Health equity initiatives address cancer ‘within the context of human circumstances’
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Years ago, when she was working on laboratory research with animal models, Valerie Montgomery Rice, MD, FACOG, kept on hand a powerful reminder of whom her hard work ultimately would help.
“I would keep a picture of a patient with ovarian cancer in my lab,” Montgomery Rice, president and dean of Morehouse School of Medicine in Atlanta, said during a Continuing Umbrella of Research Experiences (CURE) Distinguished Scholars Seminar. “The picture was to remind me that, even though I was working with mice, the end results were for that person in front of me.”
In her later roles as Morehouse’s first female president and dean and a renowned infertility specialist, Montgomery Rice never let that image of the individual patient escape her mind. This acknowledgement of the individual and his or her distinct cultural, socioeconomic and environmental influences is essential to eliminating disparities in care, she said.
“When we talk about health equity at Morehouse School of Medicine, we recognize that people are going to come into a disease process with a different set of circumstances,” she said. “Our goal is to decide — based on who is sitting in front of us — what is possible for them.”
‘Continuum of opportunity’
During the seminar — hosted by the NCI Center to Reduce Cancer Health Disparities — Montgomery Rice discussed the landscape of cancer treatment and outcomes, emphasizing the ongoing challenges to health equity.
She noted that disease occurs “within the context of human circumstances,” and that these circumstances always should be taken into consideration when treating a patient with cancer.
“Sometimes we have to remind ourselves of the differences that exist based on gender, on race and ethnicity, and on the ZIP code where one is born,” Montgomery Rice said. “Sometimes it requires that we take a step back and look at these numbers differently.”
Montgomery Rice stressed the need to have conversations with patients in order to better understand their history, culture and priorities.
“The goal is to give people what they need, when they need it, and in the amount they need to reach their optimal level of health,” she said.
She cited some essential components of health equity, including insurance, education, awareness, prevention and access.
Although she acknowledged the importance of insurance, it is only part of the equation, Montgomery Rice said. Education and awareness are crucial to helping patients make informed decisions about their health. Additionally, appropriate preventive behaviors occur only when patients are aware of increased risks inherent to their population, she said.
The term “access” is applicable not only to patient-physician interaction, but also to clinical trial participation and awareness of emerging treatments and technologies, she said. Notably, access to racially concordant health care providers has been shown to improve health equity.
“When we look at medically underserved populations, we have seen that these patients tend to have better interpersonal care from practitioners of their own race or ethnicity, especially in primary care or mental health care settings,” Montgomery Rice said. “We’ve seen that non-English-speaking patients experience better care and are more likely to keep follow-up appointments when they have a language-concordant practitioner.”
Disparities in opportunity also persist for African American students seeking to attend medical school, with African American men particularly underrepresented. She said a more diverse medical school landscape will result in a more diverse medical field.
“We know we have a responsibility to recruit, educate and train,” she said. “We know that gender diversity and representation matter, and we know that racial and ethnic diversity matter in the health care workforce.”
Patient health literacy is another area of disparity that must be addressed in minority populations, according to Montgomery Rice. She discussed harnessing the potential of cellphones to increase health literacy, citing a patient navigation tool underway at Morehouse School of Medicine that addresses prostate cancer for African American men.
“Access only truly occurs when patients are empowered to make decisions,” she said. “Underserved populations need access not only to the doctor, but to the entire continuum of opportunity.”
Montgomery Rice spoke with HemOnc Today about cultural relevance in health education, underrepresentation of African Americans in clinical trials, and ongoing racial disparities in breast cancer treatment.
Question: What areas have been a particular focus of efforts to address inequities in cancer treatment and outcomes?
Answer: One area that comes readily to mind is breast cancer. Although the gap has been narrowed in surveillance, diagnosis and treatment opportunities, the gap in mortality persists. Much of it is due to the biological difference in the tumors that affect African American vs. Caucasian women. African American women have a higher chance of having triple-negative breast cancer and inflammatory breast cancer. With those two diagnoses, treatment options are limited.
We’ve done some good work toward getting African American women screened at equal rates, and we’ve also looked at analog vs. digital screening methods. We’ve recognized that African American women are more likely to have dense breasts and, therefore, should be assessed using digital vs. analog mammography. Many people have even gone on to 3-D. However, the biological specimen indicates a different disease is occurring more among black women. Therefore, the treatment options are more limited.
Q: What would you advise oncologists to focus on when treating women with triple - negative breast cancers?
A: I would encourage them to understand the biological differences that we see based on race and ethnicity. Are there things we can do to change the incidence or have earlier diagnosis? Should we be considering different treatment options? We know early detection of breast cancer leads to a better outcome. We haven’t always seen that with triple-negative breast cancer, but it may be because these patients are being diagnosed later. So, if there were some way to understand the physiology better, that would be useful. Researchers are looking at breast cancer with BRCA1 and BRCA2 mutations to see if they are correlated with greater incidence of triple-negative breast cancer. Veena N. Rao, PhD, co-director of the cancer biology program at Morehouse School of Medicine, has seen a correlation between African American women with BRCA mutations and subsequent triple-negative breast cancer. If that correlation exists, there may be a genomic aspect we should explore.
Q: What can providers do at a community level to increase awareness of triple - negative and inflammatory breast cancer among African American women?
A: At Morehouse School of Medicine, we have a project with Color Genomics — a company that got the cost of BRCA1 and BRCA2 mutation testing down to almost $100 — called the Every Woman Program. During a lecture at Morehouse School of Medicine, Mary-Claire King, PhD — who discovered BRCA1 and BRCA2 mutations — said that every woman should be screened for BRCA mutations prior to age 35 years because, even though chances are 3% to 5% that a woman will harbor the mutations, those who do have a 50% to 60% chance of developing breast or ovarian cancer. If you screen with a test that costs $100, not only will you identify those women, but also you will have an opportunity to educate. One in eight women will be diagnosed with breast cancer anyway. It is valuable if a screening protocol increases women’s surveillance and educates them about lifestyle modifications, like watching their weight. You can also get people’s family history and introduce the fact that when a black woman is diagnosed, she may have a higher chance of triple-negative breast cancer.
Q: How can today’s researchers address the underrepresentation of minorities in clinical trials?
A: When I was at University of Kansas, I was the only person of color in the department of OB-GYN at that time. I was an OB-GYN reproductive endocrinologist. I became the clinical trials director for the university when it was first consolidating the different clinical trials. I was the principal investigator on trials for a lot of the second-generation birth control pills. I figured out early on that, in order to have diverse women in these clinical trials, the people who are going to be recruiting, screening and counseling the women need to look like the women you want to enroll. I had a white nurse coordinator, a Hispanic nurse coordinator and an African American nurse. Nationally, I had the highest percentage of people of color in any trial that I engaged in. What I was doing wasn’t magical; I was just using common sense. I was engaging those women and we talked about health literacy early on — not health literacy in terms of whether people could read or understand, but in terms of whether the way we were presenting the information to them was culturally acceptable. In the late 1990s, we underwent training to understand what cultural competence looks like.
We were successful and able to enroll these women in clinical trials.
At Morehouse School of Medicine, we had an R25 grant that allowed us to train primary care providers and their staff to enroll people in multisite clinical trials in their offices. In between trials, this group of about 75 primary care doctors meet for CME, and we continue to educate them on the opportunities for clinical trial participation. When you can take the trial to the doctor’s office, you have a greater likelihood of enrolling people in clinical trials.
African Americans account for about 12% of the population, and we probably participate in less than 5% of any type of clinical trials. This is especially true when it comes to cancer trials. This continues to be a significant challenge. – by Jennifer Byrne
For more information:
Valerie Montgomery Rice , MD, FACOG , can be reached at Morehouse School of Medicine, 720 Westview Drive SW Atlanta, GA 30310; email: presdeanoffice@msm.edu.
Disclosure: Montgomery Rice reports no relevant disclosures.