Health Disparities in Marginalized Patient Populations with Cancer

Health disparities in cancer care are extremely prevalent, and many speakers at the ONS 2023 Congress highlighted relevant disparities among patients with multiple myeloma (MM) across the oncology journey. In general, MM is a malignancy with one of the greatest disparities, with a 2- to 3-fold higher incidence in Black Americans versus White Americans; 10% of Black patients have monoclonal gammopathy undetermined significance, a precursor to MM. The average age at onset of MM is younger in most other races compared to White patients: 65 years in Hispanic patients, 66 years in Black patients, 69 years in Asian patients, and 71 years in White patients. Overall, survival rates are higher among Black patients versus White patients, and Hispanic patients tend to have a lower overall survival than any other race or ethnicity. Black patients are less likely to receive life-extending therapies; however, it has been shown that Black patients achieve better outcomes when they receive equal therapy. Nurses play a vital role in recognizing and reducing health disparities and should be aware of higher rates and earlier age at onset in Black patients. Nurses can also strive to become aware of potential conscious or unconscious bias, ensure equal access to centers of excellence and supportive care, engage each patient, and encourage Black patients with MM to connect with International Foundation Outreach.

In the session “One Size Does Not Fit All: Cancer Survivorship in Diverse Populations,” Dr Megan Mullins and Dr Lauren Ghazal highlighted health disparities in cancer survivorship in LGBTQ+ and adolescent and young adults, or AYA, populations. In general, the disparities that LGBTQ+ and gender minority cancer survivors face are driven by a history of marginalization and current biases from a lack of cultural competence. LGBTQ+ data and gender identity data are not collected in the oncology setting, which harms the ability to evaluate outcomes or disparities and can signal that patient gender identities are not welcome. Leadership support, training, and promoting a safe environment within the healthcare system are necessary components to collect LGBTQ+ and gender identity data. Efforts may include LGBTQ+ cultural competence programs, nondiscrimination policies with explicit LGBTQ+ and gender identity protection, signage, badge pins or stickers, and healthcare professional introductions using pronouns. Survivorship in this population can be influenced by the experience and expectations of prejudice and discrimination events, concealment of gender orientation, and internalization of social stigma. Coping responses to deal with these disparities, such as increased drinking, smoking, isolation, and decreased physical activity, can lead to mental health concerns and decreased access to healthcare. To improve these disparities, a focus on trustworthiness of the healthcare system is necessary in order to provide an environment that allows for disclosure of LGBTQ+ and gender identity that will better mental health and address unmet survivorship needs.

Dr Ghazal then discussed cancer survivorship concerns in AYA patients and how survivorship may vary by life stage. AYAs are diagnosed anywhere from age 15 to 39 years (definitions may vary by country) and often experience increased disparities in care. AYAs have an overall 5-year survival of 85% and are considered “survivors” at diagnosis. Transition of care can be a hurdle for AYAs as they transition from pediatric to adult and acute care, to extended survival, to permanent survivorship. Other barriers to care among AYAs include timing of diagnosis, insufficient awareness of cancer risk and symptoms, lack of a “home,” and limited long-term follow-up, as well as differences in tumor genomics and biology. Many aspects of an AYA’s life are disrupted with a cancer diagnosis, including future plans, fertility, body image, career or education, family dynamics, and financial situations. AYAs are more likely to have competing financial demands and often have a shorter work history, making them more susceptible to bankruptcy and medical debt. AYA research is limited by low referral rates and limited availability of clinical trials, leaving room for the opportunity for formalized AYA oncology programs, access to protocols, decreased study enrollment time, and participant benefits.

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