1 The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Addressing Health Dispari1es in Cancer Care: From the Bench to the Bedside and Beyond Darrell M. Gray, II, MD, MPH [email protected] @DMGrayMD
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1 The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
AddressingHealthDispari1esinCancerCare:FromtheBenchtotheBedsideandBeyond
DarrellM.Gray,II,MD,[email protected]
@DMGrayMD
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BerwickDetal.HealthAffairs2008;27(3):759-769.
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“Forthelovedoneswe’vealllost,forthefamilieswecans6llsave,let’smakeAmericathecountrythatcures
canceronceandforall.”
PresidentObama,StateoftheUnionAddress,January12,2016
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§ McCarthyAMetal.JCO2016May9.[Epubaheadofprint].§ 3,016womenwithinvasivebreastca,808oncologists,and732surgeons.§ BlackwomenlesslikelytoundergoBRCA1/2tes1ngthanwhitewomen(OR0.66;95%CI,0.53-0.81)
§ Carehighlysegregatedacrosssurgeonsandoncologists§ Blackwomenlesslikelytoreceiveaphysicianrecommenda1onfortes1ng(OR0.66;95%CI0.54-0.82)
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Wefacethechallengeofinequi1esincancercareandapplica1onofnewknowledge
§ EgglySetal.HealthExpect2015;18(5):1316-26.§ VisitswithAfricanAmericanpa1ents(n=11)thatincludedaclinicaltrialofferwerematchedtoasampleofvisitswithWhitepa1ents(n=11).§ VisitswithAfricanAmericanpa1entswere
§ Shorterwithfewmen1onsofandlessdiscussionofclinicaltrials§ Lessdiscussionofpurposeandrisksofofferedtrial(s)§ Morediscussionofvoluntarypar1cipa1on
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Wefacethechallengeofinequi1esincancercareandapplica1onofnewknowledge
§ Implicitbiascontributestodisparateoutcomes.§ HallWJetal.AmJPublicHealth2015;105(12):e60-76.
§ Systema1creviewincluding15studies§ Implicitbiashasanadverseimpactonthefollowing:
§ Pa1ent-providerinterac1ons§ Treatmentdecisions§ Treatmentadherence§ Pa1enthealthoutcomes
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Wefacethechallengeofinequi1esincancercareandapplica1onofnewknowledge
§ Implicitbiascontributestodisparateoutcomes.§ Example:ThrombolysisforACS(GreenARetal.JGenInternMed2007;22(9):1231-1238.§ Studyof287residentsat4academicmedicalcenters§ Implicitbiasmeasuresrevealedthefollowing:
§ Preference:White>Blackpa1ents§ Percep1on:Blackslesscoopera1vewithproceduresandlesscoopera1vegenerally
§ Aspro-Whitebiasésodidthelikelihoodoftrea1ngwhitepa1entsandnottrea1ngBlacks.
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Wefacethechallengeofinequi1esincancercareandapplica1onofnewknowledge
§ Clinicaltrials§ 1%oftrialpar1cipantsareHispanic.§ 5%oftrialpar1cipantsareAfricanAmerican.
§ Biobankingprograms§ Only9.94%ofcasesinTheCancerGenomeAtlas(NCI-supported)werecollectedfromracial/ethnicminori1es.
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Racial/ethnicminori1esareunderrepresentedinclinicaltrialsandbiobankingprograms
Thisislessofafunc1onofminori1es’unwillingnesstopar1cipateinsuchprogramsandmoreofareflec1onofthelackofrecommenda1onandaccess.
HagiwaraNetal.JCancerEduc2014;29:580-587.
WendlerDetal.PLoSMed2006;3(2):e19.
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Racealonedoesnotfullyexplaindispari1esinthecancercarecon1nuum:TheexampleofCRC
JemalAetal.JClinOncoldoi:10.1200/JCO.2014.58.7519
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Racealonedoesnotfullyexplaindispari1esinthecancercarecon1nuum:TheexampleofCRC
AdjustedColorectalCancerSurvivalbyStageandInsuranceStatusamongWhitePa1ents18-64yearsDiagnosedfrom1999-2000,NCDBFigurecourtesyofDr.O1sBrawley,AmericanCancerSociety
StageI,privatelyinsuredStageII,privatelyinsuredStageI,uninsured/MedicaidStageII,uninsured/Medicaid
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Racealonedoesnotfullyexplaindispari1esinthecancercarecon1nuum:TheexampleofCRC
SiegelRLetal.CancerEpidemiolBiomarkersPrev;24(8):1151-6.
Geographic “hot spots” for CRC deaths
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Utilization of Care
Access to Care
Delivery of
Services
Pa1entFactors:- Economic- Social- Behavioral- Geographic- Literacy
ProviderFactors:- Poorcommunica1on- Limitedculturalcompetence- Clinicaluncertainty- Bias/Stereotypes
AdaptedfromUnequalTreatment:Confron1ngRacialandEthnicDispari1esinHealthCare(2003).
Summary
“Truecompassionismorethanflingingacointoabeggar;itunderstandsthatanedificewhichproducesbeggarsneeds
restructuring.”
-Dr.Mar1nL.King,Jr.
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§ Howcanweprovideadequatehighqualityandhighvaluecaretopor1onsofthepopula1onthattooopendonotreceiveit?
§ WhatcanIdo?WhatshouldIdo?WhatmustIdo?
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Fundamentalscien1ficandmoralques1ons
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Wemustaddressalldeterminantsofhealth
AdaptedfromMcGinnisJMetal.HealthAffairs2002;21(2):78-93
“Itismuchmoreimportanttoknowwhatsortofapa1enthasadiseasethanwhatsortofadiseasea
pa1enthas.”-SirWilliamOsler
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§ Refiningdatacollec1onandperformancemeasurementandmonitoring.
§ Exploringtheroleofgenomicsandpharmacogenomicsinhealthdispari1esaswebuildpersonalizedmedicinestrategies.
§ Leveraginghealthinforma1ontechnologytoengage,study,andinformpa1entsanddeliverqualitycareequitably.
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Opportuni1estoaddresshealthdispari1esfromthebench
§ Awarenessofimplicitbiases§ hrps://implicit.harvard.edu/implicit/takeatest.html
§ Cross-culturalcommunica1ontrainingofdoctors,nursesandstaff
§ Engagementofpa1entsinbiobankinganddiscussionsaboutclinicaltrials
§ Useofevidence-basedinterven1onstoovercomebarrierstoaccessandcaredelivery§ Example:Pa1entnavigators
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Opportuni1estoaddresshealthdispari1esfromthebedside
§ Tacklecri1calshortageofAfricanAmericanmedicaloncologists.1
§ 2.3%ofoncologistsintheUS;4.0%ofheme/oncfellowsintheUS
§ Enhanceprogramsandpoliciesthataddressbarriersalongthecancercarecon1nuum.§ Examplesinclude:
§ TheDelawareExperiment2
§ ProjectAccessinSanDiego(unpublishedexperience)§ PACEProgramatOSU(unpublishedexperience)
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Opportuni1estoaddresshealthdispari1esinthecommunityandbeyond
1. HamelLMetal.JClinOncol2015;33(32):3697-700.2. GrubbsSSetal.JClinOncol2013;31(16):1928-30
“Each1meamanstandsupforanideal,oractstoimprovethelotofothers,orstrikesoutagainstinjus1ce,hesendsfortha1nyrippleofhope,andthoseripplesbuildacurrentwhichcansweepdownthemigh1estwallsofoppression
andresistance.”
-RobertF.Kennedy
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ACalltoAc1on
DarrellM.Gray,II,MD,MPH
DeputyDirector,CenterforCancerHealthEquity
OSUCCC-TheJamesCancerHospital&SoloveResearchIns1tute
AssistantProfessor,DivisionofGastroenterology
TheOhioStateUniversityWexnerMedicalCenter
@DMGrayMD
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Thankyou!
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hrp://interac1onins1tute.org/illustra1ng-equality-vs-equity/
Ques1ons?
CourtesyofDavidNorris,SeniorResearcher,TheKirwanIns1tute
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Bonusslidesondealingwithimplicitbias
DealingwithImplicitBias
Discoveryourimplicitbiases§ IB’scannotbeaccessedthroughintrospec1on
§ TaketheIAT(orseveralIAT’s;manyavailable)§ 8millionteststakensince1998§ Google“HarvardIAT”or“ImplicitAssocia1onTest”or“ProjectImplicit”
§ Begoodtoyourself§ Remember:WeALLhaveimplicitbiases
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DealingwithImplicitBias
CommittoEgalitarianGoalsMedicalstudentsshouldbe“encouragedtoapproacheveryencounterwithpa1entswhoaremembersofunderprivilegedorstereotypedsocialgroupsasanopportunitytoreinforceandactouttheiravowedcommitmentto[egalitarian]values”(Byrne&Tanesini,2015,p.1259).
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DealingwithImplicitBias
Engagein“effor9ul,delibera<veprocessing”inthemoment§ Spontaneousjudgmentsprovokerelianceonstereotypes
§ Delibera1veprocessing:§ Self-monitoryourbehaviorstooffsetimplicitstereotyping
§ Rethinkthestandardwayspa1entareclassified(race/ethnicity,gender,etc.)
§ Instead,focusonacommoniden1tyyousharewitheachpa1ent
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DealingwithImplicitBias
Reduceyourcogni<veload(totheextentyouareable)§ Reducedcogni1veload=more1metoprocess,lessbiaseddecision-making
§ How?§ Restructureyouday(e.g.,dohardesttasksinthemorning)
§ Advocateforchangesinhealthcareworkflow,sevng(brainstormwithcolleagues)
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DealingwithImplicitBiasIntergroupcontact§ Meaningfulengagementw/peoplewhoseiden11esdifferfromyourown§ Buildnew“other”groupassocia1ons§ Breakdownexis1ngimplicitassocia1ons
§ Forop1maleffect,shouldbe:§ Coopera1vesevng§ Workingtowardacommongoal
§ ***Equalstatus***(Beawareofpowerdynamics)
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