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Persistent Poverty and Cancer: Increasing Health Equity across the Cancer Continuum

Image of brown and green rural land with text "85 percent of counties with persistent poverty are rural"

As many as 16.5 million people in the United States live in counties with persistent poverty—areas where more than 20% of the population has lived below the poverty level for the past 30 years. Recent research has shown that death rates from cancer in counties with persistent poverty are 12% higher than in other US counties and 7% higher than in counties with more recently developed poverty. Without effective interventions, persistent poverty will continue to exacerbate health disparities in cancer and other diseases. This effect on cancer disparities is a multigenerational, population-level problem that requires institutional-level solutions.

Many counties with persistent poverty are clustered in the southeastern United States.

Credit: United States Department of Agriculture
Persistent poverty is defined as 20% or more of a county’s population living below the established poverty level for the past 30 years.

NCI is supporting research into the multilevel and multifaceted nature of this problem. Those who live in persistent poverty areas are more likely to have greater exposure to cancer-causing and infectious agents, lack adequate housing, experience food scarcity and increased stress, and have poor access to transportation and health care. Adding to this complex situation, most persistent poverty areas have high concentrations of racial minorities who face additional burdens such as racism. NCI is funding research to understand how these factors intersect to affect cancer outcomes through cooperative agreement grants with those who live in persistent poverty areas, as well as through other funding mechanisms.

More research is needed to clarify the systemic causes of persistent poverty that lead to health disparities, and specifically the associations with higher rates of cancer death. Government agencies play a critical role in supporting these public health research programs. For example, NCI engages with other federal agencies, community members, and leaders to enable training and research opportunities that improve our understanding of health inequity's effect on cancer outcomes and to develop culturally appropriate interventions with communities in mind.

Peeling back cancer disparity’s many layers

Research suggests that living in low-resource neighborhoods has a significant negative impact on health outcomes. For example, living in neighborhoods with lower income, education, employment, and housing quality is linked to worse survival among people with nonmetastatic breast, prostate, lung, and colorectal cancer. Similarly, the prognosis for people with ovarian cancer worsens relative to how poorly their neighborhoods score in these categories. These findings from NCI-supported research point to the influence of neighborhood poverty levels on individual cancer outcomes. When persistent poverty is factored in, the statistics worsen further.

In a pivotal study on cancer outcomes and persistent poverty, NCI-funded researchers from the Pennsylvania State University and NCI found that Black residents living in rural counties with persistent poverty had the highest rates of cancer death in the United States. This finding highlights the joint contributions of persistent poverty, rural environment, and race on cancer mortality. More research is needed to develop multilevel interventions that address the intersecting factors affecting a patient’s risk of developing and dying from cancer.

Many more collaborative studies are needed. NCI plans to examine how persistent poverty impacts different populations, and this will require federal-level support to build trust in cancer research and evidence-based interventions within underserved communities. By identifying the traits that make populations in persistent poverty most vulnerable to high cancer death rates, we can begin to connect research findings with interventions and improve cancer outcomes for all patients.

Ending cancer disparities from persistent poverty through evidence-based decisions

The federal government plays an important role in collecting and storing cancer data for health equity research. The Surveillance, Epidemiology, and End Results (SEER) Program collects and publishes cancer incidence and survival data from population-based cancer registries in 19 US regions. This massive undertaking feeds other NCI-supported resources, such as the NCI Cancer Atlas, a free, interactive digital tool that allows users to access US cancer statistics by geographic area, race, gender, and cancer type. Our country’s resources are best spent on evidence-based interventions, and more funding is needed to turn data into decisions that decrease the risk of cancer death for people living in communities with persistent poverty.

With new computer technology, researchers can dive into these high-quality data sets to tease out associations between community traits and cancer outcomes. For example, NCI-funded researchers analyzed SEER data using artificial intelligence software to understand what characteristics are associated with a late-stage breast cancer diagnosis. Their findings point to disparities in diagnosis among southern and western states caused by a lack of health insurance, low screening rates, poor socioeconomic status, and rural settings. More research is needed to make evidence-based decisions on how best to use local intervention programs to reduce cancer disparities.

Federally supported research, data collection, maintenance, and analysis are critical for population and community interventions to improve cancer outcomes. We can envision using high-quality data sets that link cancer outcomes, geographic areas, community traits, behavioral data, and biological data to inform comprehensive cancer care strategies for patients in communities with persistent poverty.

Beyond the individual: Addressing cancer disparities at the structural level

We can no longer focus on addressing cancer prevention and treatment solely at the individual level. Doctors encourage patients to eat right, exercise, and get routine cancer screenings, but we also need to implement structural-level prevention, care, and survivorship strategies that reach beyond the individual, into institutions and communities. NCI is committed to retooling how we think about population-level cancer disparities and tackling their causes at the structural level.

Part of NCI’s efforts include supporting research programs that evaluate remote cancer care delivery to patients who live in rural communities with persistent poverty. For example, NCI-funded researchers at Vanderbilt-Ingram Cancer Center in Nashville, TN, are exploring telehealth-based interventions that give rural providers access to specialized expertise and that give their patients access to additional supportive care. Studies like this aim to identify potential strategies that can enhance the quality of cancer care delivery in areas of persistent poverty.

NCI has also provided funding to NCI-Designated Cancer Centers to conduct studies focused on building research capacity in impoverished areas. Researchers from Roswell Park Comprehensive Cancer Center are creating community–clinic partnerships as part of cancer disparity research programs built in impoverished, rural African-American counties in Arkansas. Additionally, researchers from Vanderbilt University Medical Center are using NCI support to build capacity and bring cancer research efforts directly to areas of persistent poverty in the South.

Through these studies, NCI is taking a community-based approach to build trust among populations that have traditionally been underserved. Greater investments, however, are needed to build this trust. NCI support will enable the research community to tailor their approaches and methodologies to this community-based, population-level challenge. From these efforts, we can imagine comprehensive cancer interventions that reach and are accepted by all communities, no matter the zip code. NCI is well suited to design and implement this more inclusive model of cancer care.

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