Barriers, blocks, and barricades: Disparities to access of palliative care in cancer care

Racial, Ethnic and Language-Related Disparities in Palliative Care Utilization in Spinal Metastatic Disease

Studies indicate racial and ethnic disparities in access to palliative care services. The relationship between race, ethnicity, and associated factors and inpatient palliative care utilization in spinal metastatic disease remains unclear. We conducted a retrospective review of electronic health records to identify adult patients diagnosed with spinal metastatic disease at a single institution between January 2004 and December 2024. The primary outcome was inpatient palliative care consultation (IPCC) use. Secondary outcomes included the total number of IPCCs and time to first IPCC since diagnosis. Bivariate analyses and multivariate regression assessed disparities in IPCC utilization. Overall, 851 patients were included, with 303 (35.6%) having at least one IPCC. Bivariate analyses showed significant differences in IPCC use across racial groups, with White, Asian, Native-American, and 'Other' individuals trending towards lower utilization. Multivariate regression indicated that Native-American race had reduced odds of IPCC encounters (vs White, odds ratio [OR] = 1.16, 95% confidence interval [CI] = [0.12-11.58]) and longer time to first IPCC (Hazard ratio [HR] = 0.58 [0.08-4.19]). Asian (B-coefficient = -0.63 [-3.69-2.43]) and 'Other' race (B-coefficient = -1.26 [-4.19-1.67]), Hispanic ethnicity (vs Non-Hispanic, B-coefficient = -2.24 [-5.17-0.70]), non-English language (vs English, B-coefficient = -0.99 [-4.12-2.14]) and requiring an interpreter (vs not, B-coefficient = -1.38 [-4.64-1.88]) were associated with fewer overall IPCCs. While results did not reach statistical significance post-adjustment, our bivariate analyses and the direction and magnitude of associations in regression analyses suggest racial, ethnic and language-based disparities in access to palliative care for spinal metastatic disease patients. Further research and policy changes are needed to address these disparities and improve outcomes.

Inequities in palliative care delivery to patients with HIV and stage IV cancers in the United States (2004-2020)

BACKGROUND

People with HIV diagnosed with stage IV cancer are less likely to receive palliative care compared with those without HIV. Our objective was to evaluate inequities in palliative care receipt among people with HIV with stage IV cancer in the United States.

METHODS

We used the National Cancer Database (2004-2020), including adults (aged 18-89 years) with HIV with the 14 most common cancers that occur among people with HIV. Palliative care was defined as treatment provided with noncurative intent. Our main exposures included percent quartiles (Q) of adults without a high school degree (educational attainment) and median income quartiles within the patient's zip code. We used hierarchical multivariable Poisson regression to estimate adjusted prevalence ratios with 95% confidence intervals (CIs), adjusting for age, sex, year of diagnosis, race and ethnicity, and cancer type.

RESULTS

Among the included 10 120 people with HIV with stage IV cancer, 72% were men, 51% were either non-Hispanic Black or Hispanic or Latinx, 38% were aged 60 years and older, and 97% resided in urban areas; 14% received palliative care. Non-Hispanic Black people with HIV living in zip codes with lower quartiles of educational attainment were more likely to receive palliative care compared with those in the highest quartile (Q1 vs Q4: adjusted prevalence ratio = 1.93, 95% CI = 1.29 to 2.86). For income overall, compared with those in the highest quartile (Q4) of income, those in the lowest quartile had 26% higher likelihood of receiving palliative care (Q1 vs Q4: adjusted prevalence ratio = 1.26, 95% CI = 1.05 to 1.52), particularly among non-Hispanic Black adults (Q1 vs Q4: adjusted prevalence ratio = 1.67, 95% CI =1.25 to 2.22; Q2 vs Q4: adjusted prevalence ratio = 1.48, 95% CI = 1.09 to 2.01).

CONCLUSIONS

Palliative care use among people with HIV with stage IV cancer is low. Contextual poverty plays a role in palliative care delivery to people with HIV and cancer, particularly among non-Hispanic Black people with HIV.

"If we don't speak the language, we aren't offered the same opportunities": Qualitative perspectives of palliative care access for women of color living with advanced breast cancer

Context

Despite efforts to enhance equity, disparities in early palliative care (PC) access for historically minoritized patients with advanced breast cancer (ABC) persist. Insight into patient and clinician perspectives are needed to inform future models aimed at improving equity in PC access and outcomes.

Objectives

To explore qualitative barriers and facilitators to early PC access in an urban setting with Black and Latina women with ABC.

Methods

In this qualitative descriptive study, we conducted one-on-one interviews with Black and Latina women with ABC (N = 20) and interdisciplinary clinicians (N = 20) between February 2022 and February 2023. Participants were recruited from urban academic and community cancer clinics. Transcripts were analyzed using an inductive coding and thematic analysis approach.

Results

Barriers identified by both patients and clinicians included lack of communication between oncology, PC, and primary care teams, limited understanding of PC among patients and non-PC clinicians, language and health literacy-related communication challenges, and racism and marginalization, including implicit bias and lack of diverse racial/ethnic representation in the supportive care workforce. Facilitators identified by both patients and clinicians included patient-to-patient referrals, support groups breaking cultural stigma on topics including self-advocacy and PC, referrals from trusted providers, and community organizations' abilities to overcome challenges related to social determinants of health, most specifically logistical and financial support.

Conclusions

Patients and clinicians reported similar barriers and facilitators to PC access, most commonly through the lens of care coordination and communication. These findings will inform future adaptation of a culturally and linguistically care model to improve access to early PC services for Black and Latina women with ABC.