Abstract PL03-03: Disparities in cancer palliative care for medically underserved populations.
Authors: Fisch Michael J. 
Published: August 2014

An underserved population refers to a group of people who, for a variety of reasons, do not have equal access to health and health care services. In the United States and across the globe, examples of underserved populations are the poor or the near-poor who are uninsured or under-insured, minorities, immigrants (including undocumented immigrants), and those with mental health and/or medical multimorbidity. As a consequence of being underserved, disparities exist in terms of specific differences in the development of disease or specific syndromes and health outcomes. If you then add the dimension of value judgment, specifically the notion that health and relief of suffering is a fundamental human right, and that individuals with the same needs and preferences ought to experience a fair distribution of health resources and outcomes regardless of social standing, then the concept of health equity comes to light.

Just as terms like disparity and underserved and inequity can be confusing, so it is with palliative care as it pertains to cancer patients. This term is often linked to hospice care, pain and symptom management and supportive oncology. The World Health Organization succinctly defines palliative care as an approach to care. It is an approach that improves the QOL of patients and their families facing the problems associated with life threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. The palliative care workforce applied to cancer patients varies and ranges from trained local caregivers and community volunteers to allied health professionals to highly trained providers with or without special training or credentials in palliative care. In practice, the key dimensions of delivering on this comprehensive, interdisciplinary approach include communication, cultural competency, pain and symptom management, and integrated systems and teamwork. The root of disparities and health inequity in regards to the delivery of palliative care in cancer patients can be understood by examining both the palliative care workforce and these specific dimensions in detail.

Relevant palliative care outcomes worthy of examination for disparity and health equity include the availability of palliative care programs and specialists, the availability and appropriate use of opioid analgesics and associated teaching, early integration of palliative care with active cancer treatment, utilization of hospice, place of death according to patient preference, trust and therapeutic alliance with healthcare providers, racial/ethnic concordance between patients and providers, level of stress and burnout among the palliative care providers, level of aggressiveness in end-of-life care including use of resuscitation and intensive care units, patient understanding and acknowledgement of terminal illness, and use of advanced directives to guide end-of-life care. Across one or more of these relevant outcomes, there are both disparities and health inequities that have been noted according to geography (rural vs. urban vs. other, low-income countries versus others), race/ethnicity, comorbidity (HIV/AIDS, mental illness including substance abuse), immigration status, sexual orientation, gender, and age group.

Improving palliative cancer care and eliminating healthcare inequities in this realm will require efforts at multiple levels, including governmental policies, community engagement and advocacy, professional organizations, and the level of individual institutions, programs, and providers. Priority areas for attention are the availability and distribution of palliative care resources for care delivery as well as research, and the size, diversity, and skill level of the workforce applied to delivering this important approach to care.

Citation Format: Michael J. Fisch. Disparities in cancer palliative care for medically underserved populations. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr PL03-03.