S2E7 | It’s time to end disparities in cancer care. Here’s how.
S2E7 | It’s time to end disparities in cancer care. Here’s how.
Important progress is being made in the fight against cancer—namely, cancer incidence and death rates continue to fall across the United States. But some minority groups are immune to those advances, negatively impacted by a cancer-disparities trend that disproportionately impacts certain racial, ethnic and socioeconomic demographics—none more than the African-American community. In this episode of Focus on Cancer, our host, Pat Basu, MD, MBA, President & CEO of Cancer Treatment Centers of America® (CTCA), welcomes Anita Johnson, MD, Breast Cancer Program Director at CTCA®, for a robust conversation around the impact of cancer disparities, and what we can do to address them.
Anita Johnson, MD, FACSBreast Cancer Program Director
Dr. Pat Basu: Hi, I'm Dr. Pat Basu, President and CEO of Cancer Treatment Centers of America and the host of Focus on Cancer. Today's show is incredibly important, not just in the world of cancer, but in the world of medicine at large, and frankly, in American society. We're going to be talking about healthcare disparities and how they affect cancer patients. Joining me as our special guest is Dr. Anita Johnson. Dr. Johnson leads the breast cancer program at CTCA. She is a nationally renowned breast surgical oncologist and Dr. Johnson, I just want to say thank you so much for taking the time for joining me on the show today.
Dr. Anita Johnson: Thank you for having me, Pat.
Dr. Pat Basu: Well, before we dive into what I think is one of the most important topics in medicine and society today, I love to ask our guests and those with distinguished medical and scientific careers, such as yourself, what was your inspiration to go into medicine and to become a doctor treating cancer patients?
Dr. Anita Johnson: Well, I tell everyone I'm a self- confessed nerd. I was involved with STEM before it became fashionable. So I as well as I have had family members, as well as people in my community, in which they weren't unable to overcome very curable diseases. And so I was always interested in how we can make our communities better. I've had great mentors across my career from college, through my surgical program and bottom line, I enjoy taking care of women.
Dr. Pat Basu: Fantastic. Well, nerds... Sorry, self- confessed nerds, as you called it, they certainly make the world a better place and I appreciate the humor there. But on a serious note, we are so lucky that you made that decision. And I know from my own personal experience with talking to your colleagues and patients, how grateful we are that you chose to fight cancer with everything that you have. Getting into today's topic, you come at it from not only being an expert in the field of cancer and medicine, also as somebody who is just a very critical thinker and data driven with an expertise in healthcare disparities. But just on a personal note, as a woman of African- American descent, you went to the Morehouse School of Medicine, a historically black institution. How does your unique insight just as an individual play into today's topic?
Dr. Anita Johnson: Just training at Morehouse School of Medicine of course, we were very well aware of disparities, particularly in the African- American community, as well as individuals who are underserved. And so for me, I've been a breast surgical oncologist for over 20 years, was one of the first breast surgeon oncologist African- American in the United States. And so, there are very few people of color in oncology. And so it was always important to me to be able to provide my patients with top- of- the- line care. Throughout my training, I've seen patients present with very late stage disease, and we'll get into it later. But the bottom line is that it's been an issue for several decades and we can do better and we must do better.
Dr. Pat Basu: Absolutely. And we see this in today's society so much while it's not a prerequisite necessarily that a provider of service or care necessarily has to be of one same gender ethnic background. There's no question that inaudible that whether it is educators or law enforcement or other leaders, certainly physicians, when patients or minorities are able to see minorities sitting across from them in those positions of authority or power, not only is it impactful to their decision- making and in this case, their care, but I think we would agree in society, it is certainly inspirational to the generation behind. So really, really grateful to you and in so many ways. So with that, let's really get into the meat of today's topic. So we're doing it at a time of great advancements in cancer at large. You and I both see at CTCA and the oncology community in general, this is an exciting time with breakthroughs in cancer, some of which we've covered on the show from immunotherapy and precision medicine to earlier diagnosis and survivorship. So on one hand, we're incredibly proud to be pushing that frontier, but at the same time, as we talk about access in American healthcare and in society, if it doesn't apply to people, or if those breakthroughs aren't accessible to people, then that battle is at best half won. So, specifically, we see that the evidence is overwhelming that minorities have higher rates of diagnosis. When they get cancer, they have worse outcomes. And for African- Americans in particular, cancer incidents and mortality, essentially across the board, is worse than it is for other ethnic groups. So can you give us... Kind of frame this topic for us, give us some examples of what we're seeing in terms of healthcare disparities in cancer?
Dr. Anita Johnson: Great. So when we look at particularly specific cancers and we look at breast cancer patients, African- American women, they have an equal rate of getting breast cancer, but when we look at outcomes, survival rates, they have a 40% chance of dying from breast cancer as compared to women who are of Caucasian descent. When it comes to prostate cancer, we are so happy that the survival rates are much better, but when it comes to African- American men, they're dying at a rate twice as high as white men. And there are other disease entities, including cervical cancer, in which it's detected in women who are Hispanic descent, and those who are African- American. But even in that group, African- American women are dying at a higher rate. And location is so key. The National Cancer Institute, they recently just evaluated the Appalachian mountains in which, when we look at colorectal cancer and lung cancer, those individuals are dying at alarming rates because they're diagnosed at such a late stage. So Native Americans, they have a higher incidence of renal cell carcinoma, and the survival rates are also poor in those areas.
Dr. Pat Basu: We talk as physicians a lot in terms of numbers and statistics, but I mean, literally that means for every 100 cancer deaths that a woman has from breast cancer, if they're white, that means that there's 140 equivalent deaths among black women, which is a shocking, shocking number when standardized for the type of cancer and stage, et cetera. So really remarkable, and I'm glad that you did mention that this is across many ethnic groups. You mentioned Native Americans, Alaskan natives, it affects socioeconomic status tremendously. The National Cancer Institute's noted that in rural Appalachia, given the poverty rates, the incidents of lung cancer, colorectal cancer, cervical cancer are significantly higher than those in more urban areas. That said, the disparities do seem to be hitting black Americans particularly harder, affecting them at a much higher rate. How would we summarize the reason for that?
Dr. Anita Johnson: There are several reasons. Access to care is important. Just access to a standard of care treatment options is always an issue. When we look at certain communities, they either have poor quality insurance or they have no insurance at all. That plays a factor when it comes to screening and early detection, and also just trusting the medical community. Sometimes, there is an issue in the African- American community where we're not trusting the treatment options we're given. When it comes to lifestyle factors, you must be in an environment where healthy foods are available, where you're able to exercise, your environment is conducive to that, as well as not having access to clinical trials, or having providers who are very familiar with your community as far as being able to treat you in a reasonable fashion.
Dr. Pat Basu: Yeah. It certainly is multifactorial and I think one of the great issues that we deal with this issue in American society is that it's not only multifactorial, but in many ways, it's structural, right? It goes back in to longer issues and things that are not just an easy fix. That being said, I think we all agree this as a huge, huge issue. One that is worth the attention of all of us as leaders, as physicians, to try and essentially eliminate this issue. If we were to talk about a lack of awareness in the context of cancer disparities or screening, understanding family history, can we talk a bit about that particular factor first?
Dr. Anita Johnson: Right. Awareness is key. As we all know, early detection saves lives. And so really acting on your symptoms and knowing that if you have a strong family history of cancer, that you may need to start a screening at a much earlier age. And if you are diagnosed, just being aware that the treatment options have changed dramatically over the past decades. And so now surgery is more or less invasive when it comes to a medical therapy such as chemotherapy. We now have what we call oral chemotherapy. So some patients are just taking a pill for their cancer treatment. And when it comes to radiation, we're definitely working on some of the side effects of radiation. And nowadays for some cancers, the time period for radiation treatment is much less. So awareness is this key. Access to prevention is key as well. If you have a very strong family history, then we screen you more often than the normal population, as well as provide you with some preventive measures to lower your risk. So those are some solutions that we have in place for those who are at risk of getting any types of cancer.
Dr. Pat Basu: So Dr. Johnson, I think that's spot on. Awareness might be a part of the issue, but even as we increase awareness... And let's be honest, I mean, awareness of cancer screening and those things is an issue across the board. And we know as physicians, the power of early detection and screening, but it's a battle we constantly fight is to get those words out there. But lack of access, even if you fix awareness, lack of access can still be a tremendous barrier. I remember long ago, a patient outside of oncology, and we were talking about the benefits of eating healthy and it was a black patient and I'm sort of paraphrasing, but the issue wasn't... He nodded his head and said, absolutely, I know I need to eat healthier, but he didn't have a grocery store access to eating healthy, anywhere reasonable for him to actually take that advice. And that parallel we see here in cancer as well. So even as we increase awareness, we also have to increase access. Talk again about some of those issues where across the board, there is just barriers to access for minorities and for black Americans in particular, in oncology.
Dr. Anita Johnson: There are several issues when it comes to access or transportation to healthcare facilities to obtain screening, or just seeing your primary care physician. That's often the issue. There are several food deserts, you may have a convenience store that's nearby, but having a store that has fresh fruits and vegetables, that's key. Having the ability to exercise outdoors. Sometimes, there are communities in which it's just not safe. And so, that's where the limitations lie. And when we talk about just being a cancer patient, we know that in most cases, clinical trials are beneficial, but access to clinical trials, if you live far away, distance is an issue, and you may not be a candidate to... Well, you may not have access to those multiple visits for your treatment. And so in that way, sometimes patients delay care, including even if you're not on a clinical trial, whether it be surgery, chemotherapy, or radiation. So access to care is multifactorial. And hopefully in the next few years, we can address some of those issues. I think digital media is very important when it comes to educating individuals about prevention and screening. And with COVID, we are thankful that it has shine a light upon disparities, but now we know that with digital media, we have several opportunities to educate those patient populations.
Dr. Pat Basu: Yeah. That's very well said. And you mentioned if you don't have that access to a critical clinical trial, then that could deny a potentially life- saving option. Certainly, if there are barriers to screening or barriers to medical insurance, or a proper insurance that enables, with great comfort, a patient to get that early screening and get that early detection and diagnosis, if there's barriers there, that's going to certainly worsen outcomes. And then you did touch on nutrition, which again, just to remind our audience, is such a major protective factor... Good nutrition has such a great protective factor in the fight against cancer and bad nutrition is really a risk factor to developing cancer obesity in particular, it's been really proven to be a high risk factor for increased odds of developing cancer, which really leads us into lifestyle and societal issues. Dr. Johnson, you mentioned earlier the notion of trusting the healthcare system. Let's talk holistically about what are the cultural or lifestyle factors that are at play here, and what is their role in perpetuating these healthcare disparities?
Dr. Anita Johnson: When we talk about culture in certain communities, we're well aware that there are some trust issues. And so, when we look at that, that's where it becomes a significant challenge. And so oftentimes, just hearing the C- word or cancer diagnosis, patients feel that they don't have an opportunity to overcome this. And so that's where the education comes into play. Because as we all know, when we look at overall cancer death rates, they are declining. And so the treatment options have changed tremendously. So just having a fatalistic attitude puts us in a bind. Some patients delay their care thinking that they don't have choices. And so if you're detected at a much earlier stage, then we know the survival rates are much higher. And so today, we know that patients in most cases, have an opportunity for cure, but our goal is to get those individuals at most risk into our system at a much earlier stage.
Dr. Pat Basu: Dr. Johnson, I really couldn't agree with you more and as you and I work together, one of the things I love about your approach is you're very solution oriented. And you know from my perspective, it's absolutely about understanding the problem, what's causing the problem, but really focusing on fixing the problem. And I am a believer that no matter how complex the problem, or how grand the challenge that no problem is unsolvable, no problem is insurmountable. So this is clearly one of those huge issues in society and healthcare, and definitely in cancer care. So let's talk about solutions because I know you and I agree that this is something that we must solve and something that we can solve. So how can we begin to tackle the issues of disparities in cancer care? How would you frame the approach to next steps or solutions to quickly mitigate and eventually, totally dissipate this issue?
Dr. Anita Johnson: Right. Well, I wish we could quickly get rid of this issue that we wouldn't have to have continued conversations. It will still take some time. I think when we look at health disparities, we oftentimes talk about the numbers and the issues, but we must act on them. So as we all know, there are certain communities who present with late stage disease at a much earlier age. And so in those patient populations, I think policy will be beneficial to make sure that those patients are being seen at a much earlier age. I strongly feel that screening one size does not fit all. As we know, African- American women can present with late stage disease at a much earlier age. And so when we look at family history, we must act on it. Individuals come into our hospitals on a weekly and daily basis who have an extensive family history. They've seen multiple providers, but no action has taken place. The insurance companies, we need them to be a friend to us in this area, and agree that this patient, particularly with her risk factors, should have screening done at a much earlier age. And when it comes to just the socioeconomic issues, we know that societies who are well- educated, we know individuals who are well- educated, and who are gainfully employed, they have more access to healthcare because they don't have the fear of seeking care because they're well insured. And so the bottom line when it comes to addressing health disparities, is that patients who are symptomatic, we advise them to act quickly. And so action is the key in eliminating health disparities.
Dr. Pat Basu: Yeah, that's a powerful message is there's a lot of acknowledgement now of the issue and the numbers, but the actions definitely speak louder than words. And we know in cancer, where speed definitely matters, acting and acting boldly is important. In many ways, there are blueprints out there that other bodies have put out. Esteem bodies that we're a part of and support, ASCO, National Cancer Institute, they have a program called the Center to Reduce Cancer Health Disparities. What's in some of their blueprints that have been published?
Dr. Anita Johnson: They have an extensive program. They have some initiatives dealing with urban areas, as well as rural health areas. Just trying to educate individuals in the community about health disparities, particularly in oncology. They have support systems in which they offer grants to certain institutions who focus on oncology disparities. And so they've just done a ton and just monitoring those patient populations who are at most risk. And so we're just so very fortunate that certain organizations have provided us with a blueprint so that we can follow. Because we have proof that once you are out in the community, that we can eliminate some of the disparities, but it will take all of us every day.
Dr. Pat Basu: Couldn't agree with you more. Along those lines, I think it's incumbent for leaders to always listen and with great authority comes great responsibility. And as a CEO of a large national care provider and the only national cancer provider, what can other leaders or other CEOs such as myself, what can we do to help reduce this problem? Or act, as you said, instead of only, not only, but understand inaudible talking about it, but really acting. What are the things that can do? What are the things that other other leaders should be doing?
Dr. Anita Johnson: Well, I'm so thankful that you brought this up or just having this discussion, but that's the main thing. Allowing us to talk about this on a local and a national level is absolutely key. Providing programs which provide solutions to our patient populations, that's key. Having a diverse work environment. And so we know throughout the country, companies that have a diverse employee portfolio, they actually do better and so it's not just based on ethnicity, gender, as well as socio- economic backgrounds. It just makes our company better. It helps us to take care of our patients better. And so all of those factors play a huge role when it comes to administration of supporting us in health disparities in oncology care.
Dr. Pat Basu: Terrific, terrific. And you and I also share a mission to improve health policy and a passion for those changes at the societal or the American level. At a policy level, Dr. Johnson, are there things that we can specifically advocate for or work on to reduce disparities in cancer care and healthcare at large?
Dr. Anita Johnson: Exactly. So when it comes to screening, screening, as I stated earlier, patients who have strong family histories, they need to get in the system at a much earlier age. And so that's where we need policy. We've had policy and the most recent years when it comes to say for instance, women being diagnosed with extreme dense breast tissue. We now have policies which demand that the patient be notified that they have dense breast tissue. And in that case, women are allowed to get breast MRIs. And it does depend on their insurance company, but that's one policy where we've seen some impacts. When it comes to high risk populations, for decades, we know that women who are of Ashkenazi Jewish descent, they have the opportunity to have genetic testing. But as we know for African- American women, they have up to a 30% chance of having a genetic mutation. And so we've really not addressed that patient population. So I think that's where a policy will impact risk treatment, risk strategies, as well as cancer detection rates and with hopefully, the benefit of increasing survival rates. So it depends on the patient population, family history, and if we have coverage from our partners in insurance.
Dr. Pat Basu: Well, Dr. Johnson, this has been a time period where I think not only due to the pandemic, have we felt physically separated, but due to a number of issues in society, I think many Americans have felt tension or certainly divided. And at the same time, I do believe that all of us believe in coming together again. And I think as doctors, as leaders, as members of the cancer care community and healthcare at large, this is just such an important issue that we must really rally around and gather around. So I want to thank you for just your incredible passion, the work you've done in fighting cancer, as well as the work you are doing and continue to do in helping reduce these disparities. Any final thoughts that you have, advice you want to share, or anything that you want to close with?
Dr. Anita Johnson: Well, I just really advise that we continue to have these discussions, but we must act on the data that we have because it's important. It's the work that we promise our patients that we would do. And so I look forward to in the future, where all patients achieve health equity in this area, because we know the outcomes will be substantially better.
Dr. Pat Basu: Could not agree with you more. I know I share that vision. I know so many of us do and really look forward to making bold strides in that direction. And again, thank you for your leadership in this unbelievably important area. Thank you for all that you do for patients across the country. And thanks again for taking the time away from those patients to spend a little time with me on the show here today. Thanks, Dr. Johnson.
Dr. Anita Johnson: Thank you so much. Thank you for having me.