May 2024

Reshma Jagsi on Upstream and Downstream Disparities in Health and Medicine | Part One

Reshma Jagsi, MD, DPhil

Faculty Scholars Program Committee Member Reshma Jagsi, MD, DPhil, an Emory University radiation oncologist, focused much of her career on disparities in health and medicine, and she has recently been part of several projects that explore them. For this post, the Foundation talked with Dr. Jagsi to learn more about her work on disparate outcomes in breast cancer, in part one of this two-part blog series. You can read part two, which focuses on disparities within the profession of medicine, here. The interview has been edited for clarity and brevity. 

You were a part of the Lancet Breast Cancer Commission, which published its final report last month. What was its charge?  

The Lancet charged the commissioners to develop a report that would go beyond reviewing what is known about a disease or a condition, and focus a forward-looking piece on the gaps and the opportunities for progress that continue to exist. What was particularly important about the Breast Cancer Commission was our awareness that many might perceive that perhaps breast cancer might not even warrant a commission, because we’ve done so well with breast cancer. Is it simply time to point to the enormous strides that have been made in breast cancer as a cause for celebration and a model for other cancers that require more attention? Or was there work still to be done in breast cancer itself?

And while there certainly have been tremendous advances [in outcomes like breast cancer mortality rates], there are still many remaining gaps. There are glaring inequities: many, many groups with breast cancer systematically left behind and forgotten. 

What did the Commission find? 

There were six themes, including a focus on the hidden costs and suffering…that breast cancer imposes on patients. These include everything from the more obvious physical and psychological costs of being diagnosed with cancer, to the financial, emotional, and social costs that ultimately don’t just affect the patients themselves, but also their families, their children, their communities, and the society that relies upon them. There is also so much to be done in terms of communication, to support decision making in a tremendously emotionally charged environment. We need to improve our ability to engage with patients and return to them that sense of agency and autonomy that this cancer diagnosis robs them of.

In the concluding section of the report, we were asked to consider saying something revolutionary. I was the only bioethicist on the commission, and I said: “Is it revolutionary to say that there is an opportunity here?” Patients with breast cancer are overwhelmingly female, and we know that women in every society across the globe are marginalized. If we can transform the way that decisions about breast cancer are made and patients with breast cancer are supported in that process, might this be an opportunity to actually leave the world better off more generally, even beyond breast cancer?  

If we can do a better job of supporting the autonomy of patients who’ve been diagnosed with breast cancer—if we can help return that sense of empowerment to patients in that setting, might it extend even beyond and actually make a difference in women’s empowerment across the globe more generally? 

You gave a presentation earlier this year about the disparities in breast cancer outcomes that still need to be addressed. What are they? 

Although the breast cancer death rate for all women has gone down by 40% since 1988, not all groups have benefited the same from advances in screening and treatment. Currently, the breast cancer death rate is 40% higher in Black women versus White women in the United States.  

[My team undertook a study that found] that Black women who received radiation treatment were less likely to receive [a shorter course of radiation treatment], which is now the standard of care. [With radiation treatment,] remember, you’re going back and forth. You have to get someone to watch your kids, take time off work. There are real consequences of going back and forth for daily treatment. And a three-week course is not only equally effective, it’s probably a little bit less toxic [than a five-week course offered historically]. 

Yet what we saw was that by 2018, the [shorter course] was used in 72.7% of our White patients and only 56.7% of our Black patients. And we tried to understand why that was. Was it individual patient-level factors? Was there something going on where there was appropriate tailoring, or trying to use more aggressive treatment for more aggressive disease?

What happened was when you [considered] where the patient was getting care, we found that the facilities where Black patients were receiving care were less likely to use this more efficient approach to treatment. This speaks to a broader observation about technology diffusion, where advances tend to reach marginalized communities last. So even this thing that would so obviously make this [disproportionately harmed] population better off, didn’t reach them. 

And of course, what we’re seeing is consistent with many, many other studies that have suggested that those who inhabit the intersection of multiple marginalized identities have not only a summation of disadvantages, but a unique lived experience and a compounding of those disadvantages that come from living at that disadvantaged intersection. 

Read part two of this series here.