October 9, 2018
MARA GORDON
Justin Cook for NPR
When
she was in graduate school for public health, Niasha Fray found a job she
loved: counseling women with breast cancer about sticking to their treatment.
She
offered what's called "motivational interviewing," a type of therapy
intended to help women overcome obstacles keeping them from taking their
medications — which can have unpleasant side effects
"They
had just given up so much of their lives, so much of their bodies, so much of
their family," Fray says. "They wanted to get back to life as
usual."
Fray
was doing the counseling as part of research into disparities in cancer
outcomes at the University of North Carolina, Chapel Hill.
Then in
2017, Fray found a lump in her breast. Suddenly, she was the patient.
And all
of her work helping women — particularly black women, who are more likely to
die from breast cancer than their white counterparts — became very personal.
"
'Please take care of yourself. Please remember to slow down.' These were things
that I had told many women," Fray says. "Sometimes we're our own
worst patients."
Breast
cancer is less common in black women, yet they're about 40
percent more likelyto die from it than are white women. One reason
for this is that black women more often have advanced cancer once they do get into treatment, partly
because they are less likely to have health insurance or to get screening
mammograms.
Another
reason, a new study suggests, may be that black women are less consistent with
follow-through with the years-long course of daily endocrine therapy prescribed
for certain common types of breast cancer.
The
study, recently published in the Journal of the National Cancer Institute, showed
that black women were more likely than white women to have difficulty affording
and taking endocrine therapy, a 10-year treatment prescribed for women with
certain types of breast cancer. It's prescribed after a woman undergoes
surgery, chemotherapy or radiation therapy (or some combination of these) and
can help cut her risk of recurrence by half.
"It's
not women's fault that they're having a hard time with therapy. It's a hard
medication to take," says Stephanie Wheeler, an associate professor of health
policy and management at the University of North Carolina, Chapel Hill and the
lead author of the paper. "I think we can do a better job supporting
women."
The
study followed almost 1,300 women between 2008 and 2013 in North Carolina who
had breast cancer. About 43 percent identified as black.
Black
and white women were equally likely to stop taking the endocrine therapy before
the 10 years of treatment were up: About 10 percent of women discontinued
treatment early.
But
black women more commonly reported not taking the medication as prescribed —
skipping doses or taking breaks from the medication. Almost 14 percent of black
women did not take the medicine every day, while about 5 percent of white women
reported nonadherence.
The
reasons for this are complex, researchers say, and more research may be required
to tease them out. They note that black women were more likely to report that
paying for the medication was a financial burden, although the study showed
that even affluent black women were less likely to stick to the treatment than
white women were. They also more commonly found the side effects bothersome,
since the endocrine therapy can cause symptoms of menopause like hot flashes
and joint pain.
"I
think the big piece is probably the relationship they have with their health
care providers," says Dr. Doris Browne, a past president of the black
physician group the National Medical Association and former National Cancer
Institute leader.
If
black patients don't feel comfortable with their physicians, she says, they
won't bring up these concerns — and then they can't be addressed.
"Patients
tend to divulge some of those underlying factors to a provider that is in their
own racial and ethnic group," Browne says. "They have a relationship
that seems to be a more open relationship."
She
cites research that
shows black patients may have better outcomes when they see black doctors. Only
about 4 percent of physicians are black.
Fray,
who is now program director of the Duke Center for Community
and Population Health Improvement, thinks the disparity may have something to
do with black women identifying strongly with their roles as caregivers.
When
Fray counseled patients about taking their endocrine therapy, she says, she
often found that black women were so accustomed to taking care of other people
that it was hard for them to accept help during their treatment.
"There
was a lot of conversation about the stress of being a caregiver," Fray
says. She and her patients would often talk about "the stress of being a
black person in America and having doctors not listen to you, having employers
that don't care about you."
Motivational
counseling, such as the work Fray did, may be part of the solution. Wheeler and
colleagues are currently analyzing data about the counseling program Fray was
part of, and she says she hopes that it will provide evidence that tailored
therapy will help black women "articulate what their health goals
are."
During
her treatment, Fray says, she relied on family and friends for child care and
meals. She completed surgery, chemotherapy and radiation treatment this past
summer. "I got the whole enchilada," she says.
Now,
her prognosis is good, she adds, but contemplating the next 10 years of
endocrine therapy can be overwhelming.
"You
gotta get your mind right," Fray says. "You can't change the scenario
or the situation. How do I change my mind?"
For
now, Fray is spending time with her family and returning to her career, which
now focuses on fighting health disparities in Durham, N.C.
"Black
women like me have to put on the armor of self-care," Fray says. "We
have to create it for ourselves and be intentional about it ... No one is going
to do it for us."
No comments:
Post a Comment