Diversity in Donation and Transplantation: Lessons from Cancer Care

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1 Diversity in Donation and Transplantation: Lessons from Cancer Care September 23, 2015, AMAT Annual Conference Rishindra M. Reddy, MD, FACS Assistant Professor, Thoracic Surgery University of Michigan

2 Dislosures GlaxoSmithKline Intuitive Novadaq Covidien/Medtronic

3 Learning Objectives Review current state of diversity in donation and transplantation in the US Review state of health disparities in cancer care as a corollary to transplantation Discuss potential strategies to improve donation rates Discuss strategies to improve access to transplantation

4 Diversity in Transplant Big Picture Reasonable number of Minority donors, but higher number of Minority recipients leading to inequity in organ allocation

5 Diversity in Transplant Klein AS et al, Organ Donation and Utilization in the US , Am J of Transplant 2010 Summarized data from 2009 OPTN / SRTR Annual Report: Transplant Data # of Living donors peaked in 2004 % of minority living donors stable overall Decreased AA donors, increased Hispanic/Asian donors

6 Diversity in Transplant 2009 OPTN / SRTR Annual Report: Transplant Data

7 Diversity in Transplant 2009 OPTN / SRTR Annual Report: Transplant Data

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11 Diversity in Transplant 2009 OPTN / SRTR Annual Report: Transplant Data

12 Diversity in Transplant 2009 OPTN / SRTR Annual Report: Transplant Data

13 Diversity in Transplant AA donors are proportional to AA US population AA s constitute 34% kidney waiting list Persistent differences in AA, Hispanic, and Asian population between % of wait list and % of living donors. Bratton C, et al Curr Opin Organ Transplant 2011

14 Disparities in Esophageal Ca Big Picture African Americans have worse outcomes after being diagnosed with esophageal cancer for still unclear reasons. May be related to access to care/social support

15 Disparities in Esophageal Ca U of Michigan is one of the top esophageal cancer centers in the country Mark Orringer developed the Transhiatal Esophagectomy in the 1970 s/80s AA s have a similar proportion of esophageal cancer cases in the state Only 2.7% of patients in our surgery database are AA <5% of our UM Cancer Center referrals are AA

16 Disparities in Esophageal Ca Revels S, et al, Ann Surg Onc 2013

17 Disparities in Esophageal Ca Akateh C, et al, Equal Outcomes Between African American and Caucasian Patients After Esophagectomy for Esophageal Cancer

18 Disparities in Esophageal Ca Akateh C, et al, Equal Outcomes Between African American and Caucasian Patients After Esophagectomy for Esophageal Cancer

19 Disparities in Esophageal Ca GI PCP ER GI Med Onc Endoscopy Thoracic Surgery Rad Onc Kemp M, et al, Physician Perspectives: Barriers to Esophageal Cancer Care for African Americans

20 Disparities in Esophageal Ca Diagnosis Planning Treatment Surveillance 2-3 wks 2-3 wks 4 mos 5 yrs 1 st endoscopy CT Scan PET Scan EUS Surgery +/- GI Medical Oncology Radiation Oncology Esophagectomy: 7-14 days hospital stay Up to 6 month recovery Radiation: 28 treatments over 6 weeks Chemotherapy: 6 treatments; 3-4 hours each Kemp M, et al, Physician Perspectives: Barriers to Esophageal Cancer Care for African Americans

21 Disparities in Esophageal Ca Treatments Options Offered to Patients LOW SES High SES Chemotherapy Surgery Radiation Lineback C, Mervak C, et al Barriers and Facilitators to Accessing Optimal Esophageal Cancer Care for Socioeconomically Disadvantaged Patients

22 Disparities in Esophageal Ca 70 Barriers to Care LOW SES HIGH SES Loss of Employment Lost Trust in Physicians Financial Difficulties Lineback C, Mervak C, et al Barriers and Facilitators to Accessing Optimal Esophageal Cancer Care for Socioeconomically Disadvantaged Patients

23 Improving Donation Big Picture Well studied barriers to donation exist with potential strategies to overcome these barriers

24 Improving Donation Interview of 40 AA s 5 Barriers to donation Lack of Transplantation Awareness Religious beliefs and misperceptions Distrust of the medical community Fear of premature declaration of death Fear of Racism Callender CO et al, J Am Coll Surg 2010

25 Improving Donation Literature Review Variables that are consistent predictors of AA organ donation Trust in medical system Conversation with loved donation Individuals perception that a loved one feels that donation is important Ford D, et al, Nephrology Nursing J 2011

26 Improving Donation Communication Awareness Family Approach?

27 Improving Access to Transplant Big Picture Similar barriers to access to care as seen in esophageal cancer care There are different reasons for decreased transplantation between ethnic groups that may require different approaches to improve access Joshi S, Review of ethnic disparities in access to renal transplantation Clin Transplant 2012

28 Improving Access to Transplant Literature Review The transplantation process involves a series of steps including determination of medical appropriateness interest in transplantation transplant evaluation placement on a waiting list receipt of an organ. Joshi S, Review of ethnic disparities in access to renal transplantation Clin Transplant 2012

29 Improving Access to Transplant Literature Review The transplantation process involves a series of steps including determination of medical appropriateness interest in transplantation transplant evaluation placement on a waiting list receipt of an organ. Joshi S, Review of ethnic disparities in access to renal transplantation Clin Transplant 2012

30 Improving Access to Transplant Young AA patients may feel better on HD than other demographics Less likely to be referred by physicians Decreased rates of LDRT in minority populations Joshi S, Review of ethnic disparities in access to renal transplantation Clin Transplant 2012

31 Improving Access to Transplant Hispanics may be more willing to ask family members for LDRT help Limited info on Hispanic, Asian, NA populations Health insurance (access) and poverty may be the most relevant in explaining disparities. Future work should be ethnic specific Joshi S, Review of ethnic disparities in access to renal transplantation Clin Transplant 2012

32 Conclusions Reasonable number of Minority donors, but higher number of Minority recipients leading to inequity in organ allocation Well studied barriers to donation exist with potential strategies to overcome these barriers Similar barriers to access to care as seen in esophageal cancer care

33 Conclusions There are different reasons for decreased transplantation between ethnic groups that may require different approaches to improve access Future studies for cancer care, etc. may have broad overlap with transplant access issues

34 Thank You QUESTIONS?

35 Questions? Rishindra M. Reddy, MD, FACS (cell) (off) (fax)