**1. Introduction**

402 Cancer Prevention – From Mechanisms to Translational Benefits

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While the role of culture in addressing health care disparities in general and, cancer health disparities specifically is increasingly recognized, a systemic approach aimed at bolstering the cultural competence of our nation's health care workforce is absent. Among the health outcomes, the impact of this gap is most pronounced in cancer. Ample scientific evidence exists affirming that eliminating cancer health disparities requires a multi-sectorial approach. The lack of cultural competence among frontline providers - physicians, nurses, pharmacists, health educators – is only compounded by the cancer workforce crisis, a national threat to assuring quality cancer care to a growing vulnerable and increasingly culturally diverse global population. Traditional solutions to the health care workforce crisis in general and that of the cancer workforce specifically have largely failed because of a silorather than a systems approach, focusing on one specific segment of the workforce or one specific aspect of cancer care. Furthermore, much of those efforts were limited to addressing the quantitative aspect of the problem – increase the number of cancer care professionals, ignoring the equally important qualitative component- assuring a health care workforce, *competent* in providing cancer care across the cancer spectrum to culturally diverse populations. (C-Change 2008; Lichtveld 2009)

The cancer workforce is faced with various obstacles as cancer prevalence and mortality rates swell worldwide and cancer patients and survivors are directly affected by the shortage in a workforce to provide care. Compounding the shortfall in health prevention and clinical care, the disproportionate impact of cancer on minorities and disadvantaged populations has been apparent for decades with few innovative cancer care delivery models implemented. A growing body of evidence indicates that in addition to race, and geo-socioeconomic parameters, culture is a strong influencing factor on cancer outcomes.(Grouse 2005; Chin, Walters et al. 2007; Fisher, Burnet et al. 2007) Converting the role culture plays in eliminating cancer health disparities from a barrier to an asset, requires cultural competence from those providing care across the entire cancer care continuum – from prevention to survivorship. (Lichtveld 2009)

Creating a Sustainable Cancer Workforce: Focus on Disparities and Cultural Competence 405

Perceived Discrimination

Access to Healthcare

Housing/Shelter Quality

Social Network/Community

Provider Cultural Awareness

Impact on Health Behavior Change

Influencing Proximal, Intermediate, & Distal Factors

Genetics

Religion

Cultural Bias

Stereotyping

Health Literacy

Linguistic Barriers

Fig. 1. Social-ecological model: reversing the social determinants that widen the healthy

Social determinants are inextricably linked with socioeconomic disparities that impact every phase of the cancer care spectrum from screening to palliative care. (Smedley, Stith et al. 2003) Despite the United States nationally acclaimed decreases in breast and cervical cancer mortality due in large part to early screening and better therapeutics, African American Hispanic and American Indian/Alaska Native (AI/AN) populations have not enjoyed these same benefits. African American and Hispanic women have higher breast and cervical cancer mortality respectively despite similar screening rates to White women. Colorectal cancer screening rates are also lower while advanced stage at diagnosis higher within African American and Hispanic people. Treatment disparities are particularly concerning. The absolute proportion of African American and Hispanic women receiving radiation therapy less than 1 year after breast conserving therapy is 12% lower in African American and 19% lower in Hispanic women. There is no stable data for AI/AN women. (Natale Pereira, Enard et al. 2011) African American women with breast cancer were less likely to receive full course chemotherapy (Griggs, Sorbero et al. 2003)and more likely to receive nonstandard chemotherapy regimens (OR 1.93 [1.11 – 3.36]). (Griggs, Culakova et al. 2007; Griggs, Culakova et al. 2007)This correlated with stage of disease i.e. Stage II and III OR 2.82 (2.01 – 3.95) and 7.95 (4.06-15.98) respectively, and lower education levels i.e. less than high school OR 3.24 (1.17 – 9.0), high school graduate OR 1.8 (1.08-3.0). These data in part,

Health Disparities

divide.

Poverty

Education Insurance

Age
