How to achieve equity in cancer care? Look to Raleigh

How to achieve equity in cancer care? Look to Raleigh



By Clarissa Donnelly-DeRoven

Dr. Katherine Reeder-Hayes, an oncologist and researcher at UNC Chapel Hill, recently had a patient arrive at her office with advanced stage breast cancer. The patient listened as Reeder-Hayes explained what she was facing and how quickly they’d need to start care.

But there was resistance, Reeder-Hayes said. The patient kept asking if there was any way she could delay starting treatment.  

“She really needed to get started with her chemotherapy — that was going to enable her breast cancer surgery. And she kept asking me, ‘Could we do this in a couple of months?’ ,” Reeder-Hayes said. “I really didn’t understand the question. I thought perhaps she didn’t understand the seriousness of her diagnosis.”

As Reeder-Hayes probed more, she learned that in addition to having advanced breast cancer, her patient also did not have health insurance. She’d been trying to obtain a plan she could afford, and though she’d eventually found one, it wouldn’t kick in for a few months. 

“She was afraid that if she started cancer treatment, she and her family would be financially devastated,” Reeder-Hayes said.

The rate of many routine cancer screenings dipped during the pandemic, plummeting after the initial emergency declaration in spring 2020 and rebounding in June 2021 to levels that remained about a third lower than pre-pandemic levels. This has led researchers and health workers to worry what the decline could mean for people who already faced systemic barriers — such as being uninsured — to accessing cancer care. 

Imagining what health equity in cancer care could look like in a post-pandemic world served as the framework for a virtual conversation, conducted by the American Cancer Society in early November, in which Dr. Reeder-Hayes and two other North Carolina cancer equity health workers spoke. 

Among all the things that might help, they argued that Medicaid expansion has shown itself to be the critical first step to creating more equitable cancer care systems.

Existing disparities

Dr. Ronny Bell is a social science and health policy professor at Wake Forest School of Medicine, and the director of the Cancer Health Equity Office at Wake Forest Baptist Comprehensive Cancer Center. The facility serves many rural patients, a good chunk of whom get cancer and die of it at disproportionately higher rates.

“We serve 58 counties in western North Carolina, southwestern Virginia, and the southern portion of West Virginia,” Bell explained. “We have a number of cancer disparities in our catchment area.” 

Some disparities are connected to regionality in general: “We see a 13 percent higher overall cancer mortality rate in our catchment area and rural population, and a staggering 30 percent higher lung cancer mortality rate,” Bell said. The region has a high proportion of smokers, and also high radon exposure rates — the second leading cause of lung cancer.  

Other disparities are tied to race and the way it intersects with rurality. Black residents within the region the hospital serves experience higher rates of breast and prostate cancer, while Black, rural residents in the hospital’s region are 18 percent more likely to die from colorectal cancer than the general population. 

“We have the tendency to blame patients for the situations that they’re in,” said Dr. Angelo Moore, the associate director of community outreach, engagement, and equity at the Duke Cancer Institute

It’s a tendency that’s unfair, he said. 

“I’ve been in health care for almost 30 years, and it is very complex to me, and I have the medical knowledge, I’ve been in multiple health care systems. So just imagine individuals [who] have no knowledge of health care,” Moore said.  “We have so many structural systems that are set up to create a negative way for people to get care.” 

The institute he runs conducts patient education about preventative screenings, along with education on how to navigate the health care system. But, he said, those programs will always be insufficient if people don’t have access to health insurance. 

“When you talk about populations that are impacted the most with health disparities, these are the same individuals who don’t have access to care,” Moore said. 

Reeder-Hayes agreed. 

“In breast cancer, as in most common cancer screening programs, it’s really important to remember when we’re looking with an equity lens, that a screen doesn’t save anybody’s life,” she said. “It doesn’t help to know somebody has a cancer if the action steps that take place after that are all broken and fragmented.”

The connection between health equity and Medicaid expansion

The panelists all agreed that one critical step to expanding cancer care equity is expanding Medicaid. As a result of the 2009 Affordable Care Act, states have an option to cover all individuals with earnings that are below 138 percent of the federal poverty level. North Carolina is one of only 12 states that has not expanded the state- and federally funded program. 

In 2018, just over a million non-elderly people in the state were uninsured, about 13 percent of the state’s total population. N.C.’s uninsured rate is higher than the nationwide uninsured rate, according to the Kaiser Family Foundation.



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