Large Study Finds Inequality Increases Risk of Premature Death on Par with Unhealthy Behaviors

Suggests focus on inequality should be similar to that on lifestyle risk factors

by Hank Dart

A large, new study has found that income inequality contributes to premature death on a level similar to important lifestyle factors like smoking, physical inactivity, and diabetes.

The study, appearing in The Lancet, combined findings from 48 cohort studies in high-income countries and included over 1.7 million men and women.  Its goal was to assess the impact of socioeconomic status (SES) alongside key lifestyle factors included in the World Health Organization's (WHO) 25 x 25 initiative.

The WHO created the 25 x 25 initiative in 2011, with the goal of reducing premature deaths from non-communicable diseases, like heart disease and cancer, by 25 percent by 2025.  The initiative targets seven major risk lifestyle factors: smoking, diabetes, physical inactivity, excessive drinking, high blood pressure, overweight, and salt intake.

The study included each of these lifestyles factors, except salt intake, which was not measured in enough of the combined studies to be included in the analyses.  Income and socioeconomic status (SES) were estimated through a person's occupation, a measure available across the 48 studies.  The three main occupation levels were:  high (e.g., managers, higher professionals), intermediate (e.g., farmers, lower supervisors), and low (e.g., sales workers, semi-skilled/unskilled workers).

The researchers found that low socioeconomic status (SES) increased the risk of premature death from all causes by 26 percent compared to high SES.  This was greater than the impact of overweight and close to the impact of physical inactivity (28 percent increase), high alcohol intake (36 percent increase), and high blood pressure (31 percent increase).  Diabetes increased the risk of premature mortality 73 percent, and smoking more than doubled risk.  The findings controlled for the potential interrelation of SES with the lifestyle risk factors.

When looking at the potential impact population wide, the rankings of the risk factors included in the study shifted a bit, with inequality coming just after smoking and physical inactivity in importance.  The researchers calculated the percent of premature deaths that could be avoided if everyone in the population had a low-risk level of each factor - for example, if inequality were eliminated and everyone had a high-earning occupation, if everyone exercised, and if everyone avoided smoking.

Doing this, they found that low SES accounted for 15 percent of premature deaths in women and 19 percent in men.  This falls not too far behind smoking (21 percent in women, 29 percent in men) and physical inactivity (23 percent in women, 26 percent in men) and in front of the other lifestyle factors included in the study (see figure).

Too often, factors like inequality and socioeconomic status are left out of prevention planning - viewed as health factors that cannot be modified.  This study, however, adds to the evidence that inequality has an independent and important impact on health and that reducing inequality should be a key goal of efforts to improve individuals', and the nation's, health -- right alongside efforts focused on limiting smoking, increasing physical activity, and controlling weight.  

Photo: Cityscape Reflected by danscape (CC License, CC BY 2.0)

Siteman Cancer Center's Program for the Elimination of Cancer Disparities Celebrates 10 Years

by Katy Henke

2015 marked 10 years for The Program for the Elimination of Cancer Disparities (PECaD). PECaD, a National Cancer Institute-funded program, works to eliminate cancer disparities through cancer prevention and treatment. To celebrate 10 years of accomplishment and collaboration in the community, PECaD hosted an evening of achievement on September 15, 2015, presenting updates, overviews and recognition to those who have been involved with the organization throughout the years.

Dr. Graham Colditz welcoming attendees to the celebration.

 During the celebration, individuals were updated on the three community partnerships that have active participation in the community, addressing breast cancer, prostate cancer, and colorectal cancer. The partnerships were able to recognize key individuals for their participation and dedication in helping promote cancer education and prevention. A tribute was also included for those individuals who PECaD has lost throughout the years.

The evening  recognized recent community research fellows training graduates as well. This PECaD program aims to engage community members in a 15-week curriculum that focuses on teaching community members the basics of community-based participatory research in order to help underserved populations. Throughout PECaD’s existence, over 100 community members have completed this course, which has led to pilot projects in the community continuing the PECaD mission.

PECaD focuses on strengthening community partnerships to help reduce cancer disparities by working with individuals, organizations, cancer survivors, and advocates as well as researchers to create awareness, promote prevention, screenings and education, and provide resources to the community. In collaboration with  the Siteman Cancer Center, PECaD attends community outreach events, provides training to clinicians and community members as well as continues cancer disparities research and quality improvement efforts.

In 10 years of community engagement and support, PECaD has grown exponentially - and continues to do so. Over the past year alone, among other accomplishments (see infographic), PECaD has placed 17 billboards with cancer prevention messages, developed new partnerships with community organization, published 30 scientific papers, and trained community members as research fellows.

 

(full size PDF)

PECaD is funded by the NCI (U54 CA153460), the Foundation for Barnes-Jewish Hospital, Washington University School of Medicine and the Siteman Cancer Center. Click Here to learn more about PECaD.

Study Finds Tobacco is Even Deadlier Than Typically Estimated. Fighting It Should Remain "Our Highest Priority"

Photo (Creattive Commons): Flickr/jeffjose

It can be easy to think that we've won the fight against tobacco.  Rates of smoking have plummeted since the 1960s.  Most restaurants, bars, and workplaces across the country are now largely smoke-free.  And many of us may have trouble coming up with a single family member or close friend who smokes.

Yet, the reality is that tobacco remains a persistent and insidious problem.   Over 40 million adult Americans still smoke.  That's 18 percent of the population, and rates can vary wildly, with some groups of people in the single digits and others closer to 50 percent.  Smoking rates in adults with  advanced college degrees hovers around 6 percent, while rates in those with GEDs is over 40 percent.  Smoking rates break across income as well, with those making more money smoking at significantly lower rates than those making less.

Now, a new paper published today in the New England Journal of Medicine finds that the ill-effects of tobacco likely reach well beyond what we've typically understood.  It's estimated that in the United States there are approximately 480,000 deaths per year from the 21 broad diseases said to be caused by smoking.  This new study by Carter et al pulls together data from five large cohort studies and reveals that a number of additional categories of diseases should likely be included in the smoking mortality estimates - things like breast cancer, prostate cancer, infections, and kidney failure.  When these diseases are taken into account, the number of deaths each year in the United States from smoking balloon by an additional 60,000 to 120,000 deaths.

Cancer News in Context's Graham Colditz, MD, DrPh writes in an accompanying editorial that:

A total of 60,000 excess deaths is a number that by itself would have an important public health impact, since it is in line with annual deaths in the United States from excessive alcohol intake or low fruit and vegetable intake.

When combined with the existing estimates of smoking-related deaths it becomes abundantly clear that while there have been great successes in tobacco control there is still a great deal of work to accomplish.  Colditz continues in the editorial to highlight the complexities of tobacco use in society and that successful efforts to curb use and aid smoking cessation will take wide-ranging efforts that cut across issues of policy and healthcare, among others.

He concludes by reaffirming the need to keep up the vigorous fight against tobacco - not only for society and for the United States, but for individuals and for other countries as well:

Tobacco control must be our highest priority here and globally to advance population health, to reduce economic burden, and to extend years of health and productive life for all citizens.

More CNiC posts on tobacco, included the latest evidence on smoking and breast cancer.


References

Smoking and Mortality — Beyond Established Causes
Brian D. Carter, M.P.H., Christian C. Abnet, Ph.D., Diane Feskanich, Sc.D., Neal D. Freedman, Ph.D., Patricia Hartge, Sc.D., Cora E. Lewis, M.D., Judith K. Ockene, Ph.D., Ross L. Prentice, Ph.D., Frank E. Speizer, M.D., Michael J. Thun, M.D., and Eric J. Jacobs, Ph.D.
N Engl J Med 2015; 372:631-640

Smoke Alarm — Tobacco Control Remains Paramount
Graham A. Colditz, M.D.
N Engl J Med 2015; 372:665-666

Reducing cancer disparities through participating in clinical research

Participation in therapeutic clinical trials rarely reflects the race and ethnic composition of the patient population. To meet National Institutes of Health-mandated goals, strategies to increase participation are required. We recently reported our work from Siteman Cancer Center and the Program for the Elimination of CancerDisparities to increase trial participation.

Clinical trials are crucial to advancing science across the cancer continuum. Comprehensive inclusion of diverse participants in clinical trials is essential to assuring generalizability of prevention, diagnostic and treatment recommendations and ultimately the identification of effective treatments for all sectors of society. Although federal mandates require investigators to demonstrate sufficient representation of minorities in study samples 1-4, there continues to be disparity in the representation of racial and ethnic minorities in clinical trials 5-10.

Data available from 2000 show that accrual to National Cancer Institute-sponsored clinical trials for African Americans, Hispanics or Latinos, Asian/Pacific Islanders and American Indians was 8.2%, 4.5%, 1.8% and 0.3%, respectively 5. An update for the period 2003 to 2005 indicates that NCI and publically funded phase 1, 2, and 3 trials showed a national average of 8% African American participants among the total enrollment. Addition of Asian Pacific Islander (2.8%) and Native American Alaska Native (0.5%) and multiple (.1%) brought the total minority participation by race to 11.4% 11.

For all aforementioned groups except American Indians, clinical trial accrual percentages are considerably lower than each group’s respective make-up of the United States population (12.3%, 12.5%, 3.7% and 0.9%, respectively) 12. Additionally, other groups have been under-represented in clinical trials, including uninsured and underinsured adults, adults with lower socioeconomic status, and those living in underserved or rural areas 8,13-15.

Factors that contribute to this disproportional representation are well-documented and are influenced by multiple levels of interaction in the clinical trial recruitment process. In a recent paper, our team at Siteman published a report of our initiative through the Program for the Elimination of Cancer Disparities (see report). We present a framework for institutional enhancement of minority clinical trial accrual.

Four interrelated levels interact to influence enrollment of minorities to clinical trials. They range from individual level influences on patient trial participation (e.g. mistrust of research, faith beliefs, or fear of side effects) to interpersonal level factors (e.g. physician-patient relationships/communication or communication about trials between patients and friends or other patients) to institutional and clinical practice level influences (e.g. organizational infrastructure to reinforce minority recruitment, lack of physician awareness of available clinical trials, systemic lack of time for recruiting, or small minority patient pools), and finally, community and public policy level influences (e.g. federal mandates or inhibitive inclusion criteria that restrict participation due to a range of factors including co-morbidities) 16-31.

These discrete, but interrelated obstacles clearly indicate opportunities for intervention including careful consideration of required inclusion and exclusion criteria 19,32-35; structured evaluation of cancer trial results on strata such as age (or ethnicity) to understand tumor biology, treatment tolerability and the effects of comorbid conditions to help refine mandatory eligibility criteria for future studies 36,37; targeted patient communication via patient trusted communication vectors 38; use of peer coaches 39; and increased trust building between patient/provider and with communities 40,41.

Such interventions are essential in the path to achieve federal mandates for minorities in clinical trials. Emphasis is usually placed on individual and interpersonal levels of influence respective to both patients and providers. While this approach has merit and is part of the solution 42, closer linkage across levels of influence from individual to policy will speed attainment of minority clinical trial recruitment benchmarks over time. Sorensen et al. 43 illustrate this approach for cancer health behavior interventions across social contexts, and for achieving population-wide health advances in the United States 44. Without this linkage, interventions focused on individual and interpersonal levels of influence to increase minority participation are disconnected from parallel interventions at the community and public policy level of influence.

Consequently, an implementation gap results, which diffuses both progress toward and accountability for reaching national recruitment benchmarks, and makes way for slower progression of science discovery reinforcing poorer health status and quality of life for the population.

Fundamental to making the link across the continuum from individual to policy levels of influence is a focus on institutional level influences. Usually, there is an absence of any formal structure for ongoing monitoring of organizational/institutional progress in minority recruitment, beyond cancer center wide reporting at competitive peer review. To bridge this disconnect and underscore centralized accountability, tracking and monitoring across an organization, systematic adjustments to improve organizational infrastructure for minority clinical trial enrollment are required. Here, we describe a framework for centralized organizational accountability through systematic benchmark development, continuous progress monitoring and responsive adjustments at provider and organizational levels to enhance organizational infrastructure to induce and sustain increased minority participation in clinical trials.

Just how did we do this?

We implemented structural changes on four levels to induce and sustain minority accrual to clinical trials: (1) leadership support; (2) center-wide policy change; (3) infrastructural process control, data analysis, and reporting; and (4) follow-up with clinical investigators. A Protocol Review and Monitoring Committee reviews studies with 15 or more patients accruals as the target, and monitors accrual, and the Program for the Elimination Cancer Disparities leads efforts for proportional accrual, supporting the system through data tracking, web tools that allow investigators to see the average distribution of cancer by stage and race over the preceding 3 years, and provides feedback to investigators.

What did we find?

Following implementation in 2005, minority accrual to therapeutic trials increased from 12.0 % in 2005 to 14.0 % in 2010. The "rolling average" minority cancer incidence at the institution during this timeframe was 17.5 %. In addition to therapeutic trial accrual rates, we note significant increase in the number of minorities participating in all trials (therapeutic and nontherapeutic) from 2005 to 2010 (346-552, 60 % increase, p < 0.05) compared to a 52 % increase for Caucasians.

What dies this mean?

Implementing a system to aid investigators in planning and establishing targets for accrual, while requiring this component as a part of annual protocol review and monitoring of accrual, offers a successful strategy. We believe this approach can be replicated in other cancer centers, and may also extend to other clinical and translational research centers.


References

1. Freedman LS, Simon R, Foulkes MA, et al. Inclusion of women and minorities in clinical trials and the NIH Revitalization Act of 1993--the perspective of NIH clinical trials. Control Clin Trials. Oct 1995;16(5):277-285; discussion 286-279, 293-309.
2. Hohmann AA, Parron DL. How the new NIH Guidelines on Inclusion of Women and Minorities apply: efficacy trials, effectiveness trials, and validity. J Consult Clin Psychol. Oct 1996;64(5):851-855.
3. NIH Revitalization Act of 1993. Vol PL 103-43June 10, 1993.
4. Amendment: NIH Policy and Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research - October 2001. Vol NOT-OD-02-001 October 9, 2001.
5. Christian MC, Trimble EL. Increasing participation of physicians and patients from underrepresented racial and ethnic groups in National Cancer Institute-sponsored clinical trials. Cancer Epidemiol Biomarkers Prev. Mar 2003;12(3):S277-S283.
6. Murthy VH, Krumholz HM, Gross CP. Participation in cancer clinical trials: race-, sex-, and age-based disparities. JAMA. Jun 9 2004;291(22):2720-2726.
7. Stewart JH, Bertoni AG, Staten JL, Levine EA, Gross CP. Participation in surgical oncology clinical trials: gender-, race/ethnicity-, and age-based disparities. Ann Surg Oncol. Dec 2007;14(12):3328-3334.
8. Baquet CR, Ellison GL, Mishra SI. Analysis of Maryland cancer patient participation in national cancer institute-supported cancer treatment clinical trials. J Clin Oncol. Jul 10 2008;26(20):3380-3386.
9. National Cancer Institute. NCI-Supported clinical trials: facts and figures. [Website]. 2000; NCI clinical trials: an overview. Available at: http://www.cancer.gov/clinicaltrials/facts-and-figures/page1. Accessed 12 December, 2008.
10. Movsas B, Moughan J, Owen J, et al. Who enrolls onto clinical oncology trials? A radiation Patterns Of Care Study analysis. Int J Radiat Oncol Biol Phys. Jul 15 2007;68(4):1145-1150.
11. Springfield S. Racial and Ethnic Minorites Accrual to NCI Clinical Trials. Bethesdda, MD: Center to Reduce Cancer Health Disparities, National Cancer Institute, NIH;2010.
12. U.S. Bureau of the Census. DP-1. Profile of General Demographic Characteristics: 2000. Census 2000 Summary File 1 (SF 1) 100-Percent Data: U.S. Census Bureau; 2000.
13. Sateren WB, Trimble EL, Abrams J, et al. How sociodemographics, presence of oncology specialists, and hospital cancer programs affect accrual to cancer treatment trials. J Clin Oncol. Apr 15 2002;20(8):2109-2117.
14. Elliott TE, Elliott BA, Renier CM, Haller IV. Rural-urban differences in cancer care: results from the Lake Superior Rural Cancer Care Project. Minn Med. Sep 2004;87(9):44-50.
15. Klabunde CN, Springer BC, Butler B, White MS, Atkins J. Factors influencing enrollment in clinical trials for cancer treatment. South Med J. Dec 1999;92(12):1189-1193.
16. Ford JG, Howerton MW, Bolen S, et al. Knowledge and access to information on recruitment of underrepresented populations to cancer clinical trials. Evid Rep Technol Assess (Summ). Jun 2005(122):1-11.
17. Tournoux C, Katsahian S, Chevret S, Levy V. Factors influencing inclusion of patients with malignancies in clinical trials. Cancer. Jan 15 2006;106(2):258-270.
18. Ford JG, Howerton MW, Lai GY, et al. Barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review. Cancer. Jan 15 2008;112(2):228-242.
19. Adams-Campbell LL, Ahaghotu C, Gaskins M, et al. Enrollment of African Americans onto clinical treatment trials: study design barriers. J Clin Oncol. Feb 15 2004;22(4):730-734.
20. Holcombe RF, Jacobson J, Li A, Moinpour CM. Inclusion of black Americans in oncology clinical trials: the Louisiana State University Medical Center experience. Am J Clin Oncol. Feb 1999;22(1):18-21.
21. Baquet CR, Commiskey P, Daniel Mullins C, Mishra SI. Recruitment and participation in clinical trials: socio-demographic, rural/urban, and health care access predictors. Cancer Detect Prev. 2006;30(1):24-33.
22. Robinson SB, Ashley M, Haynes MA. Attitude of African-Americans regarding prostate cancer clinical trials. J Community Health. Apr 1996;21(2):77-87.
23. Coyne CA, Demian-Popescu C, Brown P. Rural cancer patients' perspectives on clinical trials: a qualitative study. J Cancer Educ. Fall 2004;19(3):165-169.
24. Brown DR, Fouad MN, Basen-Engquist K, Tortolero-Luna G. Recruitment and retention of minority women in cancer screening, prevention, and treatment trials. Annals of Epidemiology. 2000;10(8, Supplement 1):S13-S21.
25. Pinto HA, McCaskill-Stevens W, Wolfe P, Marcus AC. Physician perspectives on increasing minorities in cancer clinical trials: an Eastern Cooperative Oncology Group (ECOG) Initiative. Ann Epidemiol. Nov 2000;10(8 Suppl):S78-S84.
26. Advani AS, Atkeson B, Brown CL, et al. Barriers to the participation of African-American patients with cancer in clinical trials: a pilot study. Cancer. Mar 15 2003;97(6):1499-1506.
27. Outlaw FH, Bourjolly JN, Barg FK. A study on recruitment of black Americans into clinical trials through a cultural competence lens. Cancer Nurs. Dec 2000;23(6):444-451; quiz 451-442.
28. Hudson SV, Momperousse D, Leventhal H. Physician perspectives on cancer clinical trials and barriers to minority recruitment. Cancer Control. Nov 2005;12:S93-S96.
29. Giuliano AR, Mokuau N, Hughes C, et al. Participation of minorities in cancer research: The influence of structural, cultural, and linguistic factors. Annals of Epidemiology. 2000;10(8, Supplement 1):S22-S34.
30. Linden HM, Reisch LM, Hart A, Jr., et al. Attitudes toward participation in breast cancer randomized clinical trials in the African American community: a focus group study. Cancer Nurs. Jul-Aug 2007;30(4):261-269.
31. Shavers VL, Lynch CF, Burmeister LF. Racial differences in factors that influence the willingness to participate in medical research studies. Ann Epidemiol. May 2002;12(4):248-256.
32. George SL. Reducing patient eligibility criteria in cancer clinical trials. J Clin Oncol. Apr 1996;14(4):1364-1370.
33. Fuks A, Weijer C, Freedman B, Shapiro S, Skrutkowska M, Riaz A. A Study in contrasts: Eligibility criteria in a twenty-year sample of NSABP and POG clinical trials. Journal of Clinical Epidemiology. 1998;51(2):69-79.
34. McCabe MS, Varricchio CG, Padberg RM. Efforts to recruit the economically disadvantaged to national clinical trials. Semin Oncol Nurs. May 1994;10(2):123-129.
35. Elks ML. The right to participate in research studies. J Lab Clin Med. Aug 1993;122(2):130-136.
36. Townsley CA, Selby R, Siu LL. Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials. J Clin Oncol. May 1 2005;23(13):3112-3124.
37. Swanson GM, Bailar JC, 3rd. Selection and description of cancer clinical trials participants--science or happenstance? Cancer. Sep 1 2002;95(5):950-959.
38. Wood CG, Wei SJ, Hampshire MK, Devine PA, Metz JM. The influence of race on the attitudes of radiation oncology patients towards clinical trial enrollment. Am J Clin Oncol. Dec 2006;29(6):593-599.
39. Fracasso PM, Walker MS, Mathews KJ, et al. Coaching intervention as a strategy for enhancing accrual to phase I/II clinical trials. Journal of Clinical Oncology. June 20 2007;2007 ASCO Annual Meeting Proceedings Part I. Vol 25:S6580.
40. Fouad MN, Partridge E, Green BL, et al. Minority recruitment in clinical trials: a conference at Tuskegee, researchers and the community. Ann Epidemiol. Nov 2000;10(8 Suppl):S35-S40.
41. Fouad MN, Partridge E, Wynn T, Green BL, Kohler C, Nagy S. Statewide Tuskegee Alliance for clinical trials. A community coalition to enhance minority participation in medical research. Cancer. Jan 1 2001;91(1 Suppl):237-241.
42. Lai GY, Gary TL, Tilburt J, et al. Effectiveness of strategies to recruit underrepresented populations into cancer clinical trials. Clin Trials. 2006;3(2):133-141.
43. Sorensen G, Emmons K, Hunt MK, et al. Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations. Prev Med. Oct 2003;37(3):188-197.
44. Emmons K. Behavioral and Social Science Contributions to the Health of Adults in the United States. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington DC: The National Academies Press; 2000:254-321.

Improving access to colorectal cancer screening for the underserved. Eliminating cancer disparities.

As we have noted previously, colorectal cancer is a leading preventable cause of cancer mortality. See related posts. Screening can be effective reducing deaths by half. Yet it is underutilized. Multi-level interventions addressing system changes and individual factors can effectively increasing screening. To date, most interventions have been implemented and evaluated in higher-resource settings such as health maintenance organizations.  Given the disparities evident for colorectal cancer and the potential for screening to improve outcomes, we describe our ongoing NCI funded research that is expanding the population included in such studies. We recently published the protocol for our ongoing study that includes economically disadvantaged patients. (see report online). We describe the study protocol for a trial designed to increase colorectal cancer screening in those 'safety-net' health centers that serve underinsured and uninsured patients in Missouri. This trial was designed and is being implemented using a community-based participatory approach.

What was our approach?

We developed a practical clinical cluster-randomized controlled trial. We are currently recruiting 16 community health centers to participate and collaborate in this trial. This systems-level intervention consists of a menu of evidence-based implementation strategies for increasing colorectal cancer screening. Health centers in the intervention arm then collaborate with our Siteman and Washington University based  study team to tailor strategies to their own setting to maximize fit and acceptability. Data are collected at the organizational level through interviews, and at the provider and patient levels through surveys. Patients complete a survey about their healthcare and screening utilization at baseline, six months, and twelve months.

How will we assess success in brining screening to our underserved communities?

The primary outcome for our study is colorectal cancer screening that we record through patient self-report. We will supplement these self –reports with a chart-audit in a subsample of patients. This is similar to the approach we used in a primacy care based intervention in New England that showed success in creasing screening rates more than a decade ago (see report).  Implementation outcomes informed by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) conceptual framework will be measured at the patient, provider, and practice levels. This approach has been used previously to evaluate interventions in low-income settings and assess the overall public health benefit.

Why is this study important?

Our study is one of the first to integrate community participatory strategies to a randomized controlled trial in a low-income healthcare setting. The multi-level approach will support the ability of the intervention to affect screening through multiple avenues. The participatory approach will strengthen the chance that implementation strategies will be maintained after study completion and, supports external validity by increasing health center interest and willingness to participate.

Ronald Rancher, a participant in the Photovoice project, 

stands next to the photo he submitted for the project. 

The photos were on display at 

Washington University School of Medicine.

More... 

For more details on this and other innovative studies on colorectal cancer screening in low income populations see Associate Professor Dr. Aimee James' studies at Siteman Cancer Center: http://www.siteman.wustl.edu/contentpage.aspx?id=6130

Or watch the Photovoice video at… Watch the Photovoice project video