Você está na página 1de 5

Received: 2 September 2016

Accepted: 2 September 2016

DOI 10.1002/pon.4278


Tackling inequalities in cancer care and outcomes: psychosocial

mechanisms and targets for change
1 | C A N C E R HE A L T H D I S P A R I T I E S A R E A

has been found, with older patients less likely to be diagnosed at later
stages.8,11 While it is increasingly recognized that psychosocial care is
a key component of highquality, comprehensive cancer care, provi-

Disparities in cancer incidence, outcomes, and prevalence persist glob-

sion varies markedly geographically. Psychosocial care is generally

ally among countries.1,2 While incidence and mortality rates for most

more established and implemented in higherincome countries relative

cancers are falling in many highincome Western countries, the oppo-

to less developed countries and is more likely to be provided in cancer

site is true in numerous lessdeveloped and economically transitioning

centers and university hospitals, which are typically situated in urban

regions. With regard to colorectal cancer, for example, there is a 10

areas than in smaller facilities based in the community.9,12

fold variation in incidence rates worldwide, with high and rapidly

Reducing disparities in cancer care and outcomes is an ongoing

increasing incidence rates in Eastern European countries and Japan,

priority in many countries as well as internationally. For example, cur-

the lowest rates in Africa, Central and South America, and South

rent cancer strategy in England (20152020) aims for a reduction in

Central Asia, and stabilizing or declining rates in the USA, New

the variability of access to optimal diagnosis and treatment and the

Zealand, and Canada.1 Fiveyear relative survival rates for colorectal

resulting inequalities in outcomes (www.cancerresearchuk.org/about

cancer range from approximately 20% in Algeria compared with nearer

us/cancerstrategyinengland), and achieving health equity and elimi-

60% in the USA. Cancer incidence and mortality also vary within and

nating disparities is an overarching goal of the Healthy People 2020

across countries by sociodemographic factors such as gender, age,

initiative in the USA, which sets out a comprehensive agenda for

ethnicity, and socioeconomic status. For example, incidence rates of

improving the health of all Americans in numerous areas including can-

stomach cancer vary by gender, although much more so in some

cer (www.cdc.gov/nchs/healthy_people/hp2020.htm). The Union for

countries than others. Incidence rates per 100 000 are 65.8 in men

International Cancer Control's 2013 World Cancer Declaration calls

compared with 24.2 in women in Japan, for instance, but just 3.3 in

upon government leaders and health policymakers to reduce the

men relative to 2.0 in women in Egypt.1 Across countries, individuals

global cancer burden and promote greater equity (www.uicc.org/

with higher socioeconomic status have been found to have better



cancer survival rates than those with lower socioeconomic status.

In Sweden, for instance, individuals with universitylevel education

have been found to have survival rates 40% higher than those of
people with less than 9 years of school education.3

2 | O V E R V I E W O F T H E SP E C I A L I S S U E

Disparities in cancer incidence and mortality are underpinned by

geographical and sociodemographic inequalities at numerous points

This special issue of PsychoOncology focusing on cancer health dispar-

across the cancer continuum: in risk factors for cancer (e.g., smoking

ities was called for and coordinated by members of the Executive

and Helicobacter pylori infection), in cancer screening participation, in

Committee of the British Psychosocial Oncology Society in response to

cancer symptom awareness and timely diagnosis, in cancer treatment

the fact that cancer disparities persist as a global problem and priority,

including psychosocial care, and in longterm morbidities among survi-

and to highlight the contribution that psychosocial oncology research

vors (e.g., depressive symptoms and pain).1,610 Some examples of

can make in helping to tackle these. Over 50 papers were submitted to

these inequalities include the following: Research in Britain, stemming

the call for this issue (the most for any PsychoOncology special issue to

from the National Awareness and Early Diagnosis Initiative in England

date), and 148 reviewers based in 14 different countries have been

launched in 2008, has consistently found lower awareness of cancer

involved in peerreviewing the submissions. Sixteen of the submissions

warning signs and symptoms among minority ethnic groups and lower

are included in this special issue: 3 literature reviews,1315 9 research

socioeconomic status groups.7 Some research studies have found age

papers,1624 and 3 clinical correspondence pieces,2527 as well as a

disparities in stage of cancer at diagnosis, although the nature of these

report from the International Federation of PsychoOncology Societies

disparities varies by cancer type. For some cancers (e.g., cervical),

which documents and highlights the heterogeneity of the federated soci-

increasing age has been found to be associated with more advanced

eties and the global betweencountry differences in the development

stage at diagnosis, whereas for other cancers (e.g., lung), the reverse

and implementation of psychooncology care.28


Copyright 2016 John Wiley & Sons, Ltd.


PsychoOncology 2016; 25: 11221126



Collectively, the papers in this special issue use a wide range of

for some cancer types. For example, research in many countries consis-

methodologies and analytic techniques with a diverse range of sam-

tently finds an elevated incidence of prostate cancer among men of

ples, to look at disparities in cancer care and outcomes at several

African descent,34,35 and there is strong evidence of a disproportion-

points on the cancer continuum: from screening,


to symptom

ately high breast cancer mortality rate in African American women,

attribution,19,21 to diagnosis, treatment and care,20,21,25,26 and into

even after accounting for socioeconomic status.36 Nine of the papers



in relation to a number of different factors: chiefly

in this issue seek to enhance our understanding of ethnic and cultural

education,16,19,22 ethnicity,14,15,18,22,24,27 and cultural factors (such as

cancer disparities.14,15,17,18,22,2427 For instance, SeymourSmith and


) and the

colleagues18 elucidate reasons for the low uptake of digital rectal exam-

presence of comorbid health conditions13,20,22 but also residential

ination screening for prostate cancer among UK AfricanCaribbean

religious beliefs


and English language proficiency



For example, Ruiz and

men. Interviews exploring the men's perceptions of digital rectal

colleagues24 examine differences in smoking, alcohol, and drug use

examination reveal salient fears of the examination stemming from

on the basis of age and ethnicity among adolescent and young adult

cultural homophobic beliefs and in turn a fear of stigma associated with

survivors of childhood cancer, who remain at risk for poor longterm

transgressing cultural norms. In a similar study, but focused on breast

health outcomes.

cancer screening, Padela et al.17 examine how Islamic religious beliefs



and relationship status.

inform American Muslim women's intentions to undergo mamm-

3 | E L U C I D A T I N G P S YC H O S O C I A L

ography. This study highlights the influence of religious beliefs on

screening intentions, but moreover, details the complexity of this influence; although some religionrelated beliefs may be barriers to screening (e.g., modesty preservation necessitating gender concordant health
care), others may in fact enhance mammography intention (e.g., notions


Educational disparities

about duty to God and stewardship of one's body). Both Seymour

Lower educational level, and more broadly lower socioeconomic sta6,29

tus, is associated with lower uptake of cancer screening,


Smith and Padela's papers provide insight into, and inform understanding of, belief systems influencing cancer screening participation among

a more

groups with low uptake. Such knowledge is crucial for developing cul-

and poorer morbidity and mor-

turally sensitive initiatives to reduce ethnic and cultural disparities.

tality outcomes.35,10,31 Three of the papers in this special issue exam-

Perez and collegaues26 report one of the first studies to interview

ine educationbased cancer disparities.16,19,22 Importantly, these

USbased medical interpreters to obtain their perceptions of potential

papers elucidate psychosocial and behavioral factors and processes

mechanisms underlying disparities in the cancer care of patients with

that, to some extent, mediate the link between low educational attain-

limited English proficiency. The study highlights underuse of

ment and poorer preventive care and outcomes. Crucially, as these

interpreters as a principal factor compromising patient care due to

mediators are potentially modifiable, they offer a target for interven-

factors such as privacy concerns and families' desires to interpret or

tions to reduce cancer inequalities. The papers also usefully identify

withhold information, as well as lack of understanding of the US

psychosocial factors which do not appear to underpin educationbased

medical system among patients with limited English proficiency, which

disparities and are thus unpromising targets for intervention. For

linguistic interpreter services alone cannot address.


likelihood of being diagnosed with certain types of cancer,


advanced cancer stage at diagnosis,

example, in their paper concerning inequalities in colorectal cancer

screening participation in the UK, Smith et al.16 demonstrate a consis-


Disparities according to comorbidity status

tent and graded effect of education on perceived emotional and practical barriers to uptake. In particular, beliefs that one would worry more

With a growing aging population in many countries, increasing num-

about colorectal cancer after screening and concerns about tempting

bers of people living with and beyond cancer will also have a diagnosis

fate were strongly negatively associated with education. Interestingly,

of 1 or more other chronic physical, mental, and/or cognitive health

no educational gradient was observed for perceived benefits of

conditions. There is evidence to indicate that patients with cancer with

screening. Marcu and colleagues' paper19 focusing on cancer symptom

comorbidities are more likely to be diagnosed at a later stage

attribution shows that a lower level of education is associated with a

(depending on the type of cancer and the type and severity of comor-

lower likelihood of considering cancer a possible cause for breast can-

bidity),37 are less likely to be offered and to receive curative treat-

cer symptoms. Moreover, they found that this is the case not only for a

ment,37,38 and have poorer survival.5,37,38 However, evidence in this

less wellknown symptom (nipple rash) but also for a very familiar

area is lacking due to, among other things, under and unsystematic

symptom (axillary lump) and that this association persisted even after

recording of comorbidity information in medical records and cancer

adjustment for cancer avoidance.

registries and the fact that patients with comorbidities are often
excluded from randomized controlled clinical trials.37 Three papers in


Ethnic and cultural disparities

this special issue examine the experiences of patients with cancer with
comorbidities.13,20,22 These include our Editor's Choice paper by Hop-

There is some evidence to show that, in comparison with majority

kinson and colleagues,13 which reports a novel and topical systematic

ethnic groups, some minority ethnic groups are less likely to participate

review on what is currently known about the experience of cancer

in cancer screening.32,33 Also, some ethnic groups have a higher risk of

treatment and its outcomes in adults with dementia. Hopkinson et al.

being diagnosed with some types of cancer and higher mortality rates

find that, compared with other patients with cancer, those with



dementia are diagnosed at a later stage, receive less treatment, are

carefully designed to address the specific psychosocial factors and pro-

more likely to experience treatment complications, and have poorer

cesses contributing to the disadvantaged position of a particular group

survival and that the reasons for these disparities remain to be deter-

are unlikely to succeed in narrowing the inequalities gap. Smith et al.'s

mined. In their paper reporting on a national survey of USbased can-

paper,16 for instance, found that while some perceived barriers to colo-

cer survivors, Stein et al.22 show that among survivors experiencing

rectal cancer screening were strongly graded by education level, per-

ongoing pain, those with physical and/or mental health comorbidities

ceptions of the benefits of screening were not. Therefore, initiatives

had experienced more barriers to pain management at patient, pro-

focused on increasing the perceived benefits of screening may

vider, and system levels. Compared with survivors with no

improve uptake overall but are unlikely to reduce the socioeconomic

comorbidities, those with other health conditions had greater odds of

gap in participation rates. It is possible that illdesigned interventions

reporting, for example, a belief that their pain could not be relieved,

could even exacerbate inequalities, if they were to improve health out-

concerns about addiction and side effects, that their physician did

comes among already advantaged groups, but prove ineffective among

not ask them about their pain, and that their health insurance would

those groups experiencing disparities.39

not cover pain treatment.


4.2 | Boost social support and its salubrious effects

among groups experiencing disparities
A large body of literature attests to the importance of social support to
health and wellbeing,40 and some of the papers in this issue under-

Two of the clinical correspondence papers in this special issue report

score the importance of social support to good outcomes across the

pilot study results of interventions to ameliorate cancer disparities.

cancer continuum. For example, Leung et al.23 show that breast cancer


LipsonSmith et al.

examine a multifaceted communication inter-

survivors without partners have poorer healthrelated quality of life

vention to increase nonEnglish speaking migrant patients' involve-

than those with partners, and, moreover, demonstrate that this dispar-

ment in, and understanding and recall of, clinical consultations. They

ity is mediated by lower levels of social support among women without

found the intervention proved culturally acceptable, although only

partners. Interventions to reduce inequalities might look to provide or

the audiorecording of consultations component was perceived to be

enhance social support among groups experiencing disparities; this

effective. Two other aspects of the intervention (information sheets

may be particularly important in communities or countries where

and a question prompt list) were unused by many participants,

stigma surrounds cancer and its treatment. In their metasynthesis

suggesting that in future work the intervention should be simplified.

review examining minority ethnic patients' experiences of prostate

Bava et al.27 appraise a parentdirected psychoeducational interven-

cancer, Rivas et al.14 found that the literature indicates that there is a

tion to improve scholastic attainment among survivors of childhood

silencing stigma which discourages men from disclosing their diagno-

leukemia; the intervention is part of the clinical services routinely pro-

sis and thus receiving social support, yet also shows that men who do

vided at their USbased institution, which treats a high proportion of

disclose report the value to wellbeing of social support from close net-

Latino, lower socioeconomic status patients. They report that the

works. Indeed, supportive social networks may help buffer against

intervention is valued by families and shows preliminary feasibility

stigma. In their paper reporting on interviews with breast cancer survi-

and efficacy. Although just 2 of the papers in this special issue report

vors in Uganda, Meacham et al.21 show that stigma impedes women

intervention research, the findings of all the papers have, to varying

from seeking and completing medical treatment, but more importantly,

degrees, implications for intervention development. Considering these

they also show that women who do engage with, and remain in cancer

implications collectively, 3 key themes emerge: That interventions to

care, create pockets of social support which are a key enabling factor.

reduce cancer disparities (a) need to be targeted and socioculturally

tailored to groups experiencing disparities; (b) might, amid other things,
these groups; and (c) need also to focus on enhancing relevant aspects

4.3 | Enhance health professionals' knowledge and


of health professionals' knowledge and skills.

A number of the papers in this issue call for interventions to increase

fruitfully look to boost social support and its salubrious effects among

health professionals' awareness and understanding of relevant psycho-

4.1 | Target and socioculturally tailor initiatives to

groups experiencing disparities

social factors and processes contributing to cancer disparities, so that

they may provide care and services which help to mitigate these disparities. For example, Marcu et al.19 suggest that knowledge of

Several papers in this issue highlight that reducing the inequalities gap

sociodemographic variation in cancer symptom attribution would allow

requires interventions that are targeted and socioculturally tailored to

general practitioners to have a greater sense of patients who may nor-

particular groups most in need. For example, SeymourSmith et al.18

malize their symptoms and thus be at risk of late diagnosis, and Padela

assert that initiatives to increase prostate cancer digital rectal examina-

et al.17 recommend programs that sensitize health care providers to

tion screening among AfricanCaribbean men need to address the fear

the importance of modesty and gender concordance for Muslim

of homophobia in this population, and Padela et al.


recommend that

patients. Also, several papers recommend initiatives to enhance vari-

interventions to improve mammography rates among Muslim women

ous different aspects of health professionals' communication skills.

incorporate religiously tailored messages. Interventions which are not

For example, Flynn et al.20 interviewed people with intellectual



disabilities and found that they are often excluded in cancer consulta-

recommend that developing successful interventions to improve

tions from conversations and decisions about their care and treatment,

uptake requires partnering with Islamic scholars and Imams in a two

and thus call for interventions to enhance health professionals' patient

way dialogue, and SeymourSmith and colleagues18 have used the

centered skills to enable optimal involvement of patients with intellec-

findings from their interview study to produce a mobile application

tual disabilities in their own care. As Flynn et al. note, theoretically,

(PROCEE, which provides prostate cancer information and evaluates

such skills are generalizable and thus may serve to enhance consulta-

risk) which was designed with key members of the AfricanCaribbean

tions with patients with other comprehension or communication diffi-


culties (such as dementia or limited proficiency in the local language).

To summarize, the excess mortality attributable to socioeconomic

and other inequalities is considerable and reducing disparities in cancer
care and outcomes between and within countries should remain a high



priority on political and research agendas. The research in this special

issue shows the contribution that psychosocial oncology research can
make towards understanding and tackling disparities across the cancer

The work in this special issue highlights several areas and priorities for

continuum. Psychosocial research can contribute by delineating theoret-

future research. The review papers all identify a number of research

ically modifiable psychological, social, and behavioral factors and pro-

gaps. For instance, Youl and colleagues15 examined variations in

cesses underpinning cancer disparities and developing interventions to

psychosocial outcomes by residential location and indigenous status

mitigate or change these and reduce disparities. However, much remains

in women with breast cancer in Australia and found no research liter-

to be done to realize the potential of psychosocial research, and future

ature examining inequalities by indigenous status, only a few studies

work needs to focus on designing and implementing successful interven-

which directly compared outcomes according to residential location

tions which can effect change and reduce cancer inequalities.

and a lack of studies focusing on women with advanced breast cancer.

Hopkinson and colleagues' review13 highlights the dearth of research


investigating the supportive care needs and preferences of patients

We would like to thank Maggie Watson and Jimmie Holland for their

with comorbid cancer and dementia; yet, such research is needed to

support and guidance, and the editorial team at Wiley for their input

inform guidelines for the care and management of these patients.

and assistance.

Despite the vital role of family carers in supporting patients and the
adverse impact caregiving can have on carers' own health and

Laura Ashley1

wellbeing, Hopkinson et al.'s review also highlights the absence of

Iain Lawrie2,3

research considering carers and their support needs.

Faculty of Health and Social Sciences, Leeds Beckett University,

Almost all of the papers in this special issue report research

Leeds, UK

conducted in highincome, developed countries. There is a need for

more research examining inequalities in less developed and economi-


The Pennine Acute Hospitals NHS Trust, Manchester, UK

Faculty of Biology, Medicine and Health, The University of Manchester,

cally transitioning countries, particularly as the burden of cancer shifts

Manchester, UK

toward these countries, where incidence and mortality rates are

Email: L.J.Ashley@leedsbeckett.ac.uk

increasing.1 With an aging population globally, in future years, many

countries will see an increasing prevalence of comorbidity and multi
morbidity among people with cancer. More multimorbidity research
is needed to understand the influence of other cooccurring health
conditions on cancer symptom awareness, helpseeking and diagnosis,
and to inform guidelines for the management and longterm followup
of patients with cancer with other chronic conditions. This will mean
collaborative working outside the singledisease framework which is
currently typical of most specialist health care services, research, and
education. The papers in this issue examine disparities based on
numerous different factors (e.g., age, socioeconomic status, and
ethnicity); yet, many of these have overlap. Future research should
focus on the needs and outcomes of those patients at the intersection
of multiple categories of disadvantage who are likely to experience the
greatest inequalities.
A priority for future research is to develop, test, and implement
interventions to tackle cancer inequalities. Interventions may have a
greater chance of success if they are not only targeted and socioculturally tailored to particular groups experiencing disparities but also
developed in collaboration with them. In their paper on mammography
participation among Muslim women, Padela and collegaues17

1. Jemal A, Center MM, DeSantis C, Ward EM. Global patterns of cancer
incidence and mortality rates and trends. Cancer Epidemiol Biomarkers
Prev. 2010;19(8):18931907.
2. Coleman MP, Quaresma M, Berrino F, Lutz JM, De Angelis R,
Capocaccia R, Baili P, Rachet B, Gatta G, Hakulinen T, Micheli A, Sant M,
Weir HK, Elwood JM, Tsukuma H, Koifman S, E Silva GA, Francisci S,
Santaquilani M, Verdecchia A, Storm HH, Young JL, CONCORD Working
Group. Cancer survival in five continents: a worldwide populationbased
study (CONCORD). Lancet Oncol 2008; 9(8):730756.
3. Hussain SK, Lenner P, Sundquist J, Hemminki K. Influence of education
level on cancer survival in Sweden. Ann Oncol. 2008;19(1):156162.
4. Downing A, Prakash K, Gilthorpe MS, Mikeljevic JS, Forman D.
Socioeconomic background in relation to stage at diagnosis, treatment and survival in women with breast cancer. Br J Cancer.
5. Dalton SO, Schz J, Engholm G, et al. Social inequality in incidence
of and survival from cancer in a populationbased study in
Denmark, 19942003: summary of findings. Eur J Cancer. 2008;44
6. Damiani G, Federico B, Basso D, et al. Socioeconomic disparities in the
uptake of breast and cervical cancer screening in Italy: a cross sectional
study. BMC Public Health. 2012;12:99


7. Robb K, Stubbings S, Ramirez A, et al. Public awareness of cancer in

Britain: a populationbased survey of adults. Br J Cancer. 2009;101
(Suppl 2):S18S23.
8. Lyratzopoulos G, Abel GA, Brown CH, et al. Sociodemographic
inequalities in stage of cancer diagnosis: evidence from patients with
female breast, lung, colon, rectal, prostate, renal, bladder, melanoma,
ovarian and endometrial cancer. Ann Oncol. 2013;24(3):843850.
9. Travado L, Reis JC, Watson M, Borras J. Psychosocial oncology care
resources in Europe: a study under the European Partnership for Action
Against Cancer (EPAAC). Psychooncology 2015. doi: 10.1002/pon.4044.
10. Hudson MM, Mertens AC, Yasui Y, et al. Childhood Cancer Survivor
Study investigators. Health status of adult longterm survivors of childhood cancer: a report from the Childhood Cancer Survivor Study.
JAMA. 2003;290(12):15831592.
11. Fedewa SA, Cokkinides V, Virgo KS, Bandi P, Saslow D, Ward EM.
Association of insurance status and age with cervical cancer stage at
diagnosis: National Cancer Database, 20002007. Am J Public Health.
12. Mehnert A, Koch U. Psychosocial care of cancer patients international differences in definition, healthcare structures, and therapeutic
approaches. Support Care Cancer. 2005;13(8):579588.
13. Hopkinson JB, Milton R, King A, Edwards D. People with dementia:
what is known about their experience of cancer treatment and cancer
treatment outcomes? A systematic review. Psychooncology. 2016;25
(10):11371146. doi: 10.1002/pon.4185


24. Ruiz ME, Sender L, Torno L, Fortier MA. The associations of age and
ethnicity on substance use behaviours of adolescent and young adult
childhood cancer survivors. Psychooncology. 2016;25(10):12291236.
doi: 10.1002/pon.4225
25. LipsonSmith R, Hyatt A, Butow P, et al. Are audio recordings the
answer? a pilot study of a communication intervention for non
English speaking patients with cancer. Psychooncology. 2016;25
(10):12371240. doi: 10.1002/pon.4193
26. Perez GK, Mutchler J, Yang MS, TreeMcgrath CF, Park ER. Promoting
quality care in cancer patients with limited English proficiency: perspectives of medical interpreters. Psychooncology. 2016;25(10):12411245.
doi: 10.1002/pon.4176
27. Bava L, Malvar J, Sposto R, et al. A parentdirected intervention for
addressing academic risk in Latino survivors of childhood leukemia:
results of a pilot study. Psychooncology. 2016;25(10):12461249. doi:
28. Grassi L, Fujisawa D, Odyio P, et al. Disparities in psychosocial cancer
care: a report from the International Federation of PsychoOncology
Societies. Psychooncology. 2016;25(10):11271136. doi: 10.1002/
29. von Wagner C, Good A, Wright D, et al. Inequalities in colorectal
cancer screening participation in the first round of the national
screening programme in England. Br J Cancer. 2009;101(Suppl 2):

14. Rivas C, Matheson L, Nayoan J, et al. Ethnicity and the prostate cancer
experience: a qualitative metasynthesis. Psychooncology. 2016;25
(10):11471156. doi: 10.1002/pon.4222

30. Shack L, Jordan C, Thomson CS, Mak V, Mller H. UK Association of

Cancer RegistriesVariation in incidence of breast, lung and cervical
cancer and malignant melanoma of skin by socioeconomic group in
England. BMC Cancer. 2008;8:271

15. Youl PH, Dasgupta P, Youlden D, et al. A systematic review of inequalities in psychosocial outcomes for women with breast cancer according
to residential location and Indigenous status in Australia.
Psychooncology. 2016;25(10):11571167. doi: 10.1002/pon.4124

31. AshingGiwa KT, Lim JW. Examining the impact of socioeconomic

status and socioecologic stress on physical and mental health quality
of life among breast cancer survivors. Oncol Nurs Forum. 2009;36

16. Smith SG, McGregor LM, Raine R, Wardle J, von Wagner C, Robb KA.
Inequalities in cancer screening participation: examining differences in
perceived benefits and barriers. Psychooncology. 2016;25(10):1168
1174. doi: 10.1002/pon.4195

32. Hanson K, Montgomery P, Bakker D, Conlon M. Factors influencing

mammography participation in Canada: an integrative review of the
literature. Curr Oncol. 2009;16(5):6575.

17. Padela AI, Vu M, Muhammad H, et al. Religious beliefs and mammography intention: findings from a qualitative study of a diverse group of
American Muslim women. Psychooncology. 2016;25(10):11751182.
doi: 10.1002/pon.4216
18. SeymourSmith S, Brown D, Cosma G, Shopland N, Battersby S, Burton A.
Our people has got to come to terms with that: changing perceptions of
the digital rectal examination as a barrier to prostate cancer diagnosis in
AfricanCaribbean men. Psychooncology. 2016;25(10):11831190. doi:
19. Marcu A, Lyratzopoulos G, Black G, Vedsted P, Whitaker KL. Educational differences in likelihood of attributing breast symptoms to
cancer: a vignettebased study. Psychooncology. 2016;25(10):1191
1197. doi: 10.1002/pon.4177
20. Flynn S, HulbertWilliams NJ, HulbertWilliams L, Bramwell R. You
don't know what's wrong with you: an exploration of cancerrelated
experiences in people with an intellectual disability. Psychooncology.
2016;25(10):11981205. doi: 10.1002/pon.4211
21. Meacham E, Orem J, Nakigudde G, Zujewski JA, Rao D. Exploring sigma
as a barrier to cancer service engagement with breast cancer survivors
in Kampala, Uganda. Psychooncology. 2016;25(10):12061211. doi:
22. Stein KD, Alcaraz KI, Kamson C, Fallon EA, Smith TG. Sociodemographic
inequalities in barriers to cancer pain management: a report from the
American Cancer Society's Study of Cancer SurvivorsII (SCSII).
Psychooncology. 2016;25(10):12121221. doi: 10.1002/pon.4218
23. Leung J, Smith MD, McLaughlin D. Inequalities in long term health
related quality of life between partnered and not partnered breast cancer survivors through the mediation effect of social support.
Psychooncology. 2016;25(10):12221228. doi: 10.1002/pon.4131

33. Homayoon B, Shahidi NC, Cheung WY. Impact of Asian ethnicity on

colorectal cancer screening: a populationbased analysis. Am J Clin
Oncol. 2013;36(2):167173.
34. Chinegwundoh F, Enver M, Lee A, Nargund V, Oliver T, BenShlomo Y.
Risk and presenting features of prostate cancer amongst AfricanCaribbean, South Asian and European men in northeast London. BJU Int.
35. Bunker CH, Patrick AL, Konety BR, et al. High prevalence of screeningdetected prostate cancer among AfroCaribbeans: the Tobago
Prostate Cancer Survey. Cancer Epidemiol Biomarkers Prev. 2002;11
36. Newman LA, Griffith KA, Jatoi I, Simon MS, Crowe JP, Colditz GA.
Metaanalysis of survival in African American and white American
patients with breast cancer: ethnicity compared with socioeconomic
status. J Clin Oncol. 2006;24(9):13421349.
37. Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer
and its treatment. CA Cancer J Clin. 2016;66(4):337350.
38. Sarfati D, Gurney J, Stanley J, Koea JA. retrospective cohort study of
patients with stomach and liver cancers: the impact of comorbidity
and ethnicity on cancer care and outcomes. BMC Cancer.
39. White M, Adams J, Heywood P. How and why do interventions that
increase health overall widen inequalities within populations? In:
Babones SJ, ed. Social Inequality and Public Health. Bristol: Policy Press;
40. Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to
health: Durkheim in the new millennium. Soc Sci Med. 2000;51