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Cancer as a disease

Cancer as a disease

Cancer as a disease
Dissertation Chapter
Demographic Information
Cancer is a disease whose prognosis depends largely on timely diagnosis and treatment.
Patients’ fear of becoming infected in health centers may have caused them not to be screened,
delaying the diagnosis and timely treatment of the disease. In some cancers, a three-month delay
in diagnosis can have an impact on survival. Regarding demographic information, the entire
population surveyed resides in New Orleans, Louisiana. Of these patients, 38.3% have stage II
breast cancer, with the lowest percentage (10.6%) being stage 4. 11.9% have stage I (Appendix
1A).
For health care, the highest percentage of the population studied has insurance from the
government (80.9%) and the lowest percentage does not have insurance (4.3%). This means that
the population is highly assisted by state resources, which indicates that the laws have favored the
health care of citizens. Concerning the benefits of ACA, the majority 66%, choose the three
options: Before ACA (before 2010), during ACA (2010-2014), and after ACA expansion
(Appendix 1B). This type of study, for the selected target population, is of great importance,
because the lack of economic resources of people together with the excessive and uncontrolled
charging in the private sector for services provided in clinics is a fundamental limitation in the
effective exercise of the right to health (Decker et al., 2022). This is exacerbated by the current
situation worldwide, as restrictive measures have led to job losses and the material impossibility
of paying for care provided by the private health sector, to which all those who have not been able
to receive services in the overcrowded public health system turn. In terms of resources, the annual
income of the population is concentrated in a range of no more than $30,000 (46.8%), and 31.9%
with an annual income range between $30,000 and $50,000 (Appendix 2C). Cancer as a disease
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At the same time, an important aspect to be taken into account is that family history is
relevant in the population. Of the patients interviewed, 51.1% had no family antecedents, and
48.9%, the contrary, 48.9% had family antecedents. These data are necessary to evaluate and
generate care and prevention for healthy families for the detection and control of cancer.
About the ethnic group, 68.1% were African-American. 19.1% are white, 8.5% are
Hispanic and a lower percentage are Asian (4.3%). Concerning the age group, the highest
percentage of the surveyed population is over 60 years of age (36.2%), followed by the 50-60 age
group and, to a lesser extent, younger age groups in the 18-25 range. 51.1 % of the respondents
have a High School level, and only 19.1 % have a Master’s degree (Appendix 1A). At the same
time, the highest percentage of patients (48.9 %) are employed, 17 % are self-employed and 23 %
are unemployed. The highest percentage of patients (48.9%) are single and 34% are married, the
lowest percentage is widowed with 6.41%.
Dimensions of Accessibility
Accessibility implies that all available infrastructure (facilities, goods, health services)
should be accessible to the entire population. This element has four dimensions to be observed for
its fulfillment: non-discrimination (access must be, in fact, and law, real for all, including
minorities, vulnerable groups, and those excluded from society), physical accessibility (within
geographical reach of the entire population, within reasonable distances, and facilities must have
appropriate access for people with disabilities or vulnerable groups in general), economic
accessibility (payment for health services provided, whether public or private, must be based on
the principle of equity so that a disproportionate burden does not fall on poor and disadvantaged
households, with economic considerations becoming a limit to the realization of this right) and
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access to information, the right to receive, request and disseminate health-related information (AlQuteimat & Amer, 2020).
In the surveyed population, only 40.4% consider it acceptable that medical care is
accessible. At the same time, 61.7% agree that they have received the necessary information for
treatment and care from the provider (Appendix 2C).
On the other hand, 36.2 % do not agree or do not see it necessary, for the health care
provider to improve the quality of communication. In the case of information, the inadequacy and
lack of effective channels of dissemination have been elements linked to late diagnosis. This lack
of information can promote vague and abstract perceptions, either on the part of women or their
families (Chai et al., 2021). To some extent, the lack of information is explained by the fact that it
is neither accurate nor conclusive. For example, there is no consensus regarding the causes and
risk factors related to the onset of the disease. The only thing that is known with certainty is that
early detection is a key factor in the possibility of successfully combating the disease and
increasing the survival of diagnosed women (Vuagnat et al., 2020). Cancer as a disease
Acceptability
One aspect to consider, 40.4% consider that the health care provider treats the patient with
respect and dignity and with individuality. Despite the values and perceptions noted above, in the
population surveyed, 21.3% (strongly agree) and 36.2% (agree) in having suffered discrimination
in care (Appendix 3).
The discrimination pointed out in the results of the survey, once again demonstrates the
problem in health care and the barriers that are present.
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Regarding the relationship with service providers, several studies describe the lack of
awareness, interest, preparation, updating, and skills of health personnel (particularly physicians)
to determine the timely diagnosis of breast disorders (Patt et al., 2020). Likewise, women express
mistrust of health services and fear of doctors, especially when it comes to accepting certain
diagnostic procedures (breast examination and mammography).
Studies in the United States have found that cervical cancer incidence rates are 45% higher
among women of African descent and 65% higher among Hispanic women, compared to
white/mestizo women; about breast cancer, some studies show that rates are higher in young
women of African descent compared to women of other ethnicities. On the other hand, survival,
timeliness of diagnosis, and access to cancer prevention programs among Afro-descendant women
are low, as problems of access to health services, lack of health insurance and other social and
cultural factors that delay seeking care have been identified. Overall, 55.3% agree that the health
professional is sensitive to values, culture, and gender (Appendix 4).
Because of this aspect, it should be remembered that breast cancer is a public health
concern and it is necessary to provide care for this neoplasm under precepts of efficiency, quality,
and opportunity, coupled with the rational use of the limited resources available in the country for
this purpose (Alpert et al., 2021; Johnson et al., 2021). In addition, the growing complexity in the
selection of diagnostic and therapeutic procedures, the wide range of drugs, and the need to
restructure the supply of services, among others, are examples of the need to evaluate alternatives
and analyze health costs.
Studies conducted with women of African descent reveal multiple meanings given
individually and socially to cancer; thus, with cancer, it has been found that there are cultural
factors related to beliefs about the disease, fear of cancer and death, lack of knowledge about the
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adverse effects of treatments, family relationships, family support, and spirituality, as well as
multiple barriers of the health system to undergo treatment and follow-up.
As other elements, acceptability and quality are highlighted. Acceptability consists of
respect for medical ethics and cultural diversity (Paige et al., 2022).
Availability and Accommodations
Access is conceived as the process of interaction between users and services, to enable the
sick individual to receive the service, without discrimination. In other words, the population can
seek health services and obtain care. In this study, it was found that 46.8% of patients with breast
cancer pathology in the community (Appendix 3). Access depends on factors related to the
population, the organization, the delivery of services, and the relationships between them. Cancer as a disease
From a redistributive perspective of social justice, the basic capabilities of each person
must also be taken into account about the resources provided. Therefore, in addition to the
provision of technological means for scheduling and delivery of results, it will be necessary to
devise training programs for women and their families on the use of such means. The population
receives information about breast cancer care through email (48.9%) and telephone calls. In
addition, 53.2% agree that visits and appointments are available in the community (Appendix 3).
In this sense, to the results described above, it is necessary to start from an approach in
which the planning of safe programs with remote mediation is added, with educational
interventions that allow the inclusion of all women, particularly those who have family
environments with little stimulation in the technological and health care areas. The population of
36.2% considers medical care during and after emergencies acceptable (Appendix 4).
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It has been established the need to find a balance between coronavirus prevention and the
consequences that can be obtained and generated by the absence and infrequency of preventive
consultations in women who have not had cancer detected or the resulting discontinuity of
treatment. This represents a serious shortcoming in women’s health, so it is important to determine
a balance in favor of the quality of life of this population. In the study, it was found that although
more than 60% were able to continue medical care during the pandemic, a large percentage of the
population (21.3 strongly agreed and 27.7 agreed) considered that COVID-19 had a negative
impact (Appendix 5).
In times of covid pandemic, when it is difficult to care for patients due to the saturation of
hospital centers, fear of contagion and exposure of patients, and comorbidities, remote care has
been necessary. With telemedicine, certain advantages can be highlighted, such as It allows for
continuity in patient care. It generates joy and containment in the patient. It allows us to educate
and reinforce the continuity of treatments, mainly hormone therapy (Miyashita et al., 2020). It
allows for clearing doubts and concerns that arise over time, concerning hormone therapy,
examinations, and control hours. It allows the management of future care (medical or
psychological appointments, exams, and prescription renewals, among others). Facilitates
administrative patient care, such as discarding pathologies and discharge to primary care. Allows
continuing with most of the activities of the Breast Pathology Unit that do not correspond to patient
care. It allows the management of quick and effective treatments that must be received by the
patient (radiotherapy, chemotherapy, hormone therapy).
It facilitates the care of bedridden patients, those who need to be accompanied, and those
with reduced mobility or who live in remote areas. Some disadvantages can also be established
with the use of telemedicine: such as problems with physical examinations, restrictions in the
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taking of examinations, technological problems, and the impossibility of communication or
emotions, in a doctor-patient relationship. Technological problems, the impossibility of
communication, or emotional, a doctor-patient relationship.
Affordability
In addition to the consequences of physical health, psychological, education, culture,
economy and so many other aspects of life, like any crisis, it can also be seen as an opportunity to
analyze and improve our behaviors, such as the way we manage chronic patients. 44.7% and 36.2%
of the population agree that breast cancer has caused financial difficulties and problems in their
quality of life. The highest percentage of the population (29.8%) cannot afford the disease. At the
same time, 34% do not consider that they have not received medical care for their cancer treatment.
This means that health care has been significant. In these patients, health insurance covers breast
cancer care of the surveyed population, 44.7% (Appendix 5).
The current management of breast cancer requires the coordinated interaction of different
health professionals from the moment of diagnostic confrontation. This interdisciplinary concept
becomes critical during treatment planning and execution. In a public center such as ours, with
limited resources and in which not all these specialists are available on-site, it is necessary to
communicate quickly with providers of the public and private systems to articulate the care of our
patients, which presents us with a daily challenge.
It is considered that the difficulties during the COVID-19 pandemic have increased
considerably and we have had to adapt our management to provide timely, safe care that does not
8
generate more risk of contagion and taking into account the limitations inherent to the lack of
hospital infrastructure that has occurred worldwide.
A great challenge is also related to the imperative level of making a diagnosis of the impact
that this period of pandemic generates on the health condition of patients, especially to collect the
results of those who had to wait for surgeries, either in hormone therapy or neoadjuvant
chemotherapy, calculating the eventual increase in morbidity and mortality due to postponed or
suspended treatments (Chino et al., 2017). Again, it is important to describe high-priority
populations and to broaden the management alternatives in certain groups of patients at surgical
risk or who for some other reason must defer their surgery.
The pandemic had an enormous impact on hospital activity, generating an organizational
restructuring in hospitals. This has resulted in restrictions on the availability of operating rooms,
consultations, imaging tests, and other routine activities. At the same time, there is a reduction in
the number of physicians available, both staff and residents, in cancer services. There are also
reasonable suspicions of the possibility of transmission of the disease by asymptomatic carriers or
carriers with few symptoms, which could lead to inadvertent transmission between patients and
physicians. Cancer as a disease
Appropriateness
One effect of COVID-19 is that it has changed treatment plans in some cancer patients.
Some expert panels have published recommendations on this issue, such as the expert consensus
of the European Society of Medical Oncology, on, for example, which patients to defer surgery or
chemotherapy treatments. It has been determined that, in oncology patients with systemic therapy,
in 27% of the cases there was a modification in the treatment, reaching 41% in lung and head and
9
neck cancers (Resio et al., 2018). In the study, 38.3% of the population, which represents the
highest percentage (Appendix 5).
The population indicates that the opinions and thoughts to make decisions on treatment and
care are not taken into account by the healthcare provider. At the same time, the highest percentage
of the population did not experience follow-up by the care provider to ensure that they received
community care, resources, and updates (Appendix 6).
Some 27.7% and 38.3% experienced a decrease in quality due to the health crisis
(Appendix 6). The discomfort is not only reflected in poor care, which may represent a barrier, but
also in the level of danger of being infected with the virus (Schrag et al., 2020; Pigozzi et al.,
2021).
About the population studied, there was continuity in cancer treatment, but, COVID-19, as
pointed out by the respondents, had a considerable impact on treatment and health care in general.
A phenomenon that was determined worldwide is that the number of patients who consulted health
centers decreased, delaying their check-ups and not consulting for new symptoms, for fear of
contracting SARS-CoV-2. This may provoke another health crisis, with late diagnosis and
treatment, which may increase the morbidity and mortality rate for these pathologies (Brugel et
al., 2021). Some studies have shown that the time it takes for a breast tumor to double in size varies
from 45 to 260 days. This is a wide range that does not help us determine the real effect of delayed
diagnosis on survival. There are also estimates that, within 6 months, up to 50% of breast tumors
could increase in size by more than one centimeter. To this can be added that many health centers
in the world deferred screening, surgery, and adjuvant therapies to give priority to the care of
hospitalized COVID-19 patients. This was not the case in our institution where oncologic surgeries
were given priority. Cancer as a disease
10
Public Health Policies
The current management of breast cancer requires the coordinated interaction of different
health professionals from the moment of diagnosis. This interdisciplinary concept becomes critical
during treatment planning and implementation (Butler, 2020; Ueda 2020). The research population
agrees that current health policies are centered on considering the needs and requirements of the
patient, which is significant in health care. A high percentage consider that the health policies
related to the Affordable Care Act changed concerning access to health care, and breast cancer
care has improved since the enactment of the Affordable Care Act, 2010 (Appendix 6).
Despite all the difficulties faced, the fears of patients, health and administrative staff, and
logistical complications, we have generated a powerful learning process that has allowed us to
design alternative and complementary methodologies to our usual medical practice, to maintain
throughout this period continuous and adequate care of all our patients and in the best possible
way in these circumstances. It has managed to diagnose, control, and indicate treatments and thus
generate a continuum that is not affected by this unusual period, so we consider it essential to
emphasize that if we had not implemented this modality of care, we would see an impact on the
prognosis of the disease, which can be evaluated shortly. The great challenges faced after the
pandemic are related to the implementation of remote work in a more formal, organized, and
coordinated manner, in addition to recovering lost time, especially in terms of surgical activity,
since the wards were temporarily closed and reconverted to care for COVID-19 patients, which
has left a huge surgical waiting list (Marron 2020; Riera 2021). A great challenge will be the
imperative duty to make a diagnosis of the impact that this period will have on the health condition
of our patients, especially to gather the results of those who had to wait for surgery, whether
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neoadjuvant chemotherapy, calculating the eventual increase in morbimortality due to postponed
or suspended treatments, for academic purposes but also to describe high priority populations and
expand management alternatives in a certain group of patients at surgical risk or who for some
other reason must defer their surgery.
It is well known that screening mammography is a type of medical imaging that makes it
possible to discover changes in the breasts of women who are not yet showing symptoms of cancer.
A screening program with mastography consists of regularly studying healthy women and its
objective is to detect the disease early and thus increase the chances of cure with less aggressive
and cheaper treatments (Yao et al., 2021). The main advantage of organized and quality screening
programs with mastography is that they save lives, as long as they are accompanied by referral
mechanisms for timely treatment.
Finally, it should be clear that, despite Covid-19, for example, breast cancer screening is
as important as ever. It is possible to prevent and transform forms of exclusion with safe screening
programs, but the processes of collaboration and linkage of centers and hospitals that dedicate part
of their activity to the timely detection of breast cancer must also be promoted.
It has been determined that the difficulties during the COVID-19 pandemic may increase
considerably and we have had to adapt the management to provide timely, safe care that does not
generate more risk of contagion and taking into account the limitations inherent to the lack of
hospital infrastructure that has occurred worldwide (Krok-Schoen et al., 2021). A high percentage
of the population (80%) considered that mandatory closures, quarantines, and face-to-face visits
negatively affected breast cancer care (Appendix 6). Cancer as a disease
12
After confinement, there is a better understanding of the effectiveness of protective
measures, and supplies of protective materials are considered to be more stable than at the
beginning of the pandemic (Casella et al., 2020). In addition, social distancing and hygiene
measures have had a positive effect in slowing the spread of the virus.
For example, the cost of patient care includes the value of screening plus radiotherapy,
chemotherapy, the diversity of surgical procedures, and the cost of follow-up. In the specific case
of screening, it includes the cost of case detection in the general population plus diagnostic
procedures for patients who test positive for breast cancer. Cancer as a disease
The analysis presented in this paper corroborates the importance of consistent diagnosis in
the treatment and diagnosis of the disease and the quality of care while eliminating racial issues
that may affect patient care. The low use of services in case of need by the population may
represent evidence of barriers, which may be geographic, cultural, economic, functional,
informational, legal, and gender. Due to the importance of the right to health in the development
of individuals, international instruments have been issued that recognize in a particular and
fundamental way this right to certain vulnerable groups such as women and children. Cancer as a disease
13
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