmental exposures. For example, soil selenium and cadmium concentrations unique to South Carolina might have a differential affect in the rural areas of the state where ground water use is more common and where AAs are more likely to live. These metals are important in terms of prostate metabolism and cancer.78-80 The possible interaction of geological factors with underlying biological factors such as metal transporter gene expression by race needs to be explored in South Carolina.81,82 Diet and exercise are consistently seen as possible primary prevention strategies for prostate and other cancers, as noted above. There may be very good reasons to intervene on diet and physical activity, but if the intention is to make a health claim with real, specific meaning for PrCA prevention and control then studies must be designed to test the effect of these modalities in rigorous ways at specific points in the natural history of prostate carcinogenesis. Nutrition and exercise programs need to be developed in South Carolina that are



seen as acceptable by people at risk of PrCA; and they will need to focus on effective ways to prevent the development of PrCA, other cancers, and other health outcomes. Implementing diet and nutrition programs in rural parts of the state, possibly through schools or churches, offer benefit to both youth and adults alike. So, it would be possible, indeed it would be desirable, to create programs that may be used for research in one part of the population (e.g., men with PrCA), but are equally beneficial for others (e.g., their spouses and children). Organizing studies that can focus on promising new areas of research and changing the paradigms under which the research community currently operates probably will require re-conceptualizing research strategies employing methods that entail CBPR approaches. Because much of South Carolina’s African-American population resides in rural parts of the state, outreach presents a challenge for both researchers and clinicians.25 Individuals living in rural areas are more likely than urban residents to live in poverty,83 report poorer health status, and not have private health insurance. Americans living in rural areas face disparities in access to basic public health services compared to those living in metropolitan areas.84,85 In very practical ways, local public health departments are absent in many rural communities, and rural hospitals continue to close removing needed services.85 Closing of public hospitals has been shown to significantly increase the percentage of people without a primary health care provider as well as the percentage of people denied care.86 Public health departments are of particular importance to rural residents as they serve as the main avenue for public health and clinical care for this group.87 Issues such as access to care, lack of frequent physician’s visits and quality of medical care have a negative impact on outcomes for men with PrCA, particu-


larly in relationship to staging. If better outcomes are to be achieved in South Carolina, then more must be done to reach the community and provide better access to care in more rural areas of the state. Small media interventions, such as those presented in churches and barbershops may be an effective means for reaching the rural AA population. Our ability to reach out to and interact with the high-risk pockets in the state will be necessary for screening, treatment, and research (which, if conducted competently, will affect screening efficacy, treatment effectiveness, and primary prevention). It is believed that currently available decision-making materials for PrCA screening may not be appropriate due to socioeconomic as well as health literacy differences present in all male groups. It is unclear whether men in the lower socioeconomic groups are given appropriate information that allows them to make educated, informed decisions around PrCA screenings. Considering the number of males in the lower socioeconomic groups in South Carolina and the large AA male population, research evaluating the appropriateness of the existing materials could have an impact - both within the state and in national efforts. Patient education is a promising strategy, but educating the patient in the context of his family seems to be a more effective strategy for this population. Family networks and faith-based networks offer a strong support base for the patient when making health-related decisions, particularly for the African-American male. In collaboration with the SCCDCN, the South Carolina Cancer Alliance (SCCA) is currently developing a proposal to create a decision guide for prostate screening that is targeted toward the African-American male. The SCCA plans to pilot test new, culturally appropriate materials in the Low Country of South Carolina because of its comparatively large African-American population and its high rate of resi-

dential stability. South Carolina is one of only a few states to adopt expanded Medicaid coverage for the treatment of breast cancer. PrCA needs to receive equal recognition. This year alone in South Carolina 3,290 women will be diagnosed with breast cancer and 630 will die from the disease. Likewise, the American Cancer Society estimated 3,770 men in South Carolina would be diagnosed with prostate cancer and 440 will die from the disease in 2006.1 The $1 million set aside in South Carolina budget by lawmakers for treatment of breast and cervical cancer patients makes no mention of prostate cancer, which is an unfair omission. Finally, there currently exists a number of high-quality PrCA treatment, research, and referral resources in the state. Collaborations across agencies, institutes and organizations throughout South Carolina would prove to be beneficial in reaching the most rural (and therefore hardest to reach) populations. Collaborative arrangements will be pursued to increase positive outcomes and better futures for South Carolinians.

Acknowledgement We would like to acknowledge funding of the South Carolina Cancer Disparities Community Network (SCCDCN) through grant number 1 U01 CA11460101 from the National Cancer Institute (Community Networks Program). We would also like to acknowledge the South Carolina Central Cancer Registry (SCCCR) for the state cancer incidence and mortality data provided. The SCCCR is funded by the CDC National Program of Cancer Registries, cooperative agreement number U55CCU421931, and SCDHEC. Rita Jefferson, Health Disparities Consultant at the South Carolina Department of Health and Environmental Control, Office of Minority Health, contributed valuable information on special programs in South Carolina.

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Prostate Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology tumours. Cancer Causes Control, 1991. 2: p. 85-94. 53. Giovannucci, E., et al., A prospective study of dietary fat and risk of prostate cancer. J Natl Cancer Inst, 1993. 85: p. 1571-1579. 54. Mettlin, C., et al., Beta-carotene and animal fats and their relationship to prostate cancer risk: A case-control study. Cancer, 1989. 64: p. 605-612. 55. Talamini, R., et al., Nutrition, social factors, and prostatic cancer in a northern Italian population. Br J Cancer, 1986. 53: p. 817-821. 56. Hebert, J.R. and A. Rosen, Nutritional, socioeconomic, and reproductive factors in relation to female breast cancer mortality: findings from a cross-national study. Cancer Detect Prevent, 1996. 20: p. 234-44. 57. Clinton, S.K., et al., Growth of Dunning transplantable prostate adenocarcinomas in rats fed diets with various fat contents. J Nutr, 1988. 118: p. 908-914. 58. Carroll, K.K. and R.C. Noble, Dietary fat in relation to hormonal induction of mammary and prostate carcinoma in Nb rats. Carcinogenesis, 1987. 81: p. 851-853. 59. Fair, W.R., N.E. Fleshner, and W. Heston, Cancer of the prostate: a nutritional disease? Urol, 1997. 50: p. 840-848. 60. Wang, Y., W.D. Heston, and W.R. Fair, Soy isoflavones decrease the high-fat promoted growth of human prostate cancer - results of in vitro and animal studies. J Urol, 1995. 153: p. 269A. 61. Carter, J.P., et al., Hypothesis: dietary management may improve survival from nutritionally linked cancers based on analysis of respresentative cases. J Am Coll Nutr, 1993. 12: p. 209-226. 62. Dorgan, J.F., et al., Effects of dietary fat and fiber on plasma and urine estrogens in men: A controlled feeding study. Am J Clin Nutr, 1996. 64: p. 850-855. 63. Tymchuk, C.N., et al., Effects of diet and exercise on insulin resistance, sex hormone-binding globulin, and prostate-specific antigen. Nutr Cancer, 1998. 31: p. 127-131. 64. Lee, I.M., Physical activity and cancer prevention - data from epidemiologic studies. Med Sci Sports Exer, 2003. 35(11): p.

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2003. 88(2): p. 263-9. 76. Bianco, F.J., Jr., et al., Presence of circulating prostate cancer cells in African American males adversely affects survival. Urologic Oncol, 2002. 7(4): p. 147-52. 77. Bah, E., et al., Cancer in the Gambia: 198897. Br J Cancer., 2001. 84(9): p. 1207-14. 78. Palmer, S., Diet, nutrition, and cancer. Prog Food Nutr Sci, 1985. 9(3-4): p. 283-341. 79. Habib, F.K., Evaluation of androgen metabolism studies in human prostate cancer-correlation with zinc levels. Prev Med, 1980. 9(5): p. 650-656. 80. Waalkes, M.P., et al., Cadmium exposure in rats and tumours of the prostate. IARC Sci Publ, 1992. 118: p. 391-400. 81. Blackshear, P.J., et al., Polymorphisms in the genes encoding members of the tristetraprolin family of human tandem CCCH zinc finger proteins. Prog Nucleic Acid Res Molec Biol, 2003. 75: p. 43-68. 82. Vassella, E., et al., Deletion of a novel protein kinase with PX and FYVE-related domains increases the rate of differentiation of Trypanosoma brucei. Molec Microbiol, 2001. 41(1): p. 33-46. 83. Redford, L.J. and a.B. Severns, Providing community-based services to the rural elderly, in Home health services in rural America., J.A. Drout, Editor. 2004, Sage: London. 84. Ham, R.L., R.T. Goins, and D.K. Brown, Best practices in service delivery to the rural elderly. 2005, Available from: http:// www.hsc.wvu.edu/coa/publications/best_ practices/Best_Practices-Rural_Elderly. pdf: cited February 28, 2005. 85. National Advisory committee on Rural Health and Human Services. The 2004 report to the Secretary: rural health and human services issues. 2004, U.S. Department of Health and Human Services. 86. Bindman, A.B., D. Keane, and N. Lurie, A public hospital closes. Impact on patients’ access to care and health status. JAMA, 1990. 265(14): p. 1827-8. 87. Regan, J., et al., The role of federally funded health centers in serving the rural population. J Rural Health, 2003. 19(2): p. 117-24; discussion 115-6. n

Author Affiliations 1. Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC 2. Statewide Cancer Prevention and Control Program, Columbia, SC 3. Center for Community-Based Research, the Dana- Farber Cancer Institute, and Harvard School of Public Health, Boston, MA. *Work was carried out while at the Cancer Prevention and Control Program and the Department of Epidemiology and Biostatistics of the University of South Carolina, Columbia, SC 4. Department of Urology, Medical University of South Carolina, Charleston, SC 5. College of Pharmacy, University of South Carolina, Columbia, SC and Medical University of South Carolina, Charleston, SC 6. Insights Consulting, 2728 Wilmot Ave., Columbia, SC 29205 7. Statewide Cancer Prevention & Control Program, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC


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PERSPECTIVES Prostate Cancer Disparities in South Carolina: Two Generations Talking from a Male Community Perspective Lee H. Moultrie II Justin H. Smith A Screening Experience for One Generation Lee Moultrie I remember my first prostate cancer screening as if it was yesterday. It was in 1995 and I was only 39 years old. There was an advertisement in the Charleston Post and Courier newspaper indicating that a free prostate screening was available at the U.S. Naval Hospital in North Charleston, SC for AfricanAmerican men, 40 years and older and for, European-American men 50 years and older. As a U.S. Air Force retiree, I accepted the opportunity without really knowing what to expect in the screening. First of all, I have indicated that I was 39 years old, not 40 years old as they requested. I could have used the excuse that the advertisement was not speaking to me. I could have used the excuse that I was a breakfast waiter from 6:00am-10:00am and did not have time to leave my job in downtown Charleston to travel to North Charleston (about 20 minutes). I could have used the excuse that I really did not have much knowledge about prostate cancer or that I wasn’t even old enough to be screened. Upon entering the hospital and speaking with the staff, we shared several jokes and I shared that I was only 39 years old. I felt it was important for my personal health to be screened, as this article indicated. The staff, seeing my sincerity and concern, indicated that they hoped other AfricanAmericans would come to their hospital, or any other hospital, to bring down the death rate from this disease. The nurses directed me to a waiting room where I sat and read various magazines and brochures about everything except prostate cancer or anything related to men’s health issues. Based on what I have learned about prostate cancer screening (and the controversies mentioned in the article by Dr. Drake and her colleagues1) over the years, this lack of education materials really amazed me. Another nurse called me and took blood for the prostate-specific antigen (PSA) test and directed me to another room to wait on the doctor for the second part of the examination. I was not mentally prepared for this part. The doctor entered the room and we exchanged small talk and jokes. He then indicated that “It’s time to drop your pants and bend over the bed.” I replied, “I don’t know you that well”. We laughed again and he explained to me in more detail the process of the examination. I understood more from his explanation, but was

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not completely appreciative of the process. As a man, I did not understand why this second part was needed to find out if there was anything abnormal or not with my prostate. Several weeks passed and I had forgotten about the screening when one of my co-workers indicated that I received a call from the hospital. I returned the call and they put me through to the urology department. The particular doctor I asked for was not available. So, for several hours my mind was going crazy —wondering why a urologist would want to speak with me. Was something abnormal with my test? Why else would he call? When the doctor called he apologized for causing any concern, indicated that he did not detect anything abnormal, and wished more African-American men would visit their doctors for screenings. I don’t remember hearing anything about prostate health during the 18 years I was in the military. I remember speaking with others in the night clubs and traveling the world (London, Paris, Saudi Arabia, and Turkey, the United States and a host of other countries). There has not been talk of prostate cancer of in the barbershops or churches. Why not? I attended African-American churches, patronized African-American clubs and barbershops. No one discussed the process for screening or made literature available to build up the knowledge. Even more, there was absolutely no acknowledgement that it is a much bigger issue for African-Americans than other groups.

Educating Others We are to be a part of the army of soldiers on the frontline with researchers, doctors, nurses, community outreach workers and survivors. We have to discuss the importance of knowing your PSA numbers and the importance of being screened—whether you desire to or not. Being an African-American male, a Desert Storm veteran with the U.S. Air Force, a Civil Rights Activist, a member of the 100 Black Men of American, Chapter President of the 100 Black Men of Charleston, SC, and a college student. Those of us who have a voice in our community must move from being only males. We must all accept our responsibility in society and become MEN. Men to wives, partners, children, our communities and society. We must no longer make excuses about not being able to leave work, not knowing about the disease or not seeking results once we are screened. Yes,


PERSPECTIVES there is racism, prejudice, and discrimination in most aspects of life. Get over it! We are men now. We who know the truth about the process should continue researching, practicing, educating and comforting. Over the years that I have become educated and motivated to take action, I have become familiar with the complicated issues mentioned in the article by Dr. Drake and her co-authors.1 I know this is not simple; still we cannot use that as an excuse to do nothing. Doing nothing has put us in the very bad situation we now find ourselves. If we have the knowledge, we will do the right thing much more often than we will do the wrong thing. Men, do what ever it takes to achieve the goal of doing right by ourselves, our brothers, our families, and our community. Help to educate physicians and other health care providers. Access to care is a problem. We need to raise our voices and tell those who have the power that access is an issue. If our elected officials can’t resolve the issue of access to care, fire them. Elect others who have power and who care enough to go back to our communities and educate our families, friends and associates. We must stop waiting on someone to come riding in on a white horse and white hat and say, “I’m here to save you.” We have the resources within our minds and our hands to start saving ourselves. Do we care enough to tell the truth in our barbershops, churches, nightclubs and on the block? Life and death is in each of our hands to share the truth in a way that all individuals can receive it. Let’s be the agents of change that this society needs and get 30 minutes of exercise, eat nine fruits and vegetables, and drink eight glasses of water every day. Read something funny, read something to enhance your health and wealth of knowledge. Then share these small tidbits with someone else. Each of us is a “keeper” of each other, a keeper of men, whether he is black or white; we are here for each other. Brothers’ keepers should cross all racial and ethnic backgrounds. Yes, we all come to the table with our particular up-bringing and or nurturing from our specific families. But as a flower blossoms, we should blossom within the sunshine to help ourselves “get over” habits that were taught to us that were not completely truth, then we can care enough and be our Brothers keepers. We’re in the 21st century and there are millions on top of millions of pieces of information to address all of our needs and to enhance the quality or our lives. Some men make more time in their schedules to wash their cars, to go shopping for clothes to wear to the club or church, or to get their haircut (that takes a minimum of one hour in most African-American barbershops),


than we do in seeking information about preventive health for ourselves. Get up and go to a health fair (there’s one every week in each part of this state). Get familiar with health centers and community advocates – while you are at it, become one! As healthcare advocates, providers, and individuals, we must do more to engage the appropriate individuals or agencies. No is not always the last word, it could be no, not this time. But, it is not always the last word.

Influences of Prostate Cancer Disparities: Perspective from Another Generation By Justin H. Smith Researchers have discovered some of the many factors that result in the high incidence and poor prognosis of prostate cancer in African-American men. Of these, three stand out more so than others in my community: 1) the cost associated with healthcare, 2) trust between patients and medical professionals, and 3) inadequate prevention efforts. Substantial racial/ethnic disparities in health insurance persist. African-Americans are at greater risk of being uninsured compared to European-Americans. It is no secret that having health insurance matters. A substantial body of research demonstrates that lack of health insurance makes it harder for people to obtain health care, more likely that people will become sick or receive inadequate medical care, and more likely that people experience major financial problems after seeking care. The mistrust of the medical profession has emerged as a critical barrier in efforts to increase the number of African-American males seeking routine preventive medical care, such as prostate cancer screening. This distrust among African-Americans is rooted in the community’s continued awareness of historical events, such as non-voluntary medical experimentation on slaves during the antebellum period and the infamous Tuskegee Syphilis Study (see http://www.tuskegee.edu/Global/story. asp?S=1207512). Such historical memories and continued disparities in the provision of care to African-Americans are reflected in the continued fear of exploitation by the medical profession and perception that African-American lives are devalued in the medical setting as well as in society at large. In my community, many older African-American males have a belief that medical professionals diagnose multiple ailments in order to receive additional money through extensive tests and procedures. Even if this is mainly untrue, researchers and clinicians must take into consideration the perceptions and fears of the African-American community. Finally, prevention efforts are inadequate in the sense that many

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Perspectives strategies are not tailored specifically to the needs of AfricanAmerican males. For example, materials must be culturally and linguistically appropriate. In addition, perceptions about prostate cancer must be addressed earlier. Although research indicates that prostate cancer screening should be targeted to African-American men, 40 years of age and older, I believe some efforts should be focused on younger individuals to raise awareness. Most of the males in in the over-forty age group are from communities similar to the one that I was raised in. I am from a community that is 100% African-American; where the education levels of older individuals are tenth grade or below. Very few of these men have knowledge of prostate physiology or anatomy or of how prostate cancer grows and spreads. I strongly believe that if you begin to educate and change the perceptions of prostate cancer within the younger African-American population, they can actively participate in increasing the prevention efforts of their fathers, grandfathers,

uncles, and brothers. In response to Mr. Moultrie’s article, I fully agree with the fact that we as “MEN” need to exhibit that image and take part in prostate cancer screening. So my response is not to steer researchers away from screening the more age-appropriate males as Mr. Moultrie advocates, but to consider an alternative method of intervention by educating a younger population to increase awareness of prostate cancer.

References

1. Drake BF, Keane TE, Mosley CM et al. Prostate Cancer Disparities in South Carolina: Early Detection, Special Programs, and Descriptive Epidemiology. Journal of the South Carolina Medical Association. 2006;102:241-249. n

Mr. Moultrie works with the National Black Leadership Initiative on Cancer III and the Us TOO Prostate Cancer Education and Awareness Program in North Charleston, SC. Address correspondence to: Cancer Prevention and Control Program, 2221 Devine Street, Columbia, SC 29205 Email: [email protected]. Mr. Smith, a life-long resident of Columbia and recent graduate of Benedict College, worked as an undergraduate fellow with the South Carolina Cancer Disparities Community Network at the University of South Carolina in Columbia, SC. Address correspondence to: Cancer Prevention and Control Program, 2221 Devine Street, Columbia, SC 29205 Email: [email protected].

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SCMA Insurance Updates Aetna Compliance Disputes - Successfully Concluded Disputes Modifier 25 Dispute

Issue: Aetna was not paying for certain CPT procedure codes (such as visual acuity screening and developmental testing) when billed with an Evaluation and Management code appended with a -25 modifier as required by section 7.20(b)(iii). Resolution: • Aetna will fix system to pay the affected codes. (The chart containing the full list of codes is available on www.aetna.com.) • Aetna will reprocess physicians’ claims with these codes for dates of service back to July 1, 2004. These payments must be made by October 1, 2006. • Aetna will change its coding policies regarding pulse oximetry (CPT 94760, 94761, 94762) and urinalysis (CPT 81002, 81003) to allow payment when billed with an E&M code appended with a -25 modifier and will reprocess claims with these codes with dates of service back to May 1, 2006. • A Task Force comprised of State Medical Society and Aetna representatives has been convened to make recommendations on improving the Aetna Provider Website to make it more user-friendly and transparent for physician offices.

EKG Dispute Issue: Aetna was not paying CPT code 93010 when billed with an E&M code (CPT Codes 99281-99285) appended with a -25 modifier as required by section 7.20(b)(iii). However, because Medicare and some other payors do not require the use of the -25 modifier in order to be paid, many physicians submitted their claims without a modifier and therefore this code combination was considered separately. Resolution: • Aetna will reprocess physicians’ claims for dates of service back to July 1, 2004 as a result of resolution of the general modifier -24 dispute. • Aetna will remove the edit entirely effective August 12, 2005, meaning that Aetna will pay for both CPT code 93010 and an accompanying E&M code (CPT 99281 – 99285) without the need for physicians to append a -25 modifier. • Physicians will have the opportunity to resubmit claims billed without the -25 modifier back to February 10, 2006. Aetna’s voluntary agreement to do this goes further than required by the settlement agreement.

Add-on Code Dispute Issue: Aetna was not paying the add-on codes for myocardial profusion (CPT 78478 and 78480) and CAD mammography (CPT 76082 and 76083) as required by section 7.20(b)(ii). Resolution: • Aetna changed its payment policies to pay these codes correctly. • Physicians had the opportunity to submit claims with these codes for dates of service from January 1, 2004 to May 12, 2005 for myocardial profusion and from January 1, 2004 to March 31, 2005 for CAD mammography. • Because many physicians had stopped submitting claims with these codes due to Aetna’s then current payment policies, physicians were entitled to submit claims which had net been previously submitted. Aetna’s agreement to allow physicians to file never-filed claims went further than required by the settlement agreement.

Contract Dispute Issue: Aetna’s Provider Physician Contracts did not contain all the provisions required by the settlement agreement. Resolution: • Aetna sent a contract addendum to all contracted physicians containing the language required by the settlement agreement and clarifying certain contract terms. • Aetna extended the term of the most important terms of the settlement agreement by one year.

Vaccines Issue: Aetna had not set its fee schedules to cover costs of certain vaccines in certain markets as required by section 7.14(b). Resolution: Aetna has updated its fee schedules and paid physicians. continued →


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All Products Issue: Physician practice which sought to withdraw solely from Aetna’s captivated product was terminated as a participated provider from all other products in violation of section 7.13(b). Resolution: Practice was reinstated and claims were reprocessed.

Aetna Compliance Disputes - Pending Disputes Global Periods/Modifier 57 Issue: Aetna was not paying for certain E&M visits appended with a -57 modifier to indicate decision for surgery thereby extending the global period for surgery beyond that prescribed by CMS in violation of section 7.20(b)(vii). Partial Resolution: Aetna has changed its payment practices to match CMS’. Negotiations are underway regarding remaining issues.

Overpayment Recovery Issue: Aetna is seeking recovery of alleged past overpayments from several physicians beyond the 24 months permitted by section 7.22. These disputes are all fact specific, because there is no time limit on overpayment recoveries in instances of “reasonable suspicion of fraud.”

EOB Language Issue: A non-participating physician from a state that allows balance billing has filed a dispute alleging that Aetna has not changed its EOBs as required by section 7.21 of the agreement to clearly state that the physician may bill the patient.

Multiple Surgery Issue: Aetna’s payment for multiple surgeries is 100/50/25%. The dispute concerns Aetna’s alleged failure to disclose on its Provider Website its criteria for determining which surgery is paid at which level as required by section 7.8. This dispute is still in the investigational phase.

Medicare Update Non-Application of Deductible for Colorectal Cancer Screening Tests Effective January 1, 2007, Medicare will waive the annual Medicare Part B deductible for colorectal cancer screening tests billed with the following HCPCS codes: G0104, G0105, G0121, G0106, G0120.

Hold on Medicare Payment This message is a reminder for all physicians, providers, and other health care professionals who bill Medicare contractors for their services. A brief hold will be placed on Medicare payments for all claims during the last nine days of the federal fiscal year (September 22 through September 30, 2006). These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one-time hold on payments. All claims held during this time will be paid on October 2, 2006. This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non-claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements. For more information, please view the MLN Matters Article at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5047.pdf.

Medicaid Update CMS Rules on Citizenship Requirements for Medicaid On July 6, the Centers for Medicare and Medicaid Services (CMS) released its interim final regulation on the citizenship documentation requirements contained in the Deficit Reduction Act. In the final rule, CMS states that seniors and people with a disability who receive, or are eligible for, Medicare or Supplemental Security Income are exempted from the new citizenship documentation requirements. This is a reversal from CMS’ original position on this issue. Download the guidelines at www. scmanet.org/downloads/citizen_proof.pdf. continued →

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Reimbursement Increase for Anesthesiologists Effective with dates of service on or after August 1, 2006, SC Medicaid will increase the reimbursement for an anesthesiologist providing medical direction of a Certified Registered Nurse Anesthetist (CRNA) from fifty percent to sixty percent of the established reimbursement rate. CRNAs under medical direction of an anesthesiologist will be reimbursed at fifty percent of the anesthesiologist rate. Questions can be directed to your Medicaid program manager at 803-898-2660.

DHEC Update DHEC Contact Information for Reportable Diseases and Reporting Requirements Incidents of animal bites to include encounters with bats should be reported to the local DHEC office. This is consistent with South Carolina Law requiring the reporting of diseases and conditions to your state or local public health department. State Law # 44-29-10 and Regulation # 61-20 as per the DHEC 2004 List of Reportable Conditions available at: www.scdhec.gov/health/ disease/docs/reportable_conditions.pdf. Federal HIPAA legislation allows disclosure of protected health information, without consent of the individual, to public health authorities to collect and receive such information for the purpose of preventing or controlling disease (HIPAA 45 CFR §164.512).

BlueCross BlueShield Updates Attention Professional Providers: Getting an NPI is Free--Not Getting One Could be Costly! As BlueCross BlueShield of South Carolina (BCBS) has been reporting over the past year, all HIPAA covered health care providers, whether individuals or organizations, must obtain a National Provider Identifier (NPI). The NPI is required on all HIPAA electronic transactions by the compliance date of May 23, 2007. These transactions include claims, eligibility/claim status inquiries and responses, referrals and remittance advices. NPIs are generated using the National Plan and Provider Enumeration System (NPPES). Once enumerated, your NPI, which is a unique ten-digit numeric identifier, will not change and will remain with you even if you move, change specialties or practice affiliations or locations. Your individual NPI will be the sole provider identifier that replaces the multiple provider identification numbers you currently use. Use of Medicare UPINs, Blue Cross and Blue Shield provider numbers, CHAMPUS numbers, Medicaid IDs, etc. will no longer be permitted after May 23, 2007.

Get it, Share it, Test it! Providing BCBS with your NPI now and testing with them will help prevent disruptions in your practice’s cash flow. CMS says that you should get your NPI no later than November 2006 to allow time to test your NPI and share it with your healthcare trading partners, including payers, clearinghouses, vendors and other providers. BCBS strongly encourages you to transmit test claims in a controlled environment prior to the compliance date.

Already have your own NPI? BCBS asks you to complete an NPI Notification form and fax the form along with a copy of your confirmation letter from NPPES to 803-264-4795. The BCBS NPI Notification form is located at www.SouthCarolinaBlues.com. Click on the “I am a Provider” link and then select “HIPAA Critical Center.”

Don’t have your NPI yet? Apply today in one of the following ways: 1. Online Application: Takes about ten minutes. 2. Mail: You can mail the application. A copy of the application is available on https://nppes.cms.hhs.gov. 3. Third Party: With your permission, an organization may submit your application in an electronic file. This could mean that a professional association or perhaps a health care provider who is your employer could submit an electronic file containing your information and the information of other health care providers. For more information, e-mail BCBS at [email protected]. You can also call them at 803-264-8402.


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Continuing Medical Education

Melissa Hamby, Director of Education

Fourth Quarter 2006 Calendar

Baxter F. McLendon, MD, Chairperson

Published by the SCMA Committee on Continuing Medical Education Post Office Box 11188, Columbia, SC 29211 Note: CME activities in neighboring states are listed when space permits. Contact the Medical College of Georgia, Division of Continuing Education at (800) 221-6437 for other activities.

OCTOBER Monday October 2, 2006 Florence, SC: Floyd Conference Center at Carolinas Hospital System Cardiovascular Symposium SPONSOR: Carolinas Hospital System CONTACT: Angela Lorenz; (843) 674-2521 CREDITS: 8 hours, AMA Category 1 Wednesday October 4, 2006 Augusta, GA: Medical College of Georgia Advanced Botulinum Toxin Treatment of Neurological Disorders SPONSOR: Medical College of Georgia Division of Continuing Education DESCRIPTION: Provide information as well as hands-on experience with the use of botulinum toxin as a treatment for movement disorders. TARGET AUDIENCE: Neurologists and any physician interested in the treatment of neurological disorders FACULTY: Michael Rivner, MD; Kapil Sethi, MD TUITION: $300 CONTACT: Jason Norton; (800) 221-6437 CREDITS: 7 hours, AMA Category 1 Friday – Saturday October 6-7, 2006 Asheville, NC: Grove Park Inn South Carolina Neurological Association Annual Meeting SPONSOR: Medical University of South Carolina DESCRIPTION: Update on diagnosis and treatment of multiple neurological disorders. CONTACT: Pam Benjamin; (843) 876-1925

Thursday – Friday October 12-13, 2006 Greenville, SC: Toomey Conference Center, Greenville Hospital System Third Annual Cardiovascular Symposium: Cardiovascular Diseases – Management and Treatment for the Primary Care Physician SPONSOR: Greenville Hospital System TARGET AUDIENCE: Family practice physicians, internists, cardiologists, surgeons TUITION: $50 per day CONTACT: Amanda Gillespie; (864) 455-6478 CREDITS: 12.5 hours, AMA Category 1 Saturday – Sunday October 14-15, 2006 Charleston, SC: Doubletree Hotel Bone and Joint Disorders Facing the Primary Care Provider SPONSOR: Medical University of South Carolina DESCRIPTION: Update on evaluation and treatment of musculoskeletal complaints including inflammatory arthritis, osteoporosis, as well as sports injuries. Participants are encouraged to bring difficult or interesting cases for discussion with the group. FACULTY: MUSC faculty CONTACT: Odessa Ussery; (843) 876-1925 CREDITS: 7 hours, AMA Category 1 Thursday – Saturday October 19-21, 2006 Augusta, GA: Medical College of Georgia Southern States Rhinology Course SPONSOR: Medical College of Georgia Division of Continuing Education DESCRIPTION: This course includes basic and advanced courses for practicing otolaryngologists interested in learning new information and surgical techniques in the specialty.

FACULTY: Guests and MCG faculty TUITION: $1,500 with lab, $800 without lab CONTACT: Jason Norton; (800) 221-6437 CREDITS: 14.5 hours, AMA Category 1 Friday – Sunday October 20-22, 2006 Charleston, SC: Doubletree Hotel Issues in Women’s Health SPONSOR: Medical University of South Carolina TARGET AUDIENCE: Ob/gyn, internists, family physicians FACULTY: MUSC faculty CONTACT: Pam Benjamin; (843) 876-1925 Friday – Sunday October 20-22, 2006 Augusta, GA: Medical College of Georgia Primary Care Issues in Endocrine, Renal and Metabolic SPONSOR: Medical College of Georgia, Division of Continuing Education FACULTY: MCG faculty TUITION: $450 CONTACT: Jason Norton; (800) 221-6437 CREDITS: 15 hours, AMA Category 1 Saturday October 21, 2006 Columbia, SC: Embassy Suites Hotel 16th Annual Cardiology Symposium SPONSOR: USC School of Medicine – Palmetto Health Richland CME Organization TARGET AUDIENCE: Primary care physicians TUITION: $25 CONTACT: Steven Hasterok; (803) 434-4211 CREDITS: 7 hours, AMA Category 1

NOVEMBER Thursday – Friday November 9-10, 2006 Columbia, SC: Columbia Metropolitan Convention Center Ninth Annual Southeastern Trauma Symposium SPONSOR: South Carolina Medical Association CONTACT: Tammy Allison; (864) 560-6934 CREDITS: 10 hours, AMA Category 1 Thursday – Saturday November 9-11, 2006 Hilton Head Island, SC: Marriott Beach and Golf Resort SCAFP 58th Annual Scientific Assembly SPONSOR: South Carolina Academy of Family Physicians CONTACT: Shannon Lattimore or Patty Kirk; (864) 984-7237

Friday – Saturday November 10-11, 2006 Augusta, GA: Medical College of Georgia Minimally Invasive Surgical Management of Thyroid and Parathyroid Disorders SPONSOR: Medical College of Georgia, Division of Continuing Education DESCRIPTION: This course will offer the latest information on the medical and surgical management of thyroid and parathyroid diseases, emphasizing minimally invasive surgical techniques through a combination of didactic lectures, panel discussions and hands-on cadaver laboratory practice. TARGET AUDIENCE: Otolaryngologists FACULTY: MCG faculty CONTACT: Jason Norton; (800) 221-6437 CREDITS: 12.5 hours, AMA Category 1

DECEMBER Friday - Sunday December 1-3, 2006 Charleston, SC: Doubletree Hotel 9th Annual Frontiers in Pediatrics SPONSOR: Medical University of South Carolina TARGET AUDIENCE: Pediatricians, family physicians FACULTY: Guests and MUSC faculty CONTACT: Odessa Ussery; (843) 876-1925

SCMA COMMITTEE ON CME Sami B. Elhassani, MD, Chair Baxter F. McLendon, MD, Vice-Chair C. Michael Collins, MD Gary A. Goforth, MD Sandra D. Hannegan, MD Sam Kini, MD Jonathan S. Lokey, MD Robert J. Malcolm, MD Terry A. Payton, MD Jennifer R. Root, MD William M. Simpson, Jr., MD Gregory T. Squires, MD Kelly T. Watson, MD Andrew J. Pate, MD, Speaker of the House

AMA Report Report of the Annual Meeting (A-06) in Chicago, Illinois The AMA Annual Meeting (A-06) was held in Chicago June 10-14, 2006. William Plested, III, MD, a cardio thoracic surgeon from California, and a guest speaker at the SCMA Annual Meeting in April, was installed as the new president. In his inauguration address he challenged us to use the November 2006 election as a “golden opportunity to design the health care system that will bring the miracles of modern medicine to every American.” Donald M. Berwick, MD of the Institute for Health Care Improvement, gave a report on the 100,000 Lives Campaign and thanked the AMA for its commitment and leadership in this effort. Over 3,000 hospitals nationwide are participating in the campaign and the goal of 100,000 lives saved was reached during the meeting. Dr. Berwick encouraged us to be sure that all our hospitals are enrolled in the six campaign interventions by next year. Some of the results of individual hospitals are truly outstanding. For example, eleven hospitals have had no central line infection and 23 hospitals have had no ventilator-acquired pneumonia in over a year. Dr. Berwick was encouraged that physicians and nurses have shown the courage to participate in this effort to improve our hospitals and health care system. The AMA healthcare advocacy agenda for 2006 is familiar with medical liability reform as the number one issue. For the first time in several years liability reform was not the major topic at the meeting. Our efforts at reform at a national level have been unsuccessful, but efforts in individual states, including South Carolina, have been successful and are showing results with stabilization of insurance premiums and reductions in some cases. Medicare payment reform continues to be a major advocacy issue. Physicians have received a temporary fix for several years, and the underlying broken formula needs to be changed. The ongoing problem of the uninsured, now estimated at 46 million, brought attention to the need for overall reform of our health care system. For the first time, the AMA voted to support a requirement that individuals and families be required to obtain coverage for catastrophic health care and evidence-based preventive health care. This requirement would apply to families earning greater than 500% of the poverty level and would be enforced by using the tax structure to achieve compliance. There was considerable debate on this issue and some feared that it would lead to a single payor system or “socialized medicine.” In the end, the delegates decided it was reasonable to require “individual responsibility” to combat the uninsured problem. Complete coverage of the AMA meeting can be found in American Medical News. The AMA also voted to: • Support the development and adoption of a consistent format for estimating and publicly reporting health care administrative costs in order to facilitate unbiased comparisons across insurers. • Work to overturn the Recovery Audit Contractor pilot projects in Florida, New York and California. • Support the repeal or delay of federal legislation that reduces physician payments for imaging services. • Adopt as policy that any store-based health clinic should adhere to a series of principles, including ensuring that the clinic has a well-defined and limited scope of services. These clinics should encourage patients to have a primary care physician to ensure continuity of care. The AMA will continue to monitor the effects of store-based health clinics on the health care marketplace. This issue was also raised by the Greenville County Medical Society in a resolution at the 2006 SCMA meeting. • Advocate for and support initiatives that minimize physicians’ financial burden of adopting and maintaining electronic medical records. This meeting was my final one as a member of the Council on Science and Public Health. I have served the maximum allowed two terms for a total of eight years. During my time on Council, we addressed many scientific and public health issues and we have had major programs on bioterrorism and disaster preparedness, obesity, and, at this meeting, introduced the importance of reducing sodium intake. We presented a report on the relationship between dietary sodium intake, blood pressure, and cardiovascular disease and identified steps to reduce the intake of sodium on a population-wide basis. Most of us have considerably more dietary salt than is desirable and would benefit from reducing sodium intake to 1.5 grams daily, from the current U.S. average of 4.0 grams. To accomplish this as a population we need to reduce sodium in processed foods, fast food products, and restaurant meals.

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The SCMA passed a resolution at the 2006 meeting to direct the AMA to petition the Pharmaceutical Research Manufacturers of America (PhRMA) to adjust its physician gift guidelines to include both physicians and their spouses/guest at informational dinner presentations. This resolution was not adopted, primarily because it was not considered necessary or significantly contributing to physician education or patient care. The South Carolina delegation was represented by delegates Chris Hawk, MD, Chairman, Steve Imbeau, MD, Vice-Chairman, Carol Nichols, MD, William Hester, MD, Boyce Tollison, MD. Alternate delegates included Capers Hiott, MD, John Evans, MD, Gerald Harmon, MD, Gerald Wilson, MD, and Jerry Powell, MD. Other members of our delegation include: Bob Sade, MD, member of the AMA Council on Ethical and Judicial Affairs (CEJA), and the following delegates representing their respective specialty societies: Greg Slachta, MD (urology), Richard Gross, MD (orthopaedics), and Marion Burton, MD, (pediatrics). The AMA is the most effective way that we physicians can influence the important professional and public health issues facing medicine today. If you are not a member, I invite you join. The dues for the remainder of the year are half-price. Please call the SCMA at 1-800-327-1021, ext. 232 for an application. The success of the AMA depends on the participation of you and your colleagues.

J. Chris Hawk, III, MD Chairman SCMA Delegation to the AMA

Members of the SCMA delegation to the American Medical Association at the AMA Annual Meeting in Chicago, June 2006. From left, SCMA President Jerry Powell, MD; SCMA President-Elect Gerald E. Harmon, MD; SCMA Past-President John P. Evans, MD.


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ALLIANCE

Physicians Must Speak for their Patients at the Voting Booth The news was indeed rather ugly this morning. War, poverty, natural disasters—it does seem as if the world, if not drowning or drying up, is blowing up. Of course, the human toll in all of this carnage is staggering. Within the chaos, however, one group remains constant – the physicians. Whether in battlefield tents, urban centers, or make-shift rural clinics from Appalachia to Sudan to Indonesia, it is the physicians who create peace and civility in a world seemingly gone mad. Watch the news; in every segment you will find these “every-day heroes,” with bombs falling and fires raging, going about the business of saving lives. For these men and women, humanity and worth are not measured by political persuasion, race, age, or wealth but by the fact that life itself is sacred and is must be protected at all costs There is, however, another battle that does not usually make the 6:00 p.m. broadcast. Just as their colleagues in the news, physicians in this country are also under assault by regulatory bombs; shady deals between diplomats who do not understand patient care, financial decisions that leave patients and physicians at the mercy of the lowest bidder; the list continues. Medicine is at war; the battlefield is the legislative arena. Physicians cannot mass at the borders, but they can mass at the voting booths in every town and city in this country. But who will come to fight? Several years ago, statistics showed that approximately 50% of physicians WERE NOT REGISTERED TO VOTE. I doubt that the number has changed drastically. If we in the family of medicine do not care enough to show up on the front lines, we should not complain about being overrun by opposing forces. This fall, the medical alliances around the state are encouraging voter registration drives in hospitals and clinics in South Carolina. We are recruiting each of you; your office staff; your family members; and all others for whom accessible health care is a privilege to be cherished. The voting booth is the front line. The individual vote is more powerful than any armament ever made. Yes, we may be outnumbered; but we are smart, and our cause is just. We fight not for ourselves alone but for those we seek to serve. There is no more noble calling. During the days of Vietnam, there was a song “Where Have All the Flowers Gone?” The final verse spoke of young men “Gone to graveyards, every one” and asked “When will they ever learn?” Will this be the fate of the medical profession? I hope not; I believe not. But ALL must join the fight.. Register to vote. Educate yourself about the issues. Then VOTE. Fight for yourself. Fight for your family. Fight for your patients. Together, victory can be ours. Emily Hill SCMA Alliance President

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Acknowledgements A highly collaborative undertaking such as this special issue of The Journal of the South Carolina Medical Association requires the well-coordinated efforts of many individuals. The seven cancer site-specific articles that are included in this special issue received the thoughtful peer review of 12 internationally recognized scientists from around the country and the world. A hallmark of the scientific process is our reliance on such individuals to read, consider, criticize, and suggest improvements or new ways of looking at things. It is a major reason why the U.S. leads the world in biomedical research. We take this opportunity to thank these experts, who gave freely of their time and expertise to ensure a rigorous and informative examination of cancer in South Carolina. Elisa V. Bandera, M.D., Ph.D. Assistant Professor The Cancer Institute of New Jersey Robert Wood Johnson Medical School New Brunswick, New Jersey Gary G. Bennett, Ph.D. Assistant Professor Harvard School of Public Health Dana-Farber Cancer Institute Boston, Massachusetts Leslie Bernstein, Ph.D. Professor, Department of Preventive Medicine, AFLAC, Inc.,Chair in Cancer Research Keck School of Medicine and USC/Norris Comprehensive Cancer Center Los Angeles, California Roberd M. Bostick, MD, MPH Professor, Department of Epidemiology Professor (Joint), Department of Hematology & Oncology Georgia Cancer Coalition Distinguished Scholar Rollins School of Public Health, Emory University Atlanta, Georgia

Chien-Jen Chen, Sc.D. Distinguished Research Fellow Genomics Research Center Taipei, Taiwan Ann Coker, PhD Associate Professor, Division of Epidemiology University of Texas Health Science Center at Houston School of Public Health Houston, Texas Prakash C. Gupta, Ph.D. Director-Research Healis - Sekhsaria Institute for Public Health Mumbai, India Diane Harper, MD, MS, MPH Associate Professor Dartmouth University Medical School and Norris Cotton Cancer Center Lebanon, New Hampshire

Geoffrey C. Kabat, PhD, Adjunct Professor, Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx, New York Pamela Marcus, MS, PhD Epidemiologist, Department of Health and Human Services National Institutes of Health National Cancer Institute, Division of Cancer Prevention, Biometry Research Group Bethesda, Maryland Antonio René, PhD, MPH Associate Professor and Assistant Dean for Academic Affairs Texas A&M University System School of Rural Public Health College Station, Texas Zuo-Feng Zhang, MD, PhD Professor, Department of Epidemiology, Director, Molecular Epidemiology Training and Research Program Co-Director, UCLA Center for Environmental Genomics UCLA School of Public Health Los Angeles, California

Most journal special issues have several editors. We had one, and he truly did a magnificent job. His knowledge of the subject matter, the local situation, access to experts around the world, and his willingness to make the necessary connections was remarkable and greatly appreciated. We extend hearty thanks to Dr. Vena for his outstanding work as the Editor of this special issue of The Journal. We recognize, and wish to point out, that none of this would have been possible without the funding of critical elements of the programs on which we depend. Specifically, we wish to acknowledge: • Funding of the South Carolina Cancer Disparities Community Network (SCCDCN) through grant number 1 U01 CA11460101 from the National Cancer Institute (Community Networks Program); • The South Carolina Central Cancer Registry (SCCCR) for the state cancer incidence and mortality data provided. The SCCCR is funded by the Centers for Disease Control and Prevention (CDC) National Program of Cancer Registries, cooperative agreement number U55CCU421931, and SC Department of Health and Environmental Control; and • For the oral cancer and lung cancer papers, support by CDC grant number H75/CCH424532. The data analysis and maps for this paper were generated using SAS software, Version 9.1 of the SAS System for Windows 5.1.2600. Copyright © 2002-2003 SAS Institute Inc. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA. n


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On The Cover This month’s cover artwork was designed by Christina Johnson from the South Carolina Statewide Cancer Prevention and Control Program of the University of South Carolina. The imbalance in the caduceus scales held in the hands of an African American and a European American represents the racial imbalances that exist in cancer rates. We hope that this depiction invites the reader to learn about the cancer disparities that exist between African Americans and European Americans, and are generally more pronounced in South Carolina than in the nation as a whole. The placement of the hands also represents the many partners that made this special issue of The Journal of the South Carolina Medical Association possible. The South Carolina Statewide Cancer Prevention and Control Program at the University of South Carolina supports research that aims to reduce cancer disparities and promote healthier living for all people of South Carolina. The federal government supports the important work of the program by funding the South Carolina Cancer Disparities Community Network through the Cancer Networks Program of the National Cancer Institute. The South Carolina Department of Health and Environmental Control provided most of the data that are presented, through the South Carolina Central Cancer Registry. The South Carolina Cancer Alliance, through its 900 members, provides many of the linkages that make effective dialog possible.

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