publication date: Apr. 24, 2020

Guest Editorial

When disparities widen: COVID-19 in minority patients with cancer

Coral_Olazagasti

Coral Olazagasti, MD

Hematology/Oncology fellow

Zucker School of Medicine at Hofstra/Northwell Health

 

Narjust Duma2

Narjust Duma, MD

Assistant professor,

Division of Hematology, Medical Oncology and Palliative Care,

Department of Medicine, Carbone Cancer Center, University of Wisconsin-Madison

This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage, as well as the latest meeting cancellations, is available here.

In late December, rumors regarding a dangerous virus that originated in a seafood market in Wuhan, China started spreading across the world. At the time, all we knew was that the virus resembled the severe acute respiratory syndrome, better known as SARS, and that it was aggressive and deadly.

Back then, it only seemed to be a distant thought in the Western World. By January, news about this novel coronavirus or SARS-CoV-2 causing the COVID-19 infection became more prevalent when it continued to spread aggressively, affecting countries all throughout Asia and Europe. Then, on Jan. 20, our biggest fear became a reality when the first person in the United States tested positive.

Since then, this novel coronavirus has reared its ugly head all across the country. When we were first made aware of this virus threatening our country, our fear as oncologists became one: “What will happen to our patients with cancer?” Initial data from China and Italy about the infamous COVID-19 infection suggested that the virus tended to be especially dangerous to our older adult patients. That changed quickly when data later supported that pre-existing medical conditions also placed individuals at higher risk for contracting the infection and developing complications.

Recently, troubling trends and data from across the country started to suggest that minority populations, especially Hispanic and black, are experiencing higher risk for COVID-19 infections and mortality that outpace the different state’s population. Data released from New York City revealed that Hispanics make up 29% of the city’s total population, but account for 34% of COVID-19 deaths.

Blacks, on the other hand, account for 28% of COVID-19 related deaths, but make up 22% of the city’s total population.1 Similar trends were seen in Chicago, where black residents comprise 29% of the city’s population, but account for 72% of the COVID-19 deaths.2 In California, the Latinx/Hispanic community, which makes up 39% of the state’s population, has accounted for 38% of confirmed COVID-19 cases and 31% deaths. The black population, which makes up 6% of the California population, account for 7% of COVID-19 cases and 12% of deaths.3,4

The trends reported above represent only the confirmed COVID-19 infections in Hispanics and blacks. This early data can be expected to be cofounded by unequal access and availability of testing. One can presume that the actual numbers and percentages of minority patients affected is higher than what is reported, as it is likely that many have yet to be diagnosed.

Racial and ethnic minorities are often from lower socioeconomic backgrounds and commonly live in higher-density households and communities, which increases their exposure to the virus and limits the possibility of practicing social distancing.

We have also seen minority populations be targeted and negatively affected by an unfair health system that gives them inadequate access to care.  Minority patients have higher tendencies to be uninsured. Reports have showed that the uninsured rate for blacks was 11% and 18% for Hispanics as of 2018.5

As physicians, we have experienced the implications this can have on the health of these patients. It is well-documented that race/ethnic minorities have a higher prevalence of diabetes and hypertension than non-minority individuals.6,7 In 2011-2014 47% of Hispanic and 46.8% of non-Hispanic black adults had higher prevalence of obesity than non-Hispanic white adults8. These are all associated with increased risk for complications from the virus.

As of yet, there are no published data regarding COVID-19 affecting minorities with cancer, but we can safely presume how these trends will impact our patients. If otherwise non-cancer Hispanic and black people are at increased risk of infection and mortality, we can only imagine what that could mean to our minority patients who also happen to suffer from cancer. Even the thought of it makes us fear 10 times harder for our patients who have already in their battles gone through so much.

In attempts to protect our patients, we have changed the way cancer centers practice and have transitioned physical visits into virtual or telehealth ones. But how can one say that this transition can be beneficial to all?

Since the COVID ordeal started, we have heard statements such as “we are all on the same boat.” However, as many have interestingly pointed out, we might all be in the same waters, but, in the midst of this pandemic, we are certainly not in the same boat. Not all of us have the same means when it comes to facing this pandemic. Some are in yachts, others in sailboats, and some can find themselves in river rafts.

We recall the story of our patient, a 75-year-old Spanish-speaking female with high blood pressure, and heart disease who in early February had been diagnosed with acute myeloid leukemia (AML). She was due to start chemotherapy after her initial diagnosis, but she contracted COVID-19 and required a prolonged hospitalization. One with no visitors allowed and no one to speak her native language.

After weeks alone in the hospital, battling her leukemia and COVID-19, she was successfully discharged to rehab. Unfortunately, treatment for her AML continued to be delayed due to ongoing cytopenias and deconditioning from her terrible diseases, recalls Dr. Olazagasti. Like this patient, many others are experiencing delays in diagnosis and treatments since this pandemic started.

For some lower socioeconomic status’ patients with cancer, clinical trials are the only possible option to receive cancer-directed treatment and access to medication. Pausing clinical trials means no other possible treatment available for these patients.

For others, halting physical visits and transitioning to telehealth might not be as convenient. Often, they don’t have the luxury of having smartphones or laptops with internet access to be able to see their oncologist face-to-face during virtual visits. Commonly, they find themselves owning prepaid phones that can run out of available minutes at any time. Even if they have more advanced smartphones, they may lack the knowledge as to how to access newer technology.

In many instances, Hispanics and blacks, are part of essential work force with occupations like cleaning and maintenance, food preparation and serving, transportation, health care support9—occupations that may not allow them to take paid sick leave or the needed time off to check in with their oncologists through virtual visits.

Also, data has shown the risk for contracting COVID-19 according to occupations, accounting for the proximity to others during the workday. Besides health care workers,  many people who do service jobs like care aides, cashiers, fast-food workers and janitors make up the bulk of some of the most at risk and lowest income occupation10.

As physicians, we all wish we could do more for our patients during these arduous times. As oncologists, we have an innate desire to tend to our patients and provide comfort. The way we practice has drastically changed, and we have all had to adapt during this uncertain time.

All we can hope for is that we are still able to provide the support and care that our patients so desperately need. All we can strive for is to be available for our patients and show them that we are all in this fight together, and that their care and safety remain our main priority, even from afar. Every patient, regardless of their background, deserves equal treatment.

The holistic and integrative approach of cancer care has never been more essential than it is today.


References

  1. Coronavirus in NY: COVID-19 race, ethnicity data show black, Hispanic population at higher risk. www.lohud.com/story/coronavirus

  2. In Chicago, COVID-19 Is Hitting The Black Community Hard. https://www.npr.org/sections/coronavirus-live-updates/2020/04/06/828303894/in-chicago-covid-19-is-hitting-the-black-community-hard

  3. African-American COVID-19 deaths ‘disproportionately’ high in California. https://www.mercurynews.com/2020/04/16/coronavirus-african-american-covid-19-deaths-disproportionately-high-in-california/

  4. Blacks make up 6% of California’s population but 12% of coronavirus deaths, data show. https://www.latimes.com/california/story/2020-04-16/state-data-shows-coronavirus-is-killing-black-californians-in-disproportionate-numbers

  5. Kaiser Family Foundation estimates based on the Census Bureau’s American Community Survey, 2008-2018.

  6. Golden SH, et al. Health disparities in endocrine disorders: biological, clinical, and nonclinical factors–an Endocrine Society scientific statement. J Clin Endocrinol Metab. 2012;97(9):E1579–639.

  7. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Stafford R, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010; 121:948–954.

  8. Racial and Ethnic approaches to Community Health. Centers for Disease Control and Prevention.

  9. Hispanics and Latinos in industries and occupations. U.S Bureau of Labor Statistics

  10. Who is most at risk in the coronavirus crisis: 24 million of the lowest-income workers. https://www.politico.com/interactives/2020/coronavirus-impact-on-low-income-jobs-by-occupation-chart/

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