"Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane."
-- Martin Luther King, Jr.
In 2023, marginalized communities continue to face disparities and barriers to accessible care. Among women diagnosed with breast cancer, Black women are still more likely to die, and research suggests that the LGBTQ+ community is carrying a . Why has the needle toward equity barely moved? And how do we move from discussion to action to create meaningful, lasting impact for our communities, making health and wellness accessible and equitable for all?
If ever there was a time for renewed commitment to the health equity movement, that time is now. But that commitment must last longer than this moment; we cannot allow a fractured system and fractured relationships to undermine patient-centered innovation now and in the future.
Our fractured healthcare system is characterized by skyrocketing healthcare spending, the lingering impact of the COVID-19 pandemic, and hospital closings in areas of need. Despite COVID driving healthcare spending in 2020, we witnessed the near collapse of systems stretched too thin to bear the weight of the many comorbid conditions exacerbated by COVID. We visualized in real time how health disparities affect communities with decreased resources, education, and access. In cancer care, we are still seeing the pendulum effect of delayed screening, decreased trial enrollment, treatment plans altered, and COVID-related delays and their impact on recurrence and mortality. Notably, trust remains a key barrier to a true partnership with our health systems, as rampant misinformation about vaccines, cancer, clinical trials, and modern medicine has exploded on digital platforms and social media. Medical mistrust is at an all-time high, not just among Black and brown communities, but in all communities across America. Sadly, those most affected will be those who bear the greatest burden of disease and possess the fewest resources to educate and empower themselves.
Doctors like to say cancer doesn't discriminate, but we know there are racial, geographical, and socioeconomic differences in cancer incidence, treatment, and outcomes. Rather than refute their existence, we need to recognize the facts that people of different backgrounds and races experience health, healthcare, and disease differently, and all of these contribute to healthcare disparities. The statistics are often recited but haven't changed: Black women are to die from breast cancer than white women, despite being less likely to be diagnosed with it. We are more likely to be diagnosed with later-stage disease and at younger ages, but we are less likely to be offered a clinical trial and less likely to complete standard-of-care therapies. Clearly, there's work to be done by every stakeholder -- physicians, researchers, and clinician and industry leaders -- to make sure that each patient is offered equal opportunity to live and to live well.
Right now, we have the opportunity of a lifetime to take real, actionable steps -- whether we are healthcare providers, payers, or health systems -- to affect change. Addressing the "three R's" -- resources, research, and racism -- is a great place to begin and a cogent way to track our metrics of success from addressing these structural determinants.
"Resources" refers not only to educational materials and access for patients, but also community-based resources, such as cancer centers. Patient navigation, trial accrual, and enrollment are all essential. Additionally, patient-facing resources that reflect the population we wish to address can reinforce a cancer center's commitment to clinical research that will improve the lives of those within the health system's service area.
"Research" refers to making sure clinical studies are focused on the right populations. If Black patients in underserved communities receive care at , we need to bolster the in these areas. It will take the collective work of pharmaceutical companies, academic partners, cooperative groups, and clinicians to make this a reality.
The "racism" piece should be clear: we have long understood the impact of implicit bias on patient care. Young Black women with breast cancer are diagnosed at of their white counterparts, but are to face barriers to receiving follow-up care and completing therapies. Black women are less likely than non-Hispanic white women to receive for triple-negative breast cancer. In many cases they are not offered clinical trials despite being eligible and interested.
In order for the dream of healthcare equality to become reality, beyond the moral imperative, we need all key stakeholders to recognize the value and return on investment of health equity, as well as the consequences of continued disparities on our overburdened health system. We need grant-funding agencies to place a premium on research that more closely reflects the burden of disease. We need empathetic scholars, armed with data and inspired by their ideals, to create new ways of analyzing the intersection of ancestry and the epigenetic changes in individuals with similar social determinants of health (rather than race alone) and determined to make personalization of care a reality for every individual facing a cancer diagnosis. This will ensure that as we embark on the journey of our lifetime -- to end cancer as we know it -- no one is left behind.
is a breast surgical oncologist and medical director of the Grand View Health cancer program.
Disclosures
Gary has served as medical advisor/contributor for national breast cancer advocacy organizations, including Living Beyond Breast Cancer, Touch, the Black Breast Cancer Alliance, Tigerlily Foundation, the Chrysalis Initiative, and the National LGBT Cancer Network.