attempt to distinguish between what may be more useful for addressing different types of cancer. For background, the committee reviewed documents provided by NIH, primarily from NCI (these documents are listed in Appendix E). The committee also directed specific questions to NCI and reviewed related research literature.

The remainder of this chapter comprises that report, which is divided into three sections. The first section reviews pertinent research literature. The second section describes examples of dissemination practices by NCI and racial and ethnic patterns of use of the Cancer Information Service (CIS). The third section concludes with recommendations by the committee.

Related Literature on Ethnic Minority and Medically Underserved Populations

The committee's review of the literature reveals that historically, federal, state, and local public health officials have failed to establish specific programs, guidelines, or initiatives to improve health service delivery for minority and medically underserved populations. Significantly, the literature also consistently reveals that ethnic minority and medically underserved individuals are more likely to receive less appropriate or less aggressive treatment for cancer once in the health care system, a fact that may contribute to disparities in cancer survival and mortality.

Studies of disparities in health service delivery indicate that ethnic minority patients, especially African Americans, are less likely to receive appropriate screening, diagnostic, and treatment services for cancer. Some evidence suggests that while "race" and income both predict differences in clinical treatment, "race" may serve as the "overriding determinant of disparities in care" (Geiger, 1996, p. 816). Many such studies have controlled for age, gender, insurance status, income, disease severity, concomitant morbid conditions, and underlying incidence and prevalence rates in the population groups under study. For example, Gornick et al., (1996), in a study of health service delivery to a multiethnic population of Medicare beneficiaries, found that African-American patients were less likely than whites to receive mammography. This difference was attenuated modestly when patient income was controlled, although it did not eliminate "racial" differences. While further study is needed to determine whether some of the differences in clinical care are due to other potential confounding factors, such as patient preferences and lack of information about the need for care, the presence of such systemic disparities suggests that racial discrimination by health care providers and institutions, perhaps operating at "unconscious'' levels (Gieger, 1996), may be the more likely explanation.

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