Care For Minority Patients Research Articles

Abstract A073: Prisma Health Cancer Institute: Racial Analysis in Cancer Patients Using Molecular, Clinical, and Demographic Data

Abstract Background: Racial disparities among cancer patients have become a national concern because of their effects on cancer prognosis This study aims to tackle these disparities by conducting a comprehensive examination of the racial composition and potential inequalities among cancer patients treated at the Prisma Health Cancer Institute. The findings from this study will be compared with national trends to provide insights into the impact of race on patient treatment outcomes. Factors such as cancer staging, histology, molecular characteristics, treatment, demographics, and lifestyle will be analyzed to gain a comprehensive understanding of their impact on patient treatment outcomes. The significance of this study lies in its potential to benefit the community served by the Prisma Health Cancer Institute. Armed with localized and targeted information about racial disparities, that allows the hospital to focus on ways to enhance patient care. Methods: The study includes 586 cancer patients diagnosed with breast (397) and lung (171) cancer between 2014 and 2022. Patients were categorized by race: Asians, African Americans, Hawaiian/Pacific Islanders, Latinos, Multi-Race, Whites, and patients with missing race information. Through the JMP software, the analysis of racial composition was performed in diagnosis distribution, cancer staging, cancer histology, smoking status, cancer molecular subtypes, and other factors. Results: In the studied group, African American males had a higher likelihood (3.17%) of breast cancer diagnosis compared to White males (0.84%). In addition, the African American population showed a greater proportion of stage IV lung cancer (11.11%) compared to the White population (4.63%). Our data for stage IV lung cancer and breast cancer in males were similar to national trends with African Americans having an increased probability of each of these characteristics. Notably, the incidence of triple-negative breast cancer was similar between African Americans (14.63%) and Whites (13.18%) in this cohort. Our data was different for triple-negative breast cancer because of the similarity found between the African American and the White population. Conclusion: This study provides a focused examination of patients treated at the Prisma Health Cancer Institute and their disease prognosis, shedding light on population differences in two highly lethal cancers. The research aims to improve treatment and care for minority patients. Findings contribute to a better understanding of racial disparities in cancer outcomes, potentially leading to targeted interventions. Also, with more education, this research has the potential to lead to better physician-patient interactions leading to more equitable healthcare. Citation Format: Brittany K Austin, Julie Martin, Jeff Edenfield, Anna Blenda. Prisma Health Cancer Institute: Racial Analysis in Cancer Patients Using Molecular, Clinical, and Demographic Data [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Advances in Breast Cancer Research; 2023 Oct 19-22; San Diego, California. Philadelphia (PA): AACR; Cancer Res 2024;84(3 Suppl_1):Abstract nr A073.

Utilization and Barriers to Stem Cell Transplantation in Relapsed/Refractory Hodgkin Lymphoma: A ‘Real-World’ Study of Treatment Patterns and Outcomes at a Safety-Net Versus a Tertiary Academic Hospital

Background About 20-30% of patients with classical Hodgkin Lymphoma (cHL) develop relapsed or refractory disease (R/R) after initial induction therapy. The standard of care for R/R cHL involves salvage chemo- and/or immuno-therapy followed by autologous hematopoietic stem cell transplantation (ASCT), with which up to 50% of patients achieve durable remission. However, ASCT is not readily available for all patients. Safety-net hospitals disproportionately take care of minority patients who face significant barriers to care due to lack of insurance or prohibitive medical costs. With novel therapies like brentuximab vedotin (BV) and immune checkpoint inhibitors increasingly used in treating cHL, the optimal timing and role of ASCT in R/R cHL requires ongoing investigation. This study compares the demographics, treatment patterns, and survival outcomes among R/R cHL patients treated at a safety-net versus a tertiary academic institution. Methods We conducted an IRB approved, retrospective review of adult patients with cHL treated within our healthcare system between 2009 and 2023. Hypothesis testing was performed using Chi-square test or Fisher's exact test for categorical variables and t-test or Wilcoxon rank sum test for continuous variables, with a 2-tailed P value ≤ .05. Survival analysis for progression-free (PFS) and overall survival (OS) was performed using Kaplan-Meier method and evaluated by log-rank test. Univariate Cox proportional hazard regression was used to assess the relationship between pre-specified variables and the primary endpoints of PFS and OS. All statistical testing was done using R version 4.3.1. Results There was a total of 230 adult patients with cHL between the two hospital systems. Seventy-one patients (31%) in the study cohort had R/R cHL (safety-net hospital, n=30 [42%] and tertiary academic medical center, n=41 [58%]). Patients treated at the safety-net hospital were predominantly male (p=0.033), Hispanic (p=0.014) and uninsured (p<0.001) and had higher rates of HIV/AIDS (p<0.001). They also had more advanced stage disease (p=0.015), higher IPS score (p<0.001), and bone marrow involvement (p=0.031) (Table 1). Primary refractory cHL constituted 17/30 (57%) at the safety-net hospital and 22/41 (54%) at the academic medical center. Only 7/30 (23%) patients treated at the safety-net hospital received ASCT compared to 30/41 (73%) at the academic medical center (p<0.001). The main barriers to ASCT for the former were predominantly financial and social barriers (>50%) while those at the latter were based on patient/physician choice due to anticipated adverse effects and comorbid conditions. Following ASCT, 2/7 (29%) safety-net patients received BV maintenance therapy compared to 11/30 (37%) academic center patients. Rates of relapse post-ASCT were 29% (2/7) and 53% (16/30) respectively. Five patients (31%) at the academic center received allogeneic SCT at relapse post-ASCT. Univariate Cox regression analysis showed that advanced age at diagnosis and EBER positivity were associated with inferior OS (HR=1.043, p=0.004; HR=4.205, p=0.014) but not PFS (HR=1.004, p=0.699; HR=1.317, p=0.352). Higher IPS score and high ECOG performance status adversely impacted OS (HR=1.578, p=0.011; HR=10.280, p=0.025) and PFS (HR=1.261, p=0.016; HR=1.930, p=0.05). Receipt of SCT significantly improved OS (HR=0.211, p=0.016) and PFS (HR=0.333, p<0.001). This was reflected in the five-year OS of 90.2% versus 57.8% in patients receiving SCT versus those who did not. Notably, safety-net patients receiving ASCT (n=7) had a 5-year OS comparable to SCT recipients at the academic center (100.0% vs 87.7%) (Figure 1). Conclusions Our results show significant differences in treatment patterns and outcomes for R/R cHL patients at a safety-net versus a tertiary academic hospital. Even in the era of novel agents, ASCT significantly improves survival outcomes in R/R cHL. Thus, all eligible patients should be offered this curative treatment. In practice, however, socioeconomic barriers still pose significant barriers to optimal care, with less than 25% of safety-net patients having access to ASCT. Cost effectiveness may be another consideration as eligible patients barred from ASCT may need further treatment with expensive immunotherapies. Urgent policy measures are needed to mitigate these disparities experienced by safety-net hospitals.

Collaborative Care Expands Reach to Racial/Ethnic Minority Patients

Collaborative Care Expands Reach to Racial/Ethnic Minority Patients

Treatment in disproportionately minority hospitals is associated with an increased mortality in end-stage liver disease.

Racial and ethnic disparities are a barrier in delivery of healthcare across the USA. Care for minority patients tends to be clustered into a small number of providers at minority hospitals, which has been associated with worse clinical outcomes in several conditions. However, the outcomes of treatment in patients with end-stage liver disease (ESLD) at predominately minority hospitals are unknown. We investigated the burden of the problem. We utilized the nationwide in-patient sample (NIS) to conduct a retrospective nationwide cohort analysis. All patients >18 years of age admitted with ESLD were included in the analysis. A multivariate logistic regression model was used to study the mortality rate among patients with ESLD treated at minority hospitals compared to nonminority hospitals. A total of 53 281 467 hospitalizations from the 2008 to 2014 NIS were analyzed. There were 163 470 patients with ESLD that met inclusion criteria. In-hospital mortality rates for all races were 8.0 and 8.1% in black and Hispanic minority hospitals, respectively, compared to 7.3% in nonminority hospitals (P < 0.01). On multivariate analysis, treatment of ESLD in black and Hispanic minority hospitals was associated with 11% [odds ratio (OR), 1.11; 95% confidence interval (CI), 1.03-1.20; P < 0.01] and 22% (OR, 1.22; 95% CI, 1.09-1.37; P < 0.01) increased odds of death, respectively, compared to treatment in nonminority hospitals regardless of patient's race. Patients with ESLD treated at minority hospitals are faced with an increased mortality rate regardless of patient's race. This study highlights another quality gap that needs improvement to affect overall survival among patients with ESLD.

Disparities in Objective Sleep Quality as Assessed Through Wrist Actigraphy in Minority Patients With Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) is associated with a reduced quality of life. Minority patients with IBD specifically report more impairing symptoms compared with nonminority patients. Sleep quality, a key component of quality of life, is significantly compromised in minority patients compared with nonminority patients. Nevertheless, subjective and objective sleep assessments in minority patients with IBD have not explicitly been assessed. The purpose of this prospective cohort study is to assess and compare objective sleep parameters utilizing wrist actigraphy between minority and nonminority IBD patients. In this institutional review board approved study, 74 patients with IBD were recruited and stratified into 2 cohorts by self-identification: white nonminority patients and minority patients. Patients in the minority cohort included black and Hispanic individuals (black and nonblack). Exclusion criteria included significant comorbidity, a history of an underlying sleep disorder, or patients who did not self-identify into categorized cohorts. Sleep was measured not only through wrist-based actigraphy but also with sleep surveys. Sleep parameters were compared between minority and nonminority cohorts. Regression analyses were performed to assess for factors independently associated with parameters of poor sleep quality. Sixty-four patients (86.4%) were included in the final analysis. Thirty-one individuals (48.4%) were categorized into the nonminority cohort, and 33 (51.6%) patients were in the minority cohort. A significantly higher number of minority patients had poorer sleep efficiency and fragmented sleep compared with nonminority patients (90.9% vs 67.7%; P = 0.03 and 87.8% vs 61.3%; P = 0.02). In the adjusted analysis, minority status was independently associated with poor sleep efficiency (odds ratio = 6.41; 95% confidence interval, 1.48-28.17; P = 0.0139) and fragmented sleep (odds ratio = 4.98; 95% confidence interval, 1.09-22.89; P = 0.0389). Minority patients with IBD were shown to have poorer objective measures of sleep as assessed through wrist actigraphy compared to nonminority patients. Cultural competency in the care of minority patients with IBD, specifically focusing on the management of psychosocial issues, is needed to address these disparities in sleep. The inclusion of minority patients with IBD in studies investigating sleep and other psychosocial issues are warranted not only to assess potential disparities in disease course but also to determine the etiologies of poor sleep in minority patients with IBD.

A3 TREATMENT IN DISPROPORTIONATELY MINORITY HOSPITALS IS ASSOCIATED WITH AN INCREASED MORTALITY IN END STAGE LIVER DISEASE

Abstract Background Racial and ethnic disparities continue to remain a barrier in delivery of health care across the United States. Care for minority patients tends to be clustered into a small number of providers at minority hospitals, which has been associated with worse clinical outcomes in several conditions. However, the outcomes of treatment in end stage liver disease (ESLD) patients at predominately minority hospitals is unknown. Aims To evaluate in-hospital mortality rate among ESLD patients treated in minority hospitals compared to non-minority hospitals. Methods We utilized the Nationwide Inpatient Sample (NIS) to conduct a retrospective nationwide cohort analysis. All patients &amp;gt;18 years of age admitted with ESLD were included in the analysis. A multivariate logistic regression model was used to study the mortality rate among ESLD patients treated at minority hospitals compared to ESLD patients treated at non-minority hospitals. Results A total of 53,281,467 hospitalizations from the 2008–2014 NIS sample were analyzed. There were 163,470 patients with ESLD that met inclusion criteria. There were 10,178 (6.2%) and 31,226 (19.1%) ESLD patients treated at Black and Hispanic minority hospitals, respectively. In hospital mortality rate for all races were 8.0% and 8.1% in Black and Hispanic minority hospitals, respectively, compared to 7.3% in non-minority hospitals (p&amp;lt;0.01). On multivariate analysis, treatment of ESLD in Black and Hispanic minority hospitals were associated with a 11% (OR: 1.11; 95% CI: 1.03–1.20; p&amp;lt;0.01) and 22% (OR: 1.22; 95% CI: 1.09–1.37; p&amp;lt;0.01) increased odds of death, respectively, compared to treatment in a non-minority hospital regardless of patient race. Conclusions ESLD patient treated at minority hospital are faced with an increased mortality rate regardless of a patients race. The current study highlights a quality gap that needs improvement to effect overall survival among ESLD patients. Funding Agencies None

810 Disparities in Objective Sleep Quality as Assessed by Wrist Actigraphy in Minority Patients With Inflammatory Bowel Disease

INTRODUCTION: Inflammatory Bowel Disease (IBD) is associated with a reduced quality of life, including a high incidence of poor sleep. Minority patients with IBD describe poorer subjective symptoms of disease. Minority patients are more likely to report poorer sleep quality compared to Caucasian patients. There are limited data on the assessment of sleep in minority patients with IBD. In this prospective cohort study, we aim to compare objective sleep parameters assessed by wrist actigraphy in minority IBD patients compared to Caucasian IBD patients. METHODS: 73 patients with a diagnosis of IBD were recruited to take part in this IRB approved study. Subjects were stratified into two cohorts by self-identification: minority subjects (Blacks and Non-Black Hispanic subjects) and Caucasian, non-minority individuals. Subjects were excluded based on significant co-morbidity, a history of a sleep disorder, or demographics which did not fit into categorized cohorts. Subjects completed sleep surveys and were provided with an accelerometer that estimated sleep patterns. Comparisons of actigraphic parameters were performed between minority and non-minority cohorts. Regression analyses were performed to determine whether minority status was independently associated with poorer sleep parameters assessed by actigraphy. Predictors that were found to be different by &lt; 0.1 between cohorts were included in the models. RESULTS: Of the recruited subjects, 64 subjects completed 3 days of actigraphy data. 33 subjects were minority patients and 31 individuals were non-minority patients. The demographics of the cohorts are provided in Table 1. Table 2 details the univariate analyses. A higher proportion of minority patients had poorer sleep efficiency (SE) and fragmented sleep compared to Caucasian patients (90.9% vs. 67.7%, P = 0.03 and 87.8% vs. 61.3%, P = 0.02). Minority status was independently associated with both poor SE (OR: 6.41 CI: 1.48-28.17, P = 0.0139) and fragmented sleep (OR: 4.98, CI: 1.09-22.89, P = 0.0389), (Tables 3.0A and 3.0B). CONCLUSION: In our study minority subjects were found to have poorer objective measures of sleep assessed by actigraphy compared to non-minority subjects. Culturally relevant care addressing psychosocial issues, including sleep are important in the care of minority patients with IBD. Further studies investigating the role of sleep in diverse populations with IBD are warranted to determine the etiologies of poor sleep in these patients.

Disparities in access to palliative care for patients treated for gynecologic oncology.

136 Background: Palliative care intends to improve quality of life for patients with life-threatening illness, but ethnic and linguistic minority patients have worse outcomes with palliative care. Methods: This is a single institution retrospective chart review of patients with an advanced stage or recurrent gynecologic malignancy who were seen in the clinic from 2010 to 2015. Women were defined as being from a minority group if they met one of the inclusion criteria including English not the primary language, race other than white, ethnically Hispanic/Latina, or their country of origin was not the United States. We then compared rates of referral to palliative care between those women who were deemed to be minority women as compared to those who were non-minority. We also compared the time to referral between these two groups. Results: Our study included 277 women of which 20% were categorized as minority. Demographic data between the two groups were well matched with the exception that minority women were diagnosed at a younger age and were more likely to have cervical cancer. Although not statistically significant, more minority women were referred to palliative care than non-minority (79% vs. 89%, p=0.08). In contrast, fewer minority patients were referred to palliative care at least 3 months prior to death when compared to non-minority patients (50% vs. 38%, p =0.10). There was no difference between referral location [inpatients (35% vs. 36%) and outpatients (65% vs. 64%, p=.92)] in minority versus non-minority patients. There was also no significant difference in those patients entering hospice while admitted to the hospital. Minority patients had significantly more cancer-related hospitalizations per year (0.6 vs 1.0, p value 0.02). Conclusions: Our study shows that there is a tendency towards later referral to palliative care for minority patients as compared to non-minority patients. Although more minority patients are referred to palliative care, they are hospitalized for cancer related symptoms at a significantly higher rate suggesting that perhaps their utilization of palliative care services is suboptimal.

Abstract IA48: Cultural determinants of disparities in lung cancer care and outcomes

Abstract The outcome of patients with lung cancer remains poor, particularly among individuals of ethnic and racial minorities. Two well-documented causes for the currently observed disparities in survival are diagnosis at a more advanced stage and lower rates of indicated treatment of minority patients. The underlying reasons for these disparities however, are not clear. A range of potential explanations have been suggested including patient-level (beliefs, preferences, and expectations regarding lung cancer care), physician-level (biases, stereotyping, and uncertainty), patient-provider interaction-level (barriers in cross-cultural relationships) and system-level (health system organization, accessibility) factors. Understanding the influence and relative importance of these factors is an important first step towards designing interventions to improve the outcomes of minority patients with lung cancer. In this presentation, we will review the underlying reasons for the observed disparities in stage at diagnosis, treatment, and end-of-life care of minority patients, with a particular focus on cultural factors. We will discuss results from a recently completed, four-site study assessing behavioral and cultural barriers to appropriate diagnosis and treatment of minorities with lung cancer. Our focus will be on potentially modifiable barriers that could be the target for future interventions aimed at reducing disparities in care. Citation Format: Juan Wisnivesky. Cultural determinants of disparities in lung cancer care and outcomes. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA48.

Abstract A98: Physician social networks and variation in prostate cancer treatment in three cities

Abstract Background: Racial differences in cancer treatment may result, in part, from distinct physician practice styles in the setting of regional healthcare environments. Emerging methodological tools allow for physician social networks to be constructed and analyzed using claims data. Objective: To examine whether physician social networks are associated with variation and racial differences in treatment for men with localized prostate cancer. Research design: We performed a retrospective cohort study using 2004–2005 SEER-Medicare data from three cities. Algorithms were generated to identify a patient's primary care physicians, urologists, and radiation oncologists. Within each city, a network of these physicians was constructed, with physicians as the nodes and shared patients as the links (edges) between nodes. From the overall network structure, distinct subgroups of physicians were identified using the Girvan-Newman algorithm. Subgroups were defined as those physicians who were highly clustered with one another and with relatively sparse connections to physicians in other subgroups. Patients were assigned to the subgroup of their diagnosing urologist. Network measures were then incorporated in logistic regression analyses with robust standard errors to examine the predictors of treatment, adjusting for patient-level factors. Results: Patients who were seen by different subgroups of physician varied widely in their unadjusted rates of prostatectomy and the racial/ethnic and socioeconomic composition. In city A, for example, rates of prostatectomy varied from 8.6% to 25.3% for patients who saw different subgroups of doctors. Similarly, in city A, the proportion of minority patients ranged from 15.9% in one subgroup to 64.8% in another. After adjustment for patient-level covariates, patients who were diagnosed by a urologist in one of four subgroups had significantly lower odds of prostatectomy compared to those patients who saw urologists in the subgroup with the highest rates of prostatectomy. Similarly, in cities B and C, patients who saw specific subgroups had significantly lower odds of prostatectomy compared to the subgroup with the highest rates of prostatectomy. Contrary to our expectations, accounting for subgroups, did not appear to mediate racial/ethnic differences in rates of active treatment. Conclusions: Using claims data to map physician networks may provide insight into the observed variation in treatment patterns for men with prostate cancer. Physician networks may be used to identify densely connected physicians who disproportionately care for minority patients. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A98.

Modest and uneven: physician efforts to reduce racial and ethnic disparities.

While nearly half of U. S. physicians identify language or cultural communication barriers as obstacles to providing high-quality care, physician adoption of practices to overcome such barriers is modest and uneven, according to a new national study by the Center for Studying Health System Change (HSC). Despite broad consensus among the medical community about how physicians can help to address and, ultimately, reduce racial and ethnic disparities, physician adoption of several recommended practices to improve care for minority patients ranges from 7 percent reporting they have the capability to track patients' preferred language to 40 percent reporting they have received training in minority health issues to slightly more than half reporting their practices provide some interpreter services. The challenges physicians face in providing quality health care to all of their patients will keep mounting as the U.S. population continues to diversify and the minority population increases

Hospital Executives’ Perspectives on Pay-for-Performance and Racial/Ethnic Disparities in Care

With increasing attention paid to reducing racial/ethnic disparities in care and the growth of pay-for-performance programs, policy makers and payers are considering the use of such incentive mechanisms to target disparities reduction. This article describes the results of qualitative interviews with hospital executives to assess the potential impact that such programs would have on hospitals and their minority patients. The authors find that executives have significant concerns regarding funding mechanisms and implementation costs, financial risks for safety net hospitals, and resource constraints, as well as how such programs can be used to create incentives to care for minority patients. The findings suggest that payers should be hesitant to use pay-for-performance as a mechanism for reducing disparities until a wide variety of concerns about the design of such programs can be addressed.

Reducing disparities and improving quality: understanding the needs of small primary care practices.

Small practices provide a significant proportion of care in the United States and should be an essential focus of efforts to reduce racial/ethnic disparities and improve the quality of care for minority patients. This project sought to identify the resources and tools small practices need to conduct quality improvement activities to reduce disparities. We surveyed small practices about their capabilities for conducting quality improvement activities for minority and limited English proficiency patients. A subset of practices also completed a brief chart review. Grantees of the National Committee for Quality Assurance Program were independent practices required to have five or fewer physicians with little or no experience with quality improvement (mean number of physicians = 1.4). At least one-quarter of the patients served by the practice were required to be minorities. Twenty-two practices from California and New Jersey. Surveys assessed clinician preparedness, use of systematic processes, and availability of information technology to improve care for minority patients. The chart review exercise elicited information on challenges and enabling factors in recent encounters with racial/ethnic minority patients. Small practices face considerable challenges in caring for minority patients. They have limited staff and fewer resources than larger group practices, increasing the difficulty of making improvements on their own. The main challenges identified were patient adherence to treatment recommendations, staffing, language barriers and lack of information systems. Small practices will require substantial support from external organizations in order to contribute to national reductions in racial/ethnic disparities in health care.

Do Managed Care Plans’ Tiered Networks Lead To Inequities In Care For Minority Patients?

This study examined whether specialists designated as meeting efficiency thresholds in an insurance company's performance network were less likely than non-designated specialists to treat minority patients insured by that company. Claims data were used to identify patients treated by specialists. Claimants' race/ethnicity status was self-reported to the insurer at enrollment. In large part, minority patients appeared to be evenly distributed across the performance network, with the exception of Asian/Pacific Islanders, who appeared to be more likely to be treated by nondesignated physicians than by designated "good-performing" specialists.

Affirmative action in medicine

Affirmative action in medicine

Atonement

On Being a Doctor1 September 1996AtonementOra Paltiel, MDCM, MSc, FRCPCOra Paltiel, MDCM, MSc, FRCPCHadassah University Hospital, Jerusalem 91120, IsraelSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-125-5-199609010-00010 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail I trained in a large university teaching hospital in Montreal. Our patient population was cosmopolitan. We learned how to interpret the silence of one ethnic group, the screams of another. The atmosphere was a tolerant one. Empathy abounded, yet patients had to adapt to us, come on time, wait their turn, and accept any piece of information or advice that we, with our white coats, had to offer. We supplied them with the facts, often without being asked. Although patient autonomy was respected, there was no question about who had the upper hand. Medicine and its practitioners were from the ... Author, Article, and Disclosure InformationAffiliations: Hadassah University Hospital, Jerusalem 91120, IsraelCorresponding Author: Ora Paltiel, MDCM, MSc, FRCPC, Department of Social Medicine, Hadassah University Hospital, POB 12000, Jerusalem 91120, Israel. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited by“Death is inevitable – a bad death is not” report from an international workshopTruth-Telling in a Culturally Diverse WorldA physician charter on medical professionalism: a challenge for medical educationOld Lives TalesBarriers to Optimum End‐of‐life Care for Minority Patients 1 September 1996Volume 125, Issue 5Page: 416-417KeywordsCancer chemotherapyChemotherapyChildrenDiffuse large B-cell lymphomaDrugsHematology and oncologyLaparotomyLymphomaPatient advocacy Issue Published: 1 September 1996 Copyright & PermissionsCopyright © 1996 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...