Socioeconomic Status

Socioeconomic status (SES) remains the most widely studied variable in the area of health disparity. In many instances it is the most notable difference between Caucasians and minorities. SES is difficult to assess because income level, the most direct assessment of SES, is not routinely obtained when treating cancer patients. As a result SES is a value that must be estimated based on census tract data, patient location, or some other indirect assessment. The significance of SES as a contributing factor to health care disparity has been documented in several studies.3,6,9,10 Delay in care and decreased utility of surgical intervention are only a few of the outcomes influenced by low SES. Low SES is associated with a lack of resources. According to the US Census Bureau the official poverty rate in 2004 was 12.7%, an increase from 12.5% the year before; this percentage represents 37 million people in the United States. Forty-seven million people in the United States, 15.7%, are without health insurance.18 The economically disadvantaged are more likely to be uninsured, have less access to health care and are less likely to be informed about their risk for certain diseases.

Poverty itself is a significant impediment to obtaining health care. The 5-year survival rate for people who live in poorer census tract is more than 10% less than that for those who live in more affluent areas6 and this is shown in Figure 2. Poverty has many negative effects on health and many of these effects are worsened in chronic illnesses such as cancer. Those who are economically disadvantaged are more likely to be undereducated, more likely to have no insurance and more prone to engage in high- risk behavior. If SES is seen as the coalescence of many small barriers into a large possibly insurmountable barrier, then access to health care is the first barrier that must be addressed.

Lack of adequate health insurance is more common among the poor and this results in limited access to care which can manifest as problems in the following areas: screening, stage at diagnosis, and adequacy of treatment. With adequate access to health care patients may obtain preventative screening and diagnostic evaluation when appropriate. The relationship between race, ethnicity, SES, and preventative

Males

All races Non-Hispanic White African American American Indian/ Asian/Pacific Hispanic-Latino

African Native Islander

All races Non-Hispanic White African American American Indian/ Asian/Pacific Hispanic-Latino

African Native Islander

Females

Females

All races Non-Hispanic White African American American Indian/ Asian/Pacific Hispanic-Latino

African Native Islander

All races Non-Hispanic White African American American Indian/ Asian/Pacific Hispanic-Latino

African Native Islander

Percent of Cencus Tract Population Below Poverty Line in 1990 ■ <10% «10% to 19.9% ■ 20% or higher

Figure 2. SEER Cancer (All Sites Combined) Survival Among Men and Women, 1988-1994 Patient Cohort. (Reprinted with permission from Ward et al.2)

screening has been well studied. Two well-written review articles from Cancer Causes and Control summarize the literature in this field. People with lower SES are less likely to undergo screening for colorectal cancer and are more likely to be diagnosed at a later stage.19 A similar literature review for breast cancer was also performed but, difficult to compare given the complex interaction among race, ethnicity, SES, and lack of uniformity between the studies. This review concluded that people with lower SES and breast cancer present at later stages of disease. Also, elder women in lower socioeconomic groups more likely to undergo mastectomy.20 A recent study by Rosenberg and colleagues showed that health insurance was the socioeconomic variable most associated with regular mammography use even at higher levels of education and SES.21 In the 1998 data brief by the Commonwealth Fund, a survey on women's health found that not much had changed in the 5 years since a previous study. The rate for screening, though slightly improved, was still lower for minorities than Caucasians; this gap was widest between poor women (income less than $16,000 a year) and women with income greater than $50,000 a year. This survey once again demonstrated that SES remains a significant barrier to adequate and timely screening.22 Since screening reduces mortality in certain cancers lack of appropriate screening becomes even more important. Mammography for breast cancer reduces mortality by 25% and screening for colon cancer reduces mortality by 20%.23,24 Lack of adequate screening because of low SES detracts from the mortality benefit derived from screening for these diseases. The second barrier referable to SES is the advanced stage at diagnosis. Numerous studies have shown that African Americans and other minorities present with cancers at a later stage than Caucasians. While tumor aggressiveness and other patient factors may be partly responsible for this phenomenon, delay in diagnosis plays a significant role. A delay in the diagnosis of many cancers affect, the stage at presentation but it is unclear if this results in a survival difference. In two cohort studies of patients with squamous cell carcinoma of the oropharynx, non-white race was a predictor of advanced disease.25 This delay may be due to the application of screening methods as shown by Cooper et al. This study found that African Americans were less likely to undergo screening tests for the diagnosis of colorectal cancer and were more frequently diagnosed at a later stage than Caucasians.26 The reasons for lack of screening are multiple, most often is secondary to a lack of health insurance due to low SES. The delay in diagnosis and its consequences are best highlighted by breast cancer where the literature on this topic is extensive. Results are conflicting with some studies documenting no statistically significant delay in diagnosis and others showing that African American women do experience a delay in diagnosis and in the initiation of treatment.27,28 A more recent study by Gwyn et al. showed that African American women were more likely than Caucasian women to experience a delay in diagnosis and a delay in

treatment.

Once a diagnosis of cancer has been made, obtaining adequate and timely care is the next step in ensuring survival. Numerous studies have examined the relationship between the types of health insurance and the kind of health care obtained. Health insurance may be state funded such as Medicare or Medicaid or private as demonstrated by the multiple health maintenance organizations. In many states the economically disadvantaged are disproportionately taken care of by teaching and/or county hospitals. This has both positive and negative effects. Richardson et al. found that Florida teaching hospitals were more likely to diagnose breast cancer in uninsured women, Hispanic women, and those with Medicare/Medicaid than were private hospitals. In addition, they were more likely to receive chemotherapy depending on their stage.30 Insurance status in itself has been found to be an independent variable in the receipt of guideline therapy, as shown by Voti et al. in their study, which reviewed the receipt of standard therapy in Florida based on insurance. Black non-Hispanic women, when compared to white non-Hispanic, were 19% less likely to receive standard therapy and Hispanics 23% less likely. Women on Medi-caid and uninsured women were also less likely to receive guideline therapy.31 This finding is noted on a national level, as seen from the study by Harlan et al., which also documented that the use of guideline therapy was lower in patients who had Medicare or Medicaid as their only source of health insurance.32 This study also showed that though the number of private and community hospitals outnumber teaching/public hospitals, the latter carry a heavier burden in taking care of the economically disadvantaged.

While access to adequate health care is necessary to ensure optimal treatment of cancer, there are a number of studies that demonstrate that when SES is accounted for differences in cancer survival remain. These differences can be seen in the Department of Defense health care where access to health care is presumably equal.33

Socioeconomic status maybe the ;ost important factor responsible for the health disparity seen in cancer; however, there are other significant factors. SES is a crude data point that is estimated based on residence, census tract data, and lack of health insurance. These are all used as markers to estimate SES and serve as a basis for comparison of studies.

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