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Looking at cancer health disparities without 

the colored lenses 
Mohammad Aslam Khan1, Girijesh Kumar Patel1, Sanjeev Kumar Srivastava1,2, James Elliot Carter3, Jennifer 

Young Pierce4, Rodney Paul Rocconi4, Seema Singh1,5, Ajay Pratap Singh1,5* 

1Department of Oncologic Sciences, Mitchell Cancer Institute, University of South Alabama, Mobile, AL 

36604, USA; 2Division of Cell Biology and Genetics, Tatva Biosciences, Coastal Innovation Hub, 600 Clinic 

Drive, Mobile, AL, 36688, USA; 3Department of Pathology, College of medicine, University of South 

Alabama, Mobile, AL 36617, USA; 4Division of Gynecologic Oncology, Mitchell Cancer Institute, University 

of South Alabama, Mobile, AL, 36604, USA; 5Department of Biochemistry and Molecular Biology, College 

of Medicine, University of South Alabama, Mobile, AL 36688, USA 

*Corresponding author-mail: asingh@health.southalabama.edu 
 

ABSTRACT 
Cancer health disparities (CHDs), defined as the adverse differences in cancer incidence and mortality, 

are prevalent in certain racial and ethnic groups. Underlying causes of CHDs are multi-factorial and 

debatable. While low socioeconomic status, geographical location, lifestyle and behavioral factors are 

mostly believed to contribute to CHDs, regardless of ethnic and racial background, significant data 

now also exist to support a genetic basis of such disparities as well. Clearly, CHDs could best be 

understood by studying the interplay of multiple (genetic and non-genetic) factors and then translating 

the resulting knowledge into effective approaches for reducing the existing disparity gaps. This review 

article highlights these aspects in brief and calls the people of different expertise to work together to 

make an impact and tackle the challenges associated with CHDs. 

 

KEYWORDS: Cancer, health disparities, socioeconomic status, genetics, epigenetics, ancestry 

 

Citation: Khan M.A, et al (2019) Looking at cancer health disparities without the colored lenses. Cancer 

Health Disparities 3:e1-e9. doi:10.9777/chd.2019.1004.



 
 
 
 
 

 

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INTRODUCTION 

Cancer is the second most leading cause of deaths in 

the Unites States (US). American Cancer Society 

estimates that 1,735,350 new cancer cases will be 

reported and 609,640 lives will be taken by this 

devastating disease in 2018 (Siegel et al., 2018). As a 

result, besides being cause of pain and despair to 

the affected individuals and their families, cancer also 

remains a huge economic burden to the society. 

National Cancer Institute (NCI) reported that the total 

expenditures for the cancer care in the US was about 

$125 billion in 2010, and it could reach up to $156 

billion by 2020 (https://www.cancer.gov/about-

cancer/understanding/statistics). Moreover, federal 

agencies spend significant amount of money on 

cancer research to develop a better understanding 

of tumor biology at the molecular level and to find 

novel ways for its prevention and therapy. Several 

private foundations also provide funding support at 

the local and national levels for ground-breaking 

cancer research. Consequently, we have witnessed 

some decline in cancer-associated mortality since 

early 1990s for several tumor types; however, not 

every section of the society has benefitted equally 

(DeSantis et al., 2016; Deshmukh et al., 2017). 

Cancer health disparities (CHDs) are the most 

evident among certain racial and ethnic minorities 

living in America. National Cancer Act of 1971 

founded Surveillance, Epidemiology, and End Results 

(SEER) database within the National Cancer Institute 

(NCI) to track the progress in cancer care outcomes 

and to better analyze CHDs. NCI-SEER collects and 

maintains race and ethnicity information for all 

cancer types, which is helpful in analyzing the 

incidence, mortality and survival in different racial 

and ethnic groups such as African-American/Black, 

European-American/White, Asian/Pacific Islander, 

American Indian/Alaska Natives, and Hispanic/Latino 

(Polite et al., 2017)). The SEER data suggest that the 

people of some racial minorities are 

disproportionately affected by cancer in terms of 

incidence, mortality and co-morbidities associated 

with cancer. Considering these evidence, NCI and 

other funding agencies are investing in  CHDs 

research to tackle them at various levels.  

UNDERLYING CAUSES OF CANCER 

HEALTH DISPARITIES 

CHDs are multi-factorial. It is believed that various 

complex and interrelated factors are involved in 

disparate cancer incidence and clinical outcomes. 

These include differences in socioeconomic status 

(SES), geographical location, genetic predisposition, 

race, ethnicity, gender/sex identity, language barrier, 

food habits, cultural acuities, and access to health- 

care system (Polite et al., 2017; Raghavan, 2007; 

Winkleby et al., 1992).  

Socioeconomic factors: There is no doubt that SES 

determinants influence cancer risk globally and there 

is evidence to suggest that cancer mortality rates are 

declining at relatively slow rates in low SES 

individual/families as compared to those with higher 

SES (Ward et al., 2004). Residential segregation is an 

important SES factor associated with health 

disparities, and it is more prevalent among African 

Americans in the US as compared to other minorities 

(O'Keefe et al., 2015). For example, lung cancer 

mortality rate is very high in African American 

patients living in segregated neighborhoods 

(Hayanga et al., 2013). The residential segregation 

limits the access to better healthcare, recreational 

facilities and clean environment, which may all serve 

as risk factors for cancer development and/or 

enhanced mortality (Moore et al., 2008; O'Keefe et 

al., 2015; Williams, 1999). Several racial and ethnic 

minorities in the US live close to the industrial areas 



 
 
 
 
 

 

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or work in the agriculture fields wherein they expose 

themselves to pollutants, insecticides and pesticides, 

which potentially put them at a greater risk for 

developing cancer. Study suggests that Hispanics 

have high cumulative cancer risks (CCRs) due to their 

high exposure to hazardous air pollutants (HAPs) 

such as chloroform and benzene as compared to 

white people (Hun et al., 2009). The linkage of SES 

with CHDs is not limited to the people living in the 

United States. In fact, Australian women living in the 

remote or rural areas were also reported to have 

high rates of breast cancer death as compared to 

the residents of metropolitan cities (Yu et al., 2015). 

Similarly there is evidence for the high rates of 

advanced stage breast cancer in Australian and 

Pakistani women living in deprived regions (Aziz et 

al., 2008; Baade et al., 2011). Low SES groups, Maori 

and Pacific Island of New Zealand, are also reported 

to have greater cancer incidence and mortality as 

compared to European populations (Jeffreys et al., 

2005). 

Geographical factors: Cancer incidence and mortality 

rates vary among geographical locations. For 

example, the incidence of leukemia is greater in 

Australia and New Zealand, but reported least in 

Western Africa (Miranda-Filho et al., 2018). Similarly, 

mortality related to cervical cancer is three times 

higher in the Caribbean and Latin America as 

compared to North America (Melan et al., 2017). 

However, incidence and mortality related to this 

malignancy is less in many developed countries. 

Even within the United States, we see disparate 

incidence in cancer types and their clinical outcomes 

depending upon the geographical locations, which 

could be related to their exposure to certain 

pollutants and environmental conditions (Mahal et 

al., 2014; Miller et al., 2014; Zonderman et al., 2014). 

Ground water near superfund sites is highly 

contaminated in Florida and people living near those 

geographical locations have higher chances of 

developing cancer (Kirpich and Leary, 2017). Similarly, 

the incidence of lung, brain and bladder cancer is 

higher in areas with increased content of copper, 

arsenic and cadmium present in soil, respectively 

(Lopez-Abente et al., 2018). People living in Louisiana 

and Mississippi have high cadmium exposure and 

study have shown the correlation between high 

cadmium exposure and increased risk of pancreatic 

cancer (Luckett et al., 2012). Drinking water is 

significantly contaminated with arsenic in New 

Hampshire and Wisconsin regions and retrospective 

studies suggested the link between arsenic exposure 

and skin cancer (Mayer and Goldman, 2016).  

Life style and other behavioral factors: It is observed 

that the highest incidence of gastric cancer is in the 

Eastern Asian and South American countries. 

Helicobacter pylori infection is shown to put people 

at six fold higher risk of developing gastric cancer 

(Giesecke, 1993). An earlier study suggested a close 

association of diet and H. pylori infection in gastric 

cancer. Consumption of high salt and fermented 

foods is also associated with H. pylori infection 

(Rocco and Nardone, 2007). This suggests that life 

style factors and food habits could be responsible for 

existing disparities in gastric cancer (Luo et al., 2017). 

High rates of hepatitis B and C infection and aflatoxin 

exposure through diet lead to higher incidence of 

hepatocellular cancer in the region of sub-Sahara 

Africa and China. Hepatitis B and C virus infection are 

associated with chronic liver disease, and these viral 

infections are more prevalent in many low income 

countries due to lack of knowledge about the route 

of transmission, awareness and some tribal rituals 

(Coppola et al., 2015). In the US, hepatitis, which is 

more common in Latino and Asian immigrants, is an 

established risk factor for hepatocellular cancer 

development (Jemal et al., 2010). Prostate, breast and 

pancreatic malignancies are linked with obesity and 



 
 
 
 
 

 

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are more common in North America, Australia/New 

Zealand, and Europe as compared to the developing 

countries. In fact, looking at the yearly trends, we 

notice that the incidence rates of breast and prostate 

cancer have started to increase in people of Asia and 

Africa continents, which could be due to changes in 

their life style, diet and reproductive behavior-

associated factors in addition to increases in the 

reporting and awareness (Wallace et al., 2011). 

Gender and sexual orientation: High numbers of 

non-sex specific cancer cases and cancer-associated 

deaths have been reported in males as compared to 

females (Dorak and Karpuzoglu, 2012; Najari et al., 

2013). Certain types of malignancies like brain cancer 

(meningioma), thyroid cancer and bladder cancer 

are more common in women as compared to men 

and this could be due to the differences in sex 

hormones and prevalence of autoimmune disorders 

and gallbladder stone-induced chronic inflammation 

among them (Dorak and Karpuzoglu, 2012). In the 

US, sexual and gender minorities (SGM) have greater 

chance of developing cancer as compared to 

heterosexual people. A recent study suggests that 

people from sexual minorities avoid social 

gatherings, living in isolated places and more likely to 

be poor than heterosexual (McCabe et al., 2018). 

Approximately 30% of SGM do not take advantage 

of preventative healthcare services due to the lack of 

insurance or undercoverage for related mental 

health, gender affirmation surgery, hormone 

therapy, and coverage to partners (Quinn et al., 

2015). In fact, a majority of SGM members do not 

disclose their sexual orientation due to the fear of 

discrimination and social stigma (Brown and McElroy, 

2018). Collectively, all these factors contribute to the 

increasing cancer incidence in SGM relative to 

heterosexuals. Moreover in the US, many health-

related surveillance registries do not have sexual 

orientation and gender identity (SOGI) questions, 

which may lead to ignorance of many health co-

morbidities including cancer in SGM people (Brown 

and McElroy, 2018; Obedin-Maliver, 2017).  

Genetics and epigenetic factors: Gene mutations, 

deletion, amplification, and polymorphism in key 

growth homeostasis genes are considered the 

underlying causes of cancer etiology, progression 

and poor clinical outcomes. Although socio-

economic, life style and other factors were long 

believed to be the major determinants of CHDs, 

emerging data now also clearly suggest that there 

could be a genetic and/or epigenetic basis as well 

(Deshmukh et al., 2017). High frequencies of triple 

negative breast cancer and intra-tumor genetic 

heterogeneity are tied with aggressive variant of 

disease in African American women (Keenan et al., 

2015). Deregulation of immune system due to 

polymorphisms in IL-6 and IFN-γ gene has also been 

reported in African American women (Park and 

Kang, 2013). Increased serum levels of pro-

inflammatory cytokines, IL-6 and resistin, have also 

been associated with breast cancer disparity 

(Deshmukh et al., 2015). In another study, difference 

in the haplotype, PTEN/10q, is associated with 

disparate incidence and outcome of endometrial 

cancer in African American and Caucasian American 

women (Sutton et al., 2015). Prostate cancer burden 

is quite high in African American people and several 

mutations and polymorphism in genes associated 

with androgen biosynthesis, metabolism and 

androgen receptor signaling has been reported in 

this group (Bhardwaj et al., 2017). Another study 

identified locus 8q24 as a risk factor for prostate 

cancer in African American men (Freedman et al., 

2006; Wallace et al., 2011). Mutations and 

amplification of phosphatidylinositol 3-kinase 

catalytic subunit alpha (PI3KCA) gene has been 

reported in cervical cancer. PI3KCA mutations and 

amplification rate found to be higher in American 



 
 
 
 
 

 

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Indian population (Femi, 2018). Higher rate of 

alterations in mitochondrial genes of African lineage 

is also linked with cancer predisposition and 

disparities (Choudhury and Singh, 2017). Apart from 

genetic factors, epigenetic determinants are also 

suggested to be involved in CHDs. High 

hypermethylated CpG islands are associated with cell 

signaling, survival, cellular communication and cell 

death, in normal breast tissues of African American 

women as compared to their Caucasian 

counterparts. Promoters of many genes tied with 

epithelial-to-mesenchymal transition  (EMT) and cell 

cycle are found to be hypermethylated in African 

American breast cancer patients (Ahmad et al., 2017). 

Differential methylation pattern of CD44 gene may 

also be involved in the prostate cancer pathogenesis 

in African American cancer patients (Woodson et al., 

2003).  

Considering these data, it has become imperative 

that we pay attention how we categories patients 

into different racial groups. Currently, people living in 

the United States are categorized into different racial 

and ethnic groups primarily based on their self-

reporting. This could be problematic considering the 

fact that inter-racial marriages are common and 

more so in modern times leading to the genetic 

admixtures rather than defined racial/ethnic 

identities. Indeed, genetic analyses have suggested 

that some of the self-reported African Americans 

have up to 99% of European ancestry(Mersha and 

Abebe, 2015). In the US, Hispanics are highly diverse 

population and study suggest that self-reported 

Hispanic individual could be more close to being of 

African, European, or Native American lineage due 

to population admixtures (Lee et al., 2010). To 

overcome these artifacts, we should rely on genetic 

ancestry profiling by using advanced molecular 

techniques such as single nucleotide polymorphisms 

(SNPs) and short tandem repeat (STR) typing. In 

addition, haploid markers like Y-SNPs and 

mitochondrial DNA can also be used for 

determination of paternal and maternal lineage 

(Egeland et al., 2004; Phillips et al., 2007). Some of 

our recent studies took advantage of modern 

genomic technologies to classify patients based on 

their racial genetic admixtures and noticed that 

categorization of patients based on their racial 

genetic admixtures provided more accurate 

determination of clinical outcomes (Rocconi et al., 

2016; Ross et al., 2017).  

EMERGING OUTLOOK 

Years of money and manpower investment in cancer 

research has resulted in effective screening 

approaches and therapies for several cancers leading 

to considerable improvements in patient’s survival. 

Although not all sections of the society have 

benefitted equally, we have succeeded in 

recognizing such health inequalities and have 

developed an improved understanding of underlying 

causes. We have learnt that differences in SES, life 

style, and geographical location impact cancer 

incidence and mortality rates regardless of race and 

ethnic identities. Moreover, gender-based 

inequalities are also common that could in part be 

associated with life style factors, but may also have a 

biological basis as well. In addition, many new 

findings have also suggested certain races and ethnic 

groups experience greater incidence and mortality of 

cancer even when SES and other factors are 

accounted for. In support of such observations, 

several genetic and epigenetic differences in people 

belonging to these minority groups have also been 

reported. Therefore, while the skin color and 

ethnicity may not be the primary determinant of 

CHDs, there is strong evidence to suggest a genetic 

basis as well. In fact, the emerging notion now is that 

it is the interplay of multiple (genetic and non-



 
 
 
 
 

 

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genetic) factors that underlies the prevalent CHDs 

(Figure 1). Therefore, finding these connections at the 

molecular levels and translating the resulting 

knowledge into effective approaches for prevention 

and clinical management are of utmost importance 

to reduce existing disparity gaps. In addition, 

currently, the race and ethnicity classification is based 

on self-reporting, which could be socio-political or 

cultural rather than being based on genetics and 

biology of the individual (Rebbeck and Sankar, 2005; 

Wallace et al., 2011). Therefore, it is important to 

include genetic screening in categorizing race and 

ethnicity of the participant groups to avoid any 

artifacts. It is also the need of the hour that people of 

different expertise (public health professional, 

physical scientists, biologists, social scientist, 

epidemiologists, and community members) work 

together to make an impact. More research funding 

opportunities emphasizing minority health 

disparities, commitment of research centers and 

hospitals and improvisation of research policies will 

also be helpful in addressing the challenges 

associated with CHDs. 

 

 

Figure 1: Schematic diagram showing cross-talk between biological and non-biological factors involved in 

cancer health disparities (CHDs). 

Acknowledgements 



 
 
 
 
 

 

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The authors acknowledge the funding support from 

NIH/NCI CA17577204 (to APS) and CA204801 (to SS) 

and USAMCI. 

Conflict of interest 
APS and SS are co-founders and serve on executive 

management team of Tatva Biosciences, LLC, which 

is involved in the development of tools and models 

for cancer health disparity research. SKS is the 

Director of Cell Biology and Genetics at Tatva 

Biosciences LLC. 

Authors’ contributions 
Conception and design: MAK, GKP, SKS, SS and APS. 

Writing, review, and revision of the manuscript: MAK, 

GKP, SKS, JEC, JYP, RPR SS and APS.  

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