Oncologist Perceptions of Racial Disparity, Racial Anxiety, and Unconscious Bias in Clinical Interactions, Treatment, and Outcomes

Authors:
Alexandrina Balanean Cardinal Health, Dublin, OH

Search for other papers by Alexandrina Balanean in
Current site
Google Scholar
PubMed
Close
 MPH
,
Emily Bland Cardinal Health, Dublin, OH

Search for other papers by Emily Bland in
Current site
Google Scholar
PubMed
Close
 MPH
,
Ajeet Gajra Cardinal Health, Dublin, OH
Hematology-Oncology Associates of Central New York, Syracuse, NY

Search for other papers by Ajeet Gajra in
Current site
Google Scholar
PubMed
Close
 MD, MBBS
,
Yolaine Jeune-Smith Cardinal Health, Dublin, OH

Search for other papers by Yolaine Jeune-Smith in
Current site
Google Scholar
PubMed
Close
 PhD
,
Andrew J. Klink Cardinal Health, Dublin, OH

Search for other papers by Andrew J. Klink in
Current site
Google Scholar
PubMed
Close
 PhD, MPH
,
Harlen Hays Cardinal Health, Dublin, OH

Search for other papers by Harlen Hays in
Current site
Google Scholar
PubMed
Close
 MPH
, and
Bruce A. Feinberg Cardinal Health, Dublin, OH

Search for other papers by Bruce A. Feinberg in
Current site
Google Scholar
PubMed
Close
 DO
Restricted access

Background: Cancer spares no demographic or socioeconomic group; it is indeed the great equalizer. But its distribution is not equal; when structural discrimination concentrates poverty and race, zip code surpasses genetic code in predicting outcomes. Compared with White patients in the United States, Black patients are less likely to receive appropriate treatment and referral to clinical trials, genetic testing, or palliative care/hospice. Methods: In 2021, we administered a survey to 369 oncologists measuring differences in perceptions surrounding racial disparity, racial anxiety, and unconscious bias and adverse influence on clinical interactions, treatment, and outcomes for non-White patients. We analyzed responses by generational age group, sex/gender, race/ethnicity, US region, and selection of “decline to respond.” Results: The most significant differences occurred by age group followed by race/ethnicity. Racial disparity was perceived as moderate to very high by 84% of millennial, 69% of Generation X, and 57% of baby boomer oncologists, who were also 86% more likely than millennials and 63% more likely than Generation Xers to perceive low/nonexistent levels of racial anxiety/unconscious bias. Conclusions: Most oncologists rarely or never perceived racial anxiety/unconscious bias as adversely influencing clinical treatment or survival outcomes in non-White patients, and White oncologists were 85% more likely than non-White oncologists to perceive rare/nonexistent influence on referral of non-White patients to palliative care/hospice. The discrepancy between 62% of oncologists perceiving moderate to very high levels of racial anxiety/unconscious bias and 37% associating them with adverse influence on non-White patients shows a disconnect, especially among older oncologists (baby boomers), who were also least likely to select the decline option. Together, these factors hinder effective patient–provider communication and result in differential care and outcomes. Oncologists should uncover their own perceptions surrounding racial disparity, racial anxiety, and unconscious bias and modify their behaviors accordingly. It is this simple—and this complicated. Cancer does not discriminate, and neither should cancer care.

Submitted May 1, 2023; final revision received August 30, 2023; accepted for publication August 31, 2023. Published online February 27, 2024.

Previous presentation: Previous presentation and publication of the information reported in this manuscript was conducted at the 2021 ASCO Quality Care Symposium; September 24–25, 2021; Boston, Massachusetts. Abstract 104 and Abstract 141.

Author contributions: Study concept and design: Balanean, Gajra, Jeune-Smith. Data acquisition: Balanean, Jeune-Smith. Data analysis and interpretation: Balanean, Bland. Manuscript preparation: All authors. Writing—original draft: Balanean. Critical revision: All authors. Final approval of manuscript: All authors.

Data availability statement: All authors have access to the raw and final data set.

Disclosures: Ms. Balanean and Ms. Bland have disclosed that they are employed by Cardinal Health. Dr. Gajra has disclosed that he was employed by and owned stock in Cardinal Health, and is currently a contracted consultant for Cardinal Health and employed by the Hematology-Oncology Associates of Central New York. Dr. Jeune-Smith, Dr. Klink, Mr. Hays, and Dr. Feinberg have disclosed that they are salaried employees of and own stock in Cardinal Health.

Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2023.7078. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.

Correspondence: Alexandrina Balanean, MPH, Cardinal Health, 7000 Cardinal Place, Dublin, OH 43017. Email: alexandrina.balanean@cardinalhealth.com

View associated content

Supplementary Materials

    • Supplemental Materials (PDF 1.08 MB)
  • Collapse
  • Expand
  • 1.

    American Association for Cancer Research. AACR cancer disparities progress report 2022: achieving the bold vision of health equity for racial and ethnic minorities and other underserved populations. Accessed October 1, 2023. Available at: https://cancerprogressreport.aacr.org/wp-content/uploads/sites/2/2022/06/AACR_CDPR_2022.pdf

    • PubMed
    • Export Citation
  • 2.

    World Health Organization. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health: Final Report of the Commission on Social Determinants of Health. World Health Organization, 2008.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Tucker-Seeley RD. Social determinants of health and disparities in cancer care for Black people in the United States. JCO Oncol Pract 2021;17:261263.

  • 4.

    Benjamins MR, Silva A, Saiyed NS, et al. Comparison of all-cause mortality rates and inequities between Black and White populations across the 30 most populous US cities. JAMA Netw Open 2021;4:e2032086.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Sabin JA. Tackling implicit bias in health care. N Engl J Med 2022;387:105107.

  • 6.

    Tong M, Artiga S. Use of race in clinical diagnosis and decision making: overview and implications. Accessed August 1, 2023. Available at: https://www.kff.org/racial-equity-and-health-policy/issue-brief/use-of-race-in-clinical-diagnosis-and-decision-making-overview-and-implications/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Gajra A, Jeune-Smith Y, Balanean A. Cancer treatment and outcomes in patients of color or ethnic minority (PCEM): oncologist perceptions of racial anxiety and/or implicit bias (RA/IB). J Clin Oncol 2021;39(Suppl):Abstract 104.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Balanean A, Jeune-Smith Y, Feinberg BA, et al. Interaction with patients of color or ethnic minority (PCEM): oncologist perceptions of racial anxiety and/or implicit bias (RA/IB). J Clin Oncol 2021;39(Suppl):Abstract 141.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Bradley LJ, Clem J, Godsil R, et al. Racial anxiety among medical residents: institutional implications of social accountability. J Health Care Poor Underserved 2019;30(4S):105115.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Sabin J, Nosek BA, Greenwald A, et al. Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved 2009;20:896913.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015;105:e6076.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Ross H. Implicit bias: recognizing the unconscious barriers to quality care and diversity in medicine. Accessed October 1, 2023. Available at: https://www.acc.org/Latest-in-Cardiology/Articles/2020/01/01/24/42/Cover-Story-Implicit-Bias-Recognizing-the-Unconscious-Barriers-to-Quality-Care-and-Diversity-in-Medicine

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Tong M, Hill L, Artiga S. Racial disparities in cancer outcomes. Accessed August 1, 2023. Available at: https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-cancer-outcomes-screening-and-treatment/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Unger JM, Cook E, Tai E, et al. The role of clinical trial participation in cancer research: barriers, evidence, and strategies. Am Soc Clin Oncol Educ Book 2016;35:185198.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Center for Health Disparities Research. University of Wisconsin School of Medicine and Public Health: Neighborhood Atlas. Accessed October 1, 2023. Available at: https://www.neighborhoodatlas.medicine.wisc.edu/

    • PubMed
    • Export Citation
  • 16.

    Healio. Efforts to reduce racial disparities in cancer care aim to ‘make the invisible visible.’ Accessed August 10, 2023. Available at: https://www.healio.com/news/hematology-oncology/20190514/efforts-to-reduce-racial-disparities-in-cancer-care-aim-to-make-the-invisible-visible

    • PubMed
    • Export Citation
  • 17.

    Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 2007;22:12311238.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Ansell DA. The Death Gap: How Inequality Kills, 1st ed. University of Chicago Press; 2017.

  • 19.

    Siddiqui N, Faria A, Andrulis DP, et al. Mapping racial and ethnic inequities in health and opportunity. N Engl J Med 2020;383:e124.

  • 20.

    Siegel RL, Miller KD, Fuchs HE, et al. Cancer statistics, 2022. CA Cancer J Clin 2022;72:733.

  • 21.

    Friends of Cancer Research. Considerations for use of real-world evidence in oncology: lessons learned from Friends of Cancer Research collaborations. Accessed August 1, 2023. Available at: https://friendsofcancerresearch.org/wp-content/uploads/Use_of_Real-World_Evidence_in_Oncology_0.pdf

    • PubMed
    • Export Citation
  • 22.

    Sud S, Holmes J, Eblan M, et al. Clinical characteristics associated with racial disparities in endometrial cancer outcomes: a surveillance, epidemiology and end results analysis. Gynecol Oncol 2018;148:349356.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Dimock M. Defining generations: where millennials end and generation Z begins. Accessed August 1, 2023. Available at: https://www.pewresearch.org/short-reads/2019/01/17/where-millennials-end-and-generation-z-begins/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Johnson T, Walton S Jr, Levine S, et al. Racial and ethnic disparity in palliative care and hospice use. Am J Manag Care 2020;26:e3640.

  • 25.

    King TE Jr. Racial disparities in clinical trials. N Engl J Med 2002;346:14001402.

  • 26.

    Chapman-Davis E, Zhou ZN, Fields JC, et al. Racial and ethnic disparities in genetic testing at a hereditary breast and ovarian cancer center. J Gen Intern Med 2021;36:3542.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Project Implicit. Harvard implicit association test. Accessed September 2, 2023. Available at: https://implicit.harvard.edu/implicit/takeatest.html

    • PubMed
    • Export Citation
  • 28.

    Bridges KM. Implicit bias and racial disparities in health care. Accessed September 2, 2023. Available at: https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/racial-disparities-in-health-care/

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Schatz AA, Brooks-Coley K, Harrington E, et al. Patient, caregiver, and oncologist experiences with and perceptions of racial bias and discrimination in cancer care delivery. J Natl Compr Canc Netw 2022;20:10921098.e2.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Schatz AA, Chambers S, Wartman GC, et al. Advancing more equitable care through the development of a health equity report card. J Natl Compr Canc Netw 2023;21:117124.e3.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Arring N, Friese CR, Ghosh B, et al. Reaching populations to address disparities in cancer care delivery: results from a six-site initiative. J Natl Compr Canc Netw 2023;21:481486.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The National Academies Press; 2003.

  • 33.

    Daly B, Olopade OI. A perfect storm: how tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change. CA Cancer J Clin 2015;65:221238.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    NEJM Journal Watch. Racial disparities in clinical medicine: conversations, perspectives, and research on advancing medical equity. Accessed October 1, 2023. Available at: https://store.nejm.org/media/assets/nejm/register/pdf/NEJM_Group_Racial_Disparities_in_Clinical_Medicine.pdf

    • PubMed
    • Export Citation
  • 35.

    Blagev DP, Barton N, Grissom CK, et al. On the journey toward health equity: data, culture change, and the first step. NEJM Catal Innov Care Deliv 2021;2:CAT.21.0118.

  • 36.

    Penner LA, Blair IV, Albrecht TL, et al. Reducing racial health care disparities: a social psychological analysis. Policy Insights Behav Brain Sci 2014;1:204212.

  • 37.

    Gates K. Sitting in our discomfort. N Engl J Med 2022;386:e8.

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 2688 2688 1894
PDF Downloads 1846 1846 1368
EPUB Downloads 0 0 0