Thesocietalburdenofcancerisoneofthemajorpublichealthchallengesofour time. Yetthatburdenisnotequallysharedbyall. Troublingdisparitieshave been documented not only by racial/ethnic group but also by social class, insurancestatus,geography,andahostofotherdimensions. Furthermore, suchdisparitiesrepresenttheendresultofaconstellationofforcesstemming frominsideandoutsidethehealthcaresystem. Manycancerdisparitiesshould bepreventable. Fewhaveattemptedtocapturethebreadthanddepthofthedimensionsof cancerdisparitiesfrombothclinicalaswellaspublichealthperspectives. To addressthisneed,wepresentthisvolumeto: broaden concepts of disparities beyond traditional discussions of race/ ethnicitytoexplorehow,where,andwhytheyoccur; focusoncancerdisparitiesintheUS,whilecitingsomemajorexamplesfrom abroad; analyzecertainmajorcancerswithrespecttodisparities,withemphasison socioeconomicposition; examinethesourcesofdisparitiesfrombothinsideandoutsidethehealth caresystem; identifyinitialinterventionsthatattempttoreduceandeliminatethesed- parities;and identifyissuesthatdeserveattentionwithrespecttofutureresearch. Ourmonographaddressescancerdisparitiesacrossthecontinuum(fromp- vention to mortality and by the domains of social inequality). We begin by exploringbroaddimensionsuchasdefinitionsofdisparities,datasystems,the roleofgenesandenvironment,andtheroleofworkandoccupationincancer disparities. Thenwemoveintospecificchallengesincancerdisparitiessuchas tobaccouseandlungcancer,breastcancer,colorectalcancer,prostatecancer, cervicalcancer,melanoma,andhepatocellularcarcinoma. Wethenconcludewith someavenuestoaddresscancerdisparities,includingpolicyandadvocacy,health v vi Preface communication, overcoming barriers to cancer care, and community-based approaches. Oureffortsarefarfromexhaustive,buttheyrepresentoneofthe firstattemptstoaddresscancerdisparitiesfromsuchacomprehensiveperspective. Thisvolumereflectstheworkofanumberofnationalexpertsincancer disparities. Many are members of the Executive Committee of the Cancer Disparities Program-in-Development of the Dana-Farber/Harvard Cancer Center. Still others are also investigators in the National Cancer Institute Community Network Program MassCONECT (Massachusetts Community NetworkstoEliminateCancerDisparitiesthroughEducation,Researchand Training). Also,thisvolumeupdatesandexpandsaearlier2005monographon thetopicpublishedinthejournalCancerCausesandControl. Allauthorsare dedicatedtothegoalofeliminatingcancerdisparitiesandIamindebtedto them. IamparticularlygratefultoRachelWarren,TerraZipoyrnSnider,andDr. ClaudiaArriggfortheirunendingencouragementandsupport. Itismyhope thatthismonographrepresentsanothercontributiontowardhelpingallpeople enjoytheirhighestattainablestandardofhealth. Boston,MA HowardK. Koh,MD,MPH Contents PartI DimensionsofCancerDisparities 1 Defining,Investigating,andAddressingCancerInequities: CriticalIssues...3 NancyKrieger,KarenM. Emmons,andDavidWilliams 2 CancerDisparities:DataSystems,Sources,andInterpretation...29 BarbaraD. Powe,AhmedinJemal,DexterCooper, andLokieHarmond 3 Genes,Environment,andCancerDisparities...49 AlexandraE. Shields,StephanieM. Fullerton,andKennethOlden 4 WorkandOccupation:ImportantIndicatorsofSocioeconomic PositionandLifeExperiencesInfluencingCancerDisparities...83 GlorianSorensen,GraceSembajwe,AmyHarley, andLisaQuintiliani PartII SpecificChallengesinCancerDisparities 5 DisparitiesinTobaccoUseandLungCancer...109 HowardK. Koh,LorisElqura,andSarahMassinShort 6 SocioeconomicStatusandBreastCancerDisparities...137 SherrieFlyntWallington,OtisW. Brawley, andMichelleD. Holmes 7 DisparitiesandColorectalCancer...161 EricC. Schneider 8 DisparitiesinProstateCancer...179 OtisW. BrawleyandSherrieFlyntWallington vii viii Contents 9 DisparitiesandCervicalCancer...203 MarceladelCarmenandTeresaDiaz-Montez 10 MelanomaandPrimaryHepatocellularCarcinoma...227 ChristopherA. Aoki,AlanGeller,andMoonS. Chen PartIII SomeAvenuestoAddressCancerDisparities 11 Interventions,Policy,andAdvocacy...259 DeborahKleinWalkerandChristineM. Judge 12 HealthCommunicationandCommunicationInequalities inAddressingCancerDisparities...277 K. ViswanathandKarenM. Emmons 13 OvercomingBarrierstoCancerCare:PatientandPublic Perspectives...299 KarenDonelan 14 Community-BasedApproachestoCancerDisparities...317 BarbaraGottlieb Index...359 Contributors ChristopherA. Aoki DivisionofGastroenterologyandHepatology, DepartmentofInternalMedicine,SchoolofMedicine,Universityof California,Davis,CA OtisW. Brawley AmericanCancerSocietyandEmoryUniversity,Atlanta,GA MarceladelCarmen DivisionofGynecologicOncology,Massachusetts GeneralHospital,HarvardMedicalSchool,Boston,MA MoonS.

Thesocietalburdenofcancerisoneofthemajorpublichealthchallengesofour time. Yetthatburdenisnotequallysharedbyall. Troublingdisparitieshave been documented not only by racial/ethnic group but also by social class, insurancestatus,geography,andahostofotherdimensions. Furthermore, suchdisparitiesrepresenttheendresultofaconstellationofforcesstemming frominsideandoutsidethehealthcaresystem. Manycancerdisparitiesshould bepreventable. Fewhaveattemptedtocapturethebreadthanddepthofthedimensionsof cancerdisparitiesfrombothclinicalaswellaspublichealthperspectives. To addressthisneed,wepresentthisvolumeto: broaden concepts of disparities beyond traditional discussions of race/ ethnicitytoexplorehow,where,andwhytheyoccur; focusoncancerdisparitiesintheUS,whilecitingsomemajorexamplesfrom abroad; analyzecertainmajorcancerswithrespecttodisparities,withemphasison socioeconomicposition; examinethesourcesofdisparitiesfrombothinsideandoutsidethehealth caresystem; identifyinitialinterventionsthatattempttoreduceandeliminatethesed- parities;and identifyissuesthatdeserveattentionwithrespecttofutureresearch. Ourmonographaddressescancerdisparitiesacrossthecontinuum(fromp- vention to mortality and by the domains of social inequality). We begin by exploringbroaddimensionsuchasdefinitionsofdisparities,datasystems,the roleofgenesandenvironment,andtheroleofworkandoccupationincancer disparities. Thenwemoveintospecificchallengesincancerdisparitiessuchas tobaccouseandlungcancer,breastcancer,colorectalcancer,prostatecancer, cervicalcancer,melanoma,andhepatocellularcarcinoma. Wethenconcludewith someavenuestoaddresscancerdisparities,includingpolicyandadvocacy,health v vi Preface communication, overcoming barriers to cancer care, and community-based approaches. Oureffortsarefarfromexhaustive,buttheyrepresentoneofthe firstattemptstoaddresscancerdisparitiesfromsuchacomprehensiveperspective. Thisvolumereflectstheworkofanumberofnationalexpertsincancer disparities. Many are members of the Executive Committee of the Cancer Disparities Program-in-Development of the Dana-Farber/Harvard Cancer Center. Still others are also investigators in the National Cancer Institute Community Network Program MassCONECT (Massachusetts Community NetworkstoEliminateCancerDisparitiesthroughEducation,Researchand Training). Also,thisvolumeupdatesandexpandsaearlier2005monographon thetopicpublishedinthejournalCancerCausesandControl. Allauthorsare dedicatedtothegoalofeliminatingcancerdisparitiesandIamindebtedto them. IamparticularlygratefultoRachelWarren,TerraZipoyrnSnider,andDr. ClaudiaArriggfortheirunendingencouragementandsupport. Itismyhope thatthismonographrepresentsanothercontributiontowardhelpingallpeople enjoytheirhighestattainablestandardofhealth. Boston,MA HowardK. Koh,MD,MPH Contents PartI DimensionsofCancerDisparities 1 Defining,Investigating,andAddressingCancerInequities: CriticalIssues...3 NancyKrieger,KarenM. Emmons,andDavidWilliams 2 CancerDisparities:DataSystems,Sources,andInterpretation...29 BarbaraD. Powe,AhmedinJemal,DexterCooper, andLokieHarmond 3 Genes,Environment,andCancerDisparities...49 AlexandraE. Shields,StephanieM. Fullerton,andKennethOlden 4 WorkandOccupation:ImportantIndicatorsofSocioeconomic PositionandLifeExperiencesInfluencingCancerDisparities...83 GlorianSorensen,GraceSembajwe,AmyHarley, andLisaQuintiliani PartII SpecificChallengesinCancerDisparities 5 DisparitiesinTobaccoUseandLungCancer...109 HowardK. Koh,LorisElqura,andSarahMassinShort 6 SocioeconomicStatusandBreastCancerDisparities...137 SherrieFlyntWallington,OtisW. Brawley, andMichelleD. Holmes 7 DisparitiesandColorectalCancer...161 EricC. Schneider 8 DisparitiesinProstateCancer...179 OtisW. BrawleyandSherrieFlyntWallington vii viii Contents 9 DisparitiesandCervicalCancer...203 MarceladelCarmenandTeresaDiaz-Montez 10 MelanomaandPrimaryHepatocellularCarcinoma...227 ChristopherA. Aoki,AlanGeller,andMoonS. Chen PartIII SomeAvenuestoAddressCancerDisparities 11 Interventions,Policy,andAdvocacy...259 DeborahKleinWalkerandChristineM. Judge 12 HealthCommunicationandCommunicationInequalities inAddressingCancerDisparities...277 K. ViswanathandKarenM. Emmons 13 OvercomingBarrierstoCancerCare:PatientandPublic Perspectives...299 KarenDonelan 14 Community-BasedApproachestoCancerDisparities...317 BarbaraGottlieb Index...359 Contributors ChristopherA. Aoki DivisionofGastroenterologyandHepatology, DepartmentofInternalMedicine,SchoolofMedicine,Universityof California,Davis,CA OtisW. Brawley AmericanCancerSocietyandEmoryUniversity,Atlanta,GA MarceladelCarmen DivisionofGynecologicOncology,Massachusetts GeneralHospital,HarvardMedicalSchool,Boston,MA MoonS.