Racial disparities in cancer incidence and outcomes have been well documented1,2 and may be due in part to lack of physician cultural competency. A cancer diagnosis and discussions of prognosis and treatments can have widely different implications across different cultural contexts. Highlighting the importance of high-quality care for diverse cultures, the American Society of Clinical Oncology recently outlined goals for improving cultural competency within its policy statement on cancer disparities.3,4 However, nationally representative data on cultural competency among physicians is limited. We therefore examined patient–reported physician cultural competency among cancer survivors in the United States using data from a contemporary population-based survey.
The National Health Interview Survey (NHIS) collects data on a range of health indicators for noninstitutionalized, civilian adults.5 In 2017, the NHIS included a supplemental set of questions regarding physician cultural competency (eg, “How often were you treated with respect by your providers?”) (Figure). Harmonized data of participants reporting a cancer diagnosis were obtained through the Integrated Health Interview Series.6
Multivariable logistic regression defined adjusted odds ratios (AORs) with 95% CIs for each patient-reported measure of cultural competency across respondent reported race/ethnicity (non–Hispanic white [referent] vs nonwhite minority [either Hispanic/Latino ethnicity or nonwhite race]), among other sociodemographic variables (Figure). Subpopulation sample weighting defined nationally representative estimates for all end points. Statistical testing was 2-sided (α = .05) and was performed with Stata/SE 15.1 (StataCorp). The University of Texas Southwestern Institutional Review Board deemed the study exempt from review and patient informed consent requirements because deidentified data were used.
Among 2244 adult cancer survivors who responded to the survey supplement, 1866 (81.8% [sample weighted]) were non–Hispanic white, 2 (<0.1%) had unknown race/ethnicity, 1334 (59.4%) were women, and the median age was 68 years (interquartile range, 59-76 years). Nonwhite minority cancer survivors were more likely than non–Hispanic white cancer survivors to report that it was somewhat/very important for their physicians to share or understand their culture (49.6% [n = 177 of 372] vs 31.2% [n = 577 of 1857; sample weighted; excluding 13 nonresponders]; AOR, 1.92; 95% CI, 1.46-2.52), but were less likely to report frequently being able to see physicians who shared or understood their culture (65.3% [n = 133 of 200] vs 79.9% [611 of 755; excluding 24 nonresponders and 1263 participants not asked this question given the response of “not important at all” for question 1]; AOR, 0.42; 95% CI, 0.26-0.66) (Figure). Notably, 12.6% of nonwhite minority cancer survivors (n = 25 of 200) were never able to see physicians who shared or understood their culture, compared with 4.0% of non–Hispanic whites (n = 28 of 755) (AOR, 4.10; 95% CI, 2.01-8.35). Both minority and non–Hispanic white cancer survivors reported similarly high rates of frequently being treated with respect by physicians, receiving easily understandable health information from their physicians, and being asked by physicians for their opinions or beliefs regarding care (Figure).
Using national population-based data, our study suggests that minority cancer survivors appear to place greater value on physician cultural competency but are less likely to be cared for by those who share or understand their culture. This disparity could be attributed in part to the limited diversity of the oncology workforce, which is currently comprised of 5.3% black/African American and Hispanic/Latino physicians.2 Our findings could also be explained by insufficient training in cultural competency—irrespective of physician background—geographic variations in physician availability, insurance plan coverage networks, and potential preferences of physician characteristics other than cultural competency that some patients may value more. Limitations include lack of information on physician race/ethnicity precluding analysis of patient-physician racial concordance, lack of data describing whether a respondent’s primary physician was an oncologist or physician—although most cancer survivors continue seeing their oncologist longitudinally—and possible response biases given the study’s survey design.
In summary, despite longstanding efforts to improve care for minority patients with cancer and cancer survivors, there remain racial/ethnic disparities in receipt of culturally competent care. These findings should provide an impetus for evaluation of policy and guidelines designed to improve oncology training in cultural literacy.
Accepted for Publication: August 29, 2019.
Corresponding Author: Nina N. Sanford, MD, Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Rd, Dallas, TX 75390-9303 (nina.sanford@utsouthwestern.edu).
Published Online: October 31, 2019. doi:10.1001/jamaoncol.2019.4720
Author Contributions: Dr Sanford and Mr Butler had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Mahal and Sanford contributed equally as co–senior authors.
Study concept and design: Butler, Mahal, Sanford.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Butler, Mahal, Sanford.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Butler, Ahn, Mahal, Sanford.
Obtained funding: Song, Mahal.
Administrative, technical, or material support: Mahal.
Study supervision: Dee, Mahal, Sanford.
Other—Interpretation of results: Song.
Conflict of Interest Disclosures: None reported.
Funding/Support: Dr Mahal reports funding from the American Society of Radiation Oncology and the Prostate Cancer Foundation.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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