Most cases of oropharyngeal cancer are positive for the human papillomavirus, but among Blacks, 55.3% of cases are HPV-negative, and HPV-negative cases are, to say the least, understudied, said Babak Givi, MD, associate professor of otolaryngology–head and neck surgery at New York University Grossman School of Medicine, in a virtual session at the Combined Otolaryngology Spring Meetings (COSM) in April (Otolaryngol Head Neck Surg. 2021;164:131-138).
Explore This IssueJune 2021
“How many clinical trials are ongoing for HPV-negative oropharyngeal cancer?” he said. “The answer is zero. We had one trial that was closed. We aren’t even looking at the problem.”
The example was one among many described in a session on inequities in head and neck cancer, a series of talks that was a drumbeat of issues facing minority populations, but with suggestions on ways to improve.
Dr. Givi presented two graphs—one showing the diverging survival outcomes between HPV-positive and HPV-negative oropharyngeal cancers and one showing the diverging survival outcomes between Blacks and Whites. Both graphs looked practically the same. “If this isn’t an example of disparity, I don’t know what is,” he said.
Gaining Cultural Competency
Loren Saulsberry, PhD, assistant professor of health policy and politics at the University of Chicago, said shifting demographics in the U.S. will heighten the need for cultural competency. For instance, the backgrounds and experiences of physicians and their patients frequently differ, which could have an effect on health equity, she said.
Clinicians, she said, should keep a careful eye on who’s coming in for care and take into account their life situations so that their care is “truly personalized.” “What’s the patient experience when they visit these health encounters?” Dr. Saulsberry asked. “What are patient values, beliefs, and preferences regarding specific types of care? Where might opportunities exist for clinicians to align the care delivered with patient values?”
Sidharth Puram, MD, PhD, assistant professor of otolaryngology–head and neck surgery at Washington University in St. Louis, said understanding health inequities isn’t as simple as considering one race or another at higher or lower risk for a disease. Rather, it’s thinking carefully about how demographic characteristics and their interaction are vital.
For instance, he said, males are more likely than their female counterparts within a matched racial cohort to have a higher risk of oral cavity cancer, Black males are more likely to have cancers of the larynx compared to other racial and gender subgroups, and Hispanic females have a very high percentage of oral cavity cancers compared to other subsets of cancer (Oral Oncol. 2020;104:104609).
“We can’t take a broad, categorial approach to these issues,” said Dr. Puram. “There’s actually a lot of nuance related to the pathology and adjuvant treatment that might be involved.”
Cultural variation in healthcare is more than the immutable traits of a patient, Dr. Puram added. It also involves diversity in beliefs. For instance, one person’s idea of palliative care —say, medical treatment of symptoms—might be very different than someone else’s—say, leaving everything in God’s hands. Physicians need to be aware of how their own beliefs and values differ from those of their patients, honestly assess their own willingness to accept these differences, and make adjustments in how they think and behave, Dr. Puram said.
Understanding Rural Patients
About 20% of Americans live in rural settings, and they’re more likely to report fair to poor health status, to be obese, to be uninsured, to report putting off medical care because of money concerns, and to have higher rates of poverty. For otolaryngologists treating patients from rural areas, adapting to the culture can be a tricky proposition, said Eric Adjei Boakye, PhD, assistant professor of population science and policy at the Southern Illinois School of Medicine in Springfield. Rural culture involves a strong sense of independence, an emphasis on family, conservatism, and a strong influence of faith, social connectedness, and trust, he said.
Visits with patients from rural areas could differ from other types of visits, added Dr. Adjei Boakye. When seeing a patient from a rural community, for instance, it might take an otolaryngologist more patience and effort to uncover all the relevant information about their symptoms.
We obviously can’t change the fact that a lot of these people are uninsured and don’t have good health education, but I think it does come back to cultural competence. All that we have, all that we can control, is our interaction with them. —Douglas Farquhar, MD, MPH
“For rural residents, you may have to take more time than you would with someone from an urban area who may be willing to tell you up front what’s wrong with them,” he said. “You may have to ask a few more questions to get at what their issue really is, especially if trust hasn’t yet been developed over a period of time.”
Rural residents tend to have strong relationships with their local primary care provider. Otolaryngologists should always respect local providers’ opinions, and carefully craft a polite response if they differ in their approach to care. “Usually, a rural patient’s local physician is a person they’ve known for 10 years or more—they go to him or her for everything,” Dr. Adjei Boakye said. “Respect the primary physician no matter what. As with other aspects of culture, such as race and ethnicity, the complexity and heterogeneity of rurality should be considered and respected.”
The idea of “financial toxicity” also plays a role in health equity, said Samantha Tam, MD, MPH, professor of otolaryngology–head and neck surgery at Henry Ford Health System in Detroit. But this shouldn’t be regarded as just the ballooning cost of care, particularly cancer care, but also the “financial distress” of these costs—the psychological burden patients and families experience because of the financial burden, she said. “It plays a very important role in patient well-being and our patient experience in general,” she said. “Patients who have increased financial toxicity also have worse quality of care.” Race, the type of insurance, marital status, education, geography, and comorbidities can all contribute to the risk of financial toxicity, Dr. Tam said.
Physicians can help by having open discussions with patients about their financial concerns and by being aware of the cost of therapy. Hospitals should offer help with financial navigators and social workers, she suggested. On a broader level, better policies are needed to lower the cost of therapies and develop better insurance models, and research should focus on finding equitable, evidence-based solutions, said Dr. Tam.
Douglas Farquhar, MD, MPH, an otolaryngology resident at the University of North Carolina School of Medicine in Chapel Hill, said researchers at his center looked at 1,000 patients in the state and found a huge, race-based disparity in head and neck cancer outcomes. When researchers controlled for income, presentation stage, smoking history, alcohol history, and sex, the disparities were still there. But when income, rural and urban disparities, insurance, and health education were controlled for, “the disparities were gone,” he said. After that, he said, “there was no difference in survival and there was no difference in stage of presentation between Black and White patients.
“What this is getting at is that these different populations have a differential in their access to care because of things like rural populations, transportation, health insurance, and health education,” he continued. “We obviously can’t change the fact that a lot of these people are uninsured and don’t have good health education, but I think it does come back to cultural competence. We want to do something. All that we have, all that we can control, is our interaction with them.”
Thomas R. Collins is a freelance medical writer based in Florida.