Don’t Neglect Cultural Diversity in Oncology Care

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  • 1 Presented by Teresita Muñoz-Antonia, PhD, Associate Director, Molecular Oncology Program, Moffitt Cancer Center, Tampa, Florida.

The growing Hispanic population in the United States mandates the need for oncology providers to become more familiar with disease patterns and cultural belief systems that can impact cancer care. “Culturally competent care” should be the mandate of all providers. This comprises awareness of cultural differences, communication in a manner that the patient understands, and respect.

In the practice of oncology, there needs to be a better appreciation of Hispanic sub-ethnicities, according to Teresita Muñoz-Antonia, PhD, Associate Director, Molecular Oncology Program, Moffitt Cancer Center, Tampa, who spoke about “Cultural Diversity in Delivering and Receiving Oncology Care” at the NCCN 19th Annual Conference, concentrating her remarks on the Hispanic population.

“There are interethnic biological differences that affect cancer care among Hispanics, and there are cultural differences in their health-related beliefs that influence cancer care and patient management,” she said.

Hispanic (or Latino) ethnic categories include persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. In the United States, the largest Hispanic populations are found in the Southwest, especially New Mexico, Texas, and California.

The 4 most common cancers in whites are also the most common in Hispanics—colon, breast, lung, and prostate—however, mortality rates differ somewhat. For example, lung cancer carries a 50% lower mortality rate for Hispanics than for white non-Hispanics, despite the fact that Hispanics are less likely to receive treatment and more likely to be diagnosed at advanced stages.1

“We believe a combination of genetics and environmental exposures may be responsible for such differences,” Dr. Muñoz-Antonia said. A number of relevant single nucleotide polymorphisms have been identified among Hispanic populations. They have a fairly high rate (33%) of epidermal growth factor receptor mutations (close to the 40% seen in Asians)2 and they harbor novel mutations of unknown significance.

Acute lymphoblastic leukemia (ALL) is another area in which genetic differences are clear, based on a disease susceptibility locus (ARID5B) unique to Hispanics that increases the risk of pediatric ALL and its recurrence. Hispanic children are up to twice as likely as their white counterparts to inherit the high-risk version of ARID5B.3

Ethnicity also affects response to drugs, especially toxicity, a concept known as “pharmacoethnicity.” Differences in toxicity are because of genetic polymorphisms that affect drug metabolism and are evident for antimetabolites (5-fluorouracil in colon cancer), anthracyclines (cardiotoxicity), and alkylating agents (cytochrome P450 enzymes).

Ancestry Informative Markers

Ancestry informative markers (AIMs) are genetic markers used by researchers to determine ancestral origin. For example, studies using AIMs have shown that most Puerto Ricans carry more European and African ancestry but significantly less indigenous American ancestry, when compared with most Mexicans and Central Americans.4

“Once genetic ancestry is estimated, it can be used to adjust for genetic associations. The relative contribution of each ancestral genetic background can explain discrepancies in disease susceptibility between different ethnic groups,” Dr. Muñoz-Antonia explained.

The use of AIMs in breast cancer research, for example, has shown that BRCA1 and BRCA2 mutations occur with considerable frequency within the Hispanic population5; that the BRCA1 187delAG mutation is found among women of Mexican descent, a haplotype shared with Ashkenazi Jewish women6; and that Puerto Rican women carry BRCA mutations not yet discovered among other groups— BRCA1 del exon 1-2, BRCA2 4150G>T, and BRCA2 6027del4.7

Although genetic mutations should be kept in mind when treating Hispanic patients with cancer, the differences between populations, on average, are small. It has been hard to study a large enough number of individuals from diverse populations.

Differences in Belief Systems

“Culturally competent care” should be the mandate of all providers. This comprises awareness, communication, and respect, she said.

To Dr. Muñoz-Antonia, this means the following: understanding that a person’s culture and his or her individual fears will influence that individual’s decisions and care; delivering care that is understood by the patient, which may require an ethnically diverse staff; and soliciting the patient’s views on family/community/religion that might influence treatment.

At Moffitt Cancer Center, many efforts have been made to become more culturally competent. For example, the center has a Spanish-speaking pharmacist and conducts cultural diversity training.

The receipt of care in a language the patient understands is actually a legal requirement, and it is a mistake to use a family member as an interpreter, because they may withhold frightening or embarrassing information from the patient.

Language services are necessary, including a medical interpreter for verbal communication, translation services for written communication (informed consent, discharge instructions), and consulting services and in-service education within hospital departments.

Regarding end-of-life preferences, she indicated that “fatalism” (acceptance or “God’s plan”) is a common response to a cancer diagnosis among Hispanics, who also may be uncomfortable discussing end-of-life issues with their physicians, lack advance directives, and prefer to have family members make these decisions.

In all conversations, she added, “be sure to clarify and get a positive response before you assume the patient understands.”

Dr. Muñoz-Antonia has disclosed that she has no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.

References

  • 1.

    Patel MI, Schupp CW, Gomez SL. How do social factors explain outcomes in non-small cell lung cancer among Hispanics in California? Explaining the Hispanic paradox. J Clin Oncol 2013;31:35723581.

    • Search Google Scholar
    • Export Citation
  • 2.

    Arrieta O, Cardona AF, Federico Bramuglia G. Genotyping non-small cell lung cancer (NSCLC) in Latin America. J Thorac Oncol 2011;6:19551959.

    • Search Google Scholar
    • Export Citation
  • 3.

    Chokkalingam AP, Hsu LI, Metayer C. Genetic variants in ARID5B and CEBPE are childhood ALL susceptibility loci in Hispanics. Cancer Cause Control 2013;24:17891795.

    • Search Google Scholar
    • Export Citation
  • 4.

    Salari K, Choudhry S, Tang H. Genetic admixture and asthma-related phenotypes in Mexican American and Puerto Rican asthmatics. Genet Epidemiol 2005;29:7686.

    • Search Google Scholar
    • Export Citation
  • 5.

    Vogel KJ, Atchley DP, Erlichman J. BRCA1 and BRCA2 genetic testing in Hispanic patients: mutation prevalence and evaluation of the BRCAPRO risk assessment model. J Clin Oncol 2007;25:46354641.

    • Search Google Scholar
    • Export Citation
  • 6.

    Weitzel JN, Lagos V, Blazer KR. Prevalence of BRCA mutations and founder effect in high-risk Hispanic families. Cancer Epidemiol Biomarkers Prev 2005;14:16661671.

    • Search Google Scholar
    • Export Citation
  • 7.

    Dutil J, Colon-Colon JL, Matta JL. Identification of the prevalent BRCA1 and BRCA2 mutations in the female population of Puerto Rico. Cancer Genet 2012;205:242248.

    • Search Google Scholar
    • Export Citation

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Correspondence: Teresita Muñoz-Antonia, PhD, Moffitt Cancer Center, 12902 Magnolia Drive, MRC 3044, Tampa, FL 33612. E-mail: teresita.antonia@moffitt.org
  • 1.

    Patel MI, Schupp CW, Gomez SL. How do social factors explain outcomes in non-small cell lung cancer among Hispanics in California? Explaining the Hispanic paradox. J Clin Oncol 2013;31:35723581.

    • Search Google Scholar
    • Export Citation
  • 2.

    Arrieta O, Cardona AF, Federico Bramuglia G. Genotyping non-small cell lung cancer (NSCLC) in Latin America. J Thorac Oncol 2011;6:19551959.

    • Search Google Scholar
    • Export Citation
  • 3.

    Chokkalingam AP, Hsu LI, Metayer C. Genetic variants in ARID5B and CEBPE are childhood ALL susceptibility loci in Hispanics. Cancer Cause Control 2013;24:17891795.

    • Search Google Scholar
    • Export Citation
  • 4.

    Salari K, Choudhry S, Tang H. Genetic admixture and asthma-related phenotypes in Mexican American and Puerto Rican asthmatics. Genet Epidemiol 2005;29:7686.

    • Search Google Scholar
    • Export Citation
  • 5.

    Vogel KJ, Atchley DP, Erlichman J. BRCA1 and BRCA2 genetic testing in Hispanic patients: mutation prevalence and evaluation of the BRCAPRO risk assessment model. J Clin Oncol 2007;25:46354641.

    • Search Google Scholar
    • Export Citation
  • 6.

    Weitzel JN, Lagos V, Blazer KR. Prevalence of BRCA mutations and founder effect in high-risk Hispanic families. Cancer Epidemiol Biomarkers Prev 2005;14:16661671.

    • Search Google Scholar
    • Export Citation
  • 7.

    Dutil J, Colon-Colon JL, Matta JL. Identification of the prevalent BRCA1 and BRCA2 mutations in the female population of Puerto Rico. Cancer Genet 2012;205:242248.

    • Search Google Scholar
    • Export Citation
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