Examining LGBTQ+ Disparities in Cancer Care

Pride Month is celebrated each June to remember the Stonewall Uprising of 1969. That is, the impetus for the gay liberation movement in the United States. Today, we recognize Pride Month to celebrate and support LGBTQ+ rights and culture, including equal access to comprehensive cancer care.

While great strides have been made in equal rights since the Stonewall Uprising, more work is needed to raise awareness on the healthcare disparities that impact LGBTQ+ communities. Several studies have identified barriers to equity in care for LGBTQ+ people with cancer.

These barriers include:

• Healthcare providers’ lack of awareness of LGBTQ+-specific needs and health-related issues

• Healthcare providers’ lack of awareness of the importance of sexuality and gender in person-centered care

• LGBTQ+ people’s distrust in healthcare providers. (They feel that most providers do not understand them.)

• Healthcare providers’ implicit biases that impact access to and delivery of care.

Recently, Cedars-Sinai Medical Center, Cedars-Sinai Cancer Center held a first-of-its-kind LGBTQ+ cancer symposium. The focus of this effort was to bring together oncology professionals to discuss how to equalize healthcare access and treatment for those in the LGBTQ+ community. The Symposium took place June 2 to 3, 2022, in Los Angeles, Calif.

ACCCBuzz had an opportunity to speak with B.J. Rimel, MD, gynecologic oncologist, medical director of Cedars-Sinai Cancer Clinical Trials Office, and associate professor of Obstetrics and Gynecology, at Cedars-Sinai Cancer Center. Dr. Rimel is the gynecologic surgeon for the cancer center’s transgender program and is one of the architects of the event.

ACCCBuzz: You recently held the first LGBTQ+ symposium in Los Angeles. What were the key takeaways of the event?

Dr. Rimel: There were many, but a few stand out. There is a strong interest in gathering better data about the LGBTQ+ community. We recognize the way we collect data, as providers, needs to improve to capture data that will allow us to foster better health outcomes.

Next, there were a remarkable number of impassioned people interested in coming together to discuss the topic. To be able to gather with other people that work with the LGBTQ+ community, I have to say, it was a joyful experience academically.

And there was interest from people across the nation. We had providers fly in from Atlanta, Ga., and New York City.

ACCCBuzz: Where did the idea for the LGBTQ+ symposium come from?

Dr. Rimel: We have been examining our catchment area. We found that our LGBTQ+ community size is second only to New York City, and we wanted to take a deeper look at the people we serve.

ACCCBuzz: What was the expected turnout versus how many that came? And do you hope to hold the symposium annually?

Dr. Rimel: We honestly thought we would be lucky to have around 50 people. We were very excited to have almost 200 people participate, both virtually and in-person. We are also overwhelmed by the interest in continuing to work on this collectively. We hope to hold it again every two-years to be respectful of costs for attendees.

ACCCBuzz: What are the major concerns when treating someone for cancer from the LGBTQ+ community?

Dr. Rimel: Identifying that they are part of the community and who is in their support system. For many LGBTQ+ people, they don’t often have the privilege of family support.  Many times, they create a non-traditional family for themselves. As a provider, I want to make sure I identify their needs and their support system.

ACCCBuzz: What is a specific concern you may have when treating someone for cancer that is transgender?

Dr. Rimel: We are a gynecologic practice. As such, we want to make sure the treatment provided is sensitive to the patient’s needs. I want them to know I am a trustworthy provider. I will ask questions instead of making assumptions.

Furthermore, I want my patients to know that I am only asking questions that are relevant to the services being provided. I ask open-ended questions, and they usually are open to answering questions. ACCCBuzz: What disparities in care are typically associated with the LGBTQ+ community?

Dr. Rimel: It depends on what letter of the LGBTQ+ you are. Because of mistrust with the medical community, there is a lack of cancer screening. And there are some misconceptions. For example, lesbian women might think they don’t need a Pap test because they don’t engage in sex with men. But this isn’t true. Women can also have issues with the human papillomavirus (HPV) if they only have sex with women. If you have a cervix, you need to be screened.

ACCCBuzz: What is your practice doing to combat these disparities?

Dr. Rimel:  In our practice, I educate fellows, residents, and other providers about health issues specific to the LBGTQ+ community. I am trying to foster a community of physicians that can be culturally humble. The kind of doctors that we would want to send our kids to.

ACCCBuzz: You recently gained the title of medical director of the Clinical Trials Office. What barriers have you been able to identify regarding clinical trial participation for the LGBTQ+ community?

Dr. Rimel: There are a lot of disparities facing the LGBTQ+ community. When there is an intersection with race or poverty, it puts the person even more at risk.

For clinical trial enrollment, we are trying to understand how they come to the studies. We are investigating the intersections of sexual orientation with race, gender, and language. Like a prism, it’s almost an indescribable amount of variety in people to serve.

We are just starting to gather more data. Asking questions: who are you, who do you sleep with, who don’t you sleep with, what do you do in your free time, what language do you and your caregiver speak, do they need any services? We need to understand their cultural norms by better capturing data. We are looking to implement hard stops in medical records that allow us to capture this important information.

Another barrier is the ability for patients to identify providers who want to be known as part of the community, like myself. We have recently implemented a new form in clinical trials that asks consented patients to share their preferred gender identity, pronouns, and sexual orientation. To date, I have had about 30 to 40 people fill it out.

ACCCBuzz: What are some ways you would like to address the barriers these communities face?

Dr. Rimel: We are changing our assessment tools to capture data relevant to this group, based on cancer treatment toxicity. This will allow us to better counsel our patients on how treatments are likely to affect them. Currently, we don’t know what the differences might be for patients with different sexual orientations or gender expressions.

ACCCBuzz: Anything else you’d like to add before we conclude?

I want to come back to a question you asked earlier regarding patients’ feelings when asked about their sexual orientation, practices, or gender identity. In my experience, people aren’t going to be mad if you ask them these questions. As a doctor, I let them know I am there for them.  I try to frame what I’m asking to help give them better healthcare.