We can redesign our health-care delivery system to markedly reduce disparities. It’s not complicated. It doesn’t matter how poor that community is.
—Edward E. Partridge, MD
Racial inequities were a daily observation for Edward E. Partridge, MD, growing up in Alabama during the civil rights era. When he became a physician, he saw that these disparities extended into his own field, gynecologic oncology. He decided to do something about it. Dr. Partridge recently discussed his life’s work in a lecture at the Society of Gynecologic Oncology (SGO) Annual Conference on Women’s Cancers. He then shared his insight in an interview with The ASCO Post.
Dr. Partridge is Director of the University of Alabama at Birmingham Comprehensive Cancer Center.
A Collective Challenge
“Cancer disparities became obvious once we had either diagnostic or therapeutic procedures that could make a difference in outcomes,” he said. With the development of screening techniques for colorectal and breast cancers in the 1970s, disparities in the uptake of these techniques emerged—by income, insurance status, education—and this impacted mortality rates. The development of more effective treatments came next, and again, these were differentially delivered, he said.
“Disparities in cancer care began to raise their ugly head in the 1980s, and by the early 1990s we were fully aware that they existed,” Dr. Partridge said.
Disparities exist in areas where more clinicians could be making a difference: tobacco use (with higher education, smoking is less common); screening for breast, colorectal, and cervical cancer (the higher educated and insured populations receive more screening); physical activity and obesity (obesity rates are higher in persons of low income and in African Americans); and the provision of high-quality care for cancer.
“These are the areas where we deliver care differentially,” Dr. Partridge said. “If everyone had the same mortality rate as college-educated persons, there would be 216,000 fewer cancer deaths annually in the United States,” he added.
“There are no biologic or genetic differences between persons with a college education and those without, but the college-educated person does not smoke, gets age-appropriate screening, consumes a relatively healthy diet, and gets some physical activity every week. When people in this group do develop cancer, they have insurance and they seek the best care possible,” he explained. “Their lower mortality rate is what is achievable based on our knowledge today,” he said, yet this is an unrealized goal in the general population.
“Collectively, [as physicians, we can do better] to deliver what we know to the nation’s population,” Dr. Partridge maintained.
UAB Makes a Commitment
Becoming an NCI-designated cancer center in the Deep South in 1972, the University of Alabama at Birmingham expressed a “moral and ethical obligation” to alleviate cancer disparities in 1992, he said.
“We began connecting to our African American populations in both the inner city and in the rural Black Belt (named for its rich black soil, not its population) of Alabama [eventually moving into the Mississippi Delta as well],” he said. Two-thirds of the population in these regions is African American, and one-third live below the poverty line.
Thus was formed the Alabama Partnership for Cancer Control (now the Deep South Network for Cancer Control), a program that capitalized on community spirit and cohesiveness, centered around community health advisors—African American women well trained to promote breast and cervical cancer screening in their underserved communities.
The next step was to train community health advisors to be patient navigators. These navigators facilitated access to care and ensured adherence to diagnostic follow-up of positive screens or prescribed cancer treatments.
A third program trained lay workers to promote clinical trial participation and to facilitate enrollment for those deemed eligible. With this intervention, clinical trial participation doubled among African Americans, from 11% of all cancer diagnoses to 22%.
Interventions Deliver on Outcomes
The various programs described by Dr. Partridge have clearly delivered on health-care outcomes. “Over time, we demonstrated that we eliminated disparities,” he said.
Disparities in mammography screening between white and African American women on Medicare were essentially obliterated, reduced from a 16% difference prior to 2000 to a 0.5% difference in 2006. In a second intervention, 71% of women never previously screened obtained mammograms.
Cervical cancer screening increased as well, and as a result, mortality from this malignancy—which at baseline was twice as high in the Black Belt region vs higher-income areas—by 2005 had become half as likely as in other areas.
“All this suggests that volunteers working in a community can actually change behavior within a population,” he said. “This tells me we can redesign our health-care delivery system to markedly reduce disparities. It’s not complicated. It doesn’t matter how poor that community is. There are individuals who want to improve the plight of their community. This is a model of what can be done elsewhere,” he added.
“One of the more exciting things we are doing now is based on our experience with the lay navigators in early phases of the cancer continuum—essentially, it is to make our lay navigators ‘nurse extenders’ and use them in the survivorship and end-of-life phases of care,” Dr. Partridge said.
Through a $15 million 3-year Innovation Challenge Grant from the Centers for Medicare and Medicaid, the UAB Comprehensive Cancer Center and its 10 affiliated centers will train 35 lay navigators. Their aim is to overcome health system and community barriers in an effort to increase adherence to screening and lifestyle changes in the survivorship phase, to on-pathway treatments and to survivorship/advanced care plans. The program aims not only to improve health-care outcomes but to reduce costs and demonstrate value.
“Every Medicare patient will be assigned a navigator who will be an extension of the physician’s office. The goal is to intervene earlier, during the acute phase of care, to prevent unnecessary use of the emergency room, hospital, and intensive care unit,” he said.
“The ‘innovative’ part that is really exciting is this: we are going to train a supportive/palliative care team to have discussions during survivorship about end-of-life choices with the patient and family. The goal is to have patients enter hospice care a month earlier than usual and eliminate chemotherapy during the final 2 weeks of life,” he added.
Dr. Partridge estimates that this intervention alone will reduce Medicare expenditures at UAB and its 10 affiliated sites by $50 million a year. “I think we will be able to demonstrate that lay persons can do a great job as nurse extenders, if you will, and this approach will save money,” he said.
In closing, he emphasized that what has been done in Alabama and the Delta can be replicated in other underserved areas. Such programs are most likely to be successful, he added, when they “create trust, eliminate bias, and share power.” ■
Disclosure: Dr. Partridge reported no potential conflicts of interest.
Dr. Partridge recently presented his lecture “Our Failure to Deliver,” as the American Cancer Society Lectureship at the Society of Gynecologic Oncologists (SGO) Annual Meeting on Women’s Cancers in Los Angeles. The comments and opinions expressed herein are those of Dr. Partridge and do not necessarily reflect the opinion of the The ASCO Post, Harborside Press, or ASCO. For more information, visit sgo.org.