From language barriers to a lack of insurance, limited health care access, and financial hardships, older Hispanic and Latino patients face an onslaught of obstacles when it comes to navigating cancer care.  

 

Health care professionals have long recognized the impact that social determinants of health (SDOH) can have on patient outcomes, including in the oncology sphere. Where someone lives, the language they speak (or don’t speak), their racial and/or ethnic backgrounds, and even their immigration or citizenship status all play defining roles in whether patients seek and receive the care they need to treat and survive cancer. But for years, these factors have been structurally overlooked in cancer research focused on Hispanic and Latino patients.  

 

The consequences of these disparities are significant: how can health care professionals provide well-informed, high-quality, equitable care to a population of people they may not understand? Without diverse, insightful, nuanced health care data about Hispanic and Latino patients, particularly in older adults, providing better resources and improved outcomes becomes even more difficult. This is exactly the problem that Fernando Diaz, MD, hopes to address. 

 

“During my medical residency in a primary care setting, I noticed many older patients presenting with an advanced-stage cancer diagnosis,” said Dr. Diaz, who’s currently doing a fellowship in geriatric oncology and geriatric medicine at the University of North Carolina (UNC) at Chapel Hill. “The overwhelming majority of these patients were Spanish-speaking, foreign born, and uninsured. And that struck a chord with me.”  

For Dr. Diaz, addressing disparities and advancing equity for these patients is more than a research pursuit; it’s also deeply personal. As the child of parents searching for the “American Dream,” he understands all too well the difficulties that Hispanic and Latino patients face, particularly as they age. 

 

“I think, in a lot of ways, I saw my family in those patients,” Dr. Diaz shared. “Many of these patients’ stories, and the difficulties they endured, resonated with me because that’s what my family and I lived through when I was younger. The barriers and inequities they faced really fostered my interest in cancer disparities.” 

 

A pivotal moment for Dr. Diaz came during his first year of hematology-oncology fellowship when he met Hyman B. Muss, MD, FASCO, a pioneer in the field of geriatric oncology and recipient of the 2020 ASCO Allen S. Lichter Visionary Leader Award. 

 

“I struggled to find my niche within disparities and spoke to Dr. Muss about a concern I have about foreign-born Hispanic individuals with cancer,” Dr. Diaz said. “How much influence did the culture they were raised in, and the years that followed while living in the U.S., affect their understanding and decision-making regarding a cancer diagnosis?” 

 

Dr. Diaz surmised that many foreign-born Hispanic and Latino individuals leave their home countries as adults and spend several years—and in many cases, the rest of their lives—in the U.S. He also shared that many older Hispanic and Latino patients fear overtreatment or excessive cancer interventions. Meanwhile, other patients may worry about undertreatment or inadequate care. 

 

The medical community, he continued, also lacks a solid understanding of how acculturation can affect people with cancer, particularly those who have immigrated to the U.S. from different Latin American countries. For example, patients who emigrated from Mexico might experience markedly different SDOH, even as the medical community categorizes them all under the same grouping: Hispanic/Latino.  

 

“One thing that irks a lot of Hispanic and Latino communities,” Dr. Diaz said, “is how we’re often all just grouped together.” 

 

To address these concerns, Dr. Diaz focuses his research on evaluating physiological age, instead of numerical age, by exploring the impact of geriatric assessment with SDOH and acculturation on disparities in cancer outcomes. This approach can help providers to better understand each patient’s unique set of circumstances. When doctors can identify the social determinants that accompany an individual patient’s physiological age, they are better equipped to recommend and tailor the right amount of treatment at the right time. And by demonstrating a stronger grasp of each patient’s unique circumstances, physicians are better able to assure patients that they’re recommending finely tuned treatment and care plans designed specifically for that individual’s needs. 

 

Under Dr. Muss’ guidance, Dr. Diaz extended his fellowship and pursued additional training in geriatric oncology to solidify his knowledge base in caring for older adults with complex needs. 

 

“In order for us to understand how Hispanic and Latino patients age, and how best to improve cancer outcomes in these communities, we must consider integrating geriatric assessment together with Hispanic and Latino-focused SDOH into daily practice and work to disaggregate the data on these populations,” said Dr. Diaz. “Finding the right treatment for an individual requires more time and effort, but we have the tools to do so. Geriatric assessments can provide us with a lot of that information.” 

Making use of data gathered during assessments requires that it be efficiently and consistently aggregated, organized, and accessible to the research community, which is why Dr. Diaz and his research team are developing the North Carolina Hispanic Cancer Registry. Supported by the 2022 Harry F. Bisel Endowed Young Investigator Award from Conquer Cancer, the ASCO Foundation, and the UNC Lineberger Comprehensive Cancer Center, Dr. Diaz hired a research coordinator to assist in gathering patient data. The funding also allowed him to purchase supplies, build and disseminate assessments, pay travel expenses for patients, and cover travel funds for networking and collaboration.  

 

The database records information on Hispanic and Latino adults receiving care at North Carolina Basnight Cancer Hospital, which serves each of the state’s 100 counties. Having access to such a broad population enables Dr. Diaz and his team to gather data on a diverse range of patients, including those who are uninsured, underinsured, and undocumented. 

 

As part of this ongoing project, Dr. Diaz and his colleagues have launched a comprehensive study collecting data across four components: SDOH; geriatric assessment; patient-reported outcomes; and cancer-related information from the electronic medical record.  

 

Participants answer questions about where they were born, how long they’ve lived in the U.S. (to gauge acculturation, if applicable), where their parents were born, language proficiency, the highest level of education they’ve received, literacy, diet, exercise, and citizenship status, among other criteria. The study is available to both English- and Spanish-speaking individuals, and it can be conducted in digital or print formats. “By asking patients a range of intentional, substantive questions, we’ve really expanded upon the SDOH in a way that’s never been done before,” Dr. Diaz said. 

 

The geriatric assessment tool is designed to give providers greater insight into patients’ physical abilities, cognitive status, and psychosocial well-being, among other domains. It also allows Dr. Diaz and his team to evaluate the patients’ physiological health through more meaningful and telling factors than numerical age. As an example, Dr. Diaz points to a 78-year-old patient in his care, whose physiological age defies typical expectations. 

 

“People generally have a picture in their mind of what a typical 78-year-old looks like,” Dr. Diaz said. “But my patient is extremely active and independent. She does Zumba in the morning, runs mini marathons, enjoys getting lunch with her friends.” 

 

Dr. Diaz is also gauging patient-reported outcomes. He and his colleagues survey participants about their financial security, social support, and mental health to better understand how these factors can shape patients’ perception of their care. Moreover, the study aims to profile the unique circumstances of each individual patient, including cancer type and stage, course of care, treatment toxicity, emergency visits, and appointment attendance, among other factors.  

 

Armed with such a wealth of data, Dr. Diaz hopes to better segment and categorize the data pertaining to Hispanic and Latino populations so that researchers can more accurately identify the highest-risk subgroups, including patients with cancer who may need additional support.  

 

“Over time,” Dr. Diaz said, “this database will give us a better idea of how cancer can affect these subgroups and provide insight into how the Hispanic and Latino populations are aging in the U.S. based on where they were born and the influence of acculturation, among various other factors.” 

 

Next Steps: Global Collaboration  

 

As his project progresses, Dr. Diaz hopes that a significant percentage of older Hispanic and Latino patients (including people who are undocumented) will express greater interest in sharing more about their cancer journey, feel encouraged to participate in clinical trials, and express a greater interest in patient education. 

 

“I predict one of the most important takeaways will be that older Hispanic/Latino patients want to know more about their cancer diagnosis and what steps they can take,” Dr. Diaz said.  

 

Along with his colleagues, Dr. Diaz hopes to eventually collaborate with researchers across the globe to further diversify and enrich Hispanic/Latino cancer data. Amid these aspirations, he credits support from Conquer Cancer for making his initial research possible. 

 

“The infrastructure to build a cancer data registry comes at an expense, and YIA funding has been very helpful,” Dr. Diaz said. “Without that support from Conquer Cancer, I wouldn’t have been able to launch and help run this program.”