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,MPHdarrell.gray@osumc.edu

@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

darrell.gray@osumc.edu

@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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