Understanding Behavioral Oncology
in Order to Reduce Cancer Health Disparities
Marlene M. von Friederichs-Fitzwater, Ph.D., MPH, Assistant Professor,
Hematology/Oncology; Director, Outreach Research & Education, UC Davis Cancer Center
& Frederick J. Meyers, MD, MACP, Executive Associate Dean, Professor of Medicine ,UC
Davis, School of Medicine
Cancer Health Disparities
 The National Cancer Institute (NCI) defines "cancer health
disparities" as adverse differences in cancer incidence (new
cases), cancer prevalence (all existing cases), cancer death
(mortality), cancer survivorship, and burden of cancer or related
health conditions that exist among specific population groups in
the United States.
 Complex and interrelated factors contribute to the observed
disparities in cancer incidence and death among racial, ethnic,
and underserved groups. The most obvious factors are
associated with a lack of health care coverage and low
socioeconomic status.
Cancer Disparities (cont’d)

Although cancer deaths have declined for both Whites and African
Americans/Blacks living in the United States, African Americans/Blacks
continue, however, to suffer the greatest burden for each of the most
common types of cancer.

American White women have the highest incidence rate for breast
cancer, although African American/Black women are most likely to die
from the disease.

American Indian women have the poorest mammography screening
rage and the poorest 5r-year breast cancer mortality rate.

African American/Black men have the highest incidence rate for
prostate cancer in the United States and are more than twice as likely
as White men to die of the disease.
Cancer Disparities (cont’d)
 Compared to White women in the general population, African
American/Black women are more likely to be diagnosed with
cervical cancer. Hispanic/Latino women, however, have the
highest cervical cancer incidence rate.
 Interestingly, White women living in Appalachia suffer a
disproportionately higher risk for developing cervical cancer than
other White women.
 The disproportionate burden of cervical cancer in
Hispanic/Latino and African American/Black women is primarily
due to a lack of screening.
Elements that Contribute to
Cancer Health Disparities
Socioeconomic
status (low,
poverty)
Discovery
Culture
Social injustice
Delivery
Behavioral Approaches to Cancer
Prevention & Control
Four key areas:
 Behavioral approaches to cancer genetic risk
assessment and testing
 Biological mechanisms of psychosocial effects on
cancer
 Role of risk perceptions in cancer screening
adherence; and
 Impact of tailored and targeted interventions on
cancer prevention and control research
National Cancer Institute
 Behavioral science is one of key priorities at
NCI, rapidly growing area of funded research
 Incorporation of genetic risk information into
field of cancer prevention and control is
relatively new
 Increasing understanding of impact of
unhealthy behaviors as genetic “trigger.”
Behavioral Approaches to Cancer Genetic
Risk Assessment and Testing
 Goal: To design effective
methods of providing support to
individuals undergoing genetic
mutation testing
 Testing for BRCA ½ genetic
mutations – main cancer model
for mutation testing
 Additional new research:
Issues of informing families of
mutation status and subsequent
family member actions
 Physicians serve as gatekeepers
but generally under-informed about
genetic testing
 Research area new without critical
mass of studies
 Future research:
 More integrative &
comprehensive models of risk
communication and risk
information are needed
 Long-term consequences of
counseling, testing and choices
 Cultural and ethnic differences
 Other models of delivering
genetic tests (for-profit
companies)
Biological Mechanisms of
Psychosocial Effects on Cancer

Increasing interest in how mind-body interactions influence disease
processes

Association of psychological stress and adjustment, social support and
depression with cancer onset or progression

Impact of psychosocial interventions (cognitive-behavioral stress
management, group psychotherapy, etc.) on cancer and immune
activity

Expand research domain to include patient outcomes other than
survival (disease progression, response to treatment, etc.)

Understand the biobehavioral bases of risk behaviors leading to cancer
(i.e., individual differences in genetic predisposition to cigarette
smoking, substance abuse and risk-taking behaviors)

Health disparities and potential biobehavioral mechanisms - differential
incidence and mortality rates across groups
The Role of Environment and Trauma in
Disease Development and Progression
 Example: environment in mice alters gene expression with longlived effects on future social behavior and vulnerability to stress
over the animal’s life-time.
 Would this be true of populations, such as American Indians,
who have suffered historic trauma (forced migration, break-up of
families, forced changes in dietary habits, etc. )?
American Indian Women
Mother’s Wisdom Breast Health Program: community-based,
participatory research of educational intervention to change
behaviors, increase screening and reduce incidence and mortality
 California – largest American Indian population in the nation; largest
urban areas; over 109 tribes
 Poorest mammography screening of any race/ethnicity; poorest 5-year
survival rate
 Formation of 15-member American Indian Advisory Council
 18-month pilot study: Statistically increased mammography screening
among American Indian women ages 40 and over from 47% to 97%.
Awarded three year grant October, 2010 to September 2013; working
with 25 tribes and five tribal health clinics.
 Results provide significant information about cultural and tribal issues in
cancer prevention and treatment generalizable to other populations.
Slavic Women and Breast Cancer

About 100,000 Slavic immigrants in
Sacramento county

Many Slavic women were exposed to
radiation from Chernobyl (incidence
rates of breast cancer have doubled;
thyroid cancer incidence increasing)

Multiple barriers and issues related to
risk reduction in breast cancer:
 Cultural beliefs
 Healthcare customs
Young Adults and Cancer
Each year approximately 70,000
individuals in their 20s and 30s are
diagnosed with cancer in the United
States
Cancer occurs in individuals in their
20s and 30s three times more often
than in patients under the age of 15.
Young adults with cancer reportedly
have poorer outcomes when compared
to children or older patients, partly
because of less research and
improvements in care for this age
group.
Chemo’s Risk to Younger Women
New research:
 Younger breast cancer
patients seem to suffer
more serious side effects
from chemotherapy than
previously thought
-
Infection
Low blood counts
Dehydration
Nausea
(Journal of the National Cancer
Institute, August, 2006)
Specific Issues
 A cancer diagnosis is traumatic in anyone’s life,
 For young adults it is life changing
 Interrupts college
 Collides with new careers and/or new families
 Occurs as they “just beginning to live” independently diagnosis of
cancer is a traumatic episode in anyone’s life, life changing for
young adults who are often in college or starting new careers
and/or families and are “just beginning to live.”[1]
 Cancer treatments can impact sexual activity, sexuality, selfimage, and fertility
 Often, young adult patients do not fully comprehend these
implications or don’t know how to acquire more information.
Hepatitis C
 Hepatitis C virus (HCV): most common chronic viral infection in
U.S.
 Hepatitis C causes chronic infection
 More than 5 million people infected in U.S.
 HCV: silent epidemic – 60-70% have no symptoms; 75-80%
develop chronic HCV, at risk for chronic liver disease, cirrhosis
and liver cancer
 Poor attempts at prevention; understanding of all transmission
risks
 Tattooing, body piercing and sharing body jewelry –
mainstream, new risk factors
College Students & Risk
 75% potential risk for HCV (risky sex, IDU,
snorting cocaine or other drugs, blood
transfusion before 1992; tattoos, body
piercing, sharing body jewelry
 At risk for acquiring HCV because of
“Incredible lack of awareness and education
regarding hepatitis C”
Results
 n=224
 48% from Sacramento State; 59% female; 72%
juniors and seniors
 71% reported having at least one alcoholic drink in
past 30 days; 29% drink weekly; 5% drink daily; 48%
drunk in past 30 days and 24% DUI
 5% inject street drugs at some time; 1% injected
street drugs more than five times
Results (continued)
 20% have one to more than four tattoos;
43% interested in obtaining first or
additional tattoos; 5% in nonprofessional setting
 39% have body piercings; 12% in nonprofessional setting; 25% “not sure”;
10% exchange body jewelry
Results (continued)
 42% “unlikely to experience health risks
from tattoo or body piercing from a
professional shop”; 44% likely from nonprofessional shop
 68% said if getting a tattoo or body
piercing put them at risk for HCV,
“highly unlikely” they would do so
Results (continued)
 20% reported there is vaccine for HCV or
weren’t sure
 29% not aware of how HCV is transmitted
 34% “very susceptible or susceptible” to
being at risk for HCV from any of the known
ways of transmission (listed for respondent)
Next Steps
 State-wide educational campaign in
collaboration with the UC and CSU systems,
the California Department of Public Health,
and the UC Davis Cancer Center
 Web site: http://www.breakthesilencenow.org