Module 1: Cancer among [Target Population]



Module 1: Cancer Among [Target Population]

| | |

|Target Audience |Goals |

|Community members |In this session, participants will gain an understanding of the growing health concern of cancer |

|Staff of health programs serving [target |among [target population]. |

|population] |Objectives |

|Contents of |At the completion of Learning Module 1, participants will be able to demonstrate the following: |

|Learning Module |Section 1 |

|Instructor’s Guide with Pre/Post |Give two reasons why cancer is a growing health concern in today’s [target population] |

|Self-Assessment and Self-Assessment Answer|communities. |

|Key |Section 2 |

|PowerPoint presentation |Discuss two facts regarding how data contributes to our understanding about the cancer health |

|Glossary |concern for [target population]. |

|Resources for Learning More |Section 3 |

|References |Discuss two facts that contribute to poor survival for [target population] diagnosed with cancer.|

|Length |Describe two factors that are likely to improve cancer survival rates for [target population]. |

|Introduction of session/module overview |Measures of Objective Accomplishment |

|(:05) |The presenter will administer a pre self-assessment and a post self-assessment to measure |

|Pre self-assessment (:07) |participants’ knowledge of the module’s objectives. The pre self-assessment measures existing |

|Presentation of module (:30) |knowledge and the post self-assessment measures what was gained through the learning module. |

|Post self-assessment (:05) | |

|Closing (:03) | |

| | |

| |NOTE |

| |Each major learning point is clearly identified by boldface type throughout the guide and |

| |emphasized in the PowerPoint presentation. |

| |See the glossary (at the end of the module) for words that are in bold blue italics throughout |

| |the module. |

Pre/Post Self-Assessment

Cancer Among [target population]

Do you agree (A), disagree (D), with these statements, or are you not sure (NS)? Circle your choice - A, D, or NS.

|1. |A |D |NS |Increased life expectancy and lifestyles are two factors that may be associated with the |

| | | | |increase of cancer among [target population]. |

|2. |A |D |NS |Cancer is the second leading cause of death among [target population]. |

|3. |A |D |NS |Current data for [target population] provides an accurate picture of the cancer problem |

| | | | |among all [target population] in the country. |

|4. |A |D |NS |Cancer survival can be improved by participating in screening and early detection. |

|5. |A |D |NS |Access to health care that is culturally appropriate will reduce barriers to care. |

Pre/Post Self-Assessment

Answer Key

Cancer Among [target population]

The correct answer to each question, agree (A) or disagree (D),

is underlined and in red.

|1. |A |D |Increased life expectancy and lifestyles are two factors that may be associated with the increase of cancer |

| | | |among [target population]. |

| | | | |

| | | |Note: In addition to increased life expectancy and lifestyle, heredity, environmental exposures, viruses |

| | | |and bacteria are other factors that may also be associated with an increase in cancer among [target |

| | | |population]. |

|2. |A |D |Cancer is the second leading cause of death among [target population]. |

|3. |A |D |Current data for [target population] provides an accurate picture of the cancer problem among all [target |

| | | |population] in the country. |

| | | | |

| | | |Note: What we do not know about cancer relates to the “limitations” of existing cancer data among [target |

| | | |population]. Data show that [target population] throughout the U.S. have very different cancer mortality |

| | | |patterns. To understand more about these cancer patterns and develop effective risk reduction and control |

| | | |programs, accurate data on the health status of [target population] must be documented. |

|4. |A |D |Cancer survival can be improved by participating in screening and early detection. |

| | | | |

| | | |Note: Early diagnosis of cancer improves the chances that treatment will be more effective and survival |

| | | |will be lengthened. This is particularly true for cancer of the cervix, colon and rectum, and breast. |

|5. |A |D |Access to health care that is culturally appropriate will reduce barriers to care. |

| | | | |

| | | |Note: Providing access to health care that is culturally appropriate is critical to improving outcomes. |

| | | |Understanding how belief and value systems influence [target population] perceptions of health and illness |

| | | |is an important aspect of the health care process. |

Section 1

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Increased life expectancy places

American Indians and Alaska Natives

at greater risk for cancer.

_________________________________________

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For many years, cancer was not common among American Indians and Alaska Natives (AI/AN). It was thought perhaps that AI/AN had a natural immunity to this disease. Over time, however, researchers have discovered evidence that suggests that cancer did exist among AI/AN as far back as the late 1800's.[i] Today, cancer has become more common among AI/AN and is now a growing concern. Many of the factors that contribute to the development of cancer in AI/AN people have yet to be determined, however, changes in life expectancy and lifestyle are thought to play a significant role.

Life expectancy for AI/AN has increased dramatically over the last several decades from less than 50 years in the mid-1940’s, to 72.3 years in 2009.[ii] Much of this increase can be credited to advances in the treatment of infectious diseases and a decline in infant and maternal mortality.[iii] These reductions in mortality are largely due to improvements in public health measures such as immunization programs, improvements in sanitation, drinking water and access to primary medical care. Consequently, many individuals who would have died at an earlier age are now living to be much older. Given that most cancers occur in individuals over 45 years of age, the increase in life expectancy in AI/AN places them at increased risk for cancer.

As AI/AN live longer, the type of lifestyle they lead may influence their risk for developing cancer. In the past, traditional lifestyles included many practices that are thought to reduce one’s risk for developing cancer. These included daily exercise, a diet rich in fruits, vegetables, and other natural foods, and reserving tobacco for ceremonial use rather than habitual use. In today’s world, lifestyles for many AI/AN have been made more convenient by advances in technology. Although many of these advances have led to improvements in the ease of performance of day-to-day activities, they have also led to a decrease in energy expenditures. Thus, today’s lifestyles have become more sedentary. Highly processed and convenience food items have replaced a diet once rich in natural foods. An increase in personal use of tobacco that is chewed or smoked has led to increased rates of cancer in AI/AN.[iv],[v] Research is ongoing and early findings suggest lifestyles that include attention to proper diet (rich in natural foods), limited alcohol use, daily exercise, and the avoidance of known carcinogens may reduce one’s risk for developing cancer.

Although researchers have identified increased life expectancy and changing lifestyles as two factors that have influenced the rise in cancer rates among AI/AN, there are other contributing factors to consider. These factors include heredity, environmental exposures, viruses and bacteria. They will be discussed in more detail in Learning Module 3: Cancer Risk Factors and Risk Reduction.

Section 2

What is known and not known about cancer among [Target Population]

Statistical data for Hispanic cancer-related data is gathered from the two major U.S. cancer registry systems - the Center for Disease Control and Prevention’s (CDC) National Program of Cancer Registries and the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) program.[vi]

The American Cancer Society, CDC, NCI and North American Association of Central Cancer Registries collaborate on an annual report to the Nation on the status of cancer. In 2006, this report included the first comprehensive set of cancer data for Hispanics in the United States. Data included 90% of Hispanics in the country and was not shown for specific Hispanic sub-groups because it is not always complete on cancer incidence and death reports.[vii] Despite these data limitations, we do know the following:

■ Cancer is the second leading cause of death for Hispanics.[viii]

■ Cancer incidence rates among Hispanics are lower than rates among non-Hispanic whites or non-Hispanic blacks for major cancer sites (lung, colon and rectum, breast and prostate) and cancer screening data suggests that there may be differences among Hispanic sub-groups.[ix]

■ Hispanics are less likely than non-Hispanic whites to be diagnosed with cancers of the breast, lung, colon and rectum, prostate, and cervix at a localized stage.9

■ The median age of cancer diagnosis is 62 years of age for Hispanics compared to 68 years of age for non-Hispanic whites.9,[x]

We also know that patterns for certain types of cancers vary among Hispanics. For example, Hispanics have an increased incidence of cancers of the liver, stomach cervix, gallbladder, liver, and myeloma (females) when compared to non-Hispanic whites9. Data also show that Hispanics have increased mortality from cancers of the stomach, liver, gallbladder, cervix and acute lymphocytic leukemia when compared to non-Hispanic whites.10

According to cancer rates from 1999-2003, the top ten most common types of cancer occurring among Hispanics included the following: prostate (men), breast (women), colon & rectum, lung & bronchus, Non-Hodgkin Lymphoma, bladder, kidney, stomach, liver, and leukemia.9

What we do not know about cancer relates to the “limitations” of existing cancer data among Hispanics.

The term “limitations” refers to how the accuracy of the current data may be influenced by any of the following points:

■ Inconsistent reporting of ethnicity on medical records and death certificates.

■ Undercounting (due in part to inconsistent reporting of ethnicity and possibility that recent Hispanic immigrants return to their country after a cancer diagnosis).

■ Broad grouping for Hispanics may mask variations in the cancer burden among specific sub-populations (by country of origin, socio-economic status, or recent immigration status).

Hispanic populations are not randomly scattered across the country. For example, according to 2000 Census data, 55.3% of Mexicans lived in the West, 60.9% of Puerto Ricans lived in the Northeast, and 74.2% of Cubans lived in the South[xi]. Additionally, limited cancer data from 38 cancer registries have shown that Hispanic sub-groups throughout the U.S. have different cancer incidence rates. For example, between 1999-2003, cancers of the stomach and gallbladder were higher among all groups (when compared to non-Hispanic whites) except for stomach cancer in Cuban males and gallbladder cancer in Cuban females.9 To understand more about cancer patterns and develop effective risk reduction and control programs, accurate data on the health status and origin of Hispanics must be documented.

Section 3

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[Target Population]

As we become more familiar with the health concern of cancer among Hispanics, the issue of survivability grows in importance. The data tells us that overall, Hispanics have cancer survival rates similar to those of non-Hispanic whites; however they are more likely to be diagnosed with these cancers at a more advanced stage.10 Although more investigation needs to be done, the following factors have been identified as potentially influencing survival:

■ Lower socioeconomic status (education, income, health literacy).[xii]

■ Role of culture and values in shaping beliefs, attitudes and behaviors about cancer.

■ Being overweight or obese (rates of obesity are higher among Mexican-American women than non-Hispanic white women).[xiii]

■ Infectious agents as risk factors for cancers Hispanics suffer a higher burden of (Hepatitis B and C infection in relation to liver cancer, human papilloma virus in relation to cervical cancer, Helicobacter pylori infection in relation to stomach cancer).12

■ Elevated environmental exposures in farming and industrial work (occupations which tend to be held by Hispanics).12

Additional barriers to care that impact health status, contribute to lack of timely access to state-of-the-art screening, diagnostic or treatment methods and ultimately result in late-stage diagnosis of cancer include lack of:

■ insurance (Hispanics have the highest uninsured rates of all adults in the country)8

■ regular source of medical care (Hispanics are less likely than non-Hispanic whites and blacks to have a regular doctor)8

■ culturally sensitive or bilingual/bicultural Hispanic health providers (language barriers and poor provider/patient communication have led to negative experiences with the medical system)[xiv]

■ culturally relevant cancer materials and programs

■ accessible educational and training opportunities

We know that cancer survival can be improved by increasing participation in screening and early detection services. Early diagnosis of cancer improves the chances that treatment will be more effective and survival will be lengthened. This is particularly true for cancers of the cervix, colon and rectum, and breast. For other types of cancer such as those cancers that affect the lung, no reliable screening test currently exists, and prevention is the key. The critical role of prevention in lung cancer must be emphasized. The majority of lung cancers are preventable by simply not smoking.

Reducing barriers to care is also likely to improve survival rates by increasing the number of individuals participating in screening and early detection activities. Providing access to health care that is culturally appropriate is critical to improving outcomes. Understanding how belief and value systems influence Hispanics’ perceptions of health and illness is an important aspect of the health care process. For example, understanding the importance of honoring modesty during screening exams may increase the likelihood that women will continue to participate in these programs. Although more research is needed to improve survival rates for Hispanics diagnosed with cancer, encouraging participation in screening and early detection, and reducing barriers to care may have a positive influence on outcomes.

Glossary of Terms

|bacteria |These are one-celled organisms visible only through a microscope. There are many varieties, only some of which cause |

| |disease in animals and humans. Most are non-disease causing; and many are useful. |

|carcinogen |This is any type of cancer causing agent. |

|genetic |Inherited; having to do with information that is passed from parents to offspring through genes in sperm and egg |

| |cells. |

|genetic risk factors |Those risk factors that are transmitted at birth through genes (the basic units of heredity). |

|heredity |The transmission of traits from parents to offspring. |

|immunity |The resistance of the body to the effects of a harmful agent. |

|incidence |The number of newly diagnosed cases during a specific time period. |

|mortality |The number of deaths during a specific time period. |

|relative survival rate |Compares the observed survival for a set of cancer patients to that observed for a group of normal persons of a |

| |similar age, race, and sex distribution. It is important to note that relative survival does not provide an estimate |

| |of the percent of the cancer population alive five years after diagnosis. |

|risk factor |Something that increases the chance of developing a disease. Some examples of risk factors for cancer are age, a |

| |family history of certain cancers, use of tobacco products, being exposed to certain chemicals, infection with |

| |certain viruses or bacteria, and certain genetic changes. |

|statistical data |The calculation of figures that provides information about the numbers, patterns, similarities and differences among |

| |things/individuals. |

|virus |An infectious agent that requires a susceptible place to grow and reproduce. |

Resources for Learning More

American Cancer Society (ACS) – Cancer Facts & Figures: These books provide data on the number of cancer cases, cancer deaths, and cancer survivorship.



Centers for Disease Control & Prevention (CDC) – Cancer FastStats: This web page provides links to cancer data (such as number of cancer cases and cancer deaths) as well as data about cancer care (ambulatory care, hospital inpatient care, home health care, hospice care, and nursing home care.)



CDC – Cancer and Women: This link provides information for women on reducing cancer risk and getting the right cancer screening tests at every stage of their lives.



CDC – Cancer and Men: This link provides information for men on reducing cancer risk and getting the right cancer screening tests at every stage of their lives.



CDC – Top 10 Cancers Among Men: This link provides information on the 10 most commonly diagnosed cancer among men in the U.S.



Institute of Medicine – The Unequal Burden of Cancer: An Assessment of NIH Research and Programs for Minorities and the Underserved (1999): This link provides the Executive Summary for this report. The report explains that people who are poor, lack health insurance, or do not have access to high-quality cancer care, are more likely to be diagnosed with and die from cancer.



National Cancer Institute – The Human and Economic Burden of Cancer: This link contains information on understanding cancer statistics.



The Office on Women’s Health – Health Disparities Profiles: This link provides information on key health indicators for different racial and ethnic populations in the U.S.



U.S. National Library of Medicine – Information by Population Groups: This link provides information on health topics relevant to different population groups.



References

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[i] Burhansstipanov L. (1997). Cancer among elder Native Americans. Native Elder Health Care Resource Center.

[ii] Department of Health and Human Services. Indian Health Service: A Quick Look (2009). Available at . Accessed February 2, 2010.

[iii] Michielutte R, Sharp PC, Dignan MB, Blinson K. Cultural issues in the development of cancer control programs for American Indian populations. J Health Care Poor Underserved. 1994;5(4):280-296.

[iv] National Cancer Institute (1994). Native Outreach: A Report to American Indian, Alaska Native, and Native Hawaiian Communities. (NIH Publication No. 98-4341).

[v] Cobb N. Environmental causes of cancer among Native Americans. Cancer. 1996 Oct 1;78(7 Suppl):1603-6.

[vi] Ramirez AG, Suarez L (2001). The Impact of Cancer on Latino Populations. In: Aguirre-Molina M, Molina CW, Zambrana RE, (Eds.), Health Issues in the Latino Community (pp. 211-244). San Francisco, CA: Jossey-Bass/John Wiley & Sons, Inc.

[vii] Howe HL, Wu X, Ries LAG, Cokkinides V, Ahmed F, Jemal A, Miller B, Williams M, Ward E, Wingo PA, Ramirez A, Edwards BK. Annual Report to the Nation on the Status of Cancer, 1975-2003, Featuring Cancer Among U.S. Hispanic/Latino Populations. Cancer 2006 Oct 15;108(8):1711-42.

[viii] Doty MM, Holmgren AL. Health Care Disconnect: Gaps in Coverage and Care for Minority Adults: Findings from the Commonwealth Fund Biennial Health Insurance Survey 2005. New York: The Commonwealth Fund, August 2006. Available at . Accessed February 3, 2010.

[ix] Howe HL, Wu X, Ries LAG, Cokkinides V, Ahmed F, Jemal A, Miller B, Williams M, Ward E, Wingo PA, Ramirez A, Edwards BK. Annual Report to the Nation on the Status of Cancer, 1975-2003, Featuring Cancer Among U.S. Hispanic/Latino Populations. Cancer 2006 Oct 15;108(8):1711-42.

[x] American Cancer Society. Cancer Facts & Figures for Hispanics/Latinos 2009-2011. Atlanta, GA. 2009. Available at . Accessed February 3, 2010.

[xi] Guzmán B. The Hispanic Population, Census 2000 Brief. U.S. Census Bureau, U.S. Department of Commerce, May 2001. Available at . Accessed February 9, 2010.

[xii] National Cancer Institute, U.S. National Institutes of Health. Annual Report to the Nation on the Status of Cancer 1975-2003, With a Special Feature on Cancer Among U.S. Hispanic/Latino Populations: Questions and Answers. Washington, DC. September 2006. Available at . Accessed February 5, 2010.

[xiii] Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States— no change since 2003–2004. NCHS data brief no 1. Hyattsville, MD: National Center for Health Statistics. 2007. Available at . Accessed February 9, 2010.

[xiv] Hicks LS, Tovar DA, Orav EJ, Johnson PA. Experiences with Hospital Care: Perspectives of Black and Hispanic Patients. J Gen Intern Med 2008 Apr 15;23(8)1234-40.

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For more detailed information about cancer or the glossary terms,

please refer to the

Dictionary of Cancer Terms at or

call the National Cancer Institute’s

Cancer Information Service at

1-800-4-CANCER (1-800-422-6237).

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