Cultural Sensitivity Cultural Sensitivity and and

Cancer Patients Cancer Patients

Darryl L. Jordan, M.D.Darryl L. Jordan, M.D.Assistant ProfessorAssistant Professor

Liaison Medical Director for Liaison Medical Director for Veteran Affairs at MeharryVeteran Affairs at Meharry

DisclaimerDisclaimer

In accordance with accreditation counsel for In accordance with accreditation counsel for continuing medical education (ACCME) continuing medical education (ACCME) guidelines, I disclosed that I have no financial guidelines, I disclosed that I have no financial relationship with any pharmaceutical or medical relationship with any pharmaceutical or medical manufacturing companies that would pose a manufacturing companies that would pose a conflict of interest to this presentation.conflict of interest to this presentation.

ObjectivesObjectives

Review variation in cancer mortality rates

among various populations via socio- demographic factors

Identify barriers to cancer assessment and treatment of underserved minority populations

Review program designed to eliminating health disparities

March on Poverty June 1968

Summary Statement of the Summary Statement of the American Cancer Society1989: American Cancer Society1989:

Cancer in the PoorCancer in the Poor

FindingsFindings 1. Poor people endure greater pain an suffering from cancer than 1. Poor people endure greater pain an suffering from cancer than

other Americansother Americans

2. Poor people and their families must make extraordinary personal 2. Poor people and their families must make extraordinary personal sacrifices to obtain and pay for care sacrifices to obtain and pay for care..

3. 3. Poor people face substantial obstacles in obtaining and using Poor people face substantial obstacles in obtaining and using health insurance and often health insurance and often do not seek care if they cannot pay for do not seek care if they cannot pay for it.it.

4. 4. Current cancer education programs are culturally insensitive and Current cancer education programs are culturally insensitive and irrelevant to many poor people.irrelevant to many poor people.

5. Fatalism about cancer is prevalent5. Fatalism about cancer is prevalent among the poor and prevents among the poor and prevents them from seeking care.them from seeking care.

Summary Statement of the Summary Statement of the American Cancer Society1989: American Cancer Society1989:

Cancer in the PoorCancer in the Poor

Challenges for the NationChallenges for the Nation

1.1. Establish patient advocate and referral services to help Establish patient advocate and referral services to help poor patients navigate the health system and manage poor patients navigate the health system and manage personal problems that result from cancer treatment.personal problems that result from cancer treatment.

2.2. Involve community organizations serving the poor and Involve community organizations serving the poor and poor people themselves in cancer education and patient poor people themselves in cancer education and patient advocacy programs.advocacy programs.

Patient Navigator Outreach and Chronic Disease Patient Navigator Outreach and Chronic Disease Prevention Act of 2005Prevention Act of 2005

Requires the Secretary of Health and Human Services Requires the Secretary of Health and Human Services acting through the Administrator of the Health Resources acting through the Administrator of the Health Resources and Services Adminstration (HRSA) to make grants to and Services Adminstration (HRSA) to make grants to eligible entities for the development and operation of eligible entities for the development and operation of demonstration programs to provide patient navigotor demonstration programs to provide patient navigotor services to improve health care outcomes. Requires the services to improve health care outcomes. Requires the Secretary to coordinate with, and ensure the participation Secretary to coordinate with, and ensure the participation of, the Indian Health Service, the National Cancer Institute, of, the Indian Health Service, the National Cancer Institute, and of the Office of Rural Health Policy.. and of the Office of Rural Health Policy..

Reasons for Cancer Disparities

Genetics

Biology/ Patient \Tumor Factors

Environment

Social and Systemic Factors

Lifestyle

Behavioral/Patient Factors

Gabram S et. Al Cancer 2008

Impact of Socioeconomic Status on Impact of Socioeconomic Status on Survival after Cancer in the U.SSurvival after Cancer in the U.S

MethodMethod: Review of medical records, diagnosis stage, : Review of medical records, diagnosis stage, treatment and treatment and

5-yr mortality and SES, across 7 cancer registries within 5-yr mortality and SES, across 7 cancer registries within the U.S. the U.S.

from 1996-1997from 1996-1997

4,844 women with breast cancer4,844 women with breast cancer 4332 men with prostate cancer 4332 men with prostate cancer 4422 men and women with colorectal cancer4422 men and women with colorectal cancer

ResultsResults: For all 3 cancer sites, low SES was a much : For all 3 cancer sites, low SES was a much stronger predictor of mortality among individuals aged < stronger predictor of mortality among individuals aged < 65 yrs and among individuals from racial/ethnic minority 65 yrs and among individuals from racial/ethnic minority groups.groups.

Byers et. Al Cancer 2008Byers et. Al Cancer 2008

Byers et. Al Cancer 2008

Byers et. Al Cancer 2008

Byers et. Al Cancer 2008

Conclusion: The current results indicate that low SES is a risk factor for all-cause mortality after a diagnosis of cancer.

These findings support the need to focus on SES as an underlying factor in cancer disparities by race and ethnicity.

Impact of Socioeconomic Status on Survival after Cancer in the U.S

Byers et. Al Cancer 2008

Effects of an outreach and internal navigation program on Breast Effects of an outreach and internal navigation program on Breast cancer diagnosis in an urban cancer center with a large African-cancer diagnosis in an urban cancer center with a large African-American populationAmerican population

MethodMethod: : Cross-sectional study was an analysis of all women with breast Cross-sectional study was an analysis of all women with breast cancer who were diagnosed and/or treated 2001 and 2004 intervention cancer who were diagnosed and/or treated 2001 and 2004 intervention with 125 community health advocates (CHAs), educational programs and with 125 community health advocates (CHAs), educational programs and

Patient Navigators communicated directly with patients to encourage Patient Navigators communicated directly with patients to encourage screening, diagnostic procedures and treatment.screening, diagnostic procedures and treatment.

Results: Results: 487 patients were diagnosed/treated from 2001 and 2004 with 487 patients were diagnosed/treated from 2001 and 2004 with 1148 community interventions by CHAs with est. > 10,000 participants1148 community interventions by CHAs with est. > 10,000 participants, ,

proportion ofproportion of stage 0stage 0 ( ( in situ ) breast cancers increased fromin situ ) breast cancers increased from 12.412.4% to% to 25.825.8% % stage IVstage IV invasive breast cancer declined frominvasive breast cancer declined from 16.816.8% to % to 9.49.4%%

Grabam S et. Al Cancer 2008Grabam S et. Al Cancer 2008

Effects of an outreach and internal navigation program Effects of an outreach and internal navigation program on Breast cancer diagnosis in an urban cancer center on Breast cancer diagnosis in an urban cancer center

with a large African-American populationwith a large African-American population

Conclusions: Conclusions: The outreach initiatives and internal patient The outreach initiatives and internal patient navigation appear to have improved stage at diagnosis.navigation appear to have improved stage at diagnosis.

Similarly, prospective data are being collected to determine Similarly, prospective data are being collected to determine whether Patient Navigators influence treatment and whether Patient Navigators influence treatment and appointment adherence as well as the underlying reasons appointment adherence as well as the underlying reasons for barriers to specific interventions in this underserved for barriers to specific interventions in this underserved minority population.minority population.

Grabam S et. Al Cancer 2008

Racial Differences Pertaining to a Belief about Lung Cancer Racial Differences Pertaining to a Belief about Lung Cancer SurgerySurgery

Results of a Multicenter SurveyResults of a Multicenter SurveyMitchell L. Margolis, MD; Jason D. Christie, MD, MS; Gerard A. Mitchell L. Margolis, MD; Jason D. Christie, MD, MS; Gerard A.

Silvestri, MD; Larry Kaiser, MD; Silverio Santiago, MD;Silvestri, MD; Larry Kaiser, MD; Silverio Santiago, MD;and and

John Hansen-Flaschen, MDJohn Hansen-Flaschen, MD

Objective: To assess the prevalence of the belief Objective: To assess the prevalence of the belief that air exposure during lung cancer surgery might that air exposure during lung cancer surgery might cause tumor spread cause tumor spread

Setting: Philadelphia VAMC, Los Angeles VAMC and Setting: Philadelphia VAMC, Los Angeles VAMC and Medical University of South CarolinaMedical University of South Carolina

Patients: 626 consecutive patients in pulmonary and Patients: 626 consecutive patients in pulmonary and lung cancer clinicslung cancer clinics

Ann Intern Med 2003; 139:558-563

Results:Results:

3838% of patients % of patients

6161% of whom were AA and % of whom were AA and

2929% whom were Caucasians) stated that they % whom were Caucasians) stated that they believed air exposure at surgery causes tumor believed air exposure at surgery causes tumor spread; spread;

1919% of AA stated that they would oppose surgery % of AA stated that they would oppose surgery because of this belief. because of this belief.

1414% would not accept their physicians assertion % would not accept their physicians assertion

that the belief was false.that the belief was false.Ann Intern Med 2003; 139:558-563

Conclusion: Conclusion: Belief in accelerated tumor spread at surgery is Belief in accelerated tumor spread at surgery is

prevalent among pulmonary outpatients and lung prevalent among pulmonary outpatients and lung cancer patients facing lung surgery, particularly cancer patients facing lung surgery, particularly African Americans. This finding may pertain to African Americans. This finding may pertain to key racial disparities in lung cancer.key racial disparities in lung cancer.

Ann Intern Med 2003; 139:558-563

SolutionsSolutions

Role of The Patient Navigator

Founder of Navigational ApproachFounder of Navigational Approach

1989 American Cancer Society, Report to the Nation1989 American Cancer Society, Report to the Nation

Cancer in the PoorCancer in the Poor

2005 Patient Navigator Outreach and Chronic Disease 2005 Patient Navigator Outreach and Chronic Disease

Prevention ActPrevention Act

June 2007 Harold P. Freeman Patient Navigation Institute openedJune 2007 Harold P. Freeman Patient Navigation Institute opened

Harold P Freeman, M.D. Associate Director of NCI Director of the NCI Center to Reduce Cancer Health Disparities

ConclusionConclusion

Socio-economic factors and cultural sensitive play Socio-economic factors and cultural sensitive play a important role in health disparities among a important role in health disparities among minority populationsminority populations

Patient Navigator programs have proven benefit Patient Navigator programs have proven benefit in reducing the impact of health disparities in reducing the impact of health disparities

Additional studies are need to evaluate the Additional studies are need to evaluate the financial impact of such programs on future financial impact of such programs on future health care costhealth care cost

ReferencesReferences

Byers T, Wolf H, Bauer K, Bolick-Aldrich S, The Impact of Byers T, Wolf H, Bauer K, Bolick-Aldrich S, The Impact of Socioeconomic Status on Survival After Cancer in the United States, Socioeconomic Status on Survival After Cancer in the United States, Cancer Cancer 2008;113; 582-5902008;113; 582-590..

Gabram S, Lund M, Gardner J, Hatchett N, Effects of an Outreach and Gabram S, Lund M, Gardner J, Hatchett N, Effects of an Outreach and Internal Navigation Program on Breast Cancer Diagnosis in an Urban Internal Navigation Program on Breast Cancer Diagnosis in an Urban Cancer Center With a Large African-American Population, Cancer Center With a Large African-American Population, Cancer Cancer 2008; 113; 602-607.2008; 113; 602-607.

Margolis M, Christie J.D., Silvestri G, Kaiser L., Santigo S., Hansen-Margolis M, Christie J.D., Silvestri G, Kaiser L., Santigo S., Hansen-Flaschen J, Annual of Internal Medicine 2003: 139; 558-563Flaschen J, Annual of Internal Medicine 2003: 139; 558-563