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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

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