‘Science of trustworthiness’ key to reducing cancer disparities
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Reducing disparities in cancer care requires an understanding of “the science of trustworthiness” and a greater focus on social determinants of health, according to a leader in health equity research.
“My excitement about where we’re going now ... is because we are fully understanding that, in addition to the biology, we understand that the ‘ZNA’ — that ZIP code and neighborhood association — also is impacting your biology, and that there is amazing science to be understood within that interplay,” Robert A. Winn, MD, director of VCU Massey Cancer Center, said in his keynote address during the American Association for Cancer Research Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved.
Winn cited progress made during the past 50 years following President Richard M. Nixon’s declaration of “war on cancer” and signing of the National Cancer Act into law. He referred to an AACR report that showed a reduction in cancer death disparities between Black and white individuals from 1990 to 2016.
“[However], we have not eradicated the disparity gaps by any means,” he said. “We still have obstacles in the way.”
Access to new treatments and interventions — such as screening for breast and colorectal cancer — often is unequal, Winn said. And although breast cancer deaths have decreased across most parts of the US during the past 30 years, not all areas have experienced declines.
“I’d argue that ... it’s not so much the DNA as it is the ZNA and the accessibility to these interventions that are driving these unequal outcomes,” he said.
A closer look at communities also reveals disparities in colorectal cancer deaths, Winn said. Reducing such disparities requires scientists to focus on preventive interventions beyond simply engaging people in communities.
“We’re going to have to really push the health delivery scientists to start thinking about the science behind not only connectivity, but how you actually motivate and move the crowd to get them from a behavioral perspective to the perspective where they really are reducing some of these at-risk behaviors,” Winn said in response to a question about the role of smoking cessation for minority populations. “It’s not just intuitive that these people are doing it on their own. There are structures that they’re being exposed to.”
Health care professionals also are part of the issue, Winn said. He referred to a survey in which more than one-third of oncologists reported that nonwhite patients with cancer receive worse medical care and communication than white patients with cancer.
The COVID-19 pandemic illuminated many blind spots among both scientists and health care professionals, according to Winn.
“Not only were there blind spots in the context of race, but there have been blind spots in the context of the impact of women, particularly women of color,” Winn said. “Women of color have been really disproportionately hit in the economic sort of arena as a result of COVID-19, again just opening up our awareness to how these things are tied into health.”
The introduction of COVID-19 vaccines revealed that although science is necessary, it is not sufficient to move the crowd.
“We are understanding that as institutions, it is not just enough to have a great cure for COVID or a great cure for cancer. It turns out that trust matters,” he said.
Building trust requires relevance, accessibility and flexibility, Winn said. But first, clinicians should examine their own institutional trustworthiness, he said.
“You can’t get people to buy into something if ultimately they say, ‘Yeah, I get it, but I don’t really trust you,’” he said.
Elements of trustworthiness include credibility, dependability, transferability and confirmability, Winn said.
Winn also discussed the importance of focusing on social determinants of health. One example is urban heat islands that have resulted in poor areas being the hottest areas of cities. The significantly hotter temperatures have been associated with chronic diseases, including cancer, Winn said.
Although understanding of health care disparities has evolved over the past 50 years, some discussions of equity models still suggest some populations are inherently or “almost even biologically disadvantaged,” Winn said.
“The disparity issues are part and parcel of structures that have been built — economics, policies, political — that had the unintended or intended consequence of disadvantaging some populations,” he said. “We also understand quite well that science is necessary, but not sufficient to really eradicate cancer. The science of trustworthiness — we are just scratching the surface of what that looks like and we hope that will inspire a generation of people ... to tear down their silos so that we are working for one goal, one team, one fight — to eradicate cancer and to eradicate disparities wherever they exist.”
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Winn RA. Health disparity research: The new frontier (keynote address). Presented at: American Association for Cancer Research Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved (virtual conference); Oct. 6-8, 2021.
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