Seeking Solutions to Reduce Racial Inequities in Cancer Care : Oncology Times

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disparities; racial inequities:

disparities; racial inequities

Marjory Charlot, MD, MPH, MSc, uses her passion for building patient and community engagement in health care to address racial inequities, particularly in cancer care.

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Marjory Charlot, MD, MPH, MSc:

Marjory Charlot, MD, MPH, MSc

“Often there’s a top-down approach to fixing a broken system. But I believe it’s essential to include those who are impacted by that system—the patients—in the solution,” said the Assistant Professor of Medicine in the Division of Oncology at the University of North Carolina Lineberger Comprehensive Cancer Center. Charlot is also a 2021 recipient of the Conquer Cancer Advanced Clinical Research Award for Diversity and Inclusion.

In the clinic, Charlot specializes in lung cancer with a particular interest in the management of locally advanced and metastatic disease. However, her research focuses on developing interventions to improve cancer care delivery for medically underserved populations. She hopes to expand patient and community engagement to enhance cancer clinical trial participation among minoritized populations, health equity, and awareness of racial/ethnic and socioeconomic disparities in cancer outcomes.

Married and the mother of two elementary school-aged children, Charlot was just about at her children’s age when she first gained a respect for medicine and its power to help people.

“The person who influenced me most was my childhood pediatrician,” she told Oncology Times. “I’m Haitian-American and my pediatrician was also Haitian. He was a fixture of our community, caring for us in his clinical practice, as well as during home visits. He inspired me to the extent that I knew that I wanted to have a close connection to the community. By high school, I realized the science/health was certainly going to be my path, and community engagement was definitely going to be part of that future.”

Finding Her Way

After graduating with a major in biology and a minor in African-American studies from Tufts University, Charlot took a year away from the classroom to help identify volunteers for a middle school higher-achievement program in Washington, DC. Thereafter, she did post-baccalaureate work at Howard University and earned a master’s in public health from George Washington University before receiving a full academic scholarship to medical school at the University of Iowa.

Though Iowa was a big change from her institutionally blessed hometown of Boston, Charlot explained, “The curriculum in Iowa was quite innovative back in the early 2000s. They made a point of focusing on patient care early on in the curriculum and ensured we were well-trained to engage with patients and provide patient-centered care that was respectful and mindful. My training at University of Iowa was instrumental to my level of comfort in interfacing with patients and getting to know them on a personal level. I’m grateful for that experience.”

While at Iowa, an internal medicine rotation on the oncology service was pivotal in enabling Charlot to hone in on cancer care. “I concentrated on thoracic oncology, in particular, because when I was training, there wasn’t much to offer patients with metastatic lung cancer. Oftentimes, patients with lung cancer are subjected to marginalization or stigmatization, especially with the high association with smoking. I was drawn to patients who needed the most help, at a time when they were getting the worst news of their lives,” she said. “The human connection meant so much to me.”

Like other oncologists, Charlot recognizes the professional stress inherent in cancer care. “That certainly is a challenge for many people in oncology. I definitely think about my patients even when I’m not physically in the clinic. Have we explored all the options? Do they know that any decision they make should be tailored just for them? Do they know there really is not a right or wrong decision, but what is most important is an informed decision? My stance on being an oncologist is to provide medical information in a way patients can understand it, and then to help them make decisions that work specifically for them.”

Research Interests

Charlot said the division of her professional time leans heavily toward research. “I’m in clinic about once a week and on the ward on the inpatient service a couple of times a year. But the rest of my time is spent doing research,” she detailed. “Patient and community engagement is central to the work I do. My main focus is amplifying the voices and experiences of individuals with cancer and who self-identify as Black or African American. The purpose is to disrupt the status quo of racial inequities in cancer care and identify opportunities and interventions that can dismantle the impact of structural racism on cancer care and outcomes.”

Currently, Charlot is involved in a project funded through Conquer Cancer, working with five Black women with a history of breast cancer.

“Essentially, they’re partnering with me to address this issue of low participation, low enrollment, and exclusion of Black women in clinical trials,” said Charlot. “I am trying to better understand the clinical trial system and why Black individuals in particular are not offered the same opportunities to engage in clinical trials as other populations.”

Black patients typically suffer worse cancer outcomes, said the clinician researcher. The mortality difference between Black women and White women with breast cancer is unacceptable; Black women are 41 percent more likely to succumb to breast cancer than White women. Charlot said data in literature and other media platforms provide some explanations for the disparity in clinical trials, pinpointing racial bias as a big component.

“There are preconceived notions of Black people not being interested, or distrustful in the medical system. However, when we look at historical and contemporary mistreatment of African Americans either through the example of the withholding of effective treatment from Black men in the Tuskegee syphilis experiment, or the multiple recent accounts of Black women being ignored or their symptoms discounted while actively seeking medical care, we can understand the lack of trustworthiness in our health and research systems,” recounted Charlot.

In addition, she said most individuals across all racial groups get their care in community settings. “Oftentimes, therapeutic clinical trials are at academic centers, not community centers, so trials are not accessible to the patients who need them the most. And then there are other factors: the financial toxicity, in terms of people needing to take time away from work if they want to be on a clinical trial; the transportation issue, when multiple lab tests need to be done in a certain [distant] institution. There are also issues related to eligibility criteria for some clinical trials. If a population is disproportionately impacted by different exclusionary co-morbidities, for example diabetes or hypertension, then that population won’t have access. So, it’s multifactorial,” Charlot explained.

“Another barrier is found in providers having bias, sometimes implicit,” she continued. “These providers may not purposely try to exclude Black patients, but their perception of potential barriers may prevent them from even asking Black patients to participate in clinical trials.”

And yet another level of exclusion happens due to systemic factors, she noted. For example, certain community health care practices, where most people with cancer typically receive care, may not have the infrastructure to provide clinical trials. “So regardless of the color of their skin or their self-identified race, a large proportion of the community with cancer is not going to be enrolled on a trial,” she said.

Closing the Gaps in Care

So, what are the fixes? Is there a movement afoot to help reduce these inequities? “Yes,” Charlot said. “On a systemic level, the National Cancer Institute through their NCI Community Oncology Research Program (NCORP) is one opportunity through which the NCI has been able to get clinical trials out to the community; Medicaid expansion and covering the cost associated with clinical trial participation is another. Other opportunities involve engaging with the community and increasing awareness of clinical trials. That’s part of the work I’m doing now; I’m working with community-based partnerships to engage the community in discussions about clinical trials, understanding the barriers, and identifying opportunities for solutions.”

With her aforementioned grant from Conquer Cancer, Charlot is gathering information about various settings in which Black women receive breast cancer care and understanding challenges involved in getting them information they need about clinical trials.

“The next step will be to use technology to address this,” she noted. “We are developing a culturally tailored app that a woman can use when diagnosed with cancer to supply information she needs—right at her fingertips, on a computer at home, or at the local library—to learn about the disease and opportunities for clinical trials. This will empower these women to have these discussions with their providers, particularly if their providers are not proactive in initiating these talks.”

The app is still in its infancy. “Right now, we have the five women on our patient advisory council—that’s what we’re calling them now—but they’re more than advisors,” said Charlot. “They are truly research partners. We are about to undertake interviews of Black women with breast cancer in the community to learn more beyond the women on the council. We want to get a variety of insights and experiences to inform the design of the app.”

Another effort of which Charlot is proud is her participation in the Greensboro Health Disparities Collaborative born out of Greensboro, NC.

“I recently became a member of this community academic medical partnership, which designed this wonderful intervention called Accountability for Cancer Care Through Undoing Racism and Equity (ACCURE). What is fascinating to me is the impetus for this intervention was community-driven, due to the recognition of racial inequities in cancer outcomes. The intervention combines patient navigation with racial equity training of patient navigators, physician champions, and a system that looks at electronic records of surgeons dealing with lung cancers,” said Charlot, adding there is a recognized reality that Black patients with lung cancer are not offered surgery as often as their White counterparts.

“It wasn’t that providers were saying, ‘We’re not going to provide surgery to our Black patients,’ on purpose. I think providers, as a result of implicit bias, were less likely to recommend surgery for Black patients with certain co-morbidities because they had a preconception that these patients were too high risk compared to White patients with comparable comorbidities,” she explained.

Interestingly, once providers were provided with data showing the inequity between Black and White patients with the same co-morbidities, “…accountability finally came along,” said Charlot. “Providers could see their practices were differentiating based on race. Once they got that awareness, it put them in a position to change their practice. And now because there was a patient navigator to help ensure patients were getting the support they needed, like appointment reminders or assistance with any sort of barriers, there was no longer concern about whether or not the patient would adhere to any particular recommendations. The rates of surgery, as well as radiation, for early-stage lung cancer were essentially the same for both Black and White patients. I’m really interested in that model and replicating it in other aspects of cancer care.”

An abstract and preliminary findings about the ACCURE effort in relation to time to lung cancer surgery were presented at ASCO in June 2021. Subsequently papers have been published (J Clin Oncol 2022; doi: 10.1200/JCO.21.01745; Cancer Med 2019;8:1095-1102; NCI Black Patients Are More Likely to Die of Cancer—Here’s How One Group Is Tackling That Cancer Currents Blog 2021; https://bit.ly/3jkR0oc).

Looking Ahead

Asked to imagine the possible impact of her work 5 or 10 years hence, Charlot said, “The ultimate goal for my research is to actually see equitable outcomes. We are in an age of technology where we’re able to assess and evaluate how we’re doing as a cancer-provider community. We need to leverage technology to evaluate our practices and focus not so much on describing these inequities in cancer care and outcomes, but rather on doing something about them, and preventing them from happening.”

How can such an action plan be realized? “My work is just at the tip of the iceberg. I don’t think that the development of an app will totally change the course of inequities in cancer care delivery for Black women. But at the very least, it’s an opportunity to use our knowledge about the fundamental causes of these inequities and try to mitigate and prevent them,” Charlot explained.

She suggested individual oncology practices can be part of the solution in reducing racial disparity in cancer care. “There’s an opportunity for practices to get to know the surrounding community through community outreach, engagement efforts, patient advisors. See patients as people we provide care to, as well as instrumental agents within the community to really promote health and care. Providers can certainly invite patients to voice their feelings and concerns, and really listen to them. We do this to some degree with patient satisfaction surveys, but I wonder if we’re really asking the questions needed to improve care. I would say one of the questions we should ask patients is, ‘What is communication with your provider like, and do you feel the perception of your race (or perhaps gender identity) impacts the information your provider gives you?’ I think we need to be very direct. We must be intentional to be able to understand the ways we can truly improve equitable care in our practices.”

Valerie Neff Newitt is a contributing writer.


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