The lower survival of Black patients compared to White patients with cancer has been reported for many cancer sites and stages (Bach, Cramer, Warren, & Begg, 1999; Bach et al., 2002). Awareness of cancer mortality disparities has generated nearly 20 years of research to identify the underlying causes (Dayal, Polissar, Yang, & Dahlberg, 1987; Freeman, 2004; Institute of Medicine, 2003; Mayberry et al., 1995). Evidence continues to mount indicating disparities in cancer care, especially in the treatment of breast, colon, and lung cancers. The challenge to isolate the root causes of racial/ethnic treatment inequalities in cancer remains, but is likely multifactorial. Any factor evaluated must account for stage at diagnosis, socioeconomic status (SES), health insurance coverage, biologic differences, effective screening, and diagnosis and surveillance, and scores of other potentially contributing and confounding factors. In this topic, we focus on disparities in the treatment of the three common cancers—breast, colon, and lung—that constitute three of the four leading causes of mortality. We describe the evidence indicating disparities, examine potential contributory factors, discuss successful interventions in reducing disparities, and end with research and policy implications.
DISPARITIES IN TREATMENT DETERMINED BY ANALYSIS OF DATABASES
Differences in treatment have been the focus of an extensive literature based on retrospective observational studies over the past 20 years. Taken together, these studies provide strong evidence that cancer treatment disparities contribute to excess mortality in racial minorities, even when adjusting for sociodemographic and clinical factors.
Despite a lower incidence of breast cancer than in White women, Black women in the United States experience a higher mortality. From 2003 to 2007, the mortality for Black patients with breast cancer was 32.4/100,000 compared to 23.4/100,000 in White patients, which is all the more notable since incidence in Whites was 7% higher than for Blacks (Altekruse et al., 2010). Black women also present with more advanced disease and more aggressive tumors than their White counterparts. For example, only 48% of Black women have advanced breast cancer, compared to 38% of Whites at the time of diagnosis (Altekruse et al., 2010). Similarly, tumor types with a better prognosis (receptor positive) are found less often in Black women (65% of breast cancers) compared to White women (80% of breast cancers) (Chu, Anderson, Fritz, Ries, & Brawley, 2001). These differences in stage and tumor biology explain some of the difference in mortality, but certainly not all. Several studies using population-based data delineate important variation in treatment patterns according to race. Among the 22,701 women with breast cancer reported in the merged Surveillance, Epidemiology, and End Results database (SEER)-Medicare dataset between 1992 and 1999, Black and Hispanic women were significantly less likely than White to receive adequate care across the cancer control continuum, including breast-conserving surgery, radiation, estrogen receptor testing, and surveillance mammography (Haggstrom, Quale, & Smith-Bindman, 2005). In a SEER study of women diagnosed under age 35, African American and Hispanic women received surgery and radiation less frequently after undergoing breast-conserving surgery (Shavers, Harlan, & Stevens, 2003). Even in an integrated health care system, Black women are less likely to receive adjuvant radiotherapy (31% Black, 23% White, P = .03) following breast-conserving surgery, a known indicator of quality care and survival (Hershman et al., 2005).
Disparities in mortality are also evident for colon cancer, with a 10% higher death rate for Black men than White and a 7% higher rate in Black women compared to their White counterparts (Altekruse et al., 2010). Studies have found similar survival rates of colorectal cancer when African American and White patients received the same treatment, and controlling for other factors (Bach et al., 1999; Dignam et al., 1999, 2003), suggesting a strong role for treatment differences in the excess mortality experienced by Black patients with colorectal cancer. In fact, treatment patterns reported from observational studies confirm inferior colon cancer treatments in African American patients with the disease (Ayanian et al., 2003). Despite definitive standards of care for colorectal cancer that have been widely disseminated, population-based studies have consistently shown lower use of appropriate therapies in minority patients. A SEER study (1987-1995) showed that adjuvant therapy for colorectal cancer was 75% more likely to be received by White patients compared to Black (Potosky, Harlan, Kaplan, Johnson, & Lynch, 2002). A study from the California Cancer Registry (1996-1997) also found that recommended adjuvant radiation therapy occurred less frequently.
Racial/ethnic differences in surveillance post treatment for recurrence have been reported. African Americans were less likely than Hispanics, and both groups were less likely than Caucasians, to receive surveillance for recurrence after curative bowel resection for colon cancer, even after accounting for SES and other factors (Ellison, Warren, Knopf, & Brown, 2003).
Lung cancer is the leading cause of cancer mortality in the United States, with mortality rates in men of 87.5/100,000 for Black patients compared to 68.3/100,000 in White patients (Bach et al., 1999). These mortality rate disparities typify the past several decades (Jemal et al., 2004), and when considered in absolute terms—in terms of lives lost—correspond to tremendous and tragic population impacts.
Some non-small-cell lung cancers are potentially curable if resected at an early stage; thus surgical treatment can be critical to survival. Black patients with lung cancer were 13% less likely than Whites to receive surgical treatment (64.0% vs. 76.7%, respectively), which explained most of the excess mortality in early-stage disease experienced by Blacks (Altekruse et al., 2010). A study published 9 years later showed a similar under use of surgery by Blacks (44.7% Blacks compared with 63.4% Whites) (Cykert, Dilworth-Anderson, et al., 2010; Esnaola et al., 2008). In a large SEER-Medicare study examining treatment trends by race over 12 years (1991-2002), significant disparities were seen by race for almost all major lung cancer treatment modalities and were undiminished over time. For early-stage, non-small-cell lung cancer, Blacks were 37% less likely to receive surgery, 42% less likely to receive chemotherapy, and, for later stages, 57% less likely to receive chemotherapy compared with Whites (Hardy et al., 2009). Such pervasive differences across the treatment spectrum are very likely to contribute to higher mortality for Black patients with lung cancer, and suggest wide-ranging, systemic causes.
Mechanisms Underlying Disparities in Cancer Outcomes
In an effort to understand poorer outcomes for minorities with cancer, observational studies have addressed factors other than treatment. Differences in stage at diagnosis, SES, and quality of care have been examined for breast, colorectal, lung, and other cancers. From these studies, several important themes have emerged. Stage at diagnosis, a factor critical to prognosis, is nearly always more advanced for Blacks compared to Whites (McCann, 2005; Morris, Rhoads, Stain, & Birkmeyer, 2010). Stage at diagnosis is related to tumor biology and use of screening, for breast and colorectal cancers, and to care seeking or access for lung cancer. Many studies show similar breast screening rates for Black and White women (Escarce, 2007; Sabatino et al., 2008), but colorectal cancer screening is markedly underused by minorities (Morris et al., 2010). Lower screening rates are likely to be due to a number of factors, including access to care, financial barriers, and cultural beliefs.
SES is known to contribute to lower screening, inadequate treatment, and higher mortality among individuals with cancer, but is difficult to completely separate from race/ethnicity. In fact, some research suggests that low SES is a proxy for race in the disparities literature. Certainly, most studies show an attenuation of racial disparities in cancer outcomes when accounting for SES (Morris et al., 2010) but do not often show complete resolution. However, a host of studies have also shown a race effect on cancer survival independent of SES (Morris et al., 2010; Smedley, Stith, & Nelson, 2003), including analyses that specifically stratify race by SES (LaVeist, 2005).
Quality of care may contribute to disparities in cancer treatment and outcomes, as minority patients disproportionately attend poorer-quality facilities. For example, ample evidence shows that Black and low-income patients are much more likely to receive care at hospitals with fewer resources, higher surgical mortality, and lower volume (Birkmeyer et al., 2002; Neighbors et al., 2007; Onega, Duell, Shi, Demidenko, & Goodman, 2010). The effect of race on mortality seems to be much more attenuated when adjusting for hospital effects than for patient characteristics, suggesting that discrimination may occur not based on who you are but where you go, which indeed is a large-scale systemic issue.
Taken together over the past 20 years, observational research has contributed much to our understanding of cancer disparities based on race/ethnicity and demonstrates inequalities that impact the lives of many individuals. However, given the retrospective nature of these studies, and the limitations of claims and other population-based data at controlling unmeasured co-founders, these data are limited. Retrospective research does not contain the detail required to affect real-time decisions at the point of care. Prospective studies are therefore necessary to answer these questions.
DISPARITIES IN TREATMENT AS ASSESSED BY PROSPECTIVE STUDIES
Over the past few years, prospective studies have been conducted that have shed light on factors contributing to health disparities, often broader than just relating to cancer. Based on the results of these studies, we have identified eight general principles that likely contribute to treatment disparities. These include: (a) biologic response; (b) implicit bias and stereotypes; (c) experiencing racism; (d) psychosocial factors; (e) the patient-provider relationship, trust, and shared communication; (f) respecting patient preferences versus pushing for treatment; (g) physician risk aversion based in perceptions of communication, social support, and adherence to treatment; and (h) access to care. We discuss the potential role of each of these in affecting health disparities outcome.
Advances in genomics are giving rise to new investigations into genetic components of racial differences in cancer outcomes. Exploring biologic differences is compelling for breast cancer, given the higher incidence of more aggressive tumors among women of African descent. Genomic analyses of breast cancer phenotypes have determined molecular subtypes (Morris & Mitchell, 2008), and studies are identifying genes associated with breast and prostate cancers that are expressed at much higher levels in Black cancer patients than White (Brower, 2008). While this area of research is relatively young, the idea that genetics or biology will explain most of the observed racial disparities is extremely unlikely. Other biologically based differences may be due to differences in metabolism of drugs used in treatment, or biologic resistance to effective treatment. African American women more often have aggressive tumors that are less responsive to treatment compared with White women (Millikan et al., 2003), and have higher rates of estrogen, progesterone, and HER-2 receptor negative tumors that are not amenable to the newer anti-estrogen or anti-HER-2-directed therapies (Millikan et al., 2003). Yet, even when controlling for stage and grade, disparities in survival rates persist, clearly indicating that other factors play a role. Ultimately, most researchers agree that cancer survival disparities are predominantly due to race as a social construct rather than a biologic one (Bach et al., 2002; Brower, 2008). There are some researchers who hope to bridge the social and biologic by examining the complex, multilevel interplay of factors that influence cancer risk, cancer, and mortality (Brower, 2008; Gibbons et al., 2007).
Implicit Bias and Stereotypes
Although future physicians often enter medical school with idealism and positive attitudes about caring for the underserved, implicit bias and stereotyping likely play a role in formulating important medical decisions that add to persisting disparities in cancer care (Crandall, Volk, & Loemker, 1993; Woloschuk, Harasym, & Temple, 2004). Van Ryn and Burke (2000) found that physicians regarded Black patients more negatively than White patients, and their perceptions of patients, including those about "noncompliance," were influenced by the patients’ sociodemographic characteristics (van Ryn & Burke, 2000). Schulman and his team reported an increase in cardiologists’ decisions against cardiac catheterization when the same hypothetical scenario was linked to a picture of an African American rather than a White patient (Schulman et al., 1999). In another study, researchers measured 287 physicians’ "prowhite and problack" bias using Greenwald’s Implicit Association Test (IAT) in a group of physicians that held no overt racial bias. They found that physicians’ decisions against aggressive cardiac care were more common for African American scenarios when the respondents had a measured, "prowhite" implicit bias (Green et al., 2007). These studies all suggest that an overwhelmingly non-African American provider group may unconsciously use subjective clinical data, such as interpretation of comorbidity information or perceptions of noncompliance, to formulate different recommendations for minority patients compared to Whites.
A recent prospective study (Cykert, Dilworth-Anderson, et al., 2010) showed that decisions about surgical resection for early-stage non-small-cell lung cancer may help us operationalize the concept of implicit bias in cancer care. In this study, African Americans were substantially less likely than Whites to receive potentially lifesaving surgery. With surgery, at least half the patients survive more than 4 years, whereas without it, most will die within a year. Patients who reported that the doctor’s communication was ineffective or who misunderstood the improved prognosis of surgery were less likely to proceed with treatment. These findings could be related to implicit bias and physician framing, or could be a reflection of poor communication about the illness, prognosis, and treatment options. However, the finding that African American patients with two or more comorbid illnesses rarely went to surgery, while the surgical rates for White patients with similar conditions were not affected, suggests that physician calculation and decision making played a significant role. The approach to surgical intervention offered to White patients with comorbid illnesses appears to be more evidence based, as Strand, Rostad, Damhuis, and Norstein (2007) demonstrated that age and the extent of the procedure was much more predictive of postoperative mortality than high comorbidity scores.
Unexpectedly, in the Cykert, Dilworth-Anderson, et al. (2010) study, African Americans with higher trust scores also chose surgery less often. Although implicit bias was not formally measured, these findings suggest that physicians advise against surgical intervention when speaking to African Americans with higher risk. Prior studies have shown blind trust to be correlated with patient passivity (Kraetschmer, Sharpe, Urowitz, & Deber, 2004). African American patients have been found to be more passive (Gordon et al., 2006) and when facing decisions in treating cancer, passive patients want the doctor to make the decision (Salkeld, Solomon, Short, & Butow, 2004).
Patients in minority groups may experience racism or perceive discrimination. Perceived discrimination refers not so much to "everyday unfair treatment" but to major events, such as being denied housing. Either real or perceived racism may result in psychological and physical effects. Even in integrated, economically homogeneous communities, real or perceived discrimination is negatively associated with patient participation in processes of medical care— most commonly as a delay in seeking care and nonadherence to medical recommendations (Blanchard et al., 2005; ; Casagrande et al., 2007; Van Houtven et al., 2005). The likelihood of delaying or not adhering to care increases in direct proportion to the volume of major discrimination events reported (Casagrande et al., 2007). Passivity (DiMatteo, Lepper, & Croghan, 2000) and helplessness/hopelessness are also strongly associated with nonadherence (DiMatteo et al., 2000), whereas traits such as resilience and self-efficacy provide a protective effect (Keyes, 2009; Williams, Yu, Jackson, & Anderson, 1997). In contrast to major events of perceived discrimination, perception of everyday unfair treatment, such as being treated discourteously or as a dishonest person (Kessler, Mickelson, & Williams, 1999), has been associated with outcomes of care—specifically with poor physical health, reduced wellbeing, and increased psychological distress (Kressin, Raymond, & Manze, 2008; Krieger, Rowley, Herman, Avery, & Phillips, 1993; Williams, Lavizzo-Mourey, & Warren, 1994). It is likely that chronic stress mediates and moderates this relationship. The association between everyday unfair treatment and poorer health outcomes is strongest among those who internalize or are resigned to the experience (Krieger, 1990; Krieger and Sidney, 1996), and is absent among those who discuss or resist discrimination (Krieger, 1990). Several studies have found that individual psychological traits such as optimism and self-esteem protect against chronic stress (Lutgendorf, Sood, & Antoni, 2010; Segerstrom and Miller, 2004). A small but growing body of work has linked endogenous stress hormones to immune dysregulation and angiogenesis, which are linked in turn to cancer progression (Lutgendorf et al., 2010).
Lack of attention to patients’ psychological and social needs can derail the most sophisticated treatment plans. Unaddressed psychosocial issues may also interfere with the quality or utilization of health care, as well as affecting the progression of cancer through similar stress mechanisms (Institute of Medicine, 2008). Based on theory and empirical work, Magai, Consedine, Adjei, Hershman, and Neugut (2008) provide a useful conceptual model for psychosocial issues in health. They propose that three domains—cognitive, affective, and social network—account for most of the ethnic variance in both cancer screening and treatment decision making. More importantly, these domains offer potential targets for intervention. The cognitive dimension encompasses the patient’s knowledge, attitudes, and beliefs, factors that drive decision making (McDonald, Thorne, Pearson, & Adams-Campbell, 1999). Although cognitive factors are no longer accepted as a sole explanation for health behaviors, they continue to be among the easiest to influence. For example, health literacy is an important cognitive factor that is considered inadequate for more than 20% of adult Americans (about 50% of Americans are estimated to have low literacy, 20% of them with inadequate literacy). Poor health literacy disproportionately affects those of low SES and has a major impact on cancer care communication, physician recommendations, and patient adherence to care (Chew, Bradley, & Boyko, 2004; Davis et al., 2002; Michielutte, Alciati, & el-Arculli, 1999). Interventions to improve health literacy among cancer patients have been eagerly embraced, but fall short if they are focused on information and do not address beliefs (Magai et al., 2008).
The affective dimension, which includes emotion, coping, and emotion regulation, also has a major impact on uptake of cancer care (Ahmed, Lemkau, Nealeigh, & Mann, 2001; Davis et al., 2002; Lynch, Steginga, Hawkes, Pakenham, & Dunn, 2008; Ortiz, Lamdan, Johnson, & Korbage, 2009; Schulz and Beach, 1999; Sherbourne, Hays, Ordway, DiMatteo, & Kravitz, 1992). Overwhelming fear or anxiety has been found to inhibit adherence to cancer treatment, but when these fears are harnessed, they may facilitate adherence (Ahmad, Musil, Zauszniewski, & Resnick, 2005; Magai et al., 2008). Social networks are generally considered helpful in coping, but they may influence disparities in the use of chemotherapy in both positive and negative ways. Although those who receive social support tend to follow the care recommended to them and even have a significant survival advantage (Kroenke, Kubzansky, Schernhammer, Holmes, & Kawachi, 2006), those providing the support tend to delay or neglect their own care (Ortiz et al., 2009; Schulz and Beach, 1999). Black patients are more likely than Whites to be providing social support, heading single-parent households, or caring for grandchildren (Musil et al., 2010). On the other hand, Black patients are also more likely to receive support from a social network, resulting in uptake of care particularly among breast cancer patients (Eng, 1993).
The Patient-Provider Relationship, Trust, and Shared Communication
There are early data to indicate that some patients decline treatment due to aspects of the patient-provider relationship (Morris et al., 2009). This relationship includes two key components, communication and trust.
Communication (which includes information, support, and building of relationships) is usually initiated by the physician and directed toward the patient (Arora, 2003; Galassi, Schanberg, & Ware, 1992; Street, Gordon, & Haidet, 2007). Individual- and group-level differences in communication methods have been well established, and communication that is not aligned with patient preferences is unlikely to be successful (Miller & Beech, 2009; Miller, Marolen, & Beech, 2010). For example, in a study of ways to promote prostate cancer screening in Black men, supportive communication that addressed negative preconceptions such as fear of cancer and distrust of statistics was much more effective than informational counseling (Farrell, Murphy, & Schneider, 2002).
Patient trust in physicians is closely related to patient satisfaction. Trust is a good indicator of the patient-physician relationship, and is even more useful for understanding patients’ uptake of medical care. Although there are limited data regarding the specific influence of trust in cancer care (Morris et al., 2009), trust is a powerful mediator of disparities in the treatment of chronic conditions. In a study of patient trust, medication cost, and adherence to care, medication cost was only associated with nonadherence among patients with low trust in physicians (Keating, Gandhi, Orav, Bates, & Ayanian, 2004; Piette, Heisler, Krein, & Kerr, 2005). Trust levels tend to be stable, but they can be affected by the quality of physician’s communication behavior as well as the content of the communication (Keating et al., 2004). In a recent study, Black patients required more relationship-building communication before consenting to an invasive procedure (i.e., the clinicians had to build better levels of trust among their Black patients before consent was given), whereas White patients required more informational communication before they consented (Collins, Clark, Petersen, & Kressin, 2002).
Given our historical legacy of racial discrimination and unethical medical practices (Institute of Medicine, 2003), it is hardly surprising that Black patients want more supportive and open communication from their doctors. Ironically, instead of engaging in this kind of communication, physicians may respond to their own discomfort around racial discordance by relying predominantly on informational communication. In a study of race and informed decision making, investigators audio-taped patient-surgeon conversations (Levinson et al., 2008). They found that the informational content of patient-provider conversations did not differ by race. However, relationship-building words and behaviors, such as responsiveness, respect, and listening, from physicians were markedly lower toward Black patients than toward White patients. Another recent study of newly diagnosed breast cancer patients found that, in the first consultation, oncologists were significantly more likely to build relationships with White and affluent patients, and that minority patients were less likely to ask questions and volunteer information (Siminoff, Graham, & Gordon, 2006).
Respecting Patient Preferences Versus Urging Treatment
Although patients’ preferences should always be taken into consideration, there are circumstances in which this is especially and even critically important; for example, when considering aggressive cancer care in circumstances of marginal benefit, or when considering palliative care as opposed to salvage chemotherapy and adjuvant chemotherapy (Mandelblatt et al., 2010; Parr et al., 2010). However, many decisions against cancer treatment, especially when examined in the context of race, often reflect patient attitudes, misperceptions, mistrust, or physician miscommunication rather than a clear patient preference. For example, the belief that air exposure spreads lung cancer has been cited as a possible barrier to potentially life saving surgery (DeLisser, Keirns, Clinton, & Margolis, 2009). If an African American patient holds this belief and refuses surgery, should the matter be dropped as a matter of patient preference, given the impact on survival that this decision entails? The literature on quality of communication and shared decision making demonstrates limited questioning, less dialogue, and fewer explanations for African American patients during clinical encounters (Clever et al., 2006). This breakdown in information sharing likely contributes to refusal based on mistrust or misperception rather than an ingrained or rational preference. Instead of accepting reluctance toward care by invoking patient preference, performing an evaluation of barriers to care including health literacy and patient comprehension may reduce care disparities. For instance, Gabrijel and colleagues (Gabrijel et al., 2008) showed that lung cancer patients experience large knowledge gaps about treatment options as early as 3 days after a visit.
The teach-back method, establishing patient comprehension, has been used to improve care in low health literacy populations (Paasche-Orlow et al., 2005; Wilson, Baker, Nordstrom, & Legwand, 2008; Yin et al., 2008). In the teach-back method, the provider asks the patient to repeat what he or she understood about the factual information and recommendations provided by the provider. If misperceptions or other areas of concern arise, these can be immediately clarified and concerns allayed. Yet this simple effective method.In lung cancer care, half of all patients do not understand their treatment options very soon after seeing their doctor (Gabrijel et al., 2008). This is a serious knowledge gap, given the gravity of impending decisions, and could potentially be avoided using the teach-back method. Elements of low health literacy contribute to racial differences in HIV care (Waldrop-Valverde et al., 2010), receipt of preventive care (Bennett, Chen, Soroui, & White, 2009), and poor glycemic control (Osborn, Cavanaugh, Wallston, White, & Rothman, 2009; Schillinger et al., 2003), further supporting the rationale that communication interventions can differentially improve the care of Black patients. In addition to assuring comprehension, interventions that simply enhance fundamental communication have been associated with improved care. In two studies, increasing patient involvement in decisions and increasing perceptions of being treated with dignity led to improvements in depression and preventive care (Beach et al., 2005; Clever et al., 2006). By extrapolating these strategies to cancer care, similar improvements could be expected to occur.
Physician Risk Aversion
Physicians are aware of the risks that surgery entails, and weigh the risks and benefits in making treatment recommendations to patients. However, there are data to indicate that physicians may under-recommend surgery to African American patients compared to their White patients, because of poor communication with their Black patients and their perception that these patients will be noncompliant (Cykert, McGuire, et al., 2010). In this study, Cykert and his team (Cykert, McGuire, et al.) found that a quarter of physicians who took care of patients with lung cancer believed that African American patients received lung surgery less often than White patients because they felt that their communication with the Black patients was more often difficult or inadequate. In fact, half said that they would recommend against surgery because of difficult communication. Apparently connected to this difficult communication dyad, patients’ disbelief in their diagnosis was also cited as a reason for Black patients to undergo lung cancer surgery less often than White patients (Cykert, Dilworth-Anderson, et al., 2010).
There are no specific reports that directly connect physician attitudes to less cancer surgery. However, there is evidence linking these physician perceptions, especially negative attitudes about patient compliance, to reductions in other important treatments. For example, researchers examining patients referred for kidney transplantation found that physicians did not refer Black patients for this surgery because they believed that the Black patients would be noncompliant (Ayanian et al., 2004). Similar perceptions have been shown to be associated with delayed prescription of HIV medications for African Americans and Latinos (Stone, 2005; Wong et al., 2004). These reports connecting physicians’ perception of noncompliance to limitations in other health states strongly raise the question as to whether reduced rates of cancer surgery indeed mirror physicians’ risk aversion to recommending high-risk treatments for patients who suffer from serious illnesses.
Access to Care
Access to care has many dimensions, including individual, health care systems, and geographic (Aday & Andersen, 1974; Andersen, McCutcheon, Aday, Chiu, & Bell, 1983), but in its most simplistic form can be described by availability, proximity, and affordability of care. Studies of geographic access to cancer care in the United States that have examined the interaction of race/ethnicity and place of residence have shown that urban Blacks have similar or better access to specialized cancer care than urban Whites, but rural Blacks have relatively poor access and lower utilization of specialized cancer care compared with all other groups (Onega, Duell, Shi, Demidenko, & Goodman, 2008; Onega, Duell, Shi, Demidenko, & Goodman, 2009). For example, rural Black patients have to travel over 5 hours longer than rural White patients to the nearest National Cancer Institute center (Onega, Duell, Shi, Demidenko, et al., 2008). Disparities in geographic access are most marked for Native Americans, with a median travel time to any oncologist over twice that of any other group (Onega, Duell, Shi, Wang, et al., 2008). Per capita oncologist supply has not been shown to differ for Blacks compared to Whites (Onega, Duell, Shi, Wang, et al., 2008), suggesting that disparities in access to resources may be related to specialized care, advanced technology, and density of providers and services.