sented on the same topic. Some discrepancies may be due to different research methods, but many of them probably reflect the actual situation—that access has varied across time and place and that the variation has multidimensional causes and effects. Nonetheless, the material presented here is a useful guide to general patterns of differential access and to some of the interventions that have been successful in improving access.

Evidence of Access Problems

Individuals who are poor, have low educational attainment, or are members of racial or ethnic minority groups tend to have poorer cancer outcomes than members of other groups. This is supported by findings from the literature relating to different aspects of cancer care:

  • Survival from cancer is associated with social class (characterized by income and education): lower social classes tend to have poorer survival (Gordon et al., 1992; Greenwald et al., 1996; Kogevinas and Porta, 1997; Savage et al., 1984).
  • Overall cancer mortality is higher in the lower social classes, even after risk factors such as smoking are taken into account (Lantz et al., 1998).
  • Death rates among African-American hospital patients with colorectal cancer are higher than rates for white patients, even when differences in patient characteristics, insurance status, clinical factors, and providers are accounted for (Ball and Elixhauser, 1996; Cooper et al., 1996).
  • Hispanic cancer patients have lower colorectal survival rates than non-Hispanics (Goodwin et al., 1996).
  • Five-year survival rates for Native American compared to white, non-Hispanic individuals, ascertained in 1978-1981, were substantially lower for colorectal cancer (37 versus 51 percent), lung and bronchial cancer (5 versus 12 percent), and female breast cancer (53 versus 75 percent) (Miller 1996).
  • Individuals with cancer who are elderly, women, and members of racial/ethnic minority groups are more likely to have poor pain relief than others (Bernabei et al., 1998; Cleeland et al., 1994, 1997).

Why Do These Differences Exist?

Some of the factors that have been investigated as possibly affecting access to optimal cancer care are

  • health insurance coverage and type of coverage;
  • cost, including health insurance and out-of-pocket costs;
  • attributes of the health care delivery system (e.g., geographic distribution of cancer care facilities, lack of service coordination);
  • attributes of individuals (e.g., lack of knowledge or misperceptions about cancer prevention and treatment, linguistic or cultural attributes); and
  • attributes of health care providers (e.g., lack of knowledge about cancer prevention and treatment, communication styles).

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