Marginalized patient identities and the patient-physician relationship in the cancer care context: a systematic scoping review

Silent suffering: the impact of sexual health challenges on patient-clinician communication and adherence to adjuvant endocrine therapy among Black women with early-stage breast cancer

PURPOSE

Adjuvant endocrine therapy (AET) increases sexual health challenges for women with early-stage breast cancer. Black women are more likely than women of other racial/ethnic groups to report adverse symptoms and least likely to initiate and maintain AET. Little is known about how sexual health challenges influence patient-clinician communication and treatment adherence. This study explores facilitators of and barriers to patient-clinician communication about sexual health and how those factors might affect AET adherence among Black women with early-stage breast cancer.

METHODS

We conducted 32 semi-structured, in-depth interviews among Black women with early-stage breast cancer in the U.S. Mid-South region. Participants completed an online questionnaire prior to interviews. Data were analyzed using thematic analysis.

RESULTS

Participants' median age was 59 (range 40-78 years, SD = 9.0). Adverse sexual symptoms hindered participants' AET adherence. Facilitators of patient-clinician communication about sexual health included female clinicians and peer support. Barriers included perceptions of male oncologists' disinterest in Black women's sexual health, perceptions of male oncologists' biased beliefs about sexual activity among older Black women, cultural norms of sexual silence among Southern Black women, and medical mistrust.

CONCLUSIONS

Adverse sexual symptoms and poor patient-clinician communication about sexual health contribute to lower AET adherence among Black women with early-stage breast cancer. New interventions using peer support models and female clinicians trained to discuss sexual health could ameliorate communication barriers and improve treatment adherence.

IMPLICATIONS FOR CANCER SURVIVORS

Black women with early-stage breast cancer in the U.S. Mid-South may require additional resources to address sociocultural and psychosocial implications of cancer survivorship to enable candid discussions with oncologists.

Racial and ethnic disparities in conversion to mastectomy following lumpectomy

PURPOSE

Advances in contemporary breast cancer care (e.g., early detection, increased use of preoperative chemotherapy, and updated SSO-ASTRO margin guidelines) have the collective potential to influence successful breast conservation. We evaluated contemporary trends in conversion to mastectomy (lumpectomy followed by definitive mastectomy) among women with breast cancer undergoing initial lumpectomy.

METHODS

Women with unilateral clinical stage 0-III breast cancer were identified from the National Cancer Database (2009-2019). Treatment sequence was categorized into surgery first or neoadjuvant chemotherapy (NACT) followed by surgery. We used a multivariable logistic regression model to calculate the predicted probability of conversion to mastectomy across diagnosis year and race and ethnicity, controlling for socio-demographic and clinical factors. We then calculated the relative change in conversion to mastectomy over time for each race and ethnic group.

RESULTS

The study included N = 1,543,702 women. Approximately 9.2% received NACT. Conversion to mastectomy differed significantly between those who underwent surgery first (10.6%) versus women who received NACT (6.1%, p < 0.0001). For those who underwent surgery first, success of breast conservation differed significantly by race/ethnicity. During the study period, White women had a relative decrease of 7.6% (95% CI - 10.58, - 4.59), while Black women had a relative increase of 8.9% (95% CI 1.53, 16.19) in predicted probability of conversion to mastectomy.

CONCLUSION

Over the past decade, Black women deemed candidates for initial lumpectomy were more likely to be converted to mastectomy when compared to White women. A greater understanding of contributing factors is needed to improve disparities in successful breast conservation.

Racial equity in and through medical interaction scholarship: A scoping review

OBJECTIVE

We conducted a systematic scoping review to characterize the landscape of communication scholarship within racial health equity in and through the patient-provider interaction.

METHODS

We employed three waves of data collection to identify relevant articles (N = 454) about racial equity within provider-patient interactions. We iteratively developed a codebook concerning article characteristics, coding for journal names, data source, descriptive characteristics for the study samples, and presence of theory and equity in sections of the manuscripts.

RESULTS

This search identified studies (N = 206) that were published in 76 peer-reviewed scientific journals. The majority of studies reported primary data analyses and used survey and interview methodology. Many studies examined participants as patients generally rather than in reference to particular health conditions. Among those with a specific health condition, the largest proportion focused on cancer control. Very few studies included samples with Native American and Pacific Island heritage. Most studies included cisgender men and/or women, but none included transgender men or women. The vast majority of research focused on the patient experience; few centered on providers' and caregivers' experiences. The body of scholarship was largely atheoretical; the most frequently noted constructs were patient-provider communication (including patient-centered communication and patient-centered care), implicit/explicit racial bias, shared decision-making. There was wide variation in the extent to which equity was woven through the manuscripts. Equity is typically mentioned in the literature review, and racial identity in the sample may serve as a marker of racialized experiences.

CONCLUSION

This study demonstrates the need for the development of theory that elevates the centrality of health equity to attend to the bi- or multi-directional flow of communication that shapes the quality of these interactions.

PRACTICE IMPLICATIONS

These insights can serve as a strong foundation for the development of interventions to address equity in clinical interactions.

The experience of self-advocacy among cancer patients: A qualitative meta-synthesis

BACKGROUND

During cancer treatment, patients are faced with major changes in physical function, psychological challenges and decline in quality of life. Self-advocacy is a key tool for patients to cope with the challenges of treatment. By fostering self-advocacy, patients can effectively self-manage, enhancing their overall quality of life and treatment outcomes. Besides, a significant majority of cancer patients encounter barriers when attempting to articulate their healthcare needs and engage in treatment decision-making processes. It's important to identify obstacles in the process of self-advocacy. The aim of this meta-synthesis was to describe the patients' experience of self-advocacy, and identify the facilitators and barriers of self-advocacy for cancer patients.

METHODS

The review used the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines guided reporting, and appraised the quality of each eligible study using the Critical Appraisal Skills Programme (CASP) checklist. A prospective review protocol was registered in the International Prospective Register of Systematic Reviews(no: CRD42023493926). A qualitative meta-synthesis was performed by searching eight electronic databases, including PubMed, Web of Science, Embase, Ovid MEDLINE, CINAHL, CNKI, Wanfang and SinoMed for studies meeting pre-defined eligibility criteria, from inception to November, 2023. Two reviewers independently undertook screening and review of articles, using the CASP checklist for evaluating qualitative research. The data were synthesised using Thomas and Harden's method of thematic and content analysis.

RESULTS

A total of 7 papers were included, and 24 research findings were distilled and integrated into three themes: benefits; challenges; external environmental support; and seven sub-themes: Gain confidence; improve self-management ability; Interaction and share; lack of awareness; obstacles; health system support and social support.

CONCLUSIONS

Cancer patients have different levels of self-advocacy ability, which is the result of the interaction between personal consciousness and family and social environment. Factors influencing self-initiative include patient gender, personality characteristics, support from friends and family, and support from the medical system. Therefore, medical staff should pay more attention to cancer patients with weak awareness of self-advocacy and poor enthusiasm and can use patient friend exchange meetings and entertainment interventions to improve patients 'level of self-advocacy. Future interventions should comprehensively consider the characteristics of cancer patients themselves and their external environment, and engage in multidisciplinary team cooperation.

Do patients want their spirituality addressed during their hospital journey; a cross-sectional study at a tertiary care center in Lebanon

BACKGROUND

Spirituality (including religiosity) is a powerful concept in Middle Eastern populations for members of all religious affiliations. This study aims to assess the desire of cancer and critically ill adult inpatients to be asked about their spiritual history, the impact their religious and spiritual beliefs have on their medical decisions, and if such beliefs help them cope with their illnesses.

METHODS

A questionnaire consisting of demographics and spirituality questions was developed and administered to 100 patients in a cross-sectional study. We performed psychometric analysis of the questionnaire through reliability and validity testing including construct validity using PCA with a Promax rotation to define components/constructs. Analysis was performed to study the association between patient characteristics and outcomes.

RESULTS

The scale was shown to be valid and reliable and can be used to assess spiritual needs in our population of critically ill and cancer patients. 45% of patients wanted to be asked about their spirituality, only 4% had discussed it with their medical team. Christian and Muslim patients were equally likely to want their spiritual history taken. Non-Lebanese patients were 4.8 times more equally likely to want their spiritual history taken and twice more likely to believe that their spirituality helps them cope with their illness compared to Lebanese patients (p < 0.05). Critical care patients as compared to cancer patients, and patients with a lower number of hospital visits during the past year, were significantly more likely to want to be asked about their spirituality (p < 0.05).

CONCLUSION

More structured training of healthcare personnel on addressing spirituality in the cultural context is needed. In our society, advocacy for patients with chronic illness embodies enquiring and addressing their spiritual needs through all the stages of their illness.

Body Image and Self-Identity in Transgender Patients: A Comprehensive Review from a Psycho-Oncological Perspective

As the number of transgender and gender-diverse (TGD) individuals seeking gender-affirming care continues to increase, it is crucial for healthcare providers to acknowledge the distinct challenges that this community faces and to offer personalized care. This article proposes a comprehensive review aimed at synthesizing current knowledge on the psycho-oncological challenges faced by TGD individuals. By exploring existing literature, it seeks to identify research gaps and provide a framework for addressing the intersection of gender identity, body image, and cancer-related healthcare needs. We aim to explore the complex relationship between being transgender and an oncologic patient, focusing primarily on the effects of gender-affirming hormone therapy (GAHT) and the implications of anatomical structures that remain after gender-affirming surgeries. The complex interplay between GAHT and cancer risks is highlighted, emphasizing the need for ongoing monitoring and tailored healthcare strategies. Psychological aspects of body image and self-identity among transgender individuals, particularly in the context of cancer treatment, are explored, as these treatments may involve significant bodily changes. For TGD individuals, these changes are intricately linked to their sense of identity and self-worth, leading to heightened distress and impaired quality of life. The disruption of sexual function due to cancer treatments can profoundly impact sexual identity and relationships, areas already vulnerable in the TGD population due to societal stigma. The role of social factors in shaping the experiences of TGD individuals in healthcare settings is also discussed, noting how these stressors can influence both the accessibility and quality of care. Research and clinical practice currently face gaps, and more comprehensive studies and guidelines that address the specific healthcare needs of TGD patients are warranted. The importance of an interdisciplinary approach, combining oncological care with gender-affirming practices, is underscored as essential for improving the overall health outcomes and quality of life for TGD individuals facing cancer.

Covid-19 Vaccine Hesitancy and Under-Vaccination among Marginalized Populations in the United States and Canada: A Scoping Review

BACKGROUND

Amid persistent disparities in Covid-19 vaccination and burgeoning research on vaccine hesitancy (VH), we conducted a scoping review to identify multilevel determinants of Covid-19 VH and under-vaccination among marginalized populations in the U.S. and Canada.

METHODS

Using the scoping review methodology developed by the Joanna Briggs Institute, we designed a search string and explored 7 databases to identify peer-reviewed articles published from January 1, 2020-October 25, 2022. We combine frequency analysis and narrative synthesis to describe factors influencing Covid-19 VH and under-vaccination among marginalized populations.

RESULTS

The search captured 11,374 non-duplicated records, scoped to 103 peer-reviewed articles. Among 14 marginalized populations identified, African American/Black, Latinx, LGBTQ+, American Indian/Indigenous, people with disabilities, and justice-involved people were the predominant focus. Thirty-two factors emerged as influencing Covid-19 VH, with structural racism/stigma and institutional mistrust (structural)(n = 71) most prevalent, followed by vaccine safety (vaccine-specific)(n = 62), side effects (vaccine-specific)(n = 50), trust in individual healthcare provider (social/community)(n = 38), and perceived risk of infection (individual)(n = 33). Structural factors predominated across populations, including structural racism/stigma and institutional mistrust, barriers to Covid-19 vaccine access due to limited supply/availability, distance/lack of transportation, no/low paid sick days, low internet/digital technology access, and lack of culturally- and linguistically-appropriate information.

DISCUSSION

We identified multilevel and complex drivers of Covid-19 under-vaccination among marginalized populations. Distinguishing vaccine-specific, individual, and social/community factors that may fuel decisional ambivalence, more appropriately defined as VH, from structural racism/structural stigma and systemic/institutional barriers to vaccination access may better support evidence-informed interventions to promote equity in access to vaccines and informed decision-making among marginalized populations.

Socioeconomic and demographic factors influencing interpersonal communication between patients with chronic conditions and family physicians: A systematic review

OBJECTIVE

This systematic review assessed the socioeconomic and demographic factors influencing interpersonal communication between family physicians and patients with chronic diseases.

METHODS

We searched three databases (Embase, MEDLINE, and Cochrane) for published empirical studies reporting interpersonal communication between adults with chronic conditions and their family physicians. Gender, sex, race or ethnicity, low levels of literacy and/or health knowledge, and lower level of education or income were the factors of interest. Pairs of independent reviewers selected studies, extracted data, and appraised quality of the studies using MMAT-2018. We conducted descriptive and content analyses with a narrative synthesis.

RESULTS

From 7579 identified deduped studies, we included 12 with a total of 22266 participants. Suboptimal interpersonal communication in several domains was more incident amongst ethnic minorities (p < 0.01) and individuals with lower language proficiency (p < 0.05).

DISCUSSION AND CONCLUSION

Studies used sex and gender interchangeably. The classifications of racial and ethnic origin, income, and education levels were inconsistent. Our findings suggest that socioeconomic and demographic factors can affect deleteriously in-encounter interpersonal communication.

PRACTICE IMPLICATIONS

This review might help guide a communication curriculum for medical students and increase awareness of potential health inequalities pathways in clinical practice.

REGISTRATION NUMBER

CRD42023411895 (PROSPERO platform).

Developing a city-wide, community-engaged cancer disparities research agenda

INTRODUCTION

In response to high levels of cancer disparities in Philadelphia, PA, three NCI-designated clinical cancer centers formed Philadelphia Communities Conquering Cancer (PC3) to bring stakeholders together and establish infrastructure for future cancer reducing initiatives. The PC3 coalition aimed to develop a prioritized cancer disparities research agenda in order to align cancer center resources and research interests with the concerns of the community about cancer, and to ensure that initiatives were patient- and community-centered.

METHODS

Agenda development activities culminated in a city-wide cancer disparities conference. The conference, attended by 55 diverse stakeholders, was the venue for small group discussion sessions about cancer concerns related to prevention, early detection, treatment, survivorship, and quality of life. Sessions were guided by a moderator guide and were audiorecorded, transcribed, and analyzed by the PC3 leadership team. Results were reviewed and consensus was achieved with the help of PC3's Stakeholder Advisory Committee.

RESULTS

Stakeholders identified four thematic areas as top priorities for cancer disparities research and action in Philadelphia: communication between patients, providers, and caregivers; education that reaches patients and community members with tailored and targeted information; navigation that assists people in finding and accessing the right cancer screening or treatment option for them; and representation that diversifies the workforce in clinics, cancer centers, and research offices.

CONCLUSION

A community-informed, prioritized research agenda provides a road map for the three cancer centers to collaborate on future initiatives that are important to patients and stakeholders, to ultimately reduce the burden of cancer for all Philadelphians.

Understanding Multi-Level Factors Impacting Digital Health Literacy in the Deep South of the United States

As healthcare and health services become increasingly digitized, individuals with low digital health literacy (DHL) may experience inequitable care and outcomes. We explored factors impacting DHL and recommendations for improvement from community health coordinators and advisors (CHAs) in Alabama and Mississippi in United States. Semi-structured interviews were conducted with CHAs to gather insights on their perspectives on and experiences with DHL. Interviews were transcribed and analyzed using a grounded coding schema, with key barriers and recommendations mapped onto the Taplin Multi-Level Intervention model to help identify influences across various levels. Thirty-two CHAs participated, predominantly female (94%) and Black or African American (94%). At the individual level, factors involved demographic characteristics, increased patient workload, and attitudes towards technology. Social support was captured at the relationships level. At the provider level, provider-patient communication and injustices were involved, compounded by health system infrastructure and culture at the practice-setting level. Resource landscape and shared knowledge and beliefs were significant at the community level. The COVID-19 pandemic further highlighted these challenges at the societal level. CHAs provided targeted recommendations for addressing barriers at each level. CHAs identified multi-level factors contributing to DHL and emphasized levels based on comprehensive interventions.

Understanding and tackling cancer inequities: What opportunities does intersectionality offer researchers, policymakers, and providers? A scoping review

PROBLEM IDENTIFICATION

We summarised the international evidence relating to the role of intersectionality in patients' lived experience of inequities along the cancer care pathway. We produced guidance to use intersectionality in future research.

LITERATURE SEARCH

We included 42 articles published between 1989 to 2023 that used intersectionality to guide the study and interpretation of inequities in cancer care.

DATA EVALUATION/SYNTHESIS

Articles predominantly comprised North American (n = 37), followed by European (n = 4) and Asian (n = 1) studies. Similar compounding effects of racism, homophobia, and discrimination across countries exacerbated inequities in cancer care experience and cancer outcomes particularly for women of color and sexual/gender minority groups. Professionals' knowledge, attitudes, and behaviors toward minoritised groups affected patient-provider relationships and influenced cancer patients' psychosocial responses.

CONCLUSION

Intersectionality provides a framework to assess the personal, interpersonal, and structural processes through which cancer inequities manifest within and across countries.

Neuropsychological assessment, intervention, and best practices for women with non-Central nervous system cancer: A scoping review of current standards

Objective: Existing literature has sought to characterize the broad cognitive impact of non-central nervous system cancer and its treatment, including chemotherapy, radiation, surgery, and hormonal regulation. However, despite the frequency of women that are diagnosed with breast and gynecological cancer, there is limited research on the specific cognitive experiences of women undergoing cancer treatment. Presently, the current literature lacks concise guidance for neuropsychologists to support the cognitive health of women facing cancer, despite the acknowledged impact of cancer interventions and chronic illness on cognitive outcomes. Method: Applying scoping review criteria outlined by Peters et al. (2015) and adhering to Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a comprehensive examination of literature spanning multiple databases (Google Scholar, PubMed, PsychINFO) with a focus on the cognitive impact of cancer treatment on women. Conclusions: Women are subject to unique treatment-related outcomes due to the impact of hormonal alterations, differences in metabolization of certain chemotherapies, and psychosocial risk factors. Despite the known impact of cancer intervention, chronic illness, and cancer-related sequelae on cognitive outcomes, the current literature does not parsimoniously outline best practices for neuropsychologists to promote the health of women experiencing cancer. The current paper (1) provides an overview of the cognitive implications of cancer treatment with an intentional focus on cancers that are more prevalent in women versus men, (2) addresses the characteristics of this impact for women undergoing cancer intervention(s), and (3) provides possible intervention and treatment strategies for mental health providers and neuropsychologists.

Opioid Access among Advanced Cancer Patients in Low- and Middle-Income Countries in Asia

CONTEXT

Most cancer-associated pain is experienced in low- and middle-income countries (LMICs) due to inequitable access to opioids.

OBJECTIVE

To determine opioid access as estimated by both patients and providers and to understand patient and facility-level factors influencing access among patients with advanced cancer in LMICs in Asia using the Behavioral Model of Health Services Use.

METHODS

The APPROACH cross-sectional study was conducted in seven LMICs in Asia, involving in-depth surveys with providers and advanced cancer patients. A hierarchical logistic regression model was used to assess predisposing (i.e. individual factors), enabling (i.e. health care system and facility-level resources) and need (i.e. pain severity) factors predicting opioid access.

RESULTS

Among patient participants (n=1,933), approximately 40% reported opioid use. Meanwhile 80% of facilities, as reported by providers, indicated at least half of their advanced cancer patients receive oral morphine prescriptions. Predisposing characteristics factored in the least in the model, with patient education positively associated with access (Odds ratio (OR): 1.01; 95% CI=1.00, 1.03). Facility-level enabling resources, factoring the most, included oral morphine prescription duration >14 days (OR: 1.27; 95% CI=1.05, 1.53) and the extent of physician palliative care training (extensive (>160 hours) OR: 3.95; CI=3.19, 4.88; basic (up to 40 hours) OR: 1.03; CI=1.03, 1.04). Patient need as indicated by greater pain severity predicted access (OR: 1.55; CI=1.47, 1.64).

CONCLUSION

Study findings emphasize the importance of palliative care training-even a minimal amount-in supporting access to opioids for advanced cancer patients. This study also highlights pragmatic site-level policies, such as extended morphine prescription durations, enabling access.

Early-stage breast cancer treatment disparities in the Midsouth: Has anything changed?

BACKGROUND

We sought to determine if racial disparities in treatment and survival persist among patients with breast cancer in the Midsouth.

METHODS

Patients with early-stage breast cancer were identified in the tumor registry of a large healthcare system in the Midsouth. Regression analyses were performed to determine how race was associated with receipt of treatment and mortality.

RESULTS

Among 4605 patients, 38.8% were Black. Black patients were less likely to undergo surgery (OR = 0.71; 95%CI 0.53-0.97) and receive hormone therapy (OR = 0.81; 95%CI 0.69-0.95) than White patients, but more likely to receive radiation (OR = 1.20; 95%CI 1.08-1.40) and chemotherapy (OR = 1.36; 95%CI 1.16-1.61). Among Black patients, the risk of mortality was lower among those who underwent partial (OR = 0.25; 95%CI 0.12-0.51) or total (OR = 0.35; 95%CI 0.16-0.76) mastectomy and among those who received hormone therapy (OR = 0.62; 95%CI 0.40-0.97).

CONCLUSION

There remains room for improvement in providing treatments that optimize survival among this patient population.

The Experience of Informal Newcomer Cancer Caregivers with Limited Language Proficiency: A Scoping Review

This scoping review explored what is known about the experiences of informal cancer caregivers (CGs) who are newcomers with limited language proficiency. A literature search was performed in seven databases and the search yielded 11,289 articles. After duplicate removal and title and abstract screening, 216 articles underwent full text review and 57 articles and were synthesized. Most studies (n = 41, 72%) were qualitative and were published in North America (n = 35, 61%). Most CG participants were female (69%) and only 19 studies explicitly identified the CG country of origin. Of those that did, 26% originated from Asia, with most migrating from East Asia. Significant challenges were experienced by newcomer CGs and chief among these were related to communication challenges with HCPs that were exacerbated by a lack of availability of medical interpreters and the complexity of oncology health information. Efforts are needed to better integrate newcomer CGs into cancer care.

Artificial Intelligence and Cancer Control: Toward Prioritizing Justice, Equity, Diversity, and Inclusion (JEDI) in Emerging Decision Support Technologies

PURPOSE FOR REVIEW

This perspective piece has two goals: first, to describe issues related to artificial intelligence-based applications for cancer control as they may impact health inequities or disparities; and second, to report on a review of systematic reviews and meta-analyses of artificial intelligence-based tools for cancer control to ascertain the extent to which discussions of justice, equity, diversity, inclusion, or health disparities manifest in syntheses of the field's best evidence.

RECENT FINDINGS

We found that, while a significant proportion of existing syntheses of research on AI-based tools in cancer control use formal bias assessment tools, the fairness or equitability of models is not yet systematically analyzable across studies. Issues related to real-world use of AI-based tools for cancer control, such as workflow considerations, measures of usability and acceptance, or tool architecture, are more visible in the literature, but still addressed only in a minority of reviews. Artificial intelligence is poised to bring significant benefits to a wide range of applications in cancer control, but more thorough and standardized evaluations and reporting of model fairness are required to build the evidence base for AI-based tool design for cancer and to ensure that these emerging technologies promote equitable healthcare.

How Does Orthopaedic Surgeon Gender Representation Vary by Career Stage, Regional Distribution, and Practice Size? A Large-Database Medicare Study

BACKGROUND

Orthopaedic surgery has the lowest proportion of women surgeons in practice of any specialty in the United States. Preliminary studies suggest that patients who are treated by physicians of the same race, ethnicity, cultural background, or gender feel more comfortable with their care and may have better outcomes. Therefore, understanding the discrepancies in the diversity of the orthopaedic surgeon workforce is crucial to addressing system-wide healthcare inequities.

QUESTIONS/PURPOSES

(1) Does a difference exist in gender representation among practicing orthopaedic surgeons across geographic distributions and years in practice? (2) Does a difference exist in gender representation among practicing orthopaedic surgeons with regard to rural-urban setting, group practice size, and years in practice?

METHODS

Orthopaedic surgeons serving Medicare patients in 2017 were identified in the Medicare Physician and Other Supplier Public Use File and Physician Compare national databases. This dataset encompasses more than 64% of practicing orthopaedic surgeons, providing a low proportion of missing data compared with other survey techniques. Group practice size, location, and Rural-urban Commuting Area scores were compared across physician gender and years in practice. Linear and logistic regressions modeled gender and outcomes relationships adjusted by years in practice. Least-square means estimates for outcomes were calculated by gender at the median years in practice (19 years) via regression models.

RESULTS

According to the combined Medicare databases used, 5% (1019 of 19,221) of orthopaedic surgeons serving Medicare patients were women; this proportion increased with decreasing years in practice (R 2 0.97; p < 0.001). Compared by region, the West region demonstrated the highest proportion of women orthopaedic surgeons overall (7% [259 of 3811]). The Midwest and South regions were below the national mean for proportions of women orthopaedic surgeons, both overall (5% [305 of 6666] and 5% [209 of 4146], respectively) and in the first 5 years of practice (9% [54 of 574] and 9% [74 of 817], respectively). Women worked in larger group practices than men (median [interquartile range] 118 physicians [20 to 636] versus median 56 [12 to 338]; p < 0.001, respectively). Both genders were more likely to practice in an urban setting, and when controlling for years in practice, there was no difference between men and women orthopaedic surgeons practicing in rural or urban settings (respectively, R 2 = 0.0004 and 0.07; p = 0.89 and 0.09).

CONCLUSION

Among orthopaedic surgeons, there is only one woman for every 20 men caring for Medicare patients in the United States. Although gender representation is increasing longitudinally for women, it trails behind other surgical subspecialties substantially. Longitudinal mentoring programs, among other evidenced initiatives, should focus on the more pronounced underrepresentation identified in Midwestern/Southern regions and smaller group practices. Gender-based equity, inclusion, and diversity efforts should focus on recruitment strategies, and further research is needed to study how inclusion and diversity efforts among orthopaedic surgeons improves patient-centered care.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Predictors of Unrelieved Symptoms in All of Us Research Program Participants With Chronic Conditions

CONTEXT

Over half of American adults are diagnosed with a chronic condition, with an increasing prevalence being diagnosed with multiple chronic conditions. These adults are at higher risk for having unrelieved, co-occurring symptoms, known as symptom clusters.

OBJECTIVES

To identify symptom phenotypes of patients diagnosed with four common chronic conditions, specifically, cancer, chronic obstructive pulmonary disease, heart failure, and/or type 2 diabetes mellitus, and to understand factors that predict membership in symptomatic phenotypes.

METHODS

We conducted a retrospective, cross-sectional analysis using participant responses (N=14,127) to All of Us Research Program, a National Institutes of Health biomedical database, survey questions. We performed hierarchical clustering to generate symptom phenotypes of fatigue, emotional distress, and pain and used multinomial regression to determine if demographic, healthcare access and utilization, and health-related variables predict symptom phenotype.

RESULTS

Four phenotypes, one asymptomatic or mildly symptomatic and three highly symptomatic (characterized by severe symptoms, severe pain, and severe emotional distress), were identified. The percentage of participants belonging to the severe symptoms phenotype increased with the number of chronic conditions. Most notably, foregoing or delaying medical care and rating mental health as poor or fair increased the odds of belonging to a highly symptomatic phenotype.

CONCLUSION

We found meaningful relationships between demographic, healthcare access and utilization, and health-related factors and symptom phenotypes. With the increasing trends of American adults with one or more chronic conditions and a demand to individualize care in the precision health era, it is critical to understand the factors that lead to unrelieved symptoms.

Unifying and universalizing Personalised Care? An analysis of a national curriculum with implications for policy and education relating to person-centred care

OBJECTIVE

To examine the Curriculum of England's Personalised Care Institute as a national initiative to promote person-centred practice.

METHOD

Analysis of Curriculum content and discourse RESULTS: The Curriculum describes an educational framework which aspires to unify approaches and universalize provision of Personalised Care. It presents 8 "models and approaches" and 6 "components" within the "whole" of Personalised Care. It locates their unity in an underlying common core repertoire of professional capabilities and values and an anchoring belief in people's strengths, resourcefulness and ability to develop their own solutions with appropriate support. The Curriculum indicates some complexity in the provision of Personalised Care but leaves unanswered questions about the theoretical coherence of the concept. It also neglects some important aspects of person-centredness (especially values beyond empowerment and choice); the implications of entrenched social inequalities and systemic prejudices; and other practical-ethical implementation challenges that can be difficult for health professionals.

CONCLUSION

The Curriculum signals a national commitment to person-centred practice, but its practical potential is limited by its neglect of the value tensions and diverse situational challenges involved.

PRACTICE IMPLICATIONS

The Curriculum and similar policy-education initiatives could be strengthened by more explicit attention to the normative complexities of person-centred practice.

Trends in Cancer Mortality Among Black Individuals in the US From 1999 to 2019

Questions

How did cancer mortality among Black individuals change in the US from 1999 to 2019 by age, sex, and cancer site, and how did 2019 cancer mortality rates among Black individuals compare with rates in other racial and ethnic groups?

Findings

In this cross-sectional study of 1 361 663 deaths from cancer among Black individuals, although cancer mortality decreased considerably among Black individuals from 1999 to 2019, the cancer mortality rate was higher among Black men and women than in other racial and ethnic groups in 2019.

Meaning

The findings suggest that resources should be allocated toward eliminating social inequalities and barriers throughout the cancer control continuum that contribute to substantially higher cancer mortality rates among Black men and women.

Importance

Cancer is the second leading cause of mortality in the US. Despite national decreases in cancer mortality, Black individuals continue to have the highest cancer death rates.

Objective

To examine national trends in cancer mortality from 1999 to 2019 among Black individuals by demographic characteristics and to compare cancer death rates in 2019 among Black individuals with rates in other racial and ethnic groups.

Design, Setting, and Participants

This serial cross-sectional study used US national death certificate data obtained from the National Center for Health Statistics and included all cancer deaths among individuals aged 20 years or older from January 1999 to December 2019. Data were analyzed from June 2021 to January 2022.

Exposures

Age, sex, and race and ethnicity.

Main Outcomes and Measures

Trends in age-standardized mortality rates and average annual percent change (AAPC) in rates were estimated by cancer type, age, sex, and race and ethnicity.

Results

From 1999 to 2019, 1 361 663 million deaths from cancer occurred among Black individuals. The overall cancer death rate significantly decreased among Black men (AAPC, −2.6%; 95% CI, −2.6% to −2.6%) and women (AAPC, −1.5%; 95% CI, −1.7% to −1.3%). Death rates decreased for most cancer types, with the greatest decreases observed for lung cancer among men (AAPC, −3.8%; 95% CI, −4.0% to −3.6%) and stomach cancer among women (AAPC, −3.4%; 95% CI, −3.6% to −3.2%). Lung cancer mortality also had the largest absolute decreases among men (−78.5 per 100 000 population) and women (−19.5 per 100 000 population). We observed a significant increase in deaths from liver cancer among men (AAPC, 3.8%; 95% CI, 3.0%-4.6%) and women (AAPC, 1.8%; 95% CI, 1.2%-2.3%) aged 65 to 79 years. There was also an increasing trend in uterus cancer mortality among women aged 35 to 49 years (2.9%; 95% CI, 2.3% to 2.6%), 50 to 64 years (2.3%; 95% CI, 2.0% to 2.6%), and 65 to 79 years (1.6%; 95% CI, 1.2% to 2.0%). In 2019, Black men and women had the highest cancer mortality rates compared with non-Hispanic American Indian/Alaska Native, Asian or Pacific Islander, and White individuals and Hispanic/Latino individuals.

Conclusions and Relevance

In this cross-sectional study, there were substantial decreases in cancer death rates among Black individuals from 1999 to 2019, but higher cancer death rates among Black men and women compared with other racial and ethnic groups persisted in 2019. Targeted interventions appear to be needed to eliminate social inequalities that contribute to Black individuals having higher cancer mortality.

COVID-19 vaccine hesitancy among marginalized populations in the U.S. and Canada: Protocol for a scoping review

INTRODUCTION

Despite the development of safe and highly efficacious COVID-19 vaccines, extensive barriers to vaccine deployment and uptake threaten the effectiveness of vaccines in controlling the pandemic. Notably, marginalization produces structural and social inequalities that render certain populations disproportionately vulnerable to COVID-19 incidence, morbidity, and mortality, and less likely to be vaccinated. The purpose of this scoping review is to provide a comprehensive overview of definitions/conceptualizations, elements, and determinants of COVID-19 vaccine hesitancy among marginalized populations in the U.S. and Canada.

MATERIALS AND METHODS

The proposed scoping review follows the framework outlined by Arksey and O'Malley, and further developed by the Joanna Briggs Institute. It will comply with reporting guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The overall research question is: What are the definitions/conceptualizations and factors associated with vaccine hesitancy in the context of COVID-19 vaccines among adults from marginalized populations in the U.S. and Canada. Search strategies will be developed using controlled vocabulary and selected keywords, and customized for relevant databases, in collaboration with a research librarian. The results will be analyzed and synthesized quantitatively (i.e., frequencies) and qualitatively (i.e., thematic analysis) in relation to the research questions, guided by a revised WHO Vaccine Hesitancy Matrix.

DISCUSSION

This scoping review will contribute to honing and advancing the conceptualization of COVID-19 vaccine hesitancy and broader elements and determinants of underutilization of COVID-19 vaccination among marginalized populations, identify evidence gaps, and support recommendations for research and practice moving forward.

What Are the Psycho-Social and Information Needs of Adolescents and Young Adults Cancer Care Consumers with Intellectual Disability? A Systematic Review of Evidence with Recommendations for Future Research and Practice

People with intellectual disability have unmet health needs and experience health inequalities. There is limited literature regarding cancer care for children, adolescents, and young adults (AYA) with intellectual disability despite rising cancer incidence rates in this population. This systematic review aimed to identify the psycho-social and information support needs of AYA cancer care consumers with intellectual disability to generate recommendations for future research and cancer care service delivery enhancement. We searched eight databases yielding 798 articles. Following abstract and full-text review, we identified 12 articles meeting our inclusion criteria. Our three themes related to communication and accessible information; supports and system navigation, cancer service provider training, and reasonable adjustments. There was a lack of user-friendly, accessible information about cancer and screening programs available. Both paid and family carers are critical in accessing cancer supports, services, and screening programs for AYA with intellectual disability. Ongoing training should be provided to healthcare professionals regarding the importance of care screening for AYAs with intellectual disability. This review recommends that AYA with intellectual disability and their family carers be involved in developing tailored cancer services. This should focus on enabling inclusive screening programs, accessible consent, and challenging the enduring paternalism of support services via training and appropriate communication tools.