REFLECTIONS ON HEALTH EQUITY IN GYNECOLOGIC CANCER CARE | VAIDEHI MUJUMDAR, MD
Originally featured on: https://www.sgo.org/blog/reflections-on-health-equity-in-gynecologic-cancer-care-vaidehi-mujumdar-md/
I was born in Central India to a family that is no stranger to the deep impact cancer has on individuals and their families physically, mentally, and financially. The impact of this family history of cancer including the financial toxicity, access to care issues, and cultural stigma has been a part of our family history, crossing borders and oceans seeping into each generation.
As a third-year medical student at Wake Forest, David Shalowitz, MD, MSHP introduced me to cancer care delivery research, specifically looking at the impact of travel on gynecologic oncology care. It was this work that focused my interest on health care disparities into cancer equity and access to care for people living with gynecologic malignancies. His mentorship and the work already being conducted at the Wake Forest Baptist Comprehensive Cancer Center, Maya Angelou Center for Health Equity, and the Office for Cancer Health Equity showed me what a career as an oncologist, surgeon, and public health researcher could look like. This mentorship also solidified my career trajectory.
The experiences I had as medical student have transitioned into taking care of different ethnic minorities as part of the largest public hospital system in the United States (US). As a third-year resident, much of our gynecologic oncology experience is at two city public hospitals in Queens. Queens is the fifth largest city in the US with a population of 2,405,464 and 60% of residents belong to minority groups.1 We see gynecologic oncology patients in clinic at the Queens Cancer Center (QCC), which since its inception in 2002 is the only public hospital center to provide comprehensive cancer care in New York City for the uninsured and undocumented.
At the QCC, 92% are minorities, 52% of patients have either Medicaid or Medicaid Managed Care plans, and 17% are uninsured.2 Many get off the plane at La Guardia airport, with no records and vague memories of the treatment and surgeries they underwent in Surinam, Honduras, or Guyana. We see 34-year-old patients presenting with Stage IVB cervical cancer and a 72-year-old grandmother with a history of recurrent breast cancer now presenting with ovarian cancer during her annual summer visit from Guyana to see family.
Leo Lopez, MD, MHS Senior Director for Equity, Policy, and Evaluation and Mitchell Katz, MD President/CEO of New York City Health + Hospitals wrote an article in JAMA January 2021 speaking to the persistent racial and economic disparities in health that were exacerbated by COVID-19.3 These are seen in real life in our gynecologic oncology patients across New York City. In June 2020, facing a financial crisis from COVID-19, New York City Health + Hospital / Kings County called for the termination of its gynecologic oncology surgical services at a hospital whose gynecologic oncology patient population is 85% Black. One study from eight New York City area hospitals found that although Black patients with gynecologic cancer represented only one-third of patients, they accounted for disproportionate rates of hospitalization (>45%) and death (>40%) due to COVID-19 infection.4 In clinic, we were witnessing lack of access to smartphones, cancellation of screening tests and rescheduling leading to missed surveillance and frustration, fear of traveling via Subway, and financial constraints in using Ubers/Lyfts to go to appointments during COVID surge pricing.
Centers like QCC have proven to be invaluable, especially during the pandemic. Patients do not have to travel to Manhattan for care, but can have access to the physicians, treatment, and services they need closer to home. In 2005, QCC joined efforts with Memorial Sloan Kettering to bring cancer control and clinical treatment trials to Queens patients, which has established an excellent exchange of information, increased enrollment of minority patients in clinical trials, and strengthened partnerships between physicians. QCC is a model that showed that the increased investment in safety net hospitals serve individuals who are from minority, low-income, and undocumented immigrant groups can help us decreased disparities in gynecologic oncology. When I speak of some of my experiences to my parents, they ask, rhetorically almost, how my grandmothers would have fared if they had access to something like QCC.
Since I was introduced to the subspecialty of gynecologic oncology, I have viewed it is an innovative field that embraces risk stratification, preventative screening, and open conversation about sensitive patient-specific experiences to target opportunities for surgical and medical intervention. At the 2021, Mid-Atlantic Gynecologic Annual, past SGO president and Chair of Obstetrics and Gynecology at the University of Alabama, Warner Huh, MD, gave an inspirational talk on where Gynecologic Oncology is going as a field. His parting words resonated me: “We want our trainees to have a voice and to rally around the best parts of our field.” Gynecologic Oncology is one of the few fields that starts with a diagnosis and carries the patient all the way through, with intensity, honesty, and compassion. This unique relationship positions gynecologic oncology at the forefront of tackling disparities in cancer care and moving towards equity in prevention, diagnosis, care, and treatment.
- S. Census Bureau Quickfacts: Queens County, New York (n.d.). Retrieved October 18, 2021, from https://www.census.gov/quickfacts/fact/table/queenscountynewyork,US/PST045219.
- ASCO in the Community: Listening and learning from the experience of a public hospital in Queens, NY. ASCO Connection. (2019, May 7). Retrieved October 18, 2021, from https://connection.asco.org/blogs/asco-community-listening-and-learning-experience-public-hospital-queens-ny
- Lopez, L, Hart, LH, Katz, MH. Racial and Ethnic Health Disparities Related to COVID-19. 2021;325(8):719–720. doi:10.1001/jama.2020.26443
- Lara, OD, Smith, MJ, Wang, Y, O’Cearbhaill, R, Blank, SV, Kolev, V, Carr, C, Knisely, A, McEachron, J, Gabor, L, Chapman-Davis, E, Jee, J, Fehniger, J, Lee, Y-C, Isani, S, Liu, M, Wright, JD, Pothuri, B. Racial disparities in patients with coronavirus disease 2019 infection and gynecologic malignancy. Cancer. 2021. https://doi.org/10.1002/cncr.33335
Vaidehi Mujumdar, MD, is a third year resident in Obstetrics and Gynecology at the Icahn School of Medicine at Mount Sinai / New York City Health + Hospitals.