Multiple domains were implicated simultaneously in 12 out of 21 studies (57.14%), emphasizing the intricate interplay of factors contributing to cancer disparities among African Americans in Los Angeles. These findings underscore the necessity of a comprehensive and multi-faceted approach to addressing these disparities, encompassing geographic, cultural, socioeconomic, and healthcare system considerations.
Socioeconomic Status
The collection of studies paints a comprehensive picture of how socioeconomic status (SES) significantly influences cancer disparities for African Americans. Firstly, African Americans disproportionately use public county hospitals instead of private ones and tend to have more advanced disease at younger ages.17 Public county hospitals are often characterized by limited resources, overcrowding, and higher patient volumes.12 These hospitals may also face challenges such as underfunding and difficulty attracting specialized medical staff. As a result, patients, particularly African Americans, who seek care in these settings may experience delays in diagnosis and treatment due to resource constraints. This delayed access to care can contribute to more aggressive tumors at younger ages among African American patients. Furthermore, other studies contained in this review have similarly stated that low SES is a statistically significant predictor of advanced stage cancer.30,34
Similarly, another finding was that lower SES was associated with decreasing odds of receiving radiation therapy while higher SES was associated with increased breast cancer screening.24,28 This finding highlights a disparity in access to essential care based on socioeconomic factors. Patients from lower SES backgrounds may face barriers such as financial constraints, lack of health insurance, or limited access to healthcare facilities offering certain screenings or treatments such as radiation therapy. These barriers can lead to delays in receiving important screening and treatment, ultimately impacting cancer outcomes and exacerbating disparities in survival rates.
Additionally, there was an influence of underinsurance on timely colorectal cancer screening in African American males and healthcare services for African American women with breast cancer.26,27 This underscores the intersection of socioeconomic status and insurance coverage in healthcare access. Lower SES is often linked to inadequate insurance coverage, which in turn can create significant challenges in obtaining timely screenings. The combined effects of lower SES and insufficient insurance may contribute to delayed diagnoses and more advanced diseases among underserved populations. These findings underscore the need for comprehensive approaches that address both socioeconomic barriers and insurance disparities to ensure equitable access to cancer care for all individuals.
Socioeconomic status plays a pivotal role in cancer disparities, influencing access to treatment, screenings, and healthcare services. However, the impact of SES is not isolated; it intersects with various factors such as geography, healthcare equity and inclusion, and cultural considerations.
Geography
Geographic factors play a significant role in driving cancer disparities among African American populations in Los Angeles, as highlighted by our study. For instance, higher average nitrogen oxide exposure associated with region correlates with African American breast cancer cases, emphasizing the significant role of geographic factors in cancer disparities.16 The higher nitrogen oxide exposure among African American cases, indicative of poorer air quality in geographic locations associated with a higher proportion of African American, underscores how environmental factors contribute to increased cancer risks. Factors associated with an urban environment, such as proximity to highways, contribute to poorer air quality. This environmental context, coupled with historical and socioeconomic factors, creates an environment where African Americans are exposed to higher levels of pollutants which negatively impact their health.
Within the context of Los Angeles, the lower screening rates observed in the South Los Angeles sample compared to the broader LA County Health Survey underscore the significant geographic relationship in cancer disparities.18 This is further verified in literature contained within our review, which suggests a strong association between African American segregation within Los Angeles and racial disparities in prostate cancer mortality rates.21 Segregated areas can create barriers to accessing quality healthcare services, including cancer screenings and treatment.13 The communities and conditions that African Americans currently live in are rooted in a complex history of discriminatory policies such as redlining, Jim Crow laws, and urban displacement.13 South Los Angeles is home to such policies and is a major hub of social inequity.14
Geography and its intersection with SES emerge as a significant factor in driving cancer disparities, as evidenced by multiple studies. Firstly, the contrast in neighborhood SES at diagnosis is stark, with 27.0% of African American cases residing in the lowest SES neighborhoods compared to only 7.7% of European American cases.16 This disparity is further illuminated by research focusing on African American women with triple-negative breast cancer, a majority of whom live in socioeconomically deprived neighborhoods.24 Moreover, the same study marks the first documentation of a disparity in radiation therapy receipt based on both race/ethnicity and SES within LA.24 The geographic distribution of advanced disease follows a markable trend, aligning with regions characterized by larger African American populations and lower median household incomes. This correlation underscores how where one lives can significantly impact access to high-quality healthcare resources, leading to delays in diagnosis and treatment, ultimately worsening disparities in cancer outcomes. These studies collectively reveal a narrative of how geography intertwines with race and socioeconomic status to create barriers to equitable healthcare, calling for targeted interventions to address these systemic inequalities.
Another study presents a unique perspective on how geography can act as a barrier to healthcare access, particularly for African Americans. By focusing on an intervention involving oncology nurse navigation, the study aims to address the challenge of residential distance from a cancer center for African American patients participating in clinical trials.25 The mention of distance as a barrier indicates a recognition that geographic distance can impede access to clinical trials, which are often conducted in specialized centers. African Americans, who are disproportionately represented in lower SES neighborhoods according to the previous findings, may face additional hurdles due to the geographic distribution of these centers. Therefore, this study suggests that by providing specialized support like nurse navigation, it is possible to mitigate the impact of geography on access to clinical trials for African American patients, potentially improving their outcomes and addressing some of the disparities highlighted by the previous research.25
All these findings emphasize the intersection of socioeconomic status, environment, and geography in shaping cancer disparities. Addressing these disparities requires targeted efforts to improve healthcare access in disadvantaged neighborhoods, reduce environmental exposures, and confront systemic inequalities that disproportionately affect African American communities.
Culture
Cancer healthcare disparities persist among minority populations like African Americans in LA, reflecting complex interactions between cultural factors, health beliefs, and access to healthcare services. Literature included in this review explored the impact of cultural differences on African Americans, focusing on two key aspects: culturally based opinions of healthcare providers and health literacy. Cultural opinions involve the perceptions of healthcare providers within African American communities in LA, encompassing medical mistrust and the effectiveness of community-based interventions. Health literacy examines the role of education, knowledge, and socioeconomic factors in perpetuating disparities in cancer screening behaviors and healthcare utilization among underserved populations.
The influence of cultural factors on cancer healthcare disparities extends to perceptions of health advisors and physicians within African American23 communities in LA, oftentimes based on physician-patient cultural differences and medical mistrust. A certain study underscores the critical role of patient-physician communication in shaping perceptions of cancer risks and the benefits of early detection among African American women. Discussions with physicians were associated with greater cancer knowledge and optimism about survival rates, indicating the importance of culturally sensitive healthcare interactions.23
Medical mistrust significantly contributes to cancer disparities among African Americans, shaping their healthcare-seeking behaviors, treatment decisions, and overall health outcomes. Historical injustices have fostered enduring mistrust of the healthcare system among African Americans, leading to skepticism about medical recommendations and reluctance to engage with healthcare providers. This mistrust can result in delays in seeking timely medical care, lower adherence to treatment regimens, and reduced participation in clinical research studies, exacerbating disparities in cancer outcomes. Addressing medical mistrust requires healthcare systems to acknowledge historical traumas, build trust through transparent communication and culturally competent care, and actively engage with communities to foster collaborative and trusting relationships between patients and providers. Within this review, literature demonstrated this impact, indicating that medical mistrust within this community led to more negative coping with cancer, resulting in a greater incidence of aggressive treatment and a lower quality of life.28 As corroborating evidence, community-based interventions, such as training residents as health advisors, have emerged as effective strategies to bridge cultural gaps and enhance trust within African American populations in LA.15 These CHAs possess a deep understanding of the cultural nuances prevalent within their communities, enabling them to offer tailored advice and support, and were shown to influence increased medical knowledge in the community.15
Medical mistrust also results in available free services being utilized less frequently. Many African American women rejected free cancer services, stating that they viewed it as associated with a perception of poverty and receiving charity. Instead, they viewed these free services as substandard and were the reason why black communities received substandard care.33 Further supporting the impact of medical mistrust, studies in this review demonstrated that African American men in LA cited concerns over medical experimentation and mistrust of the entire medical establishment as reasons for not participating in cancer research.32 One study found no correlation between breast self-examination behaviors in African American women and receiving medical breast exams and implicated comfort level with physicians as reasoning for this lack of correlation.35 Overall, several studies contained evidence implicating a culturally-based distrust of the medical establishment as a key factor in understanding cancer disparities within the African American community in Los Angeles.
Health literacy plays a significant role in perpetuating cancer healthcare disparities, particularly among vulnerable populations with limited education and resources. Studies contained in this review have identified education gradients in cancer screening behaviors in African Americans, with lower education levels associated with reduced testing rates.29 Furthermore, disparities in accessing healthcare services for breast cancer are exacerbated by education levels.27 Literature demonstrated that even cancer research participation was impacted by health literacy, showing a higher likelihood of trial involvement with a higher education level. Regarding interventions for health literacy in this population, one study demonstrated that implementing culturally sensitive CHAs for prostate cancer resulted in significant increases in knowledge level.15 This further validates the need for culturally sensitive interventions in this community to relieve cancer disparities. Additionally, discussions with physicians were associated with greater cancer knowledge and optimism about survival rates, further indicating the importance of culturally sensitive healthcare interactions.23 One study even suggested that the already low rate of cervical cancer screening in this community may be even lower than reported due to misconceptions that cervical cancer screening occurs during every pelvic exam.33 Several studies in this review implicated health literacy as a pivotal factor contributing to the observed disparities in this community. Health literacy significantly influences cancer disparities among African Americans, serving as a critical determinant of their access to preventive care, treatment outcomes, and overall health status. Limited health literacy can hinder individuals' understanding of cancer risks, symptoms, and the importance of early detection, leading to delays in seeking care and diagnosis. Moreover, inadequate health literacy may contribute to misunderstandings about treatment options, adherence to medication regimens, and engagement in preventive behaviors such as cancer screenings. Addressing health literacy gaps through culturally tailored educational interventions, clear communication strategies, and accessible health information materials is essential for empowering African American communities to make informed decisions about their health and navigate the complexities of cancer care effectively.
Healthcare Equity and Inclusion
Within the overarching concept of healthcare equity and inclusion, literature within this review implicated disparities in physician language and behavior as serving as significant contributors to cancer healthcare disparities among minority populations. One study discussed how African American men are less likely to be engaged in conversations about the prostate specific antigen test with their physicians compared to white men, indicating unequal treatment within healthcare settings in LA.29 Another article in this review reported similar findings, with African American women reporting little knowledge of cancer screening results or purpose.33 Lack of knowledge of results reflects a lack of appropriate communication on the physicians’ behalf. Included literature also reflected African American individuals in LA reporting not undergoing screening due to the lack of their physicians indicating the necessity of the screen.20 These disparities underscore the need for healthcare systems to address implicit biases and ensure equitable access to preventive care services for all patients.
Physician behavior also influences treatment decisions and quality of life outcomes for African American patients in LA, reflecting broader systemic issues of healthcare inequity. For instance, one study in this review discussed how physician participatory style influences treatment choices and quality of life outcomes in African American patients, highlighting the need for culturally competent care and patient-centered communication to promote equitable health care delivery.28 This same study demonstrated a negative correlation between African American ethnicity and surgeon emotional support in mastectomies. African American women were also more often pushed to more drastic surgical treatments28 and other aggressive treatments.17 Other included studies upheld these findings, discussing how African American women were more likely to have unmet health needs, with cited barriers including their physicians believing treatment would not help or physicians not believing severity of needs.27. Moreover, disparities in physician encouragement for minority participation in clinical research further exacerbate inequities in healthcare access and outcomes.32
Disparities in physician-patient interactions also contribute to unmet needs and barriers to care for minority patients, perpetuating disparities in cancer outcomes. Addressing these disparities requires healthcare systems to prioritize cultural competency training for healthcare providers and implement policies that promote inclusive and patient-centered care. Literature in this review indicated how one-on-one counseling sessions led by trained Community Health Advisors (CHAs) have shown promise in encouraging discussions about cancer screening among African Americans, highlighting the importance of community engagement and culturally tailored interventions in promoting equitable access to preventive care services.18,19 The literature included within this review emphasizes the necessity of creating and executing culturally sensitive health education initiatives that are customized to match the community's existing knowledge base. Data included highlights the insufficiency of current physician language and behavior in serving the African American community in Los Angeles.15
Furthermore, disparities in healthcare facilities themselves have been implicated in racial disparities, with findings suggesting no significant differences in treatment outcomes between African Americans and Caucasians in equal-access healthcare settings, such as VA hospitals in LA, highlighting the impact of unequal access to quality care.22 This underscores the importance of healthcare facilities adopting policies and practices that promote equity and eliminate disparities in access to care, since this study demonstrated the differences these practices make in racial disparities.
Addressing disparities in physician language and behavior within the framework of healthcare equity and inclusion is essential for promoting equitable access to cancer care and improving outcomes for minority populations. By addressing implicit biases, improving cultural competency among healthcare providers, and promoting patient-centered communication, healthcare systems can work towards eliminating disparities and ensuring equitable access to quality care for all patients.