Disparities in Cancer Care: How Did You Show Up Today?

Britny R. Brown, PharmD, BCOP
Clinical Assistant Professor
University of Rhode Island College of Pharmacy
Oncology Pharmacist
Women & Infants Hospital
Providence, RI

I have been on my college’s Diversity Committee since joining the University of Rhode Island in 2017. Yet, it wasn’t until this past year that I realized I had been largely omitting health disparities from my own lectures. I postulated a few years ago that transgender women might be at an increased risk of breast cancer compared to cisgender men due to the higher use of estrogen therapy. It wasn’t until one of my students decided to take it a step further and actually do the literature search that we learned our hypothesis was true.¹

Why had I never taken the initiative to run the literature search myself? As pharmacists, we are heavily trained in finding, summarizing, and providing information. Why is it that when it comes to health disparities, we don’t have the same innate drive to find and amplify the data?

Populations that may be subject to disparities in cancer outcomes include Black, Latinx, and American Indian/ Alaska Native populations; people living with a disability; and people with low socioeconomic status.² Other groups identified by sexual orientation, gender identity, geographic location, income, education, age, sexual orientation, and national origin may also be affected.

We’re starting to witness a shift toward more cultural competence training embedded into both pharmacy education and continuing education at least in part due to the Accreditation Council for Pharmacy Education (ACPE) Accredi­tation Standards. In 2016, ACPE started requiring graduates to demonstrate cultural sensitivity in its Accreditation Standards.^3,4 In delivering educational content, it is important to be careful to avoid reinforcing stereotypes while also acknowledging how certain factors like social determinants of health and different facets of intersectionality can contribute to health disparities.⁵

As Dr. Vibhuti Arya et al so exquisitely state, “Pharmacists took an oath to protect the welfare of humanity and protect our patients. As such, to practice truly patient-centered care, pharma­cists must recognize racism as a root cause of social determinants of health and use their privilege to educate themselves and their colleagues around dismantling structural racism.”⁶

The Campinha-Bacote model, which can be shaped like a triangle, describes the necessary components of cultural competence in healthcare.7 The very bottom of the triangle is desire, de­scribing that the healthcare provider must be self-motivated and committed to engaging in work that will improve cultural competence. Awareness follows, where one explores their own biases and assumptions. Knowledge and skill come afterwards, where a provider must seek and develop knowledge and then practice the skill of collecting necessary data from patients. Finally, putting oneself in situations where they might encounter patients of minoritized populations will allow one to advocate for patients who might be subject to health disparities.

If you are reading this, you have likely surpassed the desire phase. If you haven’t had the opportunity to already, I highly encourage you to take implicit association tests (IATs) and to explore options beyond just the race IAT (Table 1).⁸ Not unlike the creators of the test, I was upset the first time I took the race IAT and saw my results--a moderate preference for white people. As I looked into this further, I realized I was not alone. Even minoritized groups often test to have a slight or moderate preference toward the “preferred” social group.⁹ It’s postulated that this is due to the associations we develop from our environments, including the media we consume, the books we read, and the people with whom we interact.

Table 1.

a. Modules funded by the American Association of Colleges of Pharmacy
A non-exhaustive table of relevant healthcare provider resources.

As were many of us, I was grateful for the attention that the resurgence of the Black Lives Matter movement brought to Diver­sity, Equity, and Inclusion (DEI) work. I began to ask myself, “how did I show up [for others] today?” Reflecting on the work I am doing and how it might intersect with health disparities and related topics allows me to adjust my traditional way of thinking. Beverly Daniel Tatum equates systemic and implicit racism as standing on a moving walkway at the airport.¹⁰ Unless we are actively moving against the tide of the moving walkway, faster than it is taking us in the opposite direction, we are not being antiracist. One could say the same about anti-ableism and similar anti-oppression work. It truly needs to be infused into everything we do.

As a Clinical Assistant Professor, I have opportunities to apply a DEI lens both in academia and in clinical practice. Throughout the past year, I have been updating my course material to include social determinants of health and health disparities, infusing this information into patient cases, lectures, and exams. In addition, I have developed a statement surrounding my stance on antiracism and DEI and included it in my syllabi, which has resulted in students feeling more comfortable to approach me surrounding relevant topics. I partnered with a local organization that was already doing antiracism work, and together we are devel­oping a Black in STEMM (science, technology, engineering, math, and medicine) mentorship program. I am lucky that my institution and my college have taken advantage of the same national momen­tum, so suggestions from our Diversity Committee are being heard and acted upon.

I have also taken my DEI work beyond the classroom and have advocated for orga­nizations in which I am involved to engage in DEI work and have consulted with those that weren’t sure where to start. Finally, I have been more mindful and knowledgeable about which patients may need an advocate and have worked with other likeminded individuals to amplify their voices when their concerns were left unheard.

Perhaps most importantly, in doing this work, we will make mistakes. Being open minded to feedback will allow us to grow. While this work can be taxing for anyone, I recognize that as a cis-white woman, I do not bear the weight of a lifetime of trauma that one with a marginalized identity often does. I am privileged, and I hope to use that privilege to lift some of the weight off of others who have carried it for far too long.

How did you show up today? Continually asking yourself this question will allow you to identify new ways that you can help to dismantle structural and systemic oppression and to work towards building a healthcare environment that strives for health equity.

REFERENCES

1. de Blok CJM, Wiepjes CM, Nota NM, et al. Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands. BMJ. 2019;365:l1652. Published 2019 May 14. doi:10.1136/bmj.l165
2. National Institute of Health. (2020, November 17). Cancer Disparities. https://www.cancer.gov/about-cancer/understanding/disparities
3. Accreditation Council for Pharmacy Education. (2021 January). ACPE Guidance to ACPE-accredited CE Providers to Incorporate Diversity, Equity and Inclusion in CE Activities. https://www.acpe-accredit.org/pdf/ ACPE_CE_Guidance_Diversity_Equity_Inclusion_Jan_2021_Final.pdf
4. Accreditation Council for Pharmacy Education. (2015 February). Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. https://www. acpe-accredit.org/pdf/Standards2016FINAL.pdf
5. Durham MJ. Inclusive Teaching Checklist. Presented at: ACCP Annual Meeting, 2020.
6. Arya V, Butler L, Leal S, et al. Systemic racism: Pharmacists’ role and responsibility. J Am Pharm Assoc 2020;60(6):e43-e46. doi:10.1016/j. japh.2020.09.003
7. Campinha-Bacote J. The Process of Cultural Competence in the Delivery of Healthcare Services: a model of care. J Transcult Nurs. 2002;13(3):181-201.
8. Project Implicit. (2011). Take a test. https://implicit.harvard.edu/implicit/ takeatest.html
9. Project Implicit. (2011). Frequently asked questions. https://implicit. harvard.edu/implicit/faqs.html#faq10
10. Adams M, Blumenfeld WJ. Readings for Diversity and Social Justice. United Kingdom: Routledge, 2018.