The United States has the largest number of individuals incarcerated in the world, the majority of whom are of racial and ethnic minority groups and lower socioeconomic status. Thehigh incarceration rate of minority and poorindividuals makes it especially important tounderstand the epidemiology of cancer among individuals with a history of incarceration and the impact of incarceration on cancer disparities. Individuals with a history of incarceration have higher rates of cancer risk factors, and some work has suggested that incarceration history is associated with a higher risk of cancer mortality. However, prior work has not examined the impact of mass incarceration on access to high quality cancer care, or the degree to which incarceration might contribute to cancer disparities. Until this knowledge gap is addressed, we will not be able to identify effective and durable interventions to mitigate observed disparities in cancer morbidity and mortality. The long-term goal of this application is to reduce disparities in cancer outcomes. The overall objective, which is a next step toward achieving this long-term goal, is to assess the impact of incarceration on cancer outcomes and disparities in cancer detection, quality of treatment, and survival. The central hypothesis of Incarceration and Cancer- Related Outcomes (ICRO) study is that incarceration contributes to racial and socioeconomic disparities in cancer detection, quality of treatment, and mortality. The underlying rationale for this proposed study is that there are currently no ongoing or past cancer epidemiologic studies that enable us to measure the contribution of incarceration on observed racial and socioeconomic disparities. To address this knowledge gap, we will create the first comprehensive linkage of a tumor registry, correctional system data, and state vital statistics supplemented with in-depth interviews, to conduct a sequential explanatory mixed methods study of individuals with cancer. We will describe the burden of cancer among individuals with a history of incarceration at the population level in Connecticut (Aim 1). And among Connecticut residents who are diagnosed with cancer (2005-2014), we will assess the relation between incarceration and cancer mortality; the quality of cancer care; and the degree to which incarceration status moderates the relation between race, socioeconomic status and quality of cancer care and mortality (Aim 2-4). We will then use these data to inform a qualitative study of individual perceptions regarding accessing cancer care in the correctional system and in the immediate post- release period (Aim 5). ICRO will be the first study to shed light on a population level how incarceration may be a substantive contributor to racial and socioeconomic cancer disparities. This study is highly innovative in its application of a mixed methods approach and construction of a novel data linkage to address the important yet understudied question of the contribution of incarceration on observed racial and socioeconomic cancer disparities. Together, the knowledge produced will have a positive impact, as it will result in potential targets for interventions to improve cancer outcomes among the millions of individuals with a history of incarceration.
The proposed work is relevant to public health given the high rates of incarceration among African-American and Latino men and individuals of low socioeconomic status and the fact that most incarcerated persons will return to mainstream health systems upon release. The project is relevant to the National Cancer Institute's mission-driven strategic goals to investigate factors that account for differences in health among populations and to optimize clinical and implementation research to improve health and reduce morbidity and mortality from cancer. Including the criminal justice system as a part of the public health infrastructure, and thus a target for clinical and implementation science research, will be important to eliminating disparities in cancer.