By the end of 2022, Toni Monteiro had no fight left in her. She had been battling a rare blood cancer for three years. Her husband had just died. She was at risk of being evicted from her Washington, DC, apartment. Also, her heart was failing.

“You’re really under stress,” Monteiro recalls her physician saying. 

Monteiro was 58, and she’d been a patient at MedStar Washington Hospital Center since 2020 for treatment of polycythemia vera, a hematologic malignancy that causes the bone marrow to produce too many red blood cells, leading to blood clots.

It was wreaking havoc on her heart.

“I was a difficult patient with all of my problems. Not only do I have the PCV with JAK2, I also have ulcers, diverticulitis in a couple of places in my colon, and hernia,” Monteiro said. “And already twice I’ve had bleeding issues, because I’m on blood thinners.”

All this notwithstanding, Monteiro had been denied Social Security benefits—her only potential source of income, given that she has been unable to work for 12 months or longer due to disability. Monteiro was falling behind on rent at the Northeast Washington apartment complex she’d called home for two decades. 

Being deprived of housing would be catastrophic. 

“In my condition, that type of stress could also kill me,” said Monteiro, a lifelong Washingtonian, born and raised in the nation’s capital. “I got really sick.”

These were problems her doctors could not solve. Monteiro needed a lawyer. 

Fortuitously, the medical team at MedStar was equipped to respond to her circumstances: 

Monteiro received a referral to Georgetown University’s Cancer Legal Assistance & Well-being Project, also known as Cancer LAW, a medical-legal partnership between the university’s medical center, law school, and MedStar Health.

Monteiro didn’t get one attorney at Cancer LAW. She got three: Allison Dowling, director of Cancer LAW, Abigail Sweeney, staff attorney, and Megan Gordon, an Equal Justice Works Fellow. 

The team immediately set out to ensure that Monteiro would get her Social Security benefits—at no cost to Monteiro.

In the meantime, Monteiro’s heart function continued to deteriorate. 

After a defibrillator malfunction, Monteiro urgently needed a left ventricular assist device, or LVAD—a pump usually used for patients with end-stage heart failure—to cope with her diminished ejection fractions.

Here, Monteiro ran into a vicious cycle she describes as a system that is “worse than broken.”

She couldn’t get approval for the LVAD, which requires reliable access to electricity, because she’d been flagged as a patient with unstable housing, because her landlord was filing for eviction, because she’d been denied her disability checks.

“The cardiologist was saying, ‘You need this surgery or you’re gonna die, but we can’t give you the surgery, because you have unstable housing,’” said Sweeney, Monteiro’s primary contact at Cancer LAW. “The reason why she had unstable housing was because she couldn’t pay the rent. The reason why she couldn’t pay the rent is because Social Security had fumbled her case, in my opinion.”

Sweeney filed an appeal to the Social Security Administration while Gordon worked to prevent the eviction in the Landlord and Tenant Court. (They won.)

Monteiro received a lump sum of more than $30,000 from Social Security—eliminating her debt to the landlord and resulting in a dismissal of the eviction case. 

Monteiro underwent surgery for the LVAD in December 2023. It was a success.

“If it wasn’t for them, I wouldn’t be alive. I just would not be here at all,” Monteiro said through tears. “They didn’t just take my case and say, ‘Okay, Ms. Monteiro, we’ll see what we can do.’ They were with me every step of the way with encouragement, help whenever I needed it, guidance, and they did it with care.

“Let’s face it, in this country, everything is expensive,” Monteiro said. “Cancer treatment is expensive, and people need a resource, even if it’s just a resource, that can help them navigate these waters, because I’m telling you, it’s Iceberg City, and without them, people will flounder and get lost in the system and die.”

Monteiro’s case illustrates why patients with cancer should have access to an attorney as part of their healthcare team, Sweeney said. Without legal counsel, many medical-legal challenges are never resolved—and the patient dies.

“That’s an example of a win,” Sweeney said. “And also an example of someone that’s in a very precarious health situation. Having a lawyer who can just meet you at the hospital to get these things done and advocate for you is truly lifesaving.”

A case for MLPs in oncology

In the 1980s, the first structured medical-legal partnerships were founded in response to the unique challenges posed by the HIV/AIDS crisis—proving to be an effective resource for patients who need legal assistance to address problems that fall outside the scope of traditional medical care.

In response to the needs of vulnerable HIV/AIDS patients, hundreds of offices providing legal services were created across the United States. In Washington, this began with Whitman-Walker Health, the first such resource known for its pathbreaking comprehensive health care and legal support services. 

This model served as the foundation for a pioneering pediatric medical-legal partnership at Boston Medical Center in 1993.

In the early 2000s, two New York attorneys drew inspiration from BMC and founded LegalHealth, the first partnership to focus on integrating legal assistance into cancer care. LegalHealth, a division of the New York Legal Assistance Group, has a network of 35 clinics throughout the state, making it the largest MLP in the U.S.

The concept continued to catch on. Founded in 2006, the National Center for Medical-Legal Partnership, now at the Department of Health Policy and Management at the Milken Institute School of Public Health at George Washington University, started providing resources and training to healthcare organizations nationwide.

In 2014, the organization successfully advocated for policy change at the U.S. Department of Health and Human Services, allowing health centers to use federal funds to support on-site civil legal aid. Also, the HHS Office of Administration for Children and Families now provides grant funding to MLPs to respond to complex social, economic, and environmental factors that “impact health outcomes of individuals, families, and communities.”

Although hundreds of MLPs exist today—up to 450, according to NCMLP, with 10 located in the nation’s capital—few of them are specifically focused on the medical-related legal needs of patients with cancer, and it appears that no list of such MLPs exists.

Researchers and cancer center leaders say more of these services are needed as more U.S. adults move up the population pyramid and as cancer survival rates improve.

Life outside a doctor’s office can determine up to 90% of a patient’s health outcome, said Allison Dowling, director of Georgetown University’s Cancer LAW.

“If you have somebody who is living with, let’s say, any kind of lung condition—whether it’s cancer, asthma, maybe both of those things—the oncologist prescribes chemotherapy to address the cancer. The pulmonologist prescribes inhalers and asthma medications. But those things don’t fully address the problem,” Dowling said. “If the patient is living in an apartment that’s infested with mold, or infested with rodents, or worse, you’re only putting a bandaid on a hemorrhaging wound. 

“Medicine can’t solve a rat-infested apartment. It can’t solve the black mold in an apartment. It can’t solve asbestos or lead issues. But a lawyer can.”

A conversation with Dowling appears in this issue.

Founded in 2019, Cancer LAW is part of a growing movement to ensure that MLPs become a key component of the cancer care pathway. 

“Cancer LAW not only has a profound impact on the lives of individual patients and their families throughout their cancer journeys, but also contributes to the MedStar Georgetown Cancer Institute by providing services that support accreditation and related efforts,” said Vicki Girard, a professor at Georgetown Law and co-founder of the university’s Health Justice Alliance, a cross-campus collaborative started in 2016 that includes Cancer LAW. 

As faculty director of the Health Justice Alliance (HJA), Girard oversees Cancer LAW’s operations, interprofessional education, research, and philanthropy.  HJA draws from institutional seed funding as well as gifts from foundations and donors to finance the perinatal and cancer MLPs, as well as to train law and medical students.

“From the moment I realized how MLP could animate Georgetown’s mission of cura personalis, care of the whole person, I knew I wanted to share it with future health and legal providers,” Girard said. “Cancer LAW has been particularly meaningful given the incidences of cancer in my own family—hearing patients and their families describe the impact of Cancer LAW on their lives is a constant reminder of the power of MLP to relieve some of the struggles that people with cancer face, and the potential it has to advance health equity.”

In a recent fiscal quarter, Cancer LAW served 61 patients and handled 91 legal issues. The vast majority of patients who received legal aid live below the federal poverty level, and many faced multiple challenges that evoked battling with the mythological Lernaean Hydra. 

“It’s rare that a patient faces only one health-harming legal need, as the systems impacting income stability are interconnected,” Sweeney said. “The beauty of the MLP is that patients have access to comprehensive screening from several professionals. Not only do they receive the best cancer care from the oncologist, but the medical team is also trained to refer patients to us for potential legal needs. 

“And while the initial referral from the medical and social work teams is often for only one potential legal issue, by the time the patient completes an intake with our attorney team, we often learn that the patient is facing closer to 10 legal issues,” Sweeney said.

“So, a patient who is screened by her oncology team for even just a few types of legal needs can ultimately receive months or years of legal services that she did not even know were options—all thanks to that initial screening in the medical setting.”

Cancer LAW also collaborates with the Ralph Lauren Center for Cancer Prevention at the university’s Lombardi Comprehensive Cancer Center. Opened in 2023, the Ralph Lauren Center is focused on reducing disparities in health care that disproportionately affect the city’s Black residents and other minorities that reside in working- and middle-class neighborhoods in the eastern quadrants of Washington (The Cancer Letter, April 28, 2023).

The differences in health outcomes are most visible when stratified by race and socioeconomic status. 

For example, despite being merely 5 miles apart, a 27-year gap in life expectancy was observed when comparing majority-white Georgetown in Northwest DC to majority-Black Trinidad in Northeast DC, according to a 2018 report produced by the Virginia Commonwealth University Center on Society and Health for the Metropolitan Washington Council of Governments Health Officials Committee.

“When we start thinking about team science and we start talking about the healthcare teams, it’s crazy to me that we always think about the medicine that gets to the patient, but we never think about all those things that are outside of that, where they live,” said Robert Winn, director and Lipman Chair in Oncology at VCU Massey Comprehensive Cancer Center, and senior associate dean for cancer innovation and professor of pulmonary disease and critical care medicine at the VCU School of Medicine.

“This is why we need outreach and engagement navigators. This is why we need our community activators,” Winn said to The Cancer Letter. “But what’s always missing from that are these medical-legal practitioners, which I think are also critical.”

MLPs do more than help patients navigate insurance, financial hardship, and advanced planning, Winn said. They are indispensable to cancer centers with catchment areas that serve vulnerable, low-resource communities. MLPs also contribute to the community outreach and engagement component of the Cancer Center Support Grant for NCI-designated institutions.

“I’ve always had an MLP. I don’t know what I would do without,” said Winn, who served as director of the University of Illinois Cancer Center prior to joining VCU Massey in 2019. “What most people miss is that, particularly in a place like Massey where we literally have a safety-net hospital, the role of the MLP is really, really important for our patient population.

“MLPs were established a couple decades ago, but most people probably won’t even know what you’re talking about. Until there is a significant recognition that we even have MLPs and that they are a functional part of our team, we’ll be stuck, I fear, in the same position five to 10 years from now,” Winn said.

“For me, the answer is we have too few MLPs. And so, I think that having more is part of the answer, but having more in a very directed manner and being part of a team actually does matter,” Winn said. “The fact that this is a topic coming up now, I think, is timely, and it’s absolutely necessary as we move forward to make progress.”

Experts: MLPs are essential to cancer care

All cancer centers should consider adopting the MLP model, said Louis Weiner, director of Georgetown University’s Lombardi Comprehensive Cancer Center.

“Try it,” Weiner said. “It is the right thing to do.”

Up to 75% of patients with cancer have at least one legal need, according to a 2023 systematic review conducted by Dowling, Sweeney and their colleagues at Georgetown. Studies included in the review also demonstrate that 50% of referrals were related to financial concerns. 

Additionally, many patients experience difficulties applying for or receiving disability and government benefits—legal problems that have a compounding effect on existing barriers for patients seeking cancer treatment.

“Cancer LAW has been a vital service for hundreds of patients at MedStar Washington Hospital Center,” said Christopher Gallagher, an oncologist at the MedStar Washington Hospital Center and former medical director of cancer services at the Washington Cancer Institute. “Successful cancer care is multidisciplinary, involving timely engagement with many different specialties. Getting to the right place at the right time for the right treatment improves cancer treatment outcomes. 

“Legal problems—employment, disability, housing, etc.—can be a hidden barrier preventing patients from timely engagement in cancer treatment.”

Only 35% of patients said they discussed legal concerns with their physicians, according to a study of women with breast cancer. Research has also shown that patients’ health-related legal needs are not met by their medical or supportive care teams despite the impact on their quality of life.

Georgetown’s Cancer LAW is designed to integrate attorneys into the patient’s care team based on their legal needs—without the added costs of hiring a law firm.

“We already have a whole circle of expertise helping this patient, and it doesn’t make sense to not include a lawyer on that team,” Dowling said. “You would never consider pitching an oncology team that doesn’t have a pharmacist. You would never consider an oncology team without a surgeon. 

“We will eventually reach the point where you would never consider a medical institution that doesn’t have lawyers for its patients because meeting their legal needs is just one component of the patient’s care plan.”

Dowling and her team’s work measurably benefits patients with cancer, Weiner said.

“In my view, Cancer LAW has had direct benefits for our patients, in that we ease their cancer journeys,” said Weiner, also Francis L. and Charlotte G. Gragnani Chair, professor of oncology, and chair of the Department of Oncology at Georgetown University Medical Center. “But, we were struck by a throwaway comment made by a member of the legal team during a routine meeting—that many of the people who had been helped by Cancer LAW went on to participate in our clinical trials. 

“It’s difficult to tease out the precise cause of this observation, of course. However, I believe that this relates to trust. If people feel cared about and that they matter to the caregiver ecosystem, perhaps they are more likely to trust their care team when they are offered participation in clinical trials. If so, we can build on this lesson.”

Surveys have found that up to 75% of patients with cancer say having access to legal support services reduces stress. Nearly half of survey respondents report a positive impact on their finances, and a quarter said legal services helped them stay on track with medical appointments. 

Researchers are now working to elucidate the impact of MLPs on health and cancer outcomes.

“Since this program has been in existence for only a few years, it is not yet possible to measure standard cancer care endpoints, such as overall survival,” MedStar’s Gallagher said. “Tracking cancer endpoints for patients who may have typically had gaps in care or may have been lost to follow up is difficult.  

“One measure that does seem important is participation in clinical trials. Enrollment in clinical trials—both interventional therapeutic and non-therapeutic—has been equal or slightly greater than the enrollment of patients not identified as having legal problems. I do not believe this would have been possible without the partnership with Cancer LAW at MedStar Washington Hospital Center. 

“Most importantly, these types of partnerships allow cancer centers to address a health equity issue to better care for the communities they serve.”

Beyond the academic research mission, clinics run more smoothly with fewer no-shows, and patients that feel empowered are better partners in their care, Weiner said.

“For other centers that wish to launch an MLP, it’s important to have legal partners who care about our mission as much as we do,” Weiner said. “We are so fortunate to have such a partner in Vicki Girard from the Georgetown Law Center. Her passion for the mission is infectious and her persistence is inspiring.”

Setting up an MLP requires institutional commitment, Girard agrees.

“I would tell anyone interested in establishing a new MLP to be prepared to make a significant investment in time and personnel for at least a couple of years,” Girard said. “Identifying the medical and legal champions who want to serve your patient population and are committed to working together are critical first steps. Making sure you understand the areas of unmet legal need, how acutely they impact patients, and which needs you can address are also important early on. 

“Ultimately, partners will need to collaborate on screening, referral, training, and feedback processes–but the good news is that there are lots of wonderful resources and tools available now, and the MLP community is a generous one. We were fortunate to benefit from the advice of existing cancer MLPs when we started and are publishing about our own efforts and best practices as a way to help spread the model.”

Putting the “M” and “L” in an academic MLP

As part of the Health Justice Alliance’s academic mission, Cancer LAW helps train medical and law students to use law and policy as tools to promote health and well-being. 

Medical students receive an opportunity to gain hands-on experience with Cancer LAW’s legal services.

Ruben Castro, a recent graduate of the Georgetown University School of Medicine, said training with Cancer LAW changed his outlook on medicine and taught him how to be a physician advocate for his patients.

“I realized—or learned—how little we as physicians know and do for our patients outside of the clinic,” said Castro, who is now a physical medicine and rehabilitation resident at the Icahn School of Medicine at Mount Sinai. “Gaining those skills to anticipate the problems or the challenges they’re going to have when they walk out of the clinic was a huge takeaway for me.

“But I don’t think the healthcare system rewards that style of practice. It rewards a type of practice where you see as many patients as you can throughout the day.”

Born in Lima, Peru, Castro moved with his family to Miami when he was five years old. Castro’s encounters with systemic barriers in the U.S. healthcare system as an immigrant child—stemming from a health scare and a hefty medical bill—sparked his drive to change the system from within.

“When I was about 13 years old, I had a perforated appendix, so I was in and out of the hospital for about a summer,” Castro said. “My mom didn’t know English; she was in her forties. She didn’t understand what was the date that I had to come in for my surgery. All of that got lost in translation. Because of that, I went through more hospitalizations, more antibiotics.”

They received an $80,000 bill.

“That would’ve killed us. At that time, we were seven people in a two-room apartment. But somehow it was forgiven,” Castro said. “I was a sick kid, I didn’t know either, but I do remember I could’ve had my appendix out way earlier than it was.”

Castro’s experience solidified his resolve to work with vulnerable populations and minority patients.

“We need more Latino physicians. We need more Black physicians. We just need more minority physicians to account for those minority populations that also need to see doctors,” Castro said. “I wish there was a way where I can tell my white colleagues that, ‘This is how you go about it,’ but there really isn’t any magic formula or anything.

“It’s just me being bilingual, being an immigrant, and being able to relate to my patients. And that’s what I do when I go into the clinic. And when I see someone who’s an immigrant who doesn’t speak English, I just can listen to them. I can understand them. I can reassure them.”

Upon starting medical school at Georgetown, Castro signed up for the Health Justice Scholars Track, which led him to take an elective advocacy rotation with Cancer LAW in his fourth year.

“I had a really positive experience,” Castro said. “When you’re only doing medicine, medicine, medicine, you’re not really caring for the whole person. There are other issues that are happening in the lives of your patients, and it is related to their health outcomes.”

Castro recommended the rotation to a fellow classmate, Francisca Finkel, who promptly signed up for training with Cancer LAW.

“When I was a child, my mom didn’t have health insurance because she couldn’t afford it,” said Finkel, who is now a general surgery resident at Harbor UCLA Medical Center. “I could see very starkly what access could do for people, with my mother’s family being very working class, low income, and needing more support.

“It was very interesting for us as medical students, to see the dynamic that we experience played out from a medical perspective where we encounter issues, predominantly of poverty and of lack of access in the clinic. We are in a position in which we can identify those things, but we can’t necessarily act on it,” Finkel said. “A lot of us come into this very optimistic. We want to save the world, but the world is complicated and we don’t have all the tools to do that.

Being able to engage the legal needs of patients with cancer is an empowering experience for physicians, Finkel said.

“I found it gave me a better understanding of my patients to be able to see what their complex social needs were on the other side, separate from their medical conditions,” Finkel said. “It gave me an opportunity to focus on a different aspect of their experience and their struggle, and also gave us the ability to see solutions at work.”

A conversation with Finkel appears in this issue.

Clinicians in physical medicine and rehabilitation, for example, need to understand the impact of non-clinical determinants of health, Castro said. Being equipped to respond is key.

“It makes a huge difference,” Castro said. “We have patients who come into the rehab hospital, they get better, and then when it’s time to discharge—this is probably the hardest part of the job—a lot of times patients themselves don’t have secure housing, they don’t have resources, they don’t have family members to help them through this process. 

“And I don’t think I’ve heard once, ‘Hey, what about an attorney who can help them through some of these legal issues that they have?’ We had social workers. But sometimes, once it becomes a legal issue, it is out of the expertise of a social worker.”

Indeed, the Cancer LAW team relies on social workers to assess patient needs in the initial screening for symptoms of psychosocial distress. This often begins with referrals from nurse navigators and medical assistants at MedStar Washington Hospital Center.

“We’ll ask patients a variety of questions and if they have a legal need, that’s where we bring in the Health Justice Alliance,” said Amy Ly, a clinical social worker coordinator at the MedStar Washington Hospital Center. “A lot of our patients are actually 55 and older. Not only are they elderly, but they already have preexisting struggles in life. A lot of previous trauma, living in poverty, and then, when cancer hits, it really hits pretty hard.”

Ly’s caseload is proof that legal and social support services are essential.

“There’s literally no way for me to actually follow up with my entire caseload right now, which is, like, a thousand. If I were to follow up with a thousand people, I wouldn’t be able to do any other work,” Ly said. “Cancer LAW helped with a variety of issues. This team has been very compassionate. A lot of times they’ll follow somebody even for a year or more for certain things. They’ve also been extremely impactful.

“I think this holistic, comprehensive service is much needed. It’s definitely needed in all cancer institutes.”

At Cancer LAW, young attorneys, too, get to train alongside their medical counterparts. 

When she was a student at Georgetown Law, Megan Gordon knew she wanted to work in public interest law, but she didn’t know how to translate her passion into real-world impact for marginalized communities. She found a mentor in Girard.

“I started talking to Vicki, and that’s how I learned about this whole model of working with doctors and patients in a hospital,” Gordon said. “I got to be part of a team in a way that lawyers don’t usually get to be. Working with a healthcare team and knowing that I can circle back and rely on them is so cool.”

Upon graduating, Gordon received an Equal Justice Works Fellowship, a two-year funded position that allows her to develop an expertise in medical-legal interventions at Cancer LAW.

“I’m talking on the phone with multiple patients every day. Even if I don’t have a court event with them, I’m checking in with them. And I made this resource for our patients about how Medicare works with their cancer care because a lot of patients, we realized, didn’t understand what their health insurance was.”

Academic partnerships are invaluable to MLPs, Girard said.

“Hearing from our law and medical students how the opportunity to work together in an MLP has changed the way they think about their professional roles and their ability to help patients and clients more holistically is a major endorsement for including academic partners in MLPs,” Girard said.

Preliminary research findings suggest that MLPs like Cancer LAW may reduce provider stress and help patients manage social drivers of health that interfere with their care, Girard said. 

“Also, legal support may have a positive impact on scheduling appointments for patients and often help to increase patient trust in the healthcare system,” Girard said. “Even more broadly, MLPs are able to leverage their direct service experiences to identify areas where policy and other efforts are needed to improve patient care and outcomes across their own communities and nationally.”

As her two-year stint at Cancer LAW came to a close, Gordon said she was resolved to continue working in a medical-legal partnership. She recently started a new position with another MLP, Healthy Together at the Children’s Law Center in Washington.

“I want to keep doing this type of work,” Gordon said. “I wish I could make safe housing appear, but I have my list of wins. I had a case with a patient who had her Medicaid wrongly turned off. She couldn’t get her chemo until we fixed it.

“We did get it fixed, and she could go get her care again.”

Monteiro: I’m here because of Cancer LAW

In Washington, northeast of the Anacostia River, Toni Monteiro celebrated her birthday with her family on July 26.

“I just turned 60 last Friday,” Monteiro said. “I’m surprised I made it!”

Thanks to advanced planning support provided by Cancer LAW, Monteiro is now focused on completing her living will.

“I would’ve been dead. I’m forever in their debt because they literally just carried me the whole way,” Monteiro said. “I will say this always: They did it basically out of the goodness of their heart. I’ve never had a team put together so well, no matter what job I’ve ever done.

“They didn’t just act like a bunch of lawyers. They acted like my counselors. They acted like social workers for me. They did everything, and especially when I myself couldn’t even fight anymore.”

Cancer centers across the U.S. should consider setting up MLPs—if they don’t already have one, Monteiro said.

“This is what we need. We need more of this. And, hopefully, people will listen,” Monteiro said. “Especially people that are in the position to do something, anything, because just having certain things like this available to people makes a difference. It really does. 

“Believe it or not, the small benefits that they can provide outweigh the treatments and stress and unreliability that some of these conditions bring upon you. And unfortunately, there is no condition out there that I know of that would not bring upon a whole bunch of stress.

“The less I had to worry about, the more I could concentrate on getting well. I think a lot of people need that.”

In the July 19 article “Platinum drugs are off the shortage list, but the underlying problem is unsolved,” FDA Commissioner Robert Califf and others describe a solution to the U.S. drug shortage as a matter of paying more for generic drugs.