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IIR 02-010 – HSR&D Study

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IIR 02-010
The Impact of Health Literacy on Racial Differences in Cancer Stage at Presentation
Ahsan M. Arozullah MD MPH
Jesse Brown VA Medical Center, Chicago, IL
Chicago, IL
Funding Period: April 2003 - March 2007

BACKGROUND/RATIONALE:
Eliminating racial disparities in health care utilization and health outcomes have become a national priority. Previous studies have found that African American males have higher mortality rates for prostate, colorectal, and lung cancer as compared to Caucasians. These three cancers are also the leading causes of cancer-associated mortality among all men in the United States and the VA. However, it is not clear how racial differences in health literacy, screening test utilization, and/or delays in obtaining appropriate care contribute to racial differences in advanced stage presentation.

OBJECTIVE(S):
The purpose of this study is to determine if racial differences in the rate of advanced stage presentation for prostate, colorectal, and lung cancer can be explained by differences in health literacy, social support, use of screening tests, or both.

METHODS:
We are conducting a cross-sectional survey and health literacy assessment for African-American and Caucasian patients with recently diagnosed prostate, colorectal, and lung cancer from the outpatient oncology, gastroenterology, and general medicine clinics at Jesse Brown VA Medical Center, Lakeside CBOC, and the Hines VA hospital. Individuals with the following conditions will be excluded: (1) dementia; (2) blindness or having severely impaired vision not correctable with eyeglasses; (3) deafness or having hearing problems uncorrectable with hearing aid; and (4) being too ill to participate in the survey. The study sample will include 300 patients with each cancer type (prostate, colorectal, and lung). Information will be obtained through personal surveys and medical record reviews. Each subject will be interviewed to assess health literacy and obtain information about age, race/ethnicity, physical and mental health status, employment and education history, health risk behavior, prior cancer screening, health service access and utilization, trust, satisfaction, and income. During the interview, subjects will be asked about prior colorectal and prostate cancer screening tests. Cancer stage information will be obtained by reviewing medical records and pathology reports.
The shortened Rapid Estimate of Adult Literacy in Medicine (REALM) will be used to assess health literacy. Analysis plan: Classification tree modeling will be used to estimate the relationship between race and advanced stage of prostate, colorectal, or lung cancer at presentation (stages A-C versus stage D), while assessing interactions between race, age, health literacy level, education, socioeconomic status, social support, health status, method of cancer diagnosis and site of care. The dependent variable will be stage D disease at presentation (yes/no). Separate analyses will be performed to assess the impact of trust, satisfaction, screening test utilization, healthcare utilization, and screening test knowledge on the relationship between race and advanced stage at presentation.

FINDINGS/RESULTS:
An analysis of the first 296 patients interviewed found that: 22% had advanced stage cancer at presentation; 46% were Caucasian and 45% were African-American; and 45% had <9th grade literacy. Numerous attributes were individually associated with advanced stage cancer, including annual household income <$843 (p<0.02), cancer diagnosis detected via symptoms, not routine screening (p<0.001), not knowing someone with the same type of cancer (p<0.002), and sometimes or never having cholesterol checked (p<0.001). Multivariable analysis revealed a two-attribute model including income and cancer type, that correctly classified 66% of early stage and 88% of advanced stage cancer patients (Effect Strength for Sensitivity=54.4, a relatively strong effect). Only 15% of patients with income >$843 had advanced stage cancer compared to 40% among patients with income <= $843 (p<0.02). Among patients with income >$843, cancer type predicted advanced stage with only 4% of prostate cancer patients having advanced stage cancer compared to 38% among colorectal and lung cancer patients (p<0.001).

IMPACT:
Insights gained from this study will guide future interventions aimed at eliminating racial disparities in cancer stage at presentation. Specifically, the study will guide whether future efforts need to focus on improving screening rates among low-literacy patients and/or patients with poor social support.

PUBLICATIONS:
None at this time.


DRA: Health Systems
DRE: Etiology, Diagnosis, Prevention
Keywords: Behavior (patient), Cancer, Screening
MeSH Terms: none

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