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“Separated by less than a month (Boseman on August 28th and Ginsburg on September 18th) and both due to gastrointestinal cancers (Boseman had colon cancer and Ginsburg had pancreatic cancer), the situations of Ginsburg’s and Boseman’s deaths is emblematic of the racial disparity in American health outcomes. Boseman was African American/Black and was diagnosed with stage III colon cancer at the age of 39 while Ginsburg was Jewish/White and fought three separate primary cancers of different stages in multiple bouts – colon, lung, and pancreatic – starting at the age of 66.”
Adeel Khan is a hematology-oncology fellow.
He shares his story and discusses his KevinMD article, “Ruth Bader Ginsburg and Chadwick Boseman: a tale of two cancers in America.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Adeel Khan. He is a hematology-oncology fellow, and he wrote the KevinMD article “Ruth Bader Ginsburg and Chadwick Boseman: a tale of two cancers in America.” Adeel, welcome to the show.
Adeel Khan: Thank you for having me. Pleasure to be here.
Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?
Adeel Khan: Yeah, absolutely. So I’m a second-year fellow of hematology-oncology at Beth Israel Deaconess Medical Center at Harvard Med School. I did my medical school training at generation Michigan, did my internal medicine residency at the Cleveland Clinic, and along the way, I did two public health degrees at Harvard and Columbia. And so I’ve been very interested in the intersection of medicine and public health, the way that medicine looks at patients as a granular entity and the way that public health looks at patients as a population and a large entity.
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Kevin Pho: All right. And we’re speaking on the last week of January. Now, what are you seeing from a pandemic standpoint through your lens as a hematology-oncology fellow?
Adeel Khan: Yeah, I think one of the interesting things that’s been a feature of COVID-19 is the blood clots and coagulopathies that we’ve seen. It’s a viral illness. It’s a respiratory illness, fundamentally. But it really causes an interesting cascade of issues, and one thing that we’ve seen really from the heme side is that these patients develop unusual blood clots. It’s been called COVID toes when we see it in the toes. We’ve seen patients with pulmonary emboli, clots in the lungs.
I don’t think this was anything that anyone had expected prior to it being characterized over the course of the illness. Fundamentally, it was seen to be a type of pneumonia. So this, I think, is a surprise to many people, and yet now it’s very well established.
Kevin Pho: Now, I see patients with mild cases of COVID from my practice as an internal medicine primary care physician. As far as you know, is there any data supporting any treatments that can stop this coagulopathy for people with asymptomatic or even mild cases of COVID in the outpatient setting?
Adeel Khan: It’s a great question. On the inpatient side, for people once they’re in the hospital, particularly once they’re in ICU, we tend to anticoagulate them with heparin or another anticoagulant kind of automatically. That’s been a controversial issue. People have said different things. We’ve seen some higher rates of heparin-induced thrombocytopenia as a result. We’ve certainly seen bleeds also as a result. So the overall answer is I don’t know that there is a right answer, and I don’t think anyone knows. And so, being a gray area, it’s hard to say.
Kevin Pho: And as far as you know, is there any evidence supporting something like a baby aspirin?
Adeel Khan: Not as far as I know. I mean, it’s less an issue of a platelet effect, more of the coagulation factors. And hence, if we really want to treat it, we need an anticoagulant, but then that enters into the bleed risk and everything that goes with it.
Kevin Pho: Sure. All right, so let’s transition now into your KevinMD article, “Ruth Bader Ginsburg and Chadwick Boseman: a tale of two cancers in America.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?
Adeel Khan: Yeah, absolutely. So 2020 was a tragedy in so many ways, made up of many small tragedies, and among them was the loss of Ruth Bader Ginsburg, a champion of gender equality, and Chadwick Boseman, who was such a celebrated actor. It was interesting to me as an oncology fellow that their deaths were spaced less than a month apart, both of GI cancer, and yet their circumstances really could not be any more different.
Ruth Bader Ginsburg was 87 years old. Chadwick Boseman was 43. He was diagnosed at a rather late stage of colon cancer back when he was 39 years old. And Ruth Bader Ginsburg, actually, this was her third malignancy she had dealt with. She originally actually had colon cancer at the age of 66. She later had lung cancer that was resected, and then what she ultimately passed with was pancreatic cancer, which had metastasized to her liver.
The attention brought to both cases, and to celebrate the lives of each, was appropriate. But when I looked at the lens of what just happened in this past month, it was interesting that the racial disparity in these outcomes of these two people was really striking to me.
Kevin Pho: Can you tell us a story of how racial disparities in cancer treatment and prevention play out in some of the patients that you’ve seen in the past?
Adeel Khan: Yeah, it’s such a heavy question, and so many individuals have looked at this. There’s an entire segment of the NCI that’s dedicated to cancer disparities. There’s an entire journal simply called Cancer Health Disparities. And what we’ve seen over years and years of research is that it really goes from womb to tomb, sort of the phrase. There are prenatal risk factors and genetic and epigenetic changes that can occur, and then later in life, there are many system issues, which have brought up quite a bit of attention, from lack of trust in the system on the part of certain minority populations, to lack of access to appropriate clinical trials, to fundamentally the fact that the health care system is uneven in the way that it treats patients. And we see that then ultimately in patients’ cancer incidence rates and their subsequent mortality.
Kevin Pho: So tell us, in a specific case of colon cancer, for instance, like Mr. Boseman, how do these racial disparities kind of stack the deck against him?
Adeel Khan: What was unfortunate about Chadwick Boseman was that he was diagnosed at the age of 39. This was well before the age of screening in anyone, standardly. In the United States, you get your screening colonoscopies at 50. There are some guidelines now to say 45. He was younger than both of those ages.
We’ve actually seen a trend in the U.S., and it’s been published before, that the age of colon cancer has gone down and down and down, and it’s impossible, that might be obesity, a lot of lifestyle risk factors. But that decline in age is actually unequal. We see that, for whatever reason, African American Blacks tend to have more of this shared burden than do whites. And again, it’s not clear why that is. The lifestyle hypothesis has been a big one, but I don’t know that that’s the only story.
The other piece is that we know that a screening colonoscopy is associated with a 50 to 60 percent increase in the incidence of colon cancer, meaning that if you screen someone at the age of 50, you find something that was there when they were 49. So it has nothing to do with the age per se, but that the precursor lesions you only find when you screen for them. And if you don’t screen these people, you don’t find them, and so they would present later, as is actually what happened with Chadwick Boseman. So he was 39, diagnosed with stage 3 colon cancer.
Now, on the flip side, Ruth Bader Ginsburg was 66. She was well beyond the age of screening. She had great health care. She was a fortunate segment of the population. And so between the age of 39 and the age of 66, where you see an advanced colon cancer case versus one that was ultimately essentially in remission and cured, and Ruth Bader Ginsburg’s death of pancreatic cancer, that’s a wide chasm.
Kevin Pho: So what are some solutions here, both from a policy, global standpoint, and what are some of the things that I can do as an individual primary care physician in the exam room?
Adeel Khan: Yeah, it’s a great question. So for one, I would say we as physicians tend to look at the patient once they’re in the exam room, and I don’t know that we always give enough thought into how the patient got to the exam, what are all the forces that got that person sick.
Anthony Iton is a California-based physician who was originally from Montreal, Canada, and he talks about how they had such an excellent health system there. Racial disparity in health is not seen in the same way that it is in the U.S., and it was something he only noted when he came to medical school at Johns Hopkins and he saw the situation in Baltimore. He has a great quote, that the key to your health lies more in perhaps your ZIP code rather than your genetic code. I’m paraphrasing that; I’m putting that in one way or the other. And it just highlights the importance of the socio-economic aspect of someone’s health.
So the big answer to the question is we really need a better system. There’s only so much that we can do as physicians, and one is being aware and trying to be mindful of these issues in disparity, trying to appropriate more focus to one patient versus another. But we need to change the colossus that is our health care system to try to address these things.
Kevin Pho: So what kind of changes specifically would be needed, and do you think the Biden administration’s plan is doing enough to make those changes?
Adeel Khan: So one thing that’s been a big issue with cancer health disparities in particular has been an issue of clinical trials and clinical trial access. So, for instance, African American men have the highest burden of colon cancer, as we’ve been talking about, and yet they’re not at all the best-studied group. It continues to be white males, and yet again, they’re not sharing the same burden per capita.
Part of that is a feature of just the fact that it’s harder to study certain minority populations, which may be an aspect of trust in the system but also just simply access. They may not live in areas where there’s a tertiary care hospital, where there’s a research institution. And so one step is that we need to get data on these people. We need to involve them in clinical trials, because that would also help highlight some of the differences in what they are facing versus a white individual or an Asian individual.
In terms of what the White House can, and I hope will, do, one, I’m very optimistic that we’ll see some positive changes. Because in 2020, one thing that we’ve seen and discussed over and over again is that COVID-19 is not an across-the-board illness. It tends to affect more populations than others, including minorities, and that again is probably a systems issue. There are probably a lot of other forces at play, but regardless of the reasons, people are aware of it, and there are attempts to try to address it. And I think, as an extension of that, we’ll see that extending to the chronic diseases like heart disease and cancer.
Kevin Pho: We’re talking to Adeel Khan. He is a hematology-oncology fellow, and he wrote the KevinMD article “Ruth Bader Ginsburg and Chadwick Boseman: a tale of two cancers in America.” Adeel, through your lens as a hematology-oncology physician and a public health expert, now, what are some tips that you could share with your primary care colleagues into how to address some of these racial disparities in cancer treatment that you’ve been talking about?
Adeel Khan: One thing I would say is look beyond simply the exam room. Think of why the patient got sick, and recognize that the patient comes from a source population. They may also have family members who are at risk for the same reasons, whether it’s a lifestyle issue or an exposure issue. And so being mindful of that and sharing that information with the patients is, I think, essential.
The other thing is knowing that some people may take more effort on the part of you as a physician to get that screening colonoscopy, to get that PSA check, to get them in the clinic, to get the appropriate care, and putting in that effort is more than worthwhile. And then, fundamentally, realizing that we need systems changes. And so what we can do by putting pen to paper, speaking to our representatives, and trying to address the health care system as a colossus goes leaps and bounds.
Kevin Pho: My final question: What is your take-home message you want to leave with the KevinMD audience?
Adeel Khan: Racial disparities exist in America, but they don’t have to, especially in the form that they do now. We can and should have a more equitable system.
Kevin Pho: Adeel, thank you so much for sharing your time and insight, and thanks again for being on the show.
Adeel Khan: Thank you for having me. Appreciate it.
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