Search

PURPOSE: Disparities in the treatment of cardiovascular disease, diabetes mellitus, and cancer among the sexes and racial groups and possible interventions are discussed. SUMMARY: The ongoing process to identify and reduce health disparities has engaged numerous federal agencies as they monitor the nation's progress toward policy-driven and health-related objectives. Cardiovascular disease disproportionately affects minority groups and is the leading cause of death among women in the United States, and both groups receive suboptimal care for the disease. Disparities in the treatment of diabetes mellitus in African Americans, women, patients with less than a high school education, and the elderly have been found. Many minority groups continue to suffer disproportionately from cancer. Racial disparities also exist in cancer screening and treatment. Minorities are underrepresented in clinical trials for multiple reasons, many of which may be related to cultural beliefs. At all levels of coinsurance, the poor are less likely to seek preventive care. Adherence to national screening and treatment guidelines, clinical trial recruitment and participation, addressing language and geographic barriers, and increasing access to insurance are part of the coordinated efforts required to reduce health disparities. Because pharmacists influence patients' health status directly through pharmaceutical care and indirectly by engaging patients in their treatment, it is essential for pharmacists to be able to provide culturally competent care. CONCLUSION: Despite significant efforts over the past several years, health disparities continue to exist, particularly among minority groups. Interventions aimed at eliminating these disparities should include ensuring cultural competence among health care providers and improving health literacy among patients. [ABSTRACT FROM AUTHOR]

Among the consequences of systemic racism in health care are significant health disparities among Black/African American individuals with comorbid physical and mental health conditions. Despite decades of studies acknowledging health disparities based on race, significant change has not occurred. There are shockingly few evidence-based antiracism interventions. New paradigms are needed to intervene on, and not just document, racism in health care systems. We are developing a transformative paradigm for new antiracism interventions for primary care settings that integrate mental and physical health care. The paradigm is the first of its kind to integrate community-based participatory research and systems science, within an established model of early phase translation to rigorously define new antiracism interventions. This protocol will use a novel application of systems sciences by combining the qualitative systems sciences methods (group model building; GMB) with quantitative methods (simulation modeling) to develop a comprehensive and community-engaged view of both the drivers of racism and the potential impact of antiracism interventions. Community participants from two integrated primary health care systems will engage in group GMB workshops with researchers to 1) Describe and map the complex dynamic systems driving racism in health care practices, 2) Identify leverage points for disruptive antiracism interventions, policies and practices, and 3) Review and prioritize a list of possible intervention strategies. Advisory committees will provide feedback on the design of GMB procedures, screen potential intervention components for impact, feasibility, and acceptability, and identify gaps for further exploration. Simulation models will be generated based on contextual factors and provider/patient characteristics. Using Item Response Theory, we will initiate the process of developing core measures for assessing the effectiveness of interventions at the organizational-systems and provider levels to be tested under a variety of conditions. While we focus on Black/African Americans, we hope that the resulting transformative paradigm can be applied to improve health equity among other marginalized groups., Competing Interests: The authors have no competing interests., (Copyright: © 2024 Naar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The Transdisciplinary Collaborative Center (TCC) in Precision Medicine for Minority Men's Health was established at the Medical University of South Carolina (MUSC) in 2015 to address disparities in the translation of precision medicine approaches among racial minority groups. This regional consortium focuses on three primary areas: (1) the development of a consortium of regional and national partners, (2) conducting transdisciplinary research examining synergistic effects of biological, social, physiological, and clinical determinants of chronic disease risks and outcomes, and (3) dissemination and implementation of precision medicine approaches, with an emphasis on reducing disparities in health care and outcomes among minority men. Given consistent calls to better translate precision medicine approaches and the focus of this consortium on addressing disparities among minority men, we provide an overview of our experience in developing the MUSC TCC, including barriers and facilitators to conducting translational research on minority men's health issues in the context of precision medicine. Lessons learned and areas for improvement include providing enough time to create consistent partnerships and community engagement to improve recruitment and retention, identifying unique ways to engage diverse partners from across the region and nation, and better approaches to dissemination and communication for large partnerships focusing on precision medicine.

The Patient Protection and Affordable Care Act focuses on improving consumer engagement and patient-centered care. This article describes the design and rationale of a study targeting family engagement in pediatric mental health services. The study is a 90-day randomized trial of a telephone-delivered Family Navigator services versus usual care for parents of Medicaid-insured youth younger than 13 years with serious mental illness. Youth are identified through a pediatric antipsychotic medication preauthorization program. Family Navigators offer peer support to empower and engage parents in their child's recovery. Outcomes include parent report of empowerment, social support, satisfaction with child mental health services, and child functioning as well as claims-based measures of psychotherapy service utilization and antipsychotic medication dosage. The focus on "family-centered" care in this study is strongly supported by the active role of consumers in study design and implementation.

Background: We describe reach, partnerships, products, benefits, and lessons learned of the 25 Community Network Programs (CNPs) that applied community-based participatory research (CBPR) to reduce cancer health disparities., Methods: Quantitative and qualitative data were abstracted from CNP final reports. Qualitative data were grouped by theme., Results: Together, the 25 CNPs worked with more than 2,000 academic, clinical, community, government, faith-based, and other partners. They completed 211 needs assessments, leveraged funds for 328 research and service projects, trained 719 new investigators, educated almost 55,000 community members, and published 991 articles. Qualitative data illustrated how use of CBPR improved research methods and participation; improved knowledge, interventions, and outcomes; and built community capacity. Lessons learned related to the need for time to nurture partnerships and the need to attend to community demand for sustained improvements in cancer services., Implications: Findings demonstrate the value of government-supported, community-academic, CBPR partnerships in cancer prevention and control research.

Genetic testing for inheritable cancer syndromes is becoming a critical part of preventive health services. The Patient Protection and Affordable Care Act (PPACA) Essential Health Benefits package addresses breast cancer susceptibility-gene testing for women who are unaffected by cancer. The absence of provisions for 1) men, 2) cancer patients, 3) other inheritable cancer syndromes, and 4) risk-reducing interventions are limitations of PPACA. We discuss provisions and limitations of PPACA pertaining to genetic testing and effects on high-risk populations, in particular minorities. The PPACA is the beginning of an ongoing process of incorporating genetic testing in the armamentarium of cancer prevention. Future efforts should focus on ensuring equitable access to genetic testing as a preventive service under PPACA to high-risk populations other than women. Consideration should also be given to provisions for risk-reducing interventions, especially in underserved minority populations, who are known to underutilize genetic testing and may have limited financial resources for medical intervention.

In August 2012 the University of Maryland School of Medicine will start a new Primary Care Track for incoming first year medical students as a collaborative program of the departments of Family and Community Medicine, Internal Medicine, and Pediatrics. Its focus will be to introduce all students to primary care role models early in medical school, and to offer a longitudinal experience in primary care in rural and urban underserved communities to interested students, with the intention of increasing the number of UMD medical students who choose primary care careers in these communities.

Cyclooxygenase-2 is frequently overexpressed and associated with poor prognosis in breast cancer. The cyclooxygenase-2 product prostaglandin E(2) elicits cellular responses through four G-protein-coupled receptors, designated EP1 to EP4, coupled to distinct intracellular signaling pathways. EP4, expressed on malignant breast cells, promotes metastasis; however, a role for EP1 in metastasis has not been investigated. Using a murine model of metastatic breast cancer, we now show that pharmacologic antagonism of EP1 with SC19220 or AH6809 promoted lung colonization of mammary tumor cells by 3.7- to 5.4-fold. Likewise, reducing EP1 gene expression by shRNA also increased metastatic capacity relative to cells transfected with nonsilencing vector but did not affect the size of transplanted tumors. Examination of invasive ductal carcinomas by immunohistochemistry shows that EP1 was detected in both the cytoplasm and nucleus of benign ducts as well as malignant cells in some samples, but was absent or limited to either the nucleus or cytoplasm in other malignant samples. Overall survival for women with tumors that were negative for nuclear EP1 was significantly worse than for women with EP1 expression (P = 0.008). There was no difference in survival for women with differences in cytoplasmic EP1 expression (P = 0.46). Comparing EP1 mRNA in breast tumors from African American and European American women revealed that many more African American breast tumors lacked detectable EP1 mRNA (P = 0.04). These studies support the hypothesis that EP1 functions as a metastasis suppressor and that loss of nuclear EP1 is associated with poorer overall survival and may contribute to disparities in outcome in different populations.

Background: Renal dysfunction in non-renal transplantation is a major arbiter of poor late allograft outcomes. Tobacco recidivism is an important modifiable risk marker for cardiac allograft loss, but its effects on renal dysfunction remain poorly studied., Methods: In a 96-well plate, 10(-5) proximal tubular epithelial (PTE) cells (HK-2, American Type Culture Collection) were cultured overnight and treated with sirolimus (SRL; 100 nmol/liter), nicotine (N; 10(-7) mol/liter) and mycophenolate mofetil (MMF; 10 micromol/liter), alone or in combination for 24 hours. Cell viability was quantified by treatment with tetrazolium salt WST-1 and calculated as the difference in percent inhibition with respect to the optical densitometry (OD) of treated and untreated cells. Gene and protein expression was analyzed using real-time polymerase chain reaction and Western blot techniques., Results: OD decreased with SRL (-52.7 +/- 2.85%), N (-47.3 +/- 3.84%) and MMF (-53.3 +/- 2.4%) in isolation. Further reduction in OD occurred when N was combined with SRL (-63 +/- 2.3%, p < 0.04), MMF (-64.3 +/- 1.45%, p < 0.02) or the combination of SRL and MMF (-78.2%, p < 0.007). Compared with control, treatment of PTE cells with N increased mRNA expression of transforming growth factor-beta (TGF-beta; 10-fold), connective tissue growth factor (CTGF; 25-fold), osteopontin (OPN; 10-fold) and NADPH oxidase components (p22(phox), NOX-1 and Rac-1 at 18-, 16- and 12-fold, respectively). The pre-treatment of cells with inhibitor of superoxide generator diphenylene iodonium (DPI) reversed these effects., Conclusions: Nicotine adversely amplified the effects of SRL and MMF on tissue repair and oxidative stress markers, subsequently modulating PTE viability. However, caution is advised in extrapolating these in vitro findings to the human model.

Human papillomavirus (HPV) detection is an integral part of cervical cancer screening, and a range of specimen collection procedures are being tested. Preliminary studies have found that the majority of women prefer self-collection of vaginal specimens instead of clinician-collected specimens of the cervix. The purposes of the current study were to explore the social and behavioral predictors of acceptance of self-collection of vaginal specimens among patients and to assess concordance in detection of HPV between clinician-collected cervical specimens and self-collected vaginal specimens. The study was conducted at a university family medicine clinic using a cross-sectional study design, and enrollment of women presenting for routine gynecological examination consecutively in a period of 1 year, self-administered questionnaires, collection of paired vaginal and cervical specimens for HPV DNA using Hybrid Capture 2, and cytologic analysis. Most women (79.8% [398/499]) agreed to collect vaginal specimens. In our study, 76.6% (216/282) African American women (AA), 88.1% (156/176) white non-Hispanic (WNH) women, and 63.4% (26/41) women of other races (P < 0.0001) agreed to self-collect vaginal specimens. HPV was detected in 16.0% (80/499) of clinician-collected cervical specimens and 26.1% (104/398) of self-collected vaginal specimens (P < 0.001). HPV detection was concordant in 13.4% (53/398) women in both cervical and vaginal specimens. Self-collection of vaginal specimens for HPV DNA detection is acceptable to most women presenting for routine gynecological examination. WNH women were more likely to obtain self-collected specimens than AA women. Vaginal specimens were more likely to be positive for HPV than were cervical specimens.

Background: Cancer is the second leading cause of death in the United States and a major contributor to healthcare expenditure. There are few studies examining disparities in treatment costs. Studies that do exist are dominated by the cost of hospital care., Methods: Utilizing Maryland Medicaid administrative claims data, a retrospective cohort, design was employed to examine disparities in ambulatory treatment costs of breast, colorectal and prostate cancer treatment by region, race and gender. We report mean and median results by each demographic category and test for the statistical significance of each. Lorenz curves are plotted and Gini coefficients calculated for each type of cancer., Results: We do not find a consistent trend in ambulatory costs across the three cancers by traditional demographic variables. Lorenz curves indicate highly unequal distributions of costs. Gini coefficients are 0.687 for breast cancer, 0.757 for colorectal cancer and 0.774 for prostate cancer., Conclusion: Significant variation in nonhospital-based expenditures exists for breast, colorectal and prostate cancers in a population of homogeneous socioeconomic status and uniform insurance entitlement. Observed individual-level disparities are not consistent across cancers by region, race or gender, but the majority of this low-income population receives very little ambulatory care.

To discover a biological basis for clinical subgroupings within breast cancers, we applied principal components (PCs) analysis to cDNA microarray data from 36 breast cancers. We correlated the resulting PCs with clinical features. The 35 PCs discovered were ranked in order of their impact on gene expression patterns. Interestingly, PC 7 identified a unique subgroup consisting of estrogen receptor (ER); (+) African-American patients. This group exhibited global molecular phenotypes significantly different from both ER (-) African-American women and ER (+) or ER (-) Caucasian women (P < 0.001). Additional significant PCs included PC 4, correlating with lymph node metastasis (P = 0.04), and PC 10, with tumor stage (stage 2 versus stage 3; P = 0.007). These results provide a molecular phenotypic basis for the existence of a biologically unique subgroup comprising ER (+) breast cancers from African-American patients. Moreover, these findings illustrate the potential of PCs analysis to detect molecular phenotypic bases for relevant clinical or biological features of human tumors in general.

Objective: The aim of this study was to evaluate the association of age, race, and comorbid illness with procedures and complications in hospitalized patients with invasive carcinoma of the cervix in a statewide population-based database over a 3-year period., Methods: Hospitalizations were classified into homogeneous subgroups based on a diagnosis of invasive cervical cancer. Cancer-related complications and comorbid diseases were evaluated. chi(2) and t tests determined differences in means or proportions. Linear regression techniques were applied to build models for hospitalization charges and lengths of stay (LOS)., Results: There were 1009 admissions. The mean age was 49.5, with a median age of 46 (21-100, SD 15.4). Of the total, 606/1009 (60%) were white, 354/1009 (35%) were African-American (AA), and 5% were "other" races. AAs were more likely to have Medicaid or be uninsured (44% vs 23%, P = 0. 001) and were more likely to be admitted for an emergency (unadjusted odds ratio (OR) = 1.6; 1.2-2.2), to have a comorbid illness (P = 0.001), to be admitted for a cancer-related complication (P = 0.036), to be admitted for a transfusion (P = 0. 01), and to be admitted for radiation therapy rather than surgery (P = 0.001). The following were associated with LOS and higher hospital costs: emergency admissions for complications of cancer, comorbid illness, and older age., Conclusions: Racial differences exist in patterns of admission, type of therapy, and severity of illness; however, there were no differences in charges or LOS for similar procedures. The large percentage of African-Americans uninsured or insured by government-supported programs indicates the potential impact of public policy on the care of these patients. Socioeconomic status rather than phenotypic appearance may be a more important determinant of outcome., (Copyright 2000 Academic Press.)

Breast carcinoma is the most common cancer in women in the U.S. and the second leading cause of cancer death in women. Furthermore, there are racial differences in breast carcinoma incidence, mortality, and survival rates. Social and economic factors within racial/ethnic groups are being examined as risk factors not only for breast carcinoma mortality and survival but also as determinants of the rate of incidence. Social and economic factors have been associated in the literature predominantly with cancer mortality and survival. When socioeconomic status (SES) is considered, certain studies suggest that racial disparities in breast carcinoma are smaller than when social and economic factors are examined alone, but these disparities still persist. Sources of data for this discussion include the National Cancer Institute (NCI) (the Surveillance, Epidemiology, and End Results [SEER] program, a group of population-based cancer registries that cover up to 14% of the U.S. population. SEER reports cancer incidence, mortality, and survival rates), the U.S. Bureau of the Census, the National Center for Health Statistics (NCHS), and numerous articles from the scientific literature. Socioeconomic factors or SES can be considered "cross-cutting risk factors" (i.e., they can be related to the risk of developing breast carcinoma [rate of incidence] as well as to the risk of dying [mortality] from this disease). They also are the risk factors that "cut across" racial and ethnic populations. Socioeconomic factors are related to breast carcinoma mortality and survival rates in multicultural women. Racial disparities in breast carcinoma mortality and survival rates can be explained partially by stage distribution at the time of diagnosis, which may be related to SES. For example, African-American women present with more advanced stage distributions for breast carcinoma than white women. Similarly, women of lower SES present with higher stage disease than women of upper SES who present with more localized breast carcinoma. The lack of data regarding the SES of cancer patients limits our understanding of the contributions of SES to cancer incidence and mortality rates. SES appears to be related to breast carcinoma incidence, mortality, and survival rates. Breast carcinoma mortality is higher in women of lower SES. Additional research on SES, race, culture, and the relation of these factors to cancer incidence rate is needed., (Copyright 2000 American Cancer Society.)

This study evaluated the association of race, comorbid illness, insurance status, and other prognostic factors on treatment and survival of patients with invasive carcinoma of the cervix, using as its methodology a retrospective study of patients with invasive carcinoma of the cervix treated from 1991 to 1998 at the University of Maryland. Of 161 such patients, 153 met the study criteria. Of these 153 women, 83 (54%) were African Americans and 70 (46%) were white. The mean (+/- SE) age of African American women was 52 +/- 1.8 years and that of white women was 50 +/- 1.8 years. African American women were more likely to present with stages II-IV disease (P = 0.01) and, as a consequence, underwent radiation therapy rather than surgery (P = 0.04). The survival of African American women with stage I-II disease was significantly lower than for white women. In the final regression model, stage III-IV disease (hazard ratio 3.2, 95% (CI 1.7, 6.1) African American race, (hazard ratio 1.9; 95% CI 1.0, 3.3) and comorbid illnesses (hazard ratio 2.3; 95% CI 1.3-4.0) were associated with poor survival. Adverse outcomes of African American women with cervical cancer persist after adjustment for stage of disease and other factors and are particularly apparent in stage I-II disease. The role of comorbid illness is deserving of further study.

Colorectal cancer is the second leading cause of cancer death in the United States. In 1997, more than 131,000 new cases and more than 54,000 deaths were estimated. Racial and ethnic disparities in incidence, mortality and survival rates, and trends exist for this disease. Differences in colorectal cancer screening, early detection, and treatment in minority communities are related to therapeutic outcomes. Age-adjusted incidence rates for men with colorectal cancer are highest for Alaskan native men, followed by Japanese, then African-American men. For women, the incidence is highest for Alaskan native women, followed by African-American, then Japanese women. Mortality rates in men are highest for African Americans, followed by Alaskan natives and then Hawaiians. In women, mortality rates are highest for Alaskan natives, then African Americans and whites. Colorectal cancer screening rates vary by race, income, and education. It is interesting that, when compared with whites, African-American men demonstrate the higher reported rate of screening for this disease. In addition, site specificity is different for African Americans compared with whites. Findings also reveal that stage at diagnosis is an influential factor with regard to mortality and survival. This may be related in part to socioeconomic factors, differences in anatomic site, and treatment differences in African Americans. Risk factor data for this disease are scarce for minority populations. Documented differences in colorectal cancer incidence, mortality, and survival rates exist between minorities and whites. Additional research is needed on risk factors specific to African Americans and other minorities, differences in treatment, and the role of socioeconomic status.

Greater attention has been given recently to information technology and telecommunication reforms and their use for the improvement of health care service delivery. Broadly defined, telemedicine is the use of advanced telecommunications technologies for the purposes of making diagnoses, conducting research, transferring patient data, and/or improving disease management and treatment in remote areas. The emphasis is on use of telecommunications technologies at remote sites. This article provides a brief overview of telemedicine, its potential clinical applications, and the various benefits and leading issues surrounding it. It also describes selected telemedicine projects conducted at the University of Maryland School of Medicine in Baltimore.

Background: The National Cancer Institute developed population-specific programs to better understand cancer as it occurs within underserved populations such as American Indians, Alaska Natives, Native Hawaiians, and American Samoans., Methods: The data for American Samoans are derived from regional studies and from data collected from the Hawaii Surveillance, Epidemiology, and End Results (SEER) Registry. Native Hawaiian data are from the Hawaii SEER program and are limited to Native Hawaiians who live in that state. Alaska Native data are from the Lanier and Knutson 15-year summary of Alaska Native cancer data. American Indian data are from the New Mexico SEER program, which is generalizable to natives living in Arizona and New Mexico only and is relatively free of racial misclassification errors., Results: An overview of age-adjusted cancer incidence and mortality rates among American Indians, Alaska Natives, Native Hawaiians, African Americans, and whites for 1977-1983 is provided. Five-year relative survival rates from cancer are from 1975-1984. Relative survival rates are provided for American Indians, Native Hawaiians, African Americans, and whites., Conclusions: Based on the limited data available, divergent cancer patterns appear to be present in these Native American populations. Alaska Natives and Native Hawaiians consistently display elevated rates that are frequently camouflaged when data are collapsed into "other" racial categories.

Although the United States spends more on health care than any country in the world, access to that care is becoming increasingly difficult. The National Cancer Institute and other federal agencies are sponsoring innovative research for delivering effective medical services, particularly to underserved populations. Models of successful collaboration between private and public sectors concerned with health care can be adapted and implemented at the national, state, and local levels. However, other measures are needed to ensure access to adequate health care for all Americans. Minimal but effective regulations are needed to ensure quality control, reduce duplication of services, and minimize cost increases. Public and private sectors also need to consider ways to extend adequate health insurance coverage to all Americans and to provide compensation for preventive services.

The burden of cancer on the U.S. black population has been compounded by a high prevalence of smoking among blacks. Lung cancer among blacks is a serious public health problem, with a mortality rate of 119 per 100,000 among black males compared to 81 per 100,000 for white males. Blacks, both male and female, have lower quit rates for smoking than does the general U.S. population. Why more blacks than whites continue to smoke is not clear, but the National Cancer Institute has recently funded several research projects to facilitate smoking cessation among blacks. It appears from preliminary findings that smoking cessation efforts among blacks are most successful if they use broadcast media that reach black audiences, if they tailor their print materials to address the needs of black smokers, and if black community networks are utilized.

Findings from previous studies suggest that differences in socioeconomic status may be responsible for some, if not all, of the elevated incidence of cancer among blacks as compared with whites. Using incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program, we tested this hypothesis by correlating black and white cancer incidence rates in three US metropolitan areas between 1978 and 1982 with data from the 1980 census on socioeconomic status within individual census tracts. The study analyzed data on the incidence of cancer at all sites combined (greater than 100 cancer sites) and at seven major sites separately. As in other studies, income and educational levels served as surrogates for socioeconomic status. The present study also used census-tract data on population density as a surrogate factor. Each of these measures of socioeconomic status was analyzed independently. Before correlation with census-tract data, age-adjusted data on cancer incidence showed statistically significant elevated risks among blacks for cancer at all sites combined and at four of the seven separate sites; whites showed an elevated risk for cancer at two sites. Cancer at only one site, the colon, showed no significant association with race. When age-adjusted incidence data were correlated with socioeconomic status, the comparative black-white risks changed: Whites showed an elevated risk of cancer at all sites combined and at three of the seven separate sites; blacks maintained their elevated risk at three sites. These findings suggest that the disproportionate distribution of blacks at lower socioeconomic levels accounts for much of the excess cancer burden among blacks. They also suggest that for both blacks and whites unidentified racial factors, which may be either cultural or genetic and which are not closely linked to socioeconomic status, may play a role in the incidence of some cancers.

About 35% (10-70%) of all cancers may be associated with nutritional causes (1). However, while natural or added substances in foods may be carcinogenic, nutritional deficiencies or excesses may promote carcinogenesis. We compared data from blacks and whites using dietary and nutritional status surveys in the United States to determine whether the poorer dietary patterns and nutritional status of American blacks may be associated with their higher incidence and mortality from certain cancers (compared with whites). Our review indicates that blacks eat more nitrate and animal foods and not enough fiber in relation to protein, fat, and carbohydrate. Blacks also have poorer nutritional status with respect to getting enough thiamine, riboflavin, vitamins A and C, and iron, to being obese (females), and to being underweight (males). This is in agreement with hypotheses regarding the interactions between diet and cancer (associations found in whites) and dose-response relationships reported for some cancers for which blacks have a higher incidence and mortality than whites. More large-scale prospective case-control and cohort studies are needed in both blacks and whites to elucidate the contribution of specific dietary and nutritional factors to the risk of specific cancers in these population groups. However, such studies must be preceded by methodological research to obtain more valid measures of dietary and nutritional status.

Emergence of cervical cancer as a public health problem is largely a twentieth-century phenomenon; although primary prevention remains elusive, secondary prevention--through use of Pap smears--has markedly reduced mortality. Yet, major differences persist in both incidence and mortality between black and white women. The "routine" policies of identifying age groups, timing, and sites for Pap testing will have to yield to more targeted approaches. Both providers and individuals at risk have challenges and responsibilities.