April 2021 Edition Vol.13, Issue 4

Achieving Health Equity Starts in the Community, Oncologists Say

By Aaron Tallent

The COVID-19 pandemic has only highlighted the extent of health care disparities in the United States. As Community Oncology Alliance President Kashyap Patel, MD, noted during the annual conference in early April, “One in 3 cancer patient deaths in America is directly linked to health care disparities.” Dr Patel and the oncologists participating in a panel discussion agreed that while introspection on why this is the case should continue, it is time for the oncology community to take sustained action.

Taking Action on Health Disparities

“It’s really incumbent upon those of us who are part of the system to really look at ways that we can be part of the solution,” said Karen Winkfield, MD, PhD, Executive Director of the Meharry-Vanderbilt Alliance and Ingram Professor of Cancer Research at Vanderbilt Ingram Cancer Center.

One of the primary causes of health inequity is due to the fact that the US physician workforce and clinical trial participants do not reflect the population. Of all physicians, 5.0% are Black, 5.8% are Hispanic, and less than 1% are American Indians. A recent cancer treatment trials analyses found that only 4% to 6% of trial participants are Black and 3% to 6% are Hispanic even though each represents nearly three times that of all people living with cancer.

Another factor that cannot be ignored is the institutional and systemic racism that still exists, of which Dr Winkfield says, “People sometimes don’t realize how much of a thread these impediments are in the way that our country is currently structured.” Segregation is the most blatant example, but other practices, including redlining, which allowed banks in the United States to deny mortgages to people of color, impacted the health and wealth of millions of Americans in ways that will take generations to fully recover.

These inequities were compounded by COVID-19, which has killed Black and Hispanic Americans at approximately twice the rate of White Americans. For all Americans, the major determinant of health outcomes is a patient’s zip code, and it is more difficult to recruit doctors to impoverished areas, so the poorer health outcomes often go unchanged.

“What we’ve learned with COVID is that because we have hardwired all of these racial inequities and poverty-shaming, that we have a whole group of people who do not trust our health care system, with good reason for many of them,” said Barbara L. McAneny, MD, FASCO, MACP, Chief Executive Officer of New Mexico Oncology Hematology Consultants, LTD, whose practice treats many patients from the Navajo, Hopi, and Zuni tribes.

Dr Winkfield served as lead author on a JCO Oncology Practice paper where members of a Cancer Continuum of Care working group outlined access barriers and laid out ways to address them.

“Some of the biggest gaps we found were related to coordination of care and transitions in care,” she said.

Dr Winkfield noted that one of the best modern examples of physicians addressing gaps care in their communities is Harold P. Freeman, MD, the father of the patient navigator program. As the Director of Surgery at Harlem Hospital Center in 1979, Dr Freeman was very concerned by the number of patients who were undiagnosed until their cancer was in an advanced stage.

Dr Freeman set up screening centers and spoke with individuals in underserved communities in Harlem and across the country. When he learned the challenges they faced just in entering the health care system, he created the first patient navigator program in 1990. This program, where individuals help patients manage every stage of their cancer care journey, is now a mainstay in oncology.

“Harold Freeman had a wonderful opportunity when he was in Harlem and made the observation that Black women with breast cancer were presenting with later stage disease. He went and talked to the community,” said Dr Winkfield.

Dr McAneny’s practice created a foundation in 2002 to help patients with their nonmedical bills. Since then, the practice has given nearly $2 million to patients to keep them from deciding between paying for their medications or buying food.

“We know we’re not going to solve poverty, but maybe we can solve the effects of poverty on our specific group of patients that we treat,” she said.

A More Diverse Oncology Workforce

Another step to rebuilding trust is having oncology care staff who reflects the diversity of the patients they treat. For Dr Winkfield, who is one of fewer than 30 Black female radiation oncologists in the United States, putting the focus entirely on doctors is shortsighted because it takes years to obtain a medical license.

“Make sure you’re thoughtful about workforce when it comes to who’s picking up the phone, who is the first person patients see when they walk through the door, who are the nurses that you’re hiring, who are the trainees, who is the clinical resource staff. It’s really important to think broadly about workforce diversity,” she said.

The fostering of a more diverse oncologist workforce is also necessary. It just needs to start early.

“The first step for a young child to come to the conclusion that he or she is capable of being a physician is to see a physician role model. I know that we are overstretching our small population of minority physicians and women physicians, but we need to be out there showing people that you too can consider a career in health care,” said Dr McAneny.

For another look at how COVID-19 has exacerbated health care disparities in the US for certain populations, see our March 2021 OBR green article, “COVID and Health Disparities in Cancer.”

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