November 16, 2022
4 thousand trains
Florez (Duma) N, et al. Equity in cancer care and survivors. Presented at: 40th Annual Chemotherapy Foundation Symposium: Innovative Cancer Therapy for Tomorrow; Nov. 9-11, 2022.
Florez (Duma) reports consultant/advisory roles at AstraZeneca, Boehringer Ingelheim Oncology, Bristol Myers Squibb, Genentech, Janssen Pharmaceuticals, Merck, Neogenomics, and Pfizer.
Understanding patients’ cultural and historical views of health care can promote equity in cancer survivorship, reduce financial costs and even save lives, according to a speaker at the Chemotherapy Foundation’s symposium.
“As oncologists, we often talk about diagnosis—diagnostic challenges and diagnostic discrepancies—but the patient’s journey only begins at diagnosis,” Narjust Florez (Duma)doctor, associate director of cancer services and thoracic oncologist at Dana-Farber Brigham Cancer Center, said during the presentation. “We need to ask patients how they see their survival, what is important to them and what their expectations are for surviving cancer and its different stages.”
Cancer survivors focus on health and wellness from diagnosis to the end of life, a period in which survivors face many physical, mental and social challenges, Florez said.
“When many of our patients are first diagnosed, it’s all hands on deck. Their neighbors are helping, people at church are praying and friends and family are posting on social media,” she said. “However, most of this disappears as time passes and the survivor’s experience changes.”
Factors known to influence cancer survival include associated comorbidities, performance status, social support, and whether the patient is married vs. single. single, according to Duma.
“A cancer diagnosis and treatment is very stressful and we often see many marriages end during treatment. “For patients, their marriages are affected by fatigue and other adverse effects of cancer,” Florez said. “[My colleagues and I] conducted a study in 2019 involving 400,000 patients with stage IV lung cancer. We found that men who were married to a woman had better outcomes compared to men who were widowed, single or divorced. However, when we looked at this in women, it didn’t matter if they were married, divorced or single. Their lives were unaffected by this episode.”
Florez said that although divorce is common after a cancer diagnosis, it is not usually discussed between doctor and patient.
“The marriage may have already been in a challenging place, but when we add the stress of cancer and treatment, it makes it even more challenging for a couple,” she said. “So it’s important to integrate caregivers into survivorship expectations and even call them on FaceTime when the patient is in your office to make sure they’re on board and hearing the information as well.” The same can be said for patients’ grown children – include them in the conversation over the phone or FaceTime if they can’t come into the office.”
Financial toxicity is another factor that affects survivors’ experiences.
“Financial toxicity is real,” Florez said. “Our patients change jobs or lose jobs; they can go from full-time to part-time, and a lot of money goes into cancer treatment.” Even parking at the clinic affects patient decisions, according to Florez.
“For example, I have two clinics – one has free parking and the other doesn’t,” Florez said. “All my patients want to go to the other clinic, the one with free parking.” We have better technology in the clinic with expensive parking, but the parking is what makes the difference for the patient and that’s important for us as doctors to understand.”
Doctors should consider the financial impact of treatment plans beyond the cost of parking and food, she said.
“We often forget that when patients are paid hourly, it’s not just the parking that affects them or a mediocre lunch in the hospital cafeteria, they’re not making money while they’re in the hospital,” Florez said. “Patients are spending more money but not making the same money.”
Cultural, historical attitudes
Cultural and historical beliefs about patients’ health care often influence their behavior, Florez said.
“For example, some patients may take certain supplements or drink certain teas that may adversely affect their health. I had a Dominican patient who was drinking tea leaves [a plant] which helps in weight loss. However, the tea made the side effects of hypophosphatemia and hypomagnesemia worse. Understanding our patients’ cultural beliefs can save our patients’ lives and reduce even more unintended healthcare costs.”
However, some non-medical remedies do work, she added.
“I am a fourth generation doctor. My grandmother is a pediatrician and will give me tea for period pains which, believe it or not, really helps. Grandma’s recipes are grandma’s recipes because they work and they are passed down from one generation to the next,” said Florez. “Instead of dismissing the patient who brings this information to you, be open about it because they’re going to do the same thing.” It’s better to ask them what remedies they use and review the remedies to see if they will interact with their cancer drugs.”
Other patients’ faith in the health care system stems from history, she added.
“There’s also a question of offering a patient a clinical trial and the patient responding by saying, ‘I’m not your test subject.’ That comes from a place of fear, not a place of confrontation,” Florez said. “Ask the patient what worries them about clinical trials and what they know about clinical trials. Some patients bring up historical events such as the Tuskegee Experiment, which can be difficult. Instead of telling them you weren’t even alive when this happened, instead say, “I’m sorry your community went through this. Let me explain to you what a clinical trial is in oncology.'”
Florez said cultural humility will help clinicians interact with cancer survivors and understand the three principles — a lifelong commitment to learning and critical self-reflection, a desire to redress power imbalances within provider and client, and institutional accountability and mutual respect based on trust.
“Take the time to understand the patient’s culture and rituals and adapt their care and treatment accordingly,” Florez said.