Podcast: Ensuring equitable access to cancer care for Black populations
Transcript
Dr. Blair Bigham: I'm Blair Bigham.
Dr. Mojola Omole: And I'm Mojola Omole.
Dr. Blair Bigham: And this is a CMAJ Podcast.
Dr. Mojola Omole: So Blair, today we are doing one of a two-part series linked to a special issue, which is a collaboration between the Black Health Education Collaborative and the CMAJ. The focus of the two volume issue is on the health of Black communities and also on anti-Black racism when we look at it in medicine. So in the podcasts we are marrying that by having two podcasts, one this week and one next week.
Dr. Blair Bigham: This is the first time we've been able to do a miniseries and it's rare that I open a CMAJ issue and want to do a podcast on every single piece in there, but we had a lot of trouble focusing in on what to talk about. But today, we have decided to focus on disparities in certain types of screening and treatment.
Dr. Mojola Omole: Yes, so we are going to be speaking to medical oncologists from Alberta, Calgary to specific and also a final year medical student at McMaster University. And both of them did analysis papers that really make compelling evidence of the lack of having Black Canadians in our screening guidelines and having their health front and center. And basically how part of this is due to the systemic underpinning of anti-Black racism. I think oftentimes people feel like anti-Black racism or racism in general is something that's overt, whether it's name calling or discrimination of someone based on their skin color. But oftentimes when we talk about systemic anti-Black racism, it's about not having guidelines that really reflect our population and exclude a group that actually does have a higher rate of mortality and morbidity with prostate cancer.
Dr. Blair Bigham: Absolutely. Super important topic and I'm really excited to get into the interviews. So let's jump right in. Kika Otiono is the lead author of an analysis in CMAJ entitled, Prostate Cancer screening in Black men in Canada: a case for risk stratified care. She'll be graduating medical school next year from McMaster University. So, Kika, tell me, how much higher is the risk for prostate cancer in Black men compared to the general population?
Kika Otiono: Yeah, that's a bit of a complicated question. In Canada, we don't really have this kind of research on what it's like for specifically Black people with prostates in Canada. But if we think about other parts of the world, we do know that men of African ancestry, men with African ancestry, whether in the Caribbean or elsewhere do have a higher risk of a higher, basically age-standardized incidence and mortality are higher for that group.
So I can give you a couple numbers. In England for example, in 2008 to 2010, the lifetime risk of a Black man in England dying from prostate cancer was 8%. When we compare that to white men from England in that same study it was 4% and 2% for Asian men living in England. Another interesting number is that in the Caribbean prostate cancer incidence rates are as high as 304 per 100,000 men. And so, statistically across the different papers, men living in Africa, living in the Caribbean and then also when we look at Black men who are in minority populations in Western countries, all these men of African ancestry are facing higher rates of prostate cancer.
Dr. Blair Bigham: And not smaller increases in risk, these are really substantial increases in risk compared to other races and other populations.
Kika Otiono: Absolutely.
Dr. Blair Bigham: Why don't we have better Canadian data that tells us this? Why are we talking about data from the UK?
Kika Otiono: Yes, that's a very complicated question and I think a question that is not just important for this paper but important when we think about all kinds of papers in medicine and all kinds of research in medicine. I think this has been a question that has been asked multiple times and it makes it difficult to carry out race-based research in Canada because we often don't care, if we do collect race based data, it's often not as granular as I would say they collect in the UK and in the US. I think one of the main barriers to this kind of research is just a lack of infrastructure and a lack of cultural acceptance of race-based data. I think it's much more accepted in the US that there are racial disparities in healthcare and they tend to collect this research in various capacities and various kind of research projects. But in Canada, I think we're still very much falling behind in terms of quantifying race-based data when we speak about racial disparities affecting Black Canadians.
Dr. Blair Bigham: I want to get into so many things with you Kika, but first tell me about the guidelines that you sort of questioned in your analysis. Tell me how the guidelines might not be working for Black men in Canada.
Kika Otiono: Absolutely. So when we first came up with this idea for this paper, one of the first questions we had was about screening. There's so many different ways we could tackle the difference in mortality and incidence rates of men of African ancestry compared to other populations. But one of the major ways that prostate cancer in general for all populations has been tackled over time is screening. The most common way that men are screened for prostate cancer, is using the prostate specific antigen test. So we thought about guidelines across different countries, or it's better to say regions, I guess, because we looked at three guidelines. So the Canadian Urological Association guidelines, the CUA, the American Urological Association guidelines, as well as the European Urological Association guidelines. But as well as that, we also have looked at what the Canadian Task Force on Preventive Healthcare has said about this, as well as there's like an entire kind of organization similar to that in the US for preventative care.
So the most recent guidelines from the Canadian Task Force they actually recommend against routine PSA screening for men of all ages, which I think is interesting. So they advocate against routine screening, but state that the greatest benefit is likely for men ages 55 to 69. So they often stop screening once men turn 70 and a lot of physicians will say you should start screening at 55. This is different from the recent two, the most recent CUA guidelines, the Canadian Urological Association in 2022, they looked at kind of three randomized control studies in order to decide on their prostate cancer screening and they emphasized more of a shared decision making approach, which I think is a move in a lot of aspects of medicine of discussing with patients in choosing a screening method.
And, according to the CUA, should a patient choose to undergo PSA screening with their doctor, they should start at age 50 or at age 45 for people at an increased risk. And that's where our paper kind of butts our head in. We elbow our way in and we say that Black men should be outrightly and explicitly stated as people at high risk, so that family doctors and urologists reading this guideline, even if they might not look at every single Black patient that comes in and say, "I think you should do this PSA test." I think at least it gets the cogs turning to have those kinds of conversations early. So that, should a patient decide to undergo the PSA screening, they're aware that as a Black person you are at a higher risk.
And a lot of the research does show that Black men are not only at a higher risk of being diagnosed with prostate cancer, they're at a higher risk of having more advanced, more aggressive tumor transformation and they're also at a higher risk of actually dying for prostate cancer unfortunately. So there's been research looking towards the genetic risk and we cite some of those studies. But I think another group, which I would say I fall into more naturally, is the group talking about the social determinants of health.
There's studies showing that men in a lower income group are lower likelihood of being screened regularly and for their prostate cancer to be caught. I think one of the most interesting papers that I cite and I'm going to shout out this paper because it really had a lot of these gears turning in my head, was by a group from Western University, led by Dr. Noah Stern, and they looked at men that were screening, looked at census data, and they did like a methodological kind of study. And they found that, when they corrected for socioeconomic factors, Black men in Canada were actually not at an increased risk of prostate cancer, which I think is extremely interesting.
And I think one of the aspects in their summary that they mention is this kind of opposes a lot of the people in that first group, a lot of the studies from that first group that have pointed to genetic ancestry as a major factor. So, I guess, I wonder if these things are not as mutually exclusive as we make them out to be. And I wonder how much the social factors affect people's genetic risk and affect how much they develop the mutations that cause such aggressive cancers.
Dr. Mojola Omole: Kika, I might have missed it. What is the recommendation in the US and the UK for Black men?
Kika Otiono: Good question. So the US, they flip flop back and forth. There's been a lot of changes to their PSA screening in the past few years. So, to be honest with you, I'm not completely sure what they say right now in their most recent guidelines about African American men, but I know in Europe, specifically in the EUA, the European Urological Association, they actually include Black men in Europe in a high risk group that can be screened earlier. So they screen Black men at 45 years as opposed to 50 or 55 in Europe.
Dr. Blair Bigham: Kika, what's your takeaway for people who collaborate to make guidelines? So as someone who sat around a lot of guideline tables, we're pretty conservative, we don't want to make a recommendation that leads to overdiagnosis or overtreatment or something that would be fiscally irresponsible. But you've also brought up some really interesting points about the way we aren't necessarily so purist in other aspects of medicine like we are with guidelines. Tell me a little bit about your thoughts on that and how you think the guidelines should maybe be a little bit more respectful of data from outside of Canada.
Kika Otiono: Yeah. Last week I was reading through the guidelines of bladder cancer and prostate cancer from the CUA and I noticed that a lot of the studies they cite are actually from America. If we think population wise, we, in some ways we don't have these large population studies, large RCTs that they can carry out in the US, also in terms of funding. And there are amazing studies from Canada that are often cited. But in a lot of papers, not just urological papers, but a lot of guidelines are predicated not just on Canadian data, I would argue most guidelines include data from elsewhere. So I think, with that in mind, I question why we can't apply data from across the world in order for us to make an argument for Black Canadian men to be in a high risk group.
Dr. Blair Bigham: So Kika, with respect to the PSA, which is easily available even if it's not always funded, What would the downside be to broadening the screening criteria other than a few extra dollars of PSA tests? What are the downsides to PSA testing in Black men, say age 48 or 50?
Kika Otiono: One of the biggest discussions broadly in prostate cancer research screening treatment is the burden of overdiagnosis and overtreatment. Because prostate cancer screening with a, for example, when you go into screening with a biopsy or if you are found to have prostate cancer and you go through a prostatectomy or you go through androgen deprivation therapy, all these things are quite invasive. And I guess one of the most common teaching we get in medical school and in general in training is that a lot of men with prostate cancer are not likely to die from prostate cancer. So it's typically something that doesn't kill men.
But something I started wondering after doing this paper is, I don't know if Black men are included in that if we look at the research. Another thing, too, I think is a valid concern is the financial aspect of it. Screening costs money, not just for the healthcare system, but actually for patients because a lot of patients pay for PSA tests. So that is another burden.
And another thing I kind of started wondering about after I finished my paper was, "Will this even make a difference anyway?" I know that's a harsh thing to say after I've done all this work, but I wondered if we changed the screening, if men are not actually being caught by the screening, what difference does it make? And the reason I'm saying that is one of the things we found in our paper and we talk about in our paper, is that Black men, by and large, we found in the research, have worse health education about prostate cancer, a lack of culturally appropriate care and also just a lack of even getting there, a lack of access to care. So if you can't get to get your screening, if you can't have someone explain the clinical decision making to you to get that screening, you're not willing to pay for it because no one's explained it to you accurately, then changing the screening guidelines isn't going to make much of a difference. We're still going to be missing a lot of people.
And to be honest with you, I tossed and turned a bit wondering about that and what can we even do for those people that are going to get missed even if we include Black men in a high risk group? I don't have an answer unfortunately.
Dr. Mojola Omole: What do you say to the pushback that, "Well, you're trying to make these changes to the guidelines and you actually don't have any good data that shows that Canadian Black men are at a higher risk of prostate cancer and aggressive prostate cancer." What's your response to that?
Kika Otiono: Yeah, I think that's a pushback that I've already seen. A lot of the guidelines from Canada in the past have always mentioned that. I've seen, maybe not in the 2022 guidelines, but in the previous guidelines which was from 2019 from the Canadian Urologic Association, they actually mentioned that we know that elsewhere Black men are at a higher risk of prostate cancer, but we don't have sufficient data that changing the screening or screening them earlier or more frequently is going to make a difference. And I think that's a very valid point. My question is just, once again, it all goes back to me, I think I'm trying to think about this from a very practical angle. And my question is, how many more men are going to die that we don't, we haven't even started the research on it yet.
So I think changing the guidelines and just putting Black... And putting Black men at a high risk group does not mean you're going to screen every single Black person with a prostate who is 45 and above, but it gets urologists and physicians saying, "Why are they high risk?" If I have a patient in front of me that has a few risk factors and they're Black, I now have a higher index of suspicion. I think the current guidelines don't reflect any of that at all. So even if the guidelines don't change, at least something I think we would benefit from is a deeper conversation about this and an explicit mention in the guideline that we might not have the data, but we are concerned that Black men are probably at a higher risk.
I think my final thing I would just say is that my question to people to consider, whether or not we change this guideline or not, the biggest question I had when doing this paper is that, in the absence of Canadian data, I want us to ask ourselves, in Europe, Black men are at a higher risk, in the US Black men are at a higher risk, in Africa men have higher risk than elsewhere in the world and same with the Caribbean. Do we really think logically that Canada's going to be an exception to that when anti-Black racism in Canada is very real and Black men and Black people in Canada have been found to be at a high risk of a bunch of different things? So my question is, do we... Logically, I think the data needs to be, we need to do that research. But I would be very shocked if the research shows that Black men in Canada have the same risk.
Dr. Mojola Omole: I would argue that the reason... There's two points I wanted to make. One, I would argue that the reason Black people are not included in the guidelines is anti-Black racism. We have other cancer guidelines where we rely on data from other countries to help guide our cancer treatment and our cancer screening because we know that certain groups have certain higher rates of certain cancers. So it's not just Canadian data that we use for that. So I don't necessarily think you have to, as you said, if you're Black in Canada and you're Black in the US, most likely you are at a higher risk of the same disease process.
And then the last thing I wanted to say is that, what we don't realize is you might not die from it, but your life might really suck after going through treatment. I see patients for radiation proctitis and pelvic pain, erectile dysfunction and just... And who the hell wants to go through cancer treatment, period? And so, I think that in medicine, because even I say that, I'm like, "Are you going to die from it?" But sometimes it's still pretty crappy even if you don't die.
Kika Otiono: Yeah. Yeah, that's a really good point. And I wonder too, with the data that show that Black men in the US are at a higher risk of more aggressive disease, is that number that we quote for everybody, is that, while, most men with prostate cancer aren't going to die from it, well, if we think men in the US and elsewhere have a more aggressive disease, we can genuinely see that they are dying from it at a higher rate. So I don't know if that idiom kind of applies to Black men.
I already have seen urologists specifically have a patient with maybe one or two risk factors, but the fact that they're Black, they actually would be more aggressive with choosing a biopsy earlier than others, which I find interesting. So I've seen urologists that even though the research hasn't reflected that, they're actually, their clinical population they've seen, and for me too, I've only been in this what, a year or two, so I have no experience, but every single urology elective I've done, I have not treated a single Black man of with prostate cancer that was not advanced. And I think that's crazy to think about. Every single Black patient I have had in urology with prostate cancer has been stage four.
And so I think a lot of urologists I have worked with have said, because I've asked this question based on my paper and they've said, "I don't know. The guidelines don't see anything, but I see Black men with advanced prostate cancer all the time. So if a Black man walks through the door and his PSA is only slightly elevated, I'm going to get a biopsy." So I think that's interesting, is that there seems to be a gap in what some people practice and I think the guidelines are lagging behind.
Dr. Blair Bigham: Kika you're so passionate about this and so articulate. Thank you so much for speaking to us today. We could go on forever, but we're going to have to wrap up and hopefully we can have you back on the podcast another time.
Kika Otiono: Yes. Thank you so much for having me.
Dr. Blair Bigham: Kika Otiono is the lead author of an analysis in CMAJ entitled, Prostate Cancer screening in Black men in Canada: a case for risk stratified care. She joins us from Hamilton.
Dr. Mojola Omole: Prostate Cancer is just one of the examples of the disparity in cancer care Black patients face. Dr. Doreen Ezeife is a medical oncologist at the Tom Baker Cancer Center in Calgary. She's the lead author of an analysis in the October 24th special issue of CMAJ entitled, Ensuring equitable access to cancer care for Black patients in Canada. So, in your work as a medical oncologist, was there something you were seeing in your practice that made you think, "Hold on, I think we need to take a closer look at this disparity?"
Dr. Doreen Ezeife: Yeah, so I wouldn't say it was so much in my practice, but what I was seeing was in some of my work with a support group, so we do a lot, we tend to do a lot of community outreach work as oncologists, and I do some work with a support group called the African Cancer Support Group and I give them a lot of speeches and webinars and the training sessions on cancer treatments to really educate them and then they really find that opportunity gives them a chance to ask me questions and learn more about their diagnosis and also meet with other cancer patients and talk about their cancer journey and compare notes and learn about what other treatments are available.
So when I saw that, over several meetings with this group, they were really finding that to be a great chance to learn more information about what they can ask their oncologist, then I really realized, this is a great opportunity to empower our Black patients. And when Black patients have this support group, they learn more and they can have really more effective discussions with their healthcare team. So, I realized that this was something that I needed to focus more on.
Dr. Mojola Omole: So when we talk about access, the first point of access, for example, is screening. If we're talking about breast cancer, it's mammograms, prostate cancer, PSA, cervical cancer, pap smears. What have you found in terms of the difference in access for Black patients versus their other counterparts?
Dr. Doreen Ezeife: So we know that Black patients don't access screening programs as much as non-Black patients. We know that the uptake of screening is decreased certainly in our visible minority population, particularly in Black patients. And there was a study by Dr. Nnorom and a group in Toronto area. They looked at a community center that had a lot of visible minorities and particularly a lot of Black patients and they looked at access and they found that breast cancer, cervical cancer and prostate cancer screening was very low, as I just said in this population. And so what they did, was they implemented a program to really increase that education and health literacy. And they did this through Afrocentric mechanisms, meaning it was a really culturally sensitive program. They had multilingual healthcare providers, lay healthcare providers that could translate health information into ways that the patients could understand. They had other Black healthcare providers providing information, so that trust is increased.
And what they actually found was that screening went up with these mechanisms. So we know that when we increase the representation of Black healthcare providers for Black patients, when we improve our culturally sensitive approaches, then it's actually a very effective intervention for improving uptake of some of our medical recommendations in healthcare.
Dr. Mojola Omole: You've mentioned that in that study and probably from what you've noticed, that there is less of an uptake in screening. What role does the distrust of cancer care within the Black community play in that?
Dr. Doreen Ezeife: It plays a big role. There has been historical distrust of medical professionals by minorities and Black patients in particular. And this stems from historic research studies that have been done that took advantage of Black patients, particularly the Tuskegee syphilis study that really had negative effects on Black patients. And even though this was over 50 years ago and since then there have been international ethical codes that have been implemented, with informed consent, we now need to go through certain processes in order to be able to conduct a study. The scars of that have remained unfortunately.
And that is also that this trust is also increased by the fact that there is not a lot of representation of Black healthcare professionals, Black nurses and Black doctors, Black medical students, Black residents. We don't see a lot of that and we need to do better at that as a society. We know that when Black patients see more healthcare providers that look like them, that trust is increased because they feel more confident in the information that they're receiving. And also, those healthcare providers tend to be culturally sensitive and more aware. We need to increase healthcare providers that are minorities in the healthcare profession and we also need to increase training for non-minority healthcare providers to improve that cultural sensitivity. And that can be some of the ways to combat that distrust.
Dr. Mojola Omole: What would you tell a non-Black medical oncologist, for example, who is having difficulty with their patient in terms of earning their trust? What would you advise in terms of what they can do or what they can incorporate into their practice?
Dr. Doreen Ezeife: That's a good question. I would tell them to find out more information about where the patient is from and what type of community they access, whether it's a community based on their ethnicity or whether it's a religious community. I will tell them to reach out to their social workers and their other healthcare team to find out what are the resources. We have so many resources available to us now in 2022 in different jurisdictions in Canada, whether it's something like the African Cancer Support group that I mentioned or another religious support group. And provide that information to the patient.
And when the patient sees, "Okay, my healthcare provider has actually gone out and learned a bit about where I'm from and what information I could find useful and what groups of people I can identify with.", then that trust is built. And then if there's a language barrier, there's always language translation lines that the physician or healthcare provider can access. There's always lay translators as well. I know a lot of our community centers here in Alberta, they have translators that can work with minority patients and translate some of that medical information into words that they understand or translate into ways that they would understand.
Dr. Mojola Omole: I'm not sure about in Calgary, for your cancer center, do you guys, for example, have support groups as part of your cancer treatment?
Dr. Doreen Ezeife: I wouldn't say that it's part of our cancer treatment, but we certainly provide all the information to patients. So, it's typically disease-sites specific. So there'll be a breast cancer support group, for example, and we'll provide patients with pamphlets, with their phone number, with the websites on how to reach out to that support group. And many patients are very effective at quickly reaching out to the support group and connecting with those groups of people now with the Internet and things. We have educational sessions too, where patients learn about chemo or radiation and what that can be like to go through. So patients meet each other there and then they often form their own support groups in that way too.
Dr. Mojola Omole: I think that is something that other hospitals have worked at that they have is a newly-diagnosed class, a newly-diagnosed patient class. And part of that is to form that network. And I do wonder if having more that are people who you identify with, patients often say they've never seen what, for example, when we talk about breast cancer, what peau d'orange looks like on Black skin. It's even hard to find images of it. I've googled it before and I'm like, "I don't think that's what it's supposed to look like."
Dr. Doreen Ezeife: True. There's not enough of that in medical training. We don't see enough of that representation of what these medical findings look like in darker skin, in different skin tones and we need to do more of that. I know that a lot of industry is also creating a lot of resources for patients as well. And I think there's one company called Rethink Breast Cancer, they're one initiative that have a lot of work that they've done with Black patients, with patient advocacy groups and they will show you pictures of what peau d'orange looks like, what mastectomy scars even look like on dark skin. Because we know that dark skin has different ways of forming scars, whether it's more keloid formation or it just appears differently depending on the skin tone and we don't see enough of that. So I really applaud this Rethink Breast Cancer Initiative for that.
Dr. Mojola Omole: So both the papers in CMAJ looked at the issue points and their lack of race-based data in Canada. How important is it for this country to start collecting this information?
Dr. Doreen Ezeife: It's very important. This is something that we've been trying to achieve for a long time now. And it's very important because we know that there are gaps that exist. We've already done some studies by linking Census data to provincial registry data and cancer registry data. And what that's taught us is that there are gaps that exist. We know that Black patients experience higher mortality compared to non-Black patients in certain cancers like breast cancer, prostate cancer, pancreatic cancer and colorectal cancer. So we know that there's gaps there, there are survival differences there, but we don't know why. We don't know whether this is due to access issues. Access to precision medicine is that difference for Black patients compared to non-Black patients. Is access or access to clinical trials different for Black patients versus non-Black patients and what is the reason for that? Is it the distrust? And how can we design some really targeted interventions to dismantle these disparities and really achieve equity in cancer care?
Dr. Mojola Omole: So I know that for us in Ontario, Black physicians have been talking about collecting race-based data, but still this hasn't been done. I guess the question is, if the government won't do the initiative to actually start doing it, should hospital systems start collecting that data themselves?
Dr. Doreen Ezeife: Yeah, I think that's a very good idea. And I think these are some routes that we're exploring. We have our electronic medical records, they have the ability to collect this data, but it has to be done carefully. We have to be aware of the sensitivity of these data. A lot of what we use now, because we lack race-based data, is we use US data and UK data and we extrapolate from that, but it's not ideal. Because we know that in Canada we don't have the same history with slavery and colonization and some of these other issues that the US and UK had. So our data is going to be different. Our issues are going to be different. And so Canadian data is really important, but we have to do it carefully.
And what I mean by carefully, is we have to really involve these minority groups in the collection of the data. And, when we observe differences, we have to be able to act on those differences to repair those problems that we find. And we can't just detect problems and not solve them. So, it has to be done very systematically and in a way that is aware of the sensitivity of that data. For example, the Indigenous group, so we do collect race-based data on the Indigenous population and that data exists, but it is done by working very closely with the Indigenous community. And I know that researchers that try to access that data, they have to ask permission from the Indigenous elders and that has to be approved. So you can see that collecting this race and ethnicity data makes it very sensitive, and it has to really be done while working closely with those vulnerable populations.
Dr. Mojola Omole: Thank you for joining us today.
Dr. Doreen Ezeife: Thank you.
Dr. Mojola Omole: Dr. Doreen Ezeife is a medical oncologist at the Tom Baker Cancer Center in Calgary. So Blair, we just finished listening to Doreen Ezeife and also Kika Otiono. I just want to hear your reaction to this being the non-Black person in this podcast episode.
Dr. Blair Bigham: So first of all, I would say that the passion and clarity that both Doreen and Kika were able to bring to our conversation was really remarkable. And I'm just so grateful that we have an issue that is focused on anti-Black racism because I can sort of reflect on my own practice, but also just the hospitals that I work in, and realize that they are in many ways white-centric. I don't think we have a system that - not only doesn't deliver great care to all populations - but probably doesn't feel very welcoming or at least relatable to all populations. So I feel privileged just to be a part of this conversation. Even though I feel like maybe I'm part of the problem and not the solution. So I'm really fascinated by this.
As an academic, I relate very much to the lack of data on this. When I was a cardiac arrest researcher, we collaborated a lot with the US and other countries and the US always had such amazing race data. It's something that they collected all the time and they reported on it. And in Canada, we never had it, it's not a tick-box on any paperwork. And so we never knew our race statistics, but looking at the American statistics, there was always vast discrepancy in care, in survival, in access, the entire chain of survival for cardiac arrest, this is back when I was a paramedic doing research, the entire chain of survival was stacked against people of color. And it's just amazing that in Canada we have not woken up to the fact that we need that data. It's almost like in Canada we think we're too good to collect that data, but clearly we need that data because our guidelines are somehow being formulated in a way that's exclusionary, which is the opposite of the intent.
Dr. Mojola Omole: Yeah, for sure. And I would say that - you mentioned being part of the problem - I feel that oftentimes people feel that when we talk about anti-Black racism that, "Oh well, I couldn't possibly be racist." But anti-Black racism can be perpetrated by anybody, it's just, it's sticking to certain, whether it's in this situation, exclusion from guidelines when we're talking about prostate cancer, which has other populations that reflect our population, like the UK, which shows that Black men have a higher rate of prostate cancer, later stage of disease, it doesn't really make much sense when we know that we don't include them in the screening guidelines.
Dr. Blair Bigham: And they take it one step further and don't even allow physicians to order, for example, a PSA, even when there's this overwhelming gut feeling that, I think it was Kika who said she's worked with preceptors who say every Black man who comes with prostate cancer has advanced prostate cancer. So to restrain that test just seems so unjust.
Dr. Mojola Omole: For sure. And I think that part of it is, we use American, UK data for treatment. There's a lot of trials that are done in the European Union that guide our principles, like they present an abstract, "Great, this is great. This becomes a standard of care here." But when it comes to screening that is a standard of care in two other countries that we use a lot of their data for, but we don't include this. And it leads us to, And this is how anti-Black racism functions within a system, is by exclusion.
Dr. Blair Bigham: Jola, how do you think you practice differently as a Black physician when a person of color comes to you for a surgical consult? What do you think you do that, aside from maybe sharing the same skin color, how does that interaction differ and what can white doctors like me or doctors of different races take away from your insights in clinical practice so that we can try to make sure that people don't feel like they're somehow being cared for differently? How do we do that practically?
Dr. Mojola Omole: I would say that for me, someone who spent quite a lot of time doing work on equity and racial equity, is understanding more about people's cultures - I think part of it is just curiosity - and not make assumptions. For me as a Nigerian, everyone thinks that I'm Jamaican. And they make that assumption right off the bat and make a comment about: I must love Reggae. I like Reggae, but I'm Nigerian and I really actually prefer Afrobeats because I'm hardcore Nigerian. And, so, I do think that's part of it.
Dr. Mojola Omole: I do think another part of it that's really important is that different cultures have different practices of who's in the room with you. We are very, in the North American population, very individualistic, where oftentimes in Black communities it is a community affair. And so I invite, I don't mind if there's - now with COVID it's a little different - but sometimes there's 10 people on a FaceTime call with me and I'm okay with that. It is a longer consultation - that is a 100% the fact of it - but I'm giving you a diagnosis that does change your life when we're talking about cancer. And so therefore we're going… I'm going to give you that long conversation.
And so that I think is part of when we talk about culturally-appropriate, is understanding that for some people, the community is part of their culture and inviting those people in. And sometimes it's not your partner, it's your cousin that you grew up with from the age of four and making sure that person is also involved in, not necessarily the decision making but the consultation so they hear what's happening.
Dr. Mojola Omole: I do think that when we talk about Afrocentric care and people are like, "What does that mean?" And part of that is just, it is this concept of a holistic approach to care. North American model of treating in medicine is very much disease-specific. We treat your disease, we cut it out, we give you chemo, you're done, move on. But when we talk about Afrocentric or Afric-centric care, is to bring in different parts of the person's culture and different parts of the person. So we're actually treating the whole entire person when we're doing the care. And part of that is health literacy and asking them, "How is this affecting your partner?" And a lot of these tools, you can use them on your non-Black patients too, because they also have partners and family and other parts of their culture that comes into the room with them and not just their disease.
Dr. Blair Bigham: This is just getting started here. The special issue is just chock-full of information on disparities and anti-Black racism and things that we can do to help right the ship. And I'm really looking forward to next week's conversation as well.
Dr. Mojola Omole: Yeah, next week it's going to be really great because we're going to talk about what anti-Black racism looks like in the medical profession, starting from just the process of getting into medical school and then practicing as a physician.
Dr. Blair Bigham: It's not just patients.
Dr. Mojola Omole: Yeah, for sure.
Dr. Blair Bigham: That's it for this week on the CMAJ Podcast. Please feel free to share or like our podcast wherever you download it. Word of mouth is the best way to spread the word and help get our message out. I'm Blair Bigham.
Dr. Mojola Omole: I'm Mojola Omole. Until next time, be well.