Cancer & Chronic Disease

Background

Chronic diseases, such as diabetes, heart disease, stroke, and asthma, along with cancer, are important physical health outcomes that can tell us a lot about a population’s overall health. In the first half of the 20th century, more people died from infectious and communicable disease and accidents, but as people are living longer and there are more risk factors in the environment and society, chronic disease prevalence is high. While dying from heart disease at age 100 isn’t necessarily a poor health outcome, earlier onset, early death, and the burden on quality of life and the healthcare system are important to tackle in order to improve the population’s overall health. 

Asthma

Asthma is the most common chronic pediatric disease in the U.S. The disease impacts close to 8 percent of the adult population [1]. The disease affects the airway passages of the lungs. During an asthma attack, the airways become inflamed, which makes it hard to breathe [1]. The symptoms are characterized by repeated episodes of wheezing, breathlessness , chest tightness , and cough.

Asthma places a significant burden on patients, healthcare systems, families, and communities. In 2017 in the US, asthma accounted for 188,986 hospital admissions and nearly 1.8 million emergency department visits [2]. Nationally as well as in the District, inequities persist along geographic, racial and gender lines. Women are more likely to die from asthma and Non-Hispanic black populations are 2 to 3 times more likely to die from the disease than any other race/ethnicity.

In the District, indicators that help track the burden of asthma improved slightly over 2014-2017. Overall 9.4 percent of the District’s adult population has asthma as compared to 7.7 percent nationally [2]. In 2017, District adults living with asthma in the District are more likely to be female, be African American, have less than a high school education , and live in Wards 7 and 8 [3]. 

The DC Healthy People 2020 goal related to asthma is:
     1. Those living with asthma to have minor complications and lead active lives. 

Asthma attacks can be triggered by several environmental factors including air pollution, indoor allergens (i.e. dust mites or mold), outdoor allergens (i.e. pollen), and irritants (i.e. smoke). Other factors include comorbidities such as respiratory illnesses (i.e. cold and flu) and other conditions. People with asthma need proper medical care to manage their condition. While there is no cure for asthma, there are individual, policy, systems, and environmental interventions that can manage and control asthma including care coordination across the health system, developing individual asthma action plans, using medication as prescribed, environmental and policy improvements to remove exposure to triggers, and understanding preventive measures are all vital to improving individuals’ quality of life [2].  

District Adults who were Diagnosed with Asthma by Gender, DC BRFSS 2017

District Adults who were Diagnosed with Asthma by Race/Ethnicity, DC BRFSS 2017

Blood Disorders & Blood Safety

Blood disorders include hemoglobinopathies (affecting the protein in red blood cells that carry oxygen) and abnormal bleeding and clotting (e.g. hemophilia). Hemoglobinopathies, such as sickle cell anemia, are inherited, lifelong blood disorders that result in abnormal hemoglobin. Deep Vein Thrombosis (VTE), where blot clots develop in the veins of the leg affects about 1.2 million Americans annually [1].

VTE is predominantly a disease of older age. In the District, the overall emergency department visits for VTE increases with age. In 2017, VTE related emergency department visits were 216 per 10,000 population for those older than 45 as compared to 28.83 per 10,000 population for those younger. Between 2014- 2017 , age-adjusted emergency department visits dropped to 23.61 from 25.99 per 10,000 population.

The DC Healthy People 2020 goals related to blood disorders and blood safety include:
      1. The blood supply is adequate, safe and effective; and
      2. Those who experience a genetic blood or clotting disorder enjoy a good quality of life.

Blood transfusions are lifesaving for people with severe bleeding disorders or decreased blood production and for people undergoing surgery or recovering from severe accidents. Although an estimated 38 per-cent of the U.S. population is eligible to donate blood at any given time, less than 10% of that eligible population actually do each year [2]. Despite efforts by blood banks, there is still a blood shortage, especially in rare blood types.

While hemoglobinopathies affect a small slice of the population, this area is important due to disproportionate morbidity and treatment costs. Early diagnosis and treatment can prevent complications of bleeding and clotting disorders [3]. Unfortunately, there is no true picture of the prevalence or screening rates in the District, other than anecdotal data from providers, which is an area of concern and one where action is needed. The literature exists and research continues on this topic, but it remains an emerging area of public health importance. 

Blood safety is of paramount importance as a safe and adequate blood supply is vital for health services such as surgeries, cancer treatment, emergency management of trauma, and care of persons with hemoglobinopathies who are on chronic transfusion therapy [2]. Outreach and education to inform the public about the importance of donating blood can help alleviate blood shortages.  

Cancer

Cancer is a group of more than 100 different diseases that begin when abnormal cells in the body grow out of control. Normally, cells grow and divide to create new cells as they are needed to keep the body healthy. Sometimes this process of growing new cells does not work properly and cancer forms [1].

Cancer is the second leading cause of death in both the District and the US [2]. According to the DC Cancer Burden Report, 2,812 District residents were newly diagnosed with cancer in 2016 and 1,044 died of cancer. Lung and Bronchus, Colon and Rectum, Prostate, and Breast cancers cause the four highest rates of cancer deaths in the District [3].  

The goals for DC Healthy People 2020 related to Cancer include:

     1. There are few new cancer cases, particularly those diagnosed at late stage and
     2. Illness, disability and death caused by cancer is greatly reduced.

Some cancers can be successfully treated and cured, but early diagnosis is vital in ensuring that treatments are effective and lead to long term survivorship. Regular screenings and improved access to health services can continue to improve early detection of cancers [5].  Although national death rates for many individual cancer types have declined over the past decade, rates for a few cancers have stabilized or even increased. Likewise, the District of Columbia has experienced overall declines in both incidence and mortality; however, cancer still remains the second leading cause of death. 

Disparities exist across the continuum of cancer diagnosis, care and treatment, and survivorship. For example, although African American/Black women have higher mammography screenings rates, (in 2016, 79.8% of Black women compared to 69.8% of White women), the mortality rate from breast cancer for Black women is twice as high as White women [6]. 

The 2017 age-adjusted mortality rate of cancer was significantly higher among non-Hispanic Black DC residents (204.1 per 100,000 persons) compared to their non-Hispanic White (95.4 per 100,000) and Hispanic residents of any race (61.6 per 100,000) peers [2]. Black (non-Hispanic) residents and Hispanic residents of any race who died of cancer in 2017 were, on average, younger than their White peers. The median age of Black residents who died from cancer was 69 years, while the median age of White non-Hispanic residents was 74 years [2].

During 2013-2017, Ward 3 had the lowest age adjusted mortality rate due to cancer (102.3 per 100,000 persons), while Ward 8 had the highest mortality rate due to cancer (270.9 per 100,000 persons).

The exact reason why a person develops cancer is still unknown. However, certain risk factors have been identified to increase the chances of developing cancer. While some of these factors such as age and family history are non-modifiable, other factors can be controlled to reduce the risk of cancer [5]. 

These include avoiding tobacco, eating a balanced diet; maintaining a healthy weight; exercising regularly; getting timely cancer screenings, health assessments and treatment; and, avoiding environmental risks such as the sun. 

A range of under-resourced and vulnerable demographic groups have unmet needs relating to cancer education, support and services. There is evidence of inequities at each stage of the patient pathway, from information sharing/education through palliative care. System-level changes offer an opportunity to expand beyond individual behavior change to creating larger population health improvements. 

Diabetes

Diabetes is a disease that is caused by the presence of high blood glucose (a type of sugar) levels in the body over an extended period of time. Diabetes is the result of the pancreas not producing enough insulin or the body not being able to properly utilize the insulin to process glucose. There are three types of diabetes. Type 1 diabetes is caused by the failure of the pancreas to produce enough insulin and is not related to lifestyle factors. Type 2 is the result of cells’ ability to properly respond to the insulin. The third kind, gestational diabetes, occurs when pregnant women, without a history of diabetes, develop high blood glucose levels during pregnancy [1].

The number of American living with Diabetes is estimated to be more than 30 million. Another 84 million U.S. adults have pre-diabetes, a condition where blood glucose levels are higher than normal but not high enough to be diagnosed as type 2 diabetes [2]. Diabetes is the 7th leading cause of death in the U.S. and the 4th leading cause of death in the District, though the rate in the District is slightly lower than the national rate [2].

In  2017, an estimated 7.5% of District residents reported being diagnosed with diabetes and 10.6%  have pre-diabetes [3]. Close to 35% of District residents with diabetes are older than 45 years of age [4]. Some of the risk factors for developing diabetes are being overweight, age, family history of diabetes , and having had gestational diabetes or have given birth to a baby who weighed more than 9 pounds [4].

The DC Healthy People 2020 goals related to diabetes include:
     1. reduce the disease and economic burden; and that
     2. those who have or are at risk for diabetes enjoy a good quality of life.

As with other chronic diseases, diabetes disproportionately affects different racial and ethnic groups, notably African-American/Black, Native American, and Hispanic/Latino populations. In 2017, African American/ Black populations made up 13% of adult District residents diagnosed with diabetes as compared to 3.6% of White populations. For District residents the impact of the disease also has a negative correlation with level of income and education. Those who made less than $15,000 a year accounted for 13.8% of adults diagnosed with diabetes. This number was only 3.7% for those who reported earnings of more than $75,000 [3]. 

Many health problems and complications can occur if the condition is not properly controlled and treated. These include complications of the heart, eyes, kidneys, feet, nerves, and other organs and body systems. The good news is that diabetes (type 2) can be prevented and controlled. Good eating habits, physical activity, weight control, and regular medical and dental check-ups can prevent or delay the onset of type 2 diabetes. It is also important to be aware of a few of the risk factors for diabetes such as a family history, lack of exercise, and high body mass index. 

District Adults who were Diagnosed with Diabetes by Race/Ethnicity, DC BRFSS 2017

Heart Disease & Stroke

Heart disease refers to several conditions that affect the blood pumping functions of the heart. The term is usually used interchangeably with Cardiovascular Disease. Some of these conditions include high blood pressure, peripheral vascular disease, and heart failure. Coronary Artery Disease is the most common form of heart disease in the United States, it affects the blood flow to the heart and results in a heart attack [1].

Stroke occurs when blood supply to the brain is blocked or when a blood vessel burst in the brain and blood build-up damages brain tissues. The results of a stroke can be death, disability, and brain damage [2].

The DC Healthy People 2020 goals for heart disease and stroke include:
    1. Heart attack and strokes are rare; and
    2. Environments (home, school, community) support cardio and cerebrovascular health through prevention, detection, and treatment of risk factors, especially in disproportionately affected populations.

In 2016, the age-adjusted death rate from heart disease in the District was higher than the national rate at 211.2 per 100,000 compared to 165.5 per 100,000 nationally [2,3]. However, the age-adjusted death rate from strokes were very similar in the District compared to the US (38.5 and 37.3 per 100,000 respectively).

In the 2017, 30.8% of all deaths in the District were the result of either heart disease or stroke [3]. Disparities are stark, especially among African-American/Black residents who experience three times the rate of heart disease deaths compared to Whites. In addition, heart disease and stroke lead to increased costs associated with hospitalizations and disability and decreased quality of life.

Several factors increase the risk of heart disease and stroke including poor nutrition, lack of physical activity, tobacco use, and mental disorders. Heart disease particularly impacts Black Americans, those older than 65 years of age, and those living in Wards 5, 7, and 8. Stroke prevalence in the District (3.2%) is higher than the national figure (2.8%) and disproportionately affects Black American residents and those living in Wards 7 and 8 [4].

Risks of heart attack and stroke can be reduced through modifying risky behaviors. These include smoking cessation, increased physical activity, reducing high salt diet, and increasing fruit and vegetable consumption [5]. In addition, early and consistent access to proper treatment of clinical risk factors such has high blood pressure, mental disorders, and tobacco use are ways the healthcare system can help lessen the burden of heart disease and stroke.

Assets and Resources

Asthma

Community Resources:

• Healthy Together Medical-Legal Partnerships for Improving Asthma in Southeast DC

Promising Practices & Policies:

• Create a standard billing structure that will allow children to visit their doctor three times a year for asthma follow-up to prevent emergency department visits and hospitalizations.

•  Increase referrals to evidence-based interventions that target a wide variety of asthma triggers through home visits. (i.e., Healthy Homes Program where specialists visit homes to assess environmental hazards that can trigger asthma or other health issues in children and work with property owners to fix a wide range of specific hazards.)

• Increase the number of children and adults with a long-term asthma management plan (i.e., asthma action plan).

Citations & Data Sources:

1. CDC. Asthma's Impact on the Nation 

2. CDC. National Center for Health Statistics

3. DC BRFSS 2017

Blood Disorders & Blood Safety

Community Resources:

• Comprehensive Pediatric Sickle Cell Disease Program

• Adult Sickle Cell Disease Clinic

• Children's Blood Disorder Program

Promising Practices & Policies:

• Build data infrastructure around population-level health indicators for sickle cell anemia incidence and prevalence.

• Improve data surrounding District blood donation rates and blood shortages.

Citations & Data Sources

1. Healthy People 2020. Blood Disorders and Blood Safety

2. American Red Cross. Blood Facts and Statistics.

3. DC Healthy People 2020. Blood Disorders and Blood Safety

4. Heit, J. A., Spencer, F. A., & White, R. H. (2016). The epidemiology of venous thromboembolism. Journal of thrombosis and thrombolysis

Cancer

Community Resources:

DC Cancer Action Partnership – The DC Cancer Action Partnership serves as the collective voice to reduce the burden of Cancer in the District.

  Nueva Vida – Provides a continuum of culturally sensitive cancer support services for Latina families in the District

 EBeauty – Supports women undergoing treatment for cancer through the EBeauty community, Wig Exchange Program and other charitable initiatives. Wig donations are excepted in soft packaging by mail at the following address: EBeauty Inc. 1350 Eye St. NW, Suite P-15, Washington, DC 20005

 Road to RecoveryProvides ambulatory (independent or semi-dependent individuals) cancer patients with ground transportation to and from cancer-related medical appointments

Smith Center for Healing and the Arts- Offers various general cancer support programs, including groups, classes, retreats, yoga, and art workshops.

Project Wish- DC women who are uninsured and underinsured and between the ages of 21 and 64 are eligible for Project WISH. Call (202) 442-5900 for more information.

American Cancer Society

Cancer Support Community

Promising Practices & Policies:

• Increase the early detection/screening and appropriate management of cancer including risk reduction.

•  Continue successful evidence-based programs such as Project WISH

•  Continue health system change programs to increase cancer screening such as the DC Colorectal Cancer Program (DC3C)

•  Expand existing databases and tracking systems to include health equity factors and cancer survivors who are living 5 years or longer after diagnosis.

•  Increase the participation of the District’s minority populations in clinical trials.

Citations & Data Sources:

1. National Cancer Institute. Understanding Cancer. 2015.

2. DC Health. Mortality Report 2012-2017.

3. Center for Disease Control and Prevention. CDC Cancer Statistics Data Visualizations. 2016

4. DC Cancer Registry

5. National Cancer Institute. Risk Factors for Cancer 2015. 

6. DC BRFSS 2016

Diabetes

Community Resources:

• Diabetes Control Program

Promising Practices & Policies:

• Create a centralized, coordinated data system in the electronic health records that can easily alert doc-tors of diabetes risk factors and refer patients to programs that will help them reduce these risk factors.

•  Increase use of community health workers to engage residents with pre-diabetes and diabetes in behavior change strategies.

•  Improve access to affordable, nutritious food through full-service grocery stores, mobile markets, and programs that provide financial assistance and incentives for buying fresh fruits and vegetables.

•  Build data infrastructure to include population-level information on those with diabetes who have annual dental visits.

Citations & Data Sources:

1. Healthy People 2020: Diabetes

2. CDC. Diabetes Basics 2019

3. DC BRFSS 2017

4. DC Health. Diabetes in the District of Columbia. 2016

Heart Disease and Stroke

Community Resources

Million Hearts Initiative

Promising Practices & Policies:

•  Increase hypertension care through improved communications and data sharing among providers, nurses, pharmacists, other care givers, and patients.

•  Increase surveillance of early diagnosis of heart disease and stroke.

Citations & Data Sources

1. CDC. Coronary Artery Disease 2019. 

2. CDC. Stroke 2019. 

3. DC Health Mortality Report, 2012-2016 and 2013-2017.

4. DC BRFSS 2017.

5. DC Health Cardiovascular Disease Burden Report 2014. 

Photo Credit:

Photo by Kate on Unsplash