Diversity in Medicine

Hypertensive disorders of pregnancy (HDP) are associated with a greater than twofold risk of developing hypertension a decade later, new research suggests.

Investigators prospectively studied patients who had and who had not experienced HDP 10 years earlier; most self-identified as Black. They found that those with a history of HDP had a 2.4-fold higher risk for new hypertension than those without such a history.

Patients who developed hypertension showed greater left ventricular (LV) remodeling (including greater relative wall thickness), worse diastolic function, more abnormal longitudinal strain, and higher effective arterial elastance than those without hypertension, regardless of the presence or absence of an HDP history.

“We know that patients with preeclampsia are at a higher risk for heart disease later in life, and it seems to be driven by the development of new hypertension,” lead author Lisa Levine, MD, MSCE, director, pregnancy and heart disease program, Hospital of the University of Pennsylvania, Philadelphia, told this news organization.

It is critically important to “study a more diverse population, including a larger percentage of Black patients, since HDP and CVD both disproportionately affect Black women,” Dr. Levine said. “And it is important to screen patients for hypertension, getting them into primary care for visits, getting them diagnosed sooner, and treating them early for hypertension.”

The study was published in the Journal of the American College of Cardiology.
 

Understudied population

HDP includes gestational hypertension and preeclampsia, Dr. Levine explained. “We already know that patients who have had preeclampsia are at higher risk for stroke, heart failure [HF], and myocardial infarction later in life,” she said. The goal of this study was to see whether, instead of waiting 20-30 years, they could look only 10 years later to see which patients would be at highest risk for future heart disease, Dr. Levine said.

In particular, it’s known that cardiovascular disease (CVD) and HDP “disproportionately affect Black women,” Dr. Levine continued. “What makes our study different from other studies is that we focused predominantly on the Black African American population, since it’s understudied and also at highest risk for preeclampsia and heart disease,” she said.

They set out to “evaluate differences in CV risk factors as well as subclinical CVD among a well-characterized group of racially diverse patients with and without a history of HDP 10 years earlier,” the authors state.

To investigate the question, the researchers performed a prospective, cross-sectional study between April 2016 and December 2019 of patients with and without a diagnosis of HDP during a previous pregnancy at least 10 years earlier (from 2005 to 2007). Patients were drawn from a parent cohort in a previously performed observational study of patients with preeclampsia or HDP and normotensive control subjects.

The current study focused on 135 patients (85% Black), 84 with a history of HDP and 51 without. Of the Black patients, 91.7% had a history of HDP, compared with 8.3% of the White patients.

During an in-person visit, the researchers assessed participants’ blood pressure and other clinical risk factors for CVD, including fasting glucose and lipids. They also used noninvasive means to measure cardiac and vascular structure and function.
 

Importance of routine screening

The risk for new hypertension was 2.4 times higher in patients with a history of HDP than in those without HDP, with stage 2 hypertension noted in 56.0% of patients with and in 23.5% without HDP (P < .001). This equates to a relative risk of 2.4 (95% confidence interval, 1.39-4.14), even after adjustment for race, maternal age, body mass index, and history of preterm birth.

“Importantly, 18% of patients with a history of HDP met criteria for a new diagnosis of hypertension identified through the study visit,” the authors report.

There were no differences in many cardiac measures (left ventricular (LV) structure, global longitudinal strain, diastolic function, arterial stiffness, or endothelial function) between patients with and without a history of HDP.

However, patients with chronic hypertension (CHTN), regardless of HDP history, had other cardiac abnormalities, including greater LV remodeling, worse diastolic function, and higher effective arterial elastance.

“The data regarding increased risk of hypertension after HDP is not a novel finding, however our cohort is unique in the high baseline rate of stage 2 hypertension, even among patients without a history of HDP,” the authors comment.

In fact, when they looked at the diagnosis of either stage 1 or stage 2 hypertension, they found that more than 80% of patients with and 60% of patients without a history of HDP had hypertension. Notably, among patients with a history of HDP, only 39% had a formal diagnosis of either stage 1 or stage 2 hypertension, further highlighting “the importance of routine screening for CHTN in this population,” they state.

“Further studies should evaluate the optimal time period to screen for postpartum hypertension and a monitoring plan for these at-risk women,” Dr. Levine added.
 

‘Opportunity of a lifetime’

Commenting for this news organization, Malamo Countouris, MD, MS, assistant professor of medicine and codirector, postpartum hypertension program, University of Pittsburgh Medical Center, said hypertension is “underrecognized and undertreated among young, premenopausal, Black women.”

Pregnancy “gives us a clue, through HDP, as to who is high risk to develop chronic hypertension and subsequent subclinical structural cardiac changes in the decade after delivery,” said Dr. Countouris, who was not involved with the study.

“The jury is still out on whether HDP contributes independently to cardiovascular changes in the years after delivery. Ongoing research is needed to clarify the unique or compounding contributions of pregnancy complications and hypertension,” she added.

In an accompanying editorial , Josephine Chou, MD, MS, director of cardio-obstetrics and codirector of maternal cardiology, Yale University, New Haven, Conn., called the study a “laudable contribution to understanding of HDP and hypertension within the first decade after pregnancy,” saying that it “paves the way for future efforts to improve postpartum CV care, enabling us to grasp this opportunity of a lifetime to ultimately reduce maternal and pregnancy-related morbidity and mortality.”

This study was supported by the National Institutes of Health, the National Heart, Lung, and Blood Institute, and the American Association of Obstetricians and Gynecologists Foundation. Dr. Levine reports no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. Countouris reports receiving funding from the American Heart Association. Dr. Chou reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Hypertensive disorders of pregnancy (HDP) are associated with a greater than twofold risk of developing hypertension a decade later, new research suggests.

Investigators prospectively studied patients who had and who had not experienced HDP 10 years earlier; most self-identified as Black. They found that those with a history of HDP had a 2.4-fold higher risk for new hypertension than those without such a history.

Patients who developed hypertension showed greater left ventricular (LV) remodeling (including greater relative wall thickness), worse diastolic function, more abnormal longitudinal strain, and higher effective arterial elastance than those without hypertension, regardless of the presence or absence of an HDP history.

“We know that patients with preeclampsia are at a higher risk for heart disease later in life, and it seems to be driven by the development of new hypertension,” lead author Lisa Levine, MD, MSCE, director, pregnancy and heart disease program, Hospital of the University of Pennsylvania, Philadelphia, told this news organization.

It is critically important to “study a more diverse population, including a larger percentage of Black patients, since HDP and CVD both disproportionately affect Black women,” Dr. Levine said. “And it is important to screen patients for hypertension, getting them into primary care for visits, getting them diagnosed sooner, and treating them early for hypertension.”

The study was published in the Journal of the American College of Cardiology.
 

Understudied population

HDP includes gestational hypertension and preeclampsia, Dr. Levine explained. “We already know that patients who have had preeclampsia are at higher risk for stroke, heart failure [HF], and myocardial infarction later in life,” she said. The goal of this study was to see whether, instead of waiting 20-30 years, they could look only 10 years later to see which patients would be at highest risk for future heart disease, Dr. Levine said.

In particular, it’s known that cardiovascular disease (CVD) and HDP “disproportionately affect Black women,” Dr. Levine continued. “What makes our study different from other studies is that we focused predominantly on the Black African American population, since it’s understudied and also at highest risk for preeclampsia and heart disease,” she said.

They set out to “evaluate differences in CV risk factors as well as subclinical CVD among a well-characterized group of racially diverse patients with and without a history of HDP 10 years earlier,” the authors state.

To investigate the question, the researchers performed a prospective, cross-sectional study between April 2016 and December 2019 of patients with and without a diagnosis of HDP during a previous pregnancy at least 10 years earlier (from 2005 to 2007). Patients were drawn from a parent cohort in a previously performed observational study of patients with preeclampsia or HDP and normotensive control subjects.

The current study focused on 135 patients (85% Black), 84 with a history of HDP and 51 without. Of the Black patients, 91.7% had a history of HDP, compared with 8.3% of the White patients.

During an in-person visit, the researchers assessed participants’ blood pressure and other clinical risk factors for CVD, including fasting glucose and lipids. They also used noninvasive means to measure cardiac and vascular structure and function.
 

Importance of routine screening

The risk for new hypertension was 2.4 times higher in patients with a history of HDP than in those without HDP, with stage 2 hypertension noted in 56.0% of patients with and in 23.5% without HDP (P < .001). This equates to a relative risk of 2.4 (95% confidence interval, 1.39-4.14), even after adjustment for race, maternal age, body mass index, and history of preterm birth.

“Importantly, 18% of patients with a history of HDP met criteria for a new diagnosis of hypertension identified through the study visit,” the authors report.

There were no differences in many cardiac measures (left ventricular (LV) structure, global longitudinal strain, diastolic function, arterial stiffness, or endothelial function) between patients with and without a history of HDP.

However, patients with chronic hypertension (CHTN), regardless of HDP history, had other cardiac abnormalities, including greater LV remodeling, worse diastolic function, and higher effective arterial elastance.

“The data regarding increased risk of hypertension after HDP is not a novel finding, however our cohort is unique in the high baseline rate of stage 2 hypertension, even among patients without a history of HDP,” the authors comment.

In fact, when they looked at the diagnosis of either stage 1 or stage 2 hypertension, they found that more than 80% of patients with and 60% of patients without a history of HDP had hypertension. Notably, among patients with a history of HDP, only 39% had a formal diagnosis of either stage 1 or stage 2 hypertension, further highlighting “the importance of routine screening for CHTN in this population,” they state.

“Further studies should evaluate the optimal time period to screen for postpartum hypertension and a monitoring plan for these at-risk women,” Dr. Levine added.
 

‘Opportunity of a lifetime’

Commenting for this news organization, Malamo Countouris, MD, MS, assistant professor of medicine and codirector, postpartum hypertension program, University of Pittsburgh Medical Center, said hypertension is “underrecognized and undertreated among young, premenopausal, Black women.”

Pregnancy “gives us a clue, through HDP, as to who is high risk to develop chronic hypertension and subsequent subclinical structural cardiac changes in the decade after delivery,” said Dr. Countouris, who was not involved with the study.

“The jury is still out on whether HDP contributes independently to cardiovascular changes in the years after delivery. Ongoing research is needed to clarify the unique or compounding contributions of pregnancy complications and hypertension,” she added.

In an accompanying editorial , Josephine Chou, MD, MS, director of cardio-obstetrics and codirector of maternal cardiology, Yale University, New Haven, Conn., called the study a “laudable contribution to understanding of HDP and hypertension within the first decade after pregnancy,” saying that it “paves the way for future efforts to improve postpartum CV care, enabling us to grasp this opportunity of a lifetime to ultimately reduce maternal and pregnancy-related morbidity and mortality.”

This study was supported by the National Institutes of Health, the National Heart, Lung, and Blood Institute, and the American Association of Obstetricians and Gynecologists Foundation. Dr. Levine reports no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. Countouris reports receiving funding from the American Heart Association. Dr. Chou reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Hypertensive disorders of pregnancy (HDP) are associated with a greater than twofold risk of developing hypertension a decade later, new research suggests.

Investigators prospectively studied patients who had and who had not experienced HDP 10 years earlier; most self-identified as Black. They found that those with a history of HDP had a 2.4-fold higher risk for new hypertension than those without such a history.

Patients who developed hypertension showed greater left ventricular (LV) remodeling (including greater relative wall thickness), worse diastolic function, more abnormal longitudinal strain, and higher effective arterial elastance than those without hypertension, regardless of the presence or absence of an HDP history.

“We know that patients with preeclampsia are at a higher risk for heart disease later in life, and it seems to be driven by the development of new hypertension,” lead author Lisa Levine, MD, MSCE, director, pregnancy and heart disease program, Hospital of the University of Pennsylvania, Philadelphia, told this news organization.

It is critically important to “study a more diverse population, including a larger percentage of Black patients, since HDP and CVD both disproportionately affect Black women,” Dr. Levine said. “And it is important to screen patients for hypertension, getting them into primary care for visits, getting them diagnosed sooner, and treating them early for hypertension.”

The study was published in the Journal of the American College of Cardiology.
 

Understudied population

HDP includes gestational hypertension and preeclampsia, Dr. Levine explained. “We already know that patients who have had preeclampsia are at higher risk for stroke, heart failure [HF], and myocardial infarction later in life,” she said. The goal of this study was to see whether, instead of waiting 20-30 years, they could look only 10 years later to see which patients would be at highest risk for future heart disease, Dr. Levine said.

In particular, it’s known that cardiovascular disease (CVD) and HDP “disproportionately affect Black women,” Dr. Levine continued. “What makes our study different from other studies is that we focused predominantly on the Black African American population, since it’s understudied and also at highest risk for preeclampsia and heart disease,” she said.

They set out to “evaluate differences in CV risk factors as well as subclinical CVD among a well-characterized group of racially diverse patients with and without a history of HDP 10 years earlier,” the authors state.

To investigate the question, the researchers performed a prospective, cross-sectional study between April 2016 and December 2019 of patients with and without a diagnosis of HDP during a previous pregnancy at least 10 years earlier (from 2005 to 2007). Patients were drawn from a parent cohort in a previously performed observational study of patients with preeclampsia or HDP and normotensive control subjects.

The current study focused on 135 patients (85% Black), 84 with a history of HDP and 51 without. Of the Black patients, 91.7% had a history of HDP, compared with 8.3% of the White patients.

During an in-person visit, the researchers assessed participants’ blood pressure and other clinical risk factors for CVD, including fasting glucose and lipids. They also used noninvasive means to measure cardiac and vascular structure and function.
 

Importance of routine screening

The risk for new hypertension was 2.4 times higher in patients with a history of HDP than in those without HDP, with stage 2 hypertension noted in 56.0% of patients with and in 23.5% without HDP (P < .001). This equates to a relative risk of 2.4 (95% confidence interval, 1.39-4.14), even after adjustment for race, maternal age, body mass index, and history of preterm birth.

“Importantly, 18% of patients with a history of HDP met criteria for a new diagnosis of hypertension identified through the study visit,” the authors report.

There were no differences in many cardiac measures (left ventricular (LV) structure, global longitudinal strain, diastolic function, arterial stiffness, or endothelial function) between patients with and without a history of HDP.

However, patients with chronic hypertension (CHTN), regardless of HDP history, had other cardiac abnormalities, including greater LV remodeling, worse diastolic function, and higher effective arterial elastance.

“The data regarding increased risk of hypertension after HDP is not a novel finding, however our cohort is unique in the high baseline rate of stage 2 hypertension, even among patients without a history of HDP,” the authors comment.

In fact, when they looked at the diagnosis of either stage 1 or stage 2 hypertension, they found that more than 80% of patients with and 60% of patients without a history of HDP had hypertension. Notably, among patients with a history of HDP, only 39% had a formal diagnosis of either stage 1 or stage 2 hypertension, further highlighting “the importance of routine screening for CHTN in this population,” they state.

“Further studies should evaluate the optimal time period to screen for postpartum hypertension and a monitoring plan for these at-risk women,” Dr. Levine added.
 

‘Opportunity of a lifetime’

Commenting for this news organization, Malamo Countouris, MD, MS, assistant professor of medicine and codirector, postpartum hypertension program, University of Pittsburgh Medical Center, said hypertension is “underrecognized and undertreated among young, premenopausal, Black women.”

Pregnancy “gives us a clue, through HDP, as to who is high risk to develop chronic hypertension and subsequent subclinical structural cardiac changes in the decade after delivery,” said Dr. Countouris, who was not involved with the study.

“The jury is still out on whether HDP contributes independently to cardiovascular changes in the years after delivery. Ongoing research is needed to clarify the unique or compounding contributions of pregnancy complications and hypertension,” she added.

In an accompanying editorial , Josephine Chou, MD, MS, director of cardio-obstetrics and codirector of maternal cardiology, Yale University, New Haven, Conn., called the study a “laudable contribution to understanding of HDP and hypertension within the first decade after pregnancy,” saying that it “paves the way for future efforts to improve postpartum CV care, enabling us to grasp this opportunity of a lifetime to ultimately reduce maternal and pregnancy-related morbidity and mortality.”

This study was supported by the National Institutes of Health, the National Heart, Lung, and Blood Institute, and the American Association of Obstetricians and Gynecologists Foundation. Dr. Levine reports no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. Countouris reports receiving funding from the American Heart Association. Dr. Chou reports no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Lower levels of household income and education in the United States are associated with higher rates of adolescent obesity. These socioeconomic disparities “have widened during the last two decades,” new research shows.

Because obesity in adolescence has immediate and long-term health consequences, this phenomenon “may exacerbate socioeconomic disparities in chronic diseases into adulthood,” study author Ryunosuke Goto, MD, of University of Tokyo Hospital, and colleagues reported  in JAMA Pediatrics.

Groups with higher rates of obesity may also be less likely to access treatment, said Kyung E. Rhee, MD, professor of pediatrics at University of California, San Diego School of Medicine, who was not involved in the new analysis.

“These are the families who have a harder time getting to the doctor’s office or getting to programs because they are working multiple jobs, or they don’t have as much flexibility,” Dr. Rhee told this news organization.
 

20 years of data

A recent study showed a relationship between socioeconomic status (SES) and weight in adults. Research examining current trends in adolescents has been limited, however, according to the authors of the new study.

To address this gap, Dr. Goto and colleagues looked at obesity trends among approximately 20,000 U.S. children aged 10-19 years using cross-sectional data from the 1999-2018 National Health and Nutrition Examination Surveys.

They compared the prevalence of obesity among participants whose household income was 138% of the federal poverty level or less versus those with higher levels of household income. They also examined obesity prevalence according to whether the head of household had graduated college.

Relative to higher-income households, adolescents from lower-income households were more likely to be non-Hispanic Black (21.7% vs. 10.4%) or Hispanic (30.6% vs. 13.4%) and to have an unmarried parent (54.5% vs. 23%). They were also more likely to have obesity (22.8% vs. 17.3%).

The prevalence of obesity likewise was higher among adolescents whose head of household did not have a college degree (21.8% vs. 11.6%).  

In an analysis that adjusted for race, ethnicity, height, and marital status of the head of household, the prevalence of obesity increased over 20 years, particularly among adolescents from lower-income homes, the researchers reported.

Lower income was associated with an increase in obesity prevalence of 4.2 percentage points, and less education was associated with an increase in obesity prevalence of 9 percentage points.  

By 2015-2018, the gap in obesity prevalence between low-income households and higher-income households was 6.4 percentage points more than it had been during 1999-2002 (95% confidence interval, 1.5-11.4). “When we assessed linear trends, the gap in obesity prevalence by income and education increased by an average of 1.5 (95% CI, 0.4-2.6) and 1.1 (95% CI, 0.0-2.3) percentage points every 4 years, respectively,” according to the researchers.
 

How to treat

Separately, researchers are studying ways to help treat patients with obesity and increase access to treatment. To that end, Dr. Rhee and colleagues developed a new program called Guided Self-Help Obesity Treatment in the Doctor’s Office (GOT Doc).

The guided self-help program was designed to provide similar resources as a leading treatment approach – family-based treatment – but in a less intensive, more accessible way.

Results from a randomized trial comparing this guided self-help approach with family-based treatment were published in Pediatrics.

The trial included 159 children and their parents. The children had an average age of 9.6 years and body mass index z-score of 2.1. Participants were primarily Latinx and from lower income neighborhoods.

Whereas family-based treatment included hour-long sessions at an academic center, the guided self-help program featured a 20-minute session in the office where patients typically see their primary care physician.

Both programs covered how to self-monitor food intake, set healthy goals, and modify the home environment to promote behavioral change. They also discussed body image, bullying, and emotional health. The program is framed around developing a healthy lifestyle rather than weight loss itself, Dr. Rhee said.

Children in both groups had significant reductions in their body mass index percentiles after the 6-month treatment programs. The reductions were largely maintained at 6-month follow-up.

Families in the guided self-help program, however, had a 67% lower risk of dropping out of the study and reported greater satisfaction and convenience. They attended more than half of the treatment sessions, whereas participants assigned to family-based treatment attended 1 in 5 sessions, on average.

The trial was conducted before the COVID-19 pandemic. Next, the researchers plan to test delivery of a guided self-help program via video calls, Dr. Rhee said.

Having options readily available for families who are interested in treatment for obesity proved valuable to clinicians, Dr. Rhee said. “They could then just refer them down the hall to the interventionist who was there, who was going to then work with the family to make these changes,” she said.

The study by Dr. Goto and colleagues was supported by grants from the Japan Society for the Promotion of Science. The trial by Dr. Rhee et al. was supported by a grant from the Health Resources and Services Administration. Neither research team had conflict of interest disclosures.

A version of this article first appeared on Medscape.com.

Lower levels of household income and education in the United States are associated with higher rates of adolescent obesity. These socioeconomic disparities “have widened during the last two decades,” new research shows.

Because obesity in adolescence has immediate and long-term health consequences, this phenomenon “may exacerbate socioeconomic disparities in chronic diseases into adulthood,” study author Ryunosuke Goto, MD, of University of Tokyo Hospital, and colleagues reported  in JAMA Pediatrics.

Groups with higher rates of obesity may also be less likely to access treatment, said Kyung E. Rhee, MD, professor of pediatrics at University of California, San Diego School of Medicine, who was not involved in the new analysis.

“These are the families who have a harder time getting to the doctor’s office or getting to programs because they are working multiple jobs, or they don’t have as much flexibility,” Dr. Rhee told this news organization.
 

20 years of data

A recent study showed a relationship between socioeconomic status (SES) and weight in adults. Research examining current trends in adolescents has been limited, however, according to the authors of the new study.

To address this gap, Dr. Goto and colleagues looked at obesity trends among approximately 20,000 U.S. children aged 10-19 years using cross-sectional data from the 1999-2018 National Health and Nutrition Examination Surveys.

They compared the prevalence of obesity among participants whose household income was 138% of the federal poverty level or less versus those with higher levels of household income. They also examined obesity prevalence according to whether the head of household had graduated college.

Relative to higher-income households, adolescents from lower-income households were more likely to be non-Hispanic Black (21.7% vs. 10.4%) or Hispanic (30.6% vs. 13.4%) and to have an unmarried parent (54.5% vs. 23%). They were also more likely to have obesity (22.8% vs. 17.3%).

The prevalence of obesity likewise was higher among adolescents whose head of household did not have a college degree (21.8% vs. 11.6%).  

In an analysis that adjusted for race, ethnicity, height, and marital status of the head of household, the prevalence of obesity increased over 20 years, particularly among adolescents from lower-income homes, the researchers reported.

Lower income was associated with an increase in obesity prevalence of 4.2 percentage points, and less education was associated with an increase in obesity prevalence of 9 percentage points.  

By 2015-2018, the gap in obesity prevalence between low-income households and higher-income households was 6.4 percentage points more than it had been during 1999-2002 (95% confidence interval, 1.5-11.4). “When we assessed linear trends, the gap in obesity prevalence by income and education increased by an average of 1.5 (95% CI, 0.4-2.6) and 1.1 (95% CI, 0.0-2.3) percentage points every 4 years, respectively,” according to the researchers.
 

How to treat

Separately, researchers are studying ways to help treat patients with obesity and increase access to treatment. To that end, Dr. Rhee and colleagues developed a new program called Guided Self-Help Obesity Treatment in the Doctor’s Office (GOT Doc).

The guided self-help program was designed to provide similar resources as a leading treatment approach – family-based treatment – but in a less intensive, more accessible way.

Results from a randomized trial comparing this guided self-help approach with family-based treatment were published in Pediatrics.

The trial included 159 children and their parents. The children had an average age of 9.6 years and body mass index z-score of 2.1. Participants were primarily Latinx and from lower income neighborhoods.

Whereas family-based treatment included hour-long sessions at an academic center, the guided self-help program featured a 20-minute session in the office where patients typically see their primary care physician.

Both programs covered how to self-monitor food intake, set healthy goals, and modify the home environment to promote behavioral change. They also discussed body image, bullying, and emotional health. The program is framed around developing a healthy lifestyle rather than weight loss itself, Dr. Rhee said.

Children in both groups had significant reductions in their body mass index percentiles after the 6-month treatment programs. The reductions were largely maintained at 6-month follow-up.

Families in the guided self-help program, however, had a 67% lower risk of dropping out of the study and reported greater satisfaction and convenience. They attended more than half of the treatment sessions, whereas participants assigned to family-based treatment attended 1 in 5 sessions, on average.

The trial was conducted before the COVID-19 pandemic. Next, the researchers plan to test delivery of a guided self-help program via video calls, Dr. Rhee said.

Having options readily available for families who are interested in treatment for obesity proved valuable to clinicians, Dr. Rhee said. “They could then just refer them down the hall to the interventionist who was there, who was going to then work with the family to make these changes,” she said.

The study by Dr. Goto and colleagues was supported by grants from the Japan Society for the Promotion of Science. The trial by Dr. Rhee et al. was supported by a grant from the Health Resources and Services Administration. Neither research team had conflict of interest disclosures.

A version of this article first appeared on Medscape.com.

Lower levels of household income and education in the United States are associated with higher rates of adolescent obesity. These socioeconomic disparities “have widened during the last two decades,” new research shows.

Because obesity in adolescence has immediate and long-term health consequences, this phenomenon “may exacerbate socioeconomic disparities in chronic diseases into adulthood,” study author Ryunosuke Goto, MD, of University of Tokyo Hospital, and colleagues reported  in JAMA Pediatrics.

Groups with higher rates of obesity may also be less likely to access treatment, said Kyung E. Rhee, MD, professor of pediatrics at University of California, San Diego School of Medicine, who was not involved in the new analysis.

“These are the families who have a harder time getting to the doctor’s office or getting to programs because they are working multiple jobs, or they don’t have as much flexibility,” Dr. Rhee told this news organization.
 

20 years of data

A recent study showed a relationship between socioeconomic status (SES) and weight in adults. Research examining current trends in adolescents has been limited, however, according to the authors of the new study.

To address this gap, Dr. Goto and colleagues looked at obesity trends among approximately 20,000 U.S. children aged 10-19 years using cross-sectional data from the 1999-2018 National Health and Nutrition Examination Surveys.

They compared the prevalence of obesity among participants whose household income was 138% of the federal poverty level or less versus those with higher levels of household income. They also examined obesity prevalence according to whether the head of household had graduated college.

Relative to higher-income households, adolescents from lower-income households were more likely to be non-Hispanic Black (21.7% vs. 10.4%) or Hispanic (30.6% vs. 13.4%) and to have an unmarried parent (54.5% vs. 23%). They were also more likely to have obesity (22.8% vs. 17.3%).

The prevalence of obesity likewise was higher among adolescents whose head of household did not have a college degree (21.8% vs. 11.6%).  

In an analysis that adjusted for race, ethnicity, height, and marital status of the head of household, the prevalence of obesity increased over 20 years, particularly among adolescents from lower-income homes, the researchers reported.

Lower income was associated with an increase in obesity prevalence of 4.2 percentage points, and less education was associated with an increase in obesity prevalence of 9 percentage points.  

By 2015-2018, the gap in obesity prevalence between low-income households and higher-income households was 6.4 percentage points more than it had been during 1999-2002 (95% confidence interval, 1.5-11.4). “When we assessed linear trends, the gap in obesity prevalence by income and education increased by an average of 1.5 (95% CI, 0.4-2.6) and 1.1 (95% CI, 0.0-2.3) percentage points every 4 years, respectively,” according to the researchers.
 

How to treat

Separately, researchers are studying ways to help treat patients with obesity and increase access to treatment. To that end, Dr. Rhee and colleagues developed a new program called Guided Self-Help Obesity Treatment in the Doctor’s Office (GOT Doc).

The guided self-help program was designed to provide similar resources as a leading treatment approach – family-based treatment – but in a less intensive, more accessible way.

Results from a randomized trial comparing this guided self-help approach with family-based treatment were published in Pediatrics.

The trial included 159 children and their parents. The children had an average age of 9.6 years and body mass index z-score of 2.1. Participants were primarily Latinx and from lower income neighborhoods.

Whereas family-based treatment included hour-long sessions at an academic center, the guided self-help program featured a 20-minute session in the office where patients typically see their primary care physician.

Both programs covered how to self-monitor food intake, set healthy goals, and modify the home environment to promote behavioral change. They also discussed body image, bullying, and emotional health. The program is framed around developing a healthy lifestyle rather than weight loss itself, Dr. Rhee said.

Children in both groups had significant reductions in their body mass index percentiles after the 6-month treatment programs. The reductions were largely maintained at 6-month follow-up.

Families in the guided self-help program, however, had a 67% lower risk of dropping out of the study and reported greater satisfaction and convenience. They attended more than half of the treatment sessions, whereas participants assigned to family-based treatment attended 1 in 5 sessions, on average.

The trial was conducted before the COVID-19 pandemic. Next, the researchers plan to test delivery of a guided self-help program via video calls, Dr. Rhee said.

Having options readily available for families who are interested in treatment for obesity proved valuable to clinicians, Dr. Rhee said. “They could then just refer them down the hall to the interventionist who was there, who was going to then work with the family to make these changes,” she said.

The study by Dr. Goto and colleagues was supported by grants from the Japan Society for the Promotion of Science. The trial by Dr. Rhee et al. was supported by a grant from the Health Resources and Services Administration. Neither research team had conflict of interest disclosures.

A version of this article first appeared on Medscape.com.

Although breast cancer occurs less frequently in Black women, compared with White women, they have a much higher risk of dying from the disease.

In the United States, age-adjusted breast cancer mortality between 2014 and 2018 was approximately 40% higher among Black women than among non-Hispanic White women.

This mortality gap likely reflects the fact that Black women face substantial barriers to obtaining timely, high-quality medical care, compared with White women, lead author Ismail Jatoi, MD, PhD, University of Texas Health Science Center, San Antonio, and colleagues suggest in a recent opinion piece.

The article was published online  in The New England Journal of Medicine.

When the team examined the statistics for breast cancer mortality, they found a surprise: The mortality gap between races only dates back to 1980.

Prior to 1980, mortality from breast cancer among Black women was slightly lower than White women, Dr. Jatoi and colleagues point out.

That year was a turning point in breast cancer management, as in 1980, both mammography screening and adjuvant endocrine therapy became available.

This was also when the mortality gap between the races started to show up.

It was disparities in access to the two new interventions that precipitated the divergence, as the authors suggest. Why this occurred is fairly self-evident, they comment.

“Black women are more likely than White women to lack health insurance or to have inadequate coverage, which has limited their access to mammography screening and adversely affected therapeutic decisionmaking,” researchers point out.

Moreover, both mammography screening and endocrine therapy primarily benefit patients with hormone receptor (HR)-positive breast cancer, which is equally common in Black and White patients. However, Black women have a 65% higher rate of HR-negative cancers than White women – and HR-negative tumors are often detected during the interval between mammography screening exams as palpable cancers.

Black women also have an 81% higher rate of triple-negative breast cancer, so they have benefited less from mammography screening and adjuvant endocrine therapy, both of which favor the detection and treatment of HR-positive breast cancer, the authors emphasize.

Some have suggested that the excess HR-negative breast cancer in Black women might be explained by hereditary factors. Yet as Dr. Jatoi and colleagues point out, the incidence of HR-negative breast cancer has actually been falling across all races in the United States since 1992.

However, the declines have been slower among Black women, and reductions in its incidence have been smaller among White women living in less affluent regions of the United States compared with White women from more affluent regions.

These patterns suggest that social determinants of health influence not only access to and quality of health care but also the development of HR-negative breast cancers, as the authors observe.

“If all people with breast cancer benefited equally from effective medical interventions, racial differences in mortality for individual tumor subtypes would largely reflect differences in incidence,” Dr. Jatoi and colleagues continue.

Yet the statistics show that the substantial racial disparities in mortality for both HR-positive and HR-negative cancers between Black and White women cannot be explained by differences in the incidence of either tumor alone, they write.

For example, mortality for HR-positive breast cancer is 19% higher among Black women than among White women, yet the incidence of HR-positive breast cancer is 22% lower among Black women.

Similarly, mortality from HR-negative breast cancer is over twice as high among Black women as it is among White women – a substantially larger disparity, compared with the 65% relative difference in the incidence of HR-negative breast cancer between the two races.

“Universal health care coverage could reduce disparities in treatment for cancers of all subtypes, including triple-negative breast cancer,” Dr. Jatoi and colleagues emphasize.

“Ensuring universal access to high-quality medical care can substantially narrow the racial disparity in U.S. breast-cancer mortality,” they conclude. 

The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Although breast cancer occurs less frequently in Black women, compared with White women, they have a much higher risk of dying from the disease.

In the United States, age-adjusted breast cancer mortality between 2014 and 2018 was approximately 40% higher among Black women than among non-Hispanic White women.

This mortality gap likely reflects the fact that Black women face substantial barriers to obtaining timely, high-quality medical care, compared with White women, lead author Ismail Jatoi, MD, PhD, University of Texas Health Science Center, San Antonio, and colleagues suggest in a recent opinion piece.

The article was published online  in The New England Journal of Medicine.

When the team examined the statistics for breast cancer mortality, they found a surprise: The mortality gap between races only dates back to 1980.

Prior to 1980, mortality from breast cancer among Black women was slightly lower than White women, Dr. Jatoi and colleagues point out.

That year was a turning point in breast cancer management, as in 1980, both mammography screening and adjuvant endocrine therapy became available.

This was also when the mortality gap between the races started to show up.

It was disparities in access to the two new interventions that precipitated the divergence, as the authors suggest. Why this occurred is fairly self-evident, they comment.

“Black women are more likely than White women to lack health insurance or to have inadequate coverage, which has limited their access to mammography screening and adversely affected therapeutic decisionmaking,” researchers point out.

Moreover, both mammography screening and endocrine therapy primarily benefit patients with hormone receptor (HR)-positive breast cancer, which is equally common in Black and White patients. However, Black women have a 65% higher rate of HR-negative cancers than White women – and HR-negative tumors are often detected during the interval between mammography screening exams as palpable cancers.

Black women also have an 81% higher rate of triple-negative breast cancer, so they have benefited less from mammography screening and adjuvant endocrine therapy, both of which favor the detection and treatment of HR-positive breast cancer, the authors emphasize.

Some have suggested that the excess HR-negative breast cancer in Black women might be explained by hereditary factors. Yet as Dr. Jatoi and colleagues point out, the incidence of HR-negative breast cancer has actually been falling across all races in the United States since 1992.

However, the declines have been slower among Black women, and reductions in its incidence have been smaller among White women living in less affluent regions of the United States compared with White women from more affluent regions.

These patterns suggest that social determinants of health influence not only access to and quality of health care but also the development of HR-negative breast cancers, as the authors observe.

“If all people with breast cancer benefited equally from effective medical interventions, racial differences in mortality for individual tumor subtypes would largely reflect differences in incidence,” Dr. Jatoi and colleagues continue.

Yet the statistics show that the substantial racial disparities in mortality for both HR-positive and HR-negative cancers between Black and White women cannot be explained by differences in the incidence of either tumor alone, they write.

For example, mortality for HR-positive breast cancer is 19% higher among Black women than among White women, yet the incidence of HR-positive breast cancer is 22% lower among Black women.

Similarly, mortality from HR-negative breast cancer is over twice as high among Black women as it is among White women – a substantially larger disparity, compared with the 65% relative difference in the incidence of HR-negative breast cancer between the two races.

“Universal health care coverage could reduce disparities in treatment for cancers of all subtypes, including triple-negative breast cancer,” Dr. Jatoi and colleagues emphasize.

“Ensuring universal access to high-quality medical care can substantially narrow the racial disparity in U.S. breast-cancer mortality,” they conclude. 

The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Although breast cancer occurs less frequently in Black women, compared with White women, they have a much higher risk of dying from the disease.

In the United States, age-adjusted breast cancer mortality between 2014 and 2018 was approximately 40% higher among Black women than among non-Hispanic White women.

This mortality gap likely reflects the fact that Black women face substantial barriers to obtaining timely, high-quality medical care, compared with White women, lead author Ismail Jatoi, MD, PhD, University of Texas Health Science Center, San Antonio, and colleagues suggest in a recent opinion piece.

The article was published online  in The New England Journal of Medicine.

When the team examined the statistics for breast cancer mortality, they found a surprise: The mortality gap between races only dates back to 1980.

Prior to 1980, mortality from breast cancer among Black women was slightly lower than White women, Dr. Jatoi and colleagues point out.

That year was a turning point in breast cancer management, as in 1980, both mammography screening and adjuvant endocrine therapy became available.

This was also when the mortality gap between the races started to show up.

It was disparities in access to the two new interventions that precipitated the divergence, as the authors suggest. Why this occurred is fairly self-evident, they comment.

“Black women are more likely than White women to lack health insurance or to have inadequate coverage, which has limited their access to mammography screening and adversely affected therapeutic decisionmaking,” researchers point out.

Moreover, both mammography screening and endocrine therapy primarily benefit patients with hormone receptor (HR)-positive breast cancer, which is equally common in Black and White patients. However, Black women have a 65% higher rate of HR-negative cancers than White women – and HR-negative tumors are often detected during the interval between mammography screening exams as palpable cancers.

Black women also have an 81% higher rate of triple-negative breast cancer, so they have benefited less from mammography screening and adjuvant endocrine therapy, both of which favor the detection and treatment of HR-positive breast cancer, the authors emphasize.

Some have suggested that the excess HR-negative breast cancer in Black women might be explained by hereditary factors. Yet as Dr. Jatoi and colleagues point out, the incidence of HR-negative breast cancer has actually been falling across all races in the United States since 1992.

However, the declines have been slower among Black women, and reductions in its incidence have been smaller among White women living in less affluent regions of the United States compared with White women from more affluent regions.

These patterns suggest that social determinants of health influence not only access to and quality of health care but also the development of HR-negative breast cancers, as the authors observe.

“If all people with breast cancer benefited equally from effective medical interventions, racial differences in mortality for individual tumor subtypes would largely reflect differences in incidence,” Dr. Jatoi and colleagues continue.

Yet the statistics show that the substantial racial disparities in mortality for both HR-positive and HR-negative cancers between Black and White women cannot be explained by differences in the incidence of either tumor alone, they write.

For example, mortality for HR-positive breast cancer is 19% higher among Black women than among White women, yet the incidence of HR-positive breast cancer is 22% lower among Black women.

Similarly, mortality from HR-negative breast cancer is over twice as high among Black women as it is among White women – a substantially larger disparity, compared with the 65% relative difference in the incidence of HR-negative breast cancer between the two races.

“Universal health care coverage could reduce disparities in treatment for cancers of all subtypes, including triple-negative breast cancer,” Dr. Jatoi and colleagues emphasize.

“Ensuring universal access to high-quality medical care can substantially narrow the racial disparity in U.S. breast-cancer mortality,” they conclude. 

The authors have reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A neighborhood analysis of socioeconomic status conducted in the Pittsburgh area found worse metastatic breast cancer survival outcomes among patients of low socioeconomic status. The findings suggest that race is not a relevant factor in outcomes.

“This study demonstrates that metastatic breast cancer patients of low socioeconomic status have worse outcomes than those with higher socioeconomic status at our center. It also underscores the idea that race is not so much a biological construct but more a consequence of socioeconomic issues. The effect of race is likely mediated by lower socioeconomic status,” said Susrutha Puthanmadhom Narayanan, MD, who presented the results of her study earlier this month in Chicago at the annual meeting of the American Society of Clinical Oncology.

“The current study should make clinicians cognizant of the potential for biases in the management of metastatic breast cancer in terms of socioeconomic status and race. One should think of socioeconomic status as a predictor of bad outcomes, almost like a comorbidity, and think of [associations between race and outcomes], as a consequence of socioeconomic inequality,” said Dr. Puthanmadhom Narayanan, who is an internal medicine resident at University of Pittsburgh Medical Center.

She and her colleagues intend to dig deeper into the relationships. “We are interested in looking at utilization of different treatment options for metastatic breast cancer between the socioeconomic status groups. In the preliminary analysis, we saw that ER-positive metastatic breast cancer patients with lower socioeconomic status get treated with tamoxifen more often than aromatase inhibitors and newer agents. And, we have plans to study stress signaling and inflammation as mediators of bad outcomes in the low socioeconomic status population,” Dr. Puthanmadhom Narayanan said.

In fact, that tendency for lower socioeconomic status patients to receive older treatments should be a call to action for physicians. “This study should make clinicians cognizant of the potential for biases in management of metastatic breast cancer in terms of socioeconomic status and race,” she said.

The study is based on an analysis of data from the Neighborhood Atlas in which a Neighborhood Deprivation Index (NDI) score was calculated. An NDI score in the bottom tertile meant that patients were better off than patients with mid to high range NDI scores. In this study, socioeconomic status was described as “low deprivation” or “high depreviation.” Higher deprivation correlated with lower overall survival. And, there were more Black patients in the higher deprivation group (10.5%), compared with the low deprivation group (3.7%). In multivariate Cox proportional hazard model, socioeconomic status, but not race, had a significant effect on overall survival (HR for high deprivation was 1.19 [95% confidence interval; 1.04-1.37], P = 0.01).

It included 1,246 patients who were treated at the University of Pittsburgh Medical Center between 2000 and 2017. Of 1,246 patients, 414 patients considered in the bottom tertile of NDI as having low deprivation, while 832 patients in the middle or top tertiles were classified as having high deprivation.

The two socioeconomic status groups were similar in baseline characteristics, with the exception of race: 10.5% of the high deprivation group were African American, compared with 3.7% of the low deprivation group (P =.000093).

Univariate analyses showed worse survival in both Black women and women in the lower socioeconomic status group, but a multivariate analysis found only socioeconomic status was associated with overall survival (hazard ratio for lower socioeconomic status, 1.19; P = .01).

The study had several strengths, according to Rachel Freedman, MD, MPH, who served as a discussant for the abstract. “It included both de novo and recurrent metastatic breast cancer, unlike previous studies based on the Surveillance, Epidemiology, and End Results (SEER) database that only included de novo cases. It also employed a novel tool to define socioeconomic status in the form of the Neighborhood Atlas. The study “adds more evidence that socioeconomic status likely mediates much of what we see when it comes to racial disparities,” said Dr. Freedman, who is a senior physician at Dana Farber Cancer Institute.

Nevertheless, more work needs to be done. Dr. Freedman pointed out that the current study did not include information on treatment.

The findings underscore the failure to date to address disparities in breast cancer treatment, an effort that is hampered by difficulty in teasing out complex factors that may impact survival. “We need to standardize the way that we collect social determinants of health and act upon findings, and we need to standardize patient navigation, and we need to commit as a community to diverse clinical trial populations,” Dr. Freedman said.

Dr. Narayanan has no relevant financial disclosures. Dr. Freedman is an employee and stockholder of Firefly Health.

A neighborhood analysis of socioeconomic status conducted in the Pittsburgh area found worse metastatic breast cancer survival outcomes among patients of low socioeconomic status. The findings suggest that race is not a relevant factor in outcomes.

“This study demonstrates that metastatic breast cancer patients of low socioeconomic status have worse outcomes than those with higher socioeconomic status at our center. It also underscores the idea that race is not so much a biological construct but more a consequence of socioeconomic issues. The effect of race is likely mediated by lower socioeconomic status,” said Susrutha Puthanmadhom Narayanan, MD, who presented the results of her study earlier this month in Chicago at the annual meeting of the American Society of Clinical Oncology.

“The current study should make clinicians cognizant of the potential for biases in the management of metastatic breast cancer in terms of socioeconomic status and race. One should think of socioeconomic status as a predictor of bad outcomes, almost like a comorbidity, and think of [associations between race and outcomes], as a consequence of socioeconomic inequality,” said Dr. Puthanmadhom Narayanan, who is an internal medicine resident at University of Pittsburgh Medical Center.

She and her colleagues intend to dig deeper into the relationships. “We are interested in looking at utilization of different treatment options for metastatic breast cancer between the socioeconomic status groups. In the preliminary analysis, we saw that ER-positive metastatic breast cancer patients with lower socioeconomic status get treated with tamoxifen more often than aromatase inhibitors and newer agents. And, we have plans to study stress signaling and inflammation as mediators of bad outcomes in the low socioeconomic status population,” Dr. Puthanmadhom Narayanan said.

In fact, that tendency for lower socioeconomic status patients to receive older treatments should be a call to action for physicians. “This study should make clinicians cognizant of the potential for biases in management of metastatic breast cancer in terms of socioeconomic status and race,” she said.

The study is based on an analysis of data from the Neighborhood Atlas in which a Neighborhood Deprivation Index (NDI) score was calculated. An NDI score in the bottom tertile meant that patients were better off than patients with mid to high range NDI scores. In this study, socioeconomic status was described as “low deprivation” or “high depreviation.” Higher deprivation correlated with lower overall survival. And, there were more Black patients in the higher deprivation group (10.5%), compared with the low deprivation group (3.7%). In multivariate Cox proportional hazard model, socioeconomic status, but not race, had a significant effect on overall survival (HR for high deprivation was 1.19 [95% confidence interval; 1.04-1.37], P = 0.01).

It included 1,246 patients who were treated at the University of Pittsburgh Medical Center between 2000 and 2017. Of 1,246 patients, 414 patients considered in the bottom tertile of NDI as having low deprivation, while 832 patients in the middle or top tertiles were classified as having high deprivation.

The two socioeconomic status groups were similar in baseline characteristics, with the exception of race: 10.5% of the high deprivation group were African American, compared with 3.7% of the low deprivation group (P =.000093).

Univariate analyses showed worse survival in both Black women and women in the lower socioeconomic status group, but a multivariate analysis found only socioeconomic status was associated with overall survival (hazard ratio for lower socioeconomic status, 1.19; P = .01).

The study had several strengths, according to Rachel Freedman, MD, MPH, who served as a discussant for the abstract. “It included both de novo and recurrent metastatic breast cancer, unlike previous studies based on the Surveillance, Epidemiology, and End Results (SEER) database that only included de novo cases. It also employed a novel tool to define socioeconomic status in the form of the Neighborhood Atlas. The study “adds more evidence that socioeconomic status likely mediates much of what we see when it comes to racial disparities,” said Dr. Freedman, who is a senior physician at Dana Farber Cancer Institute.

Nevertheless, more work needs to be done. Dr. Freedman pointed out that the current study did not include information on treatment.

The findings underscore the failure to date to address disparities in breast cancer treatment, an effort that is hampered by difficulty in teasing out complex factors that may impact survival. “We need to standardize the way that we collect social determinants of health and act upon findings, and we need to standardize patient navigation, and we need to commit as a community to diverse clinical trial populations,” Dr. Freedman said.

Dr. Narayanan has no relevant financial disclosures. Dr. Freedman is an employee and stockholder of Firefly Health.

A neighborhood analysis of socioeconomic status conducted in the Pittsburgh area found worse metastatic breast cancer survival outcomes among patients of low socioeconomic status. The findings suggest that race is not a relevant factor in outcomes.

“This study demonstrates that metastatic breast cancer patients of low socioeconomic status have worse outcomes than those with higher socioeconomic status at our center. It also underscores the idea that race is not so much a biological construct but more a consequence of socioeconomic issues. The effect of race is likely mediated by lower socioeconomic status,” said Susrutha Puthanmadhom Narayanan, MD, who presented the results of her study earlier this month in Chicago at the annual meeting of the American Society of Clinical Oncology.

“The current study should make clinicians cognizant of the potential for biases in the management of metastatic breast cancer in terms of socioeconomic status and race. One should think of socioeconomic status as a predictor of bad outcomes, almost like a comorbidity, and think of [associations between race and outcomes], as a consequence of socioeconomic inequality,” said Dr. Puthanmadhom Narayanan, who is an internal medicine resident at University of Pittsburgh Medical Center.

She and her colleagues intend to dig deeper into the relationships. “We are interested in looking at utilization of different treatment options for metastatic breast cancer between the socioeconomic status groups. In the preliminary analysis, we saw that ER-positive metastatic breast cancer patients with lower socioeconomic status get treated with tamoxifen more often than aromatase inhibitors and newer agents. And, we have plans to study stress signaling and inflammation as mediators of bad outcomes in the low socioeconomic status population,” Dr. Puthanmadhom Narayanan said.

In fact, that tendency for lower socioeconomic status patients to receive older treatments should be a call to action for physicians. “This study should make clinicians cognizant of the potential for biases in management of metastatic breast cancer in terms of socioeconomic status and race,” she said.

The study is based on an analysis of data from the Neighborhood Atlas in which a Neighborhood Deprivation Index (NDI) score was calculated. An NDI score in the bottom tertile meant that patients were better off than patients with mid to high range NDI scores. In this study, socioeconomic status was described as “low deprivation” or “high depreviation.” Higher deprivation correlated with lower overall survival. And, there were more Black patients in the higher deprivation group (10.5%), compared with the low deprivation group (3.7%). In multivariate Cox proportional hazard model, socioeconomic status, but not race, had a significant effect on overall survival (HR for high deprivation was 1.19 [95% confidence interval; 1.04-1.37], P = 0.01).

It included 1,246 patients who were treated at the University of Pittsburgh Medical Center between 2000 and 2017. Of 1,246 patients, 414 patients considered in the bottom tertile of NDI as having low deprivation, while 832 patients in the middle or top tertiles were classified as having high deprivation.

The two socioeconomic status groups were similar in baseline characteristics, with the exception of race: 10.5% of the high deprivation group were African American, compared with 3.7% of the low deprivation group (P =.000093).

Univariate analyses showed worse survival in both Black women and women in the lower socioeconomic status group, but a multivariate analysis found only socioeconomic status was associated with overall survival (hazard ratio for lower socioeconomic status, 1.19; P = .01).

The study had several strengths, according to Rachel Freedman, MD, MPH, who served as a discussant for the abstract. “It included both de novo and recurrent metastatic breast cancer, unlike previous studies based on the Surveillance, Epidemiology, and End Results (SEER) database that only included de novo cases. It also employed a novel tool to define socioeconomic status in the form of the Neighborhood Atlas. The study “adds more evidence that socioeconomic status likely mediates much of what we see when it comes to racial disparities,” said Dr. Freedman, who is a senior physician at Dana Farber Cancer Institute.

Nevertheless, more work needs to be done. Dr. Freedman pointed out that the current study did not include information on treatment.

The findings underscore the failure to date to address disparities in breast cancer treatment, an effort that is hampered by difficulty in teasing out complex factors that may impact survival. “We need to standardize the way that we collect social determinants of health and act upon findings, and we need to standardize patient navigation, and we need to commit as a community to diverse clinical trial populations,” Dr. Freedman said.

Dr. Narayanan has no relevant financial disclosures. Dr. Freedman is an employee and stockholder of Firefly Health.

When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Ms. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, S.C.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Ms. Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

Ms. Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Ms. Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Ms. Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection – on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist at the Icahn School of Medicine at Mount Sinai, New York.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be – were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

More than 1 million women undergo cesarean deliveries in the United States every year, composing over 31% of all births in 2020, according to the Centers for Disease Control and Prevention.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of White women. Black women are also about three times more likely to die of pregnancy-related causes than White women.
 

Risk becomes reality

Ms. Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Ms. Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

“When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Dr. Glazer says.
 

Clinical discretion leads to biased judgment calls

Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in White women. Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among White women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Dr. Glazer says. “Once you adjust for all these measures, prepregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown. Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.
 

Dealing with the aftermath

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

“Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, D.C. The cost of a cesarean delivery averages about $17,000, compared with about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Dr. Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Dr. Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system – if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Dr. Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for White women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Dr. Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine, Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decisionmaking, and that by standardizing practices we could address these differences – people were somewhat resistant at first,” Dr. Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3, to reduce maternal mortality through mobile technology.

The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine, Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

A version of this article first appeared on WebMD.com.

When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Ms. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, S.C.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Ms. Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

Ms. Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Ms. Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Ms. Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection – on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist at the Icahn School of Medicine at Mount Sinai, New York.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be – were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

More than 1 million women undergo cesarean deliveries in the United States every year, composing over 31% of all births in 2020, according to the Centers for Disease Control and Prevention.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of White women. Black women are also about three times more likely to die of pregnancy-related causes than White women.
 

Risk becomes reality

Ms. Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Ms. Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

“When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Dr. Glazer says.
 

Clinical discretion leads to biased judgment calls

Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in White women. Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among White women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Dr. Glazer says. “Once you adjust for all these measures, prepregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown. Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.
 

Dealing with the aftermath

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

“Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, D.C. The cost of a cesarean delivery averages about $17,000, compared with about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Dr. Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Dr. Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system – if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Dr. Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for White women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Dr. Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine, Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decisionmaking, and that by standardizing practices we could address these differences – people were somewhat resistant at first,” Dr. Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3, to reduce maternal mortality through mobile technology.

The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine, Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

A version of this article first appeared on WebMD.com.

When 29-year-old Sakeenah Fowler was pregnant with her first child, doctors kept a close watch. Ms. Fowler has lupus, high blood pressure, a history of blood clotting, and kidney problems that all could have endangered her or the health of her unborn baby.

She saw maternal-fetal specialists who could keep watch of her high-risk pregnancy, and she collected urine samples every 24 hours to make sure her kidneys were functioning properly from her home in Roebuck, S.C.

But the pregnancy ultimately proved uneventful; even her kidneys remained stable. So Ms. Fowler said she was shocked when her doctors ordered an emergency cesarean delivery after she had gone into active labor.

“I was already dilated all the way to 6 cm,” but the baby’s heart rate had decreased by a small amount, she says. “They thought it was best to just go ahead with a C-section.”

Ms. Fowler, who is Black, said she believes the surgical intervention was unnecessary and that she wasn’t given a chance to discuss her options for a vaginal childbirth.  

“They already had it in their minds that I wasn’t going to make it through the pregnancy without any issues; then when I did, it was like they wanted to find something that made me have to have a C-section,” Ms. Fowler said. “It was close to the holidays; everybody was ready to go home. It was just like I was pushed to do what they wanted me to do.”

Ms. Fowler’s sense of a lack of choice is important beyond the measure of patient experience. While cesarean deliveries can be a lifeline for mother and baby, they can put up massive roadblocks to maternal and infant health when not necessary.

“The risk of hemorrhage, infection – on average, all of these go up when you have surgery instead of a vaginal delivery,” says Kimberly B. Glazer, PhD, a perinatal epidemiologist at the Icahn School of Medicine at Mount Sinai, New York.

“Birth is one of the most salient experiences you can have. People want to feel like their values and preferences – whatever they may be – were honored and respected. Even if the delivery goes a different way than you wanted, feeling like your values were taken into account is very important.”

More than 1 million women undergo cesarean deliveries in the United States every year, composing over 31% of all births in 2020, according to the Centers for Disease Control and Prevention.

The World Health Organization, meanwhile, recommends a rate of cesarean delivery of no more than 15% per region. Whether or not all the U.S. procedures were medically warranted is unclear, however.

Black women have higher odds of undergoing a cesarean: 36% undergo surgical deliveries annually, compared with about 30% of White women. Black women are also about three times more likely to die of pregnancy-related causes than White women.
 

Risk becomes reality

Ms. Fowler eventually developed an infection in her cesarean surgical wound, but her doctors initially insisted her alternating chills and fever were merely postpartum hormonal swings, she says.

“I thought something had to be wrong, but they just kept saying nothing was wrong,” she says.

By the time her doctors caught the infection, Ms. Fowler was readmitted to the hospital for several days of IV antibiotic therapy. The infection “almost got into my bloodstream and could have killed me,” she says.  

While cesarean deliveries are associated with decreases in maternal, neonatal, and infant mortality, the benefits are only seen up to a certain threshold. The WHO, for instance, has reported that over the 15% threshold, that lower mortality benefit disappears.

“When medically necessary, cesarean delivery can improve outcomes for mother and baby. But the fact that cesarean section rates have increased in recent years without a corresponding improvement in health outcomes indicates overreliance on the procedure,” Dr. Glazer says.
 

Clinical discretion leads to biased judgment calls

Rates of cesarean deliveries are even higher among low-risk pregnancies in women of color than in White women. Between 2016 and 2019, the overall rate of cesarean deliveries for low-risk births was 23%, according to a recent analysis. But the rate was almost 18% higher among Black women than among White women (27% vs. 22%).

“When you see data about these subjective indications varying by race and ethnicity, I think that’s pointing us toward some answers,” Dr. Glazer says. “Once you adjust for all these measures, prepregnancy characteristics, and risk factors, the research identifies variation in quality and outcomes that is rooted in structural and systemic racism in health care, implicit bias from clinicians.”

Researchers investigating cesarean deliveries have found that Black women are more likely to undergo the surgery for reasons that are highly subjective, such as fetal distress.

“There is a huge range of how concerning a fetal heart rate can be, and some health providers might perform a C-section for only minor changes in the fetal heart rate, while others might wait until it is much worse,” said Rebecca Hamm, MD, an assistant professor of obstetrics and gynecology at the Perelman School of Medicine at the University of Pennsylvania.

At least some of the differences in care can be explained by where women deliver their babies, studies have shown. Women of color disproportionately deliver at hospitals with poorer quality outcomes for moms and babies.
 

Dealing with the aftermath

There can be costs that reverberate throughout the life of a mother, child, and their family as the result of surgical delivery.

“Cesarean sections cost a lot more,” says Jamila Taylor, PhD, director of health care reform and a senior fellow with The Century Foundation, a progressive policy think tank in Washington, D.C. The cost of a cesarean delivery averages about $17,000, compared with about $12,200 for a vaginal birth; for uninsured patients, surgical deliveries cost about $9,000 more than vaginal deliveries.

Dr. Taylor, who has studied the historical mistreatment of Black women in obstetrics, noted that this cost includes not just the bill for surgery but also a prolonged recovery time that is often spent in a hospital bed.

Beyond the detrimental effect that a large hospital bill for delivery and aftercare can have on families, other costs can crop up later. Infants delivered by cesarean surgery are more likely to develop an infection, breathing problems, and to spend time in the neonatal intensive care unit than babies born vaginally. Although studies suggest these outcomes may result from a medically necessary health concern that spurred the cesarean surgery, they often stem from the delivery itself.  

Babies born surgically also miss out on the benefits of passing through the birth canal, such as supporting a newborn’s immune system and preparing their lungs to breathe oxygen after birth.

Most of the efforts to reduce inequities in maternal care are happening at the clinical level, aimed at both patients and providers, Dr. Taylor says.

“As advocates, we’re talking about how we can help Black women be advocates for themselves in the health care system – if the physician suggests a C-section, getting a second opinion, or walking through what a [surgical delivery] will mean and what their recovery will look like,” she says.

Women are also increasingly choosing non-hospital settings to deliver when possible, Dr. Taylor says. Including doulas or midwife practitioners in the maternal care team can reduce unnecessary cesarean deliveries among Black women, according to Camille Clare, MD, chair of the New York chapter of the American College of Obstetricians and Gynecologists.

Also, last year, race was removed from the vaginal birth after C-section (VBAC) calculator, which is used to gauge the safety of vaginal delivery in women with a history of surgical birth. The original calculator included race-based correction factors for Black women and Hispanic women. It predicted a lower likelihood of successful vaginal deliveries for women who already had a C-section and who identify as Black or Hispanic than for White women with otherwise identical characteristics, such as age, weight, and a history of cesarean delivery.

“Those are things that over time should reduce the high rates of cesarean section for Black women in particular,” Dr. Clare says.

In addition to embracing the updated calculator and including nurse-midwives and doulas in their obstetrics services, Penn Medicine, Philadelphia received a federal grant to study the impact of creating a standard plan for deliveries. This includes standardizing the induction of labor and any effect that might have on reducing C-section rates.

“This idea that biases lead to difference in decisionmaking, and that by standardizing practices we could address these differences – people were somewhat resistant at first,” Dr. Hamm says. “They didn’t believe there were differences in their practices.”

People struggle to recognize those differences, she says, and “it takes active participation in reducing disparities to make that happen.”

At the community level, Synergistic Sisters in Science (SIS), a group of maternal health experts and health equity advocates, is working on a project called PM3, to reduce maternal mortality through mobile technology.

The smartphone app will provide information for new moms to empower them to start conversations with health care providers. It also connects users to social support and resources. SIS is especially hoping to engage Black women living in rural areas.

“There is so much mistrust due to things like unnecessary C-sections and the fact that Black women feel they aren’t heard,” said Natalie Hernandez, PhD, executive director of the Center for Maternal Health Equity at Morehouse School of Medicine, Atlanta. “Here is a tool that gives a woman information that’s culturally centered, looks like her, and was informed by her voice.”

A version of this article first appeared on WebMD.com.

President Joe Biden issued an executive order on June 15 banning conversion therapy and offering other LBGTQIA+ protections as part of White House efforts to advance equality during Pride Month.

“My order will use the full force of the federal government to end inhumane practices of conversion therapy,” President Biden said in a speech before signing the order. “This is the first time the federal government is making a coordinated effort against this dangerous and discredited practice.”

Conversion therapy is any emotional or physical therapy used to “cure” or “repair” a person’s attraction to the same sex, or their gender identity and expression. Providers claim these therapies can make someone heterosexual or “straight.” But there’s no evidence to support this.

Medical and mental health experts have rejected conversion therapy practices as dangerous and discriminatory for decades.

The executive order also addresses:

• The LGBTQIA+ youth mental health crisis, in part by expanding suicide prevention resources for that at-risk population.
• Discrimination within the foster care system against LGBTQIA+ children and parents.
• Discrimination, poverty and isolation challenges faced by LGBTQIA+ seniors.
• Efforts to strengthen federal data collection in this population to counter homelessness, housing insecurity and barriers to health care access.

Enforcement of executive order will rely on legal experts, including the Justice Department.

President Biden’s order comes at a time when multiple states are promoting or passing anti-LGBTQIA+ laws.

“I don’t have to tell you about the ultra-MAGA agenda attacking our freedoms. There are more than 300 discriminatory bills introduced in states across this country,” President Biden said. “In Texas, they are knocking on front doors to investigate parents who are raising transgender children, and in Florida they are going after Mickey Mouse for God’s sake.”

First Lady Jill Biden, PhD, said the order will not solve all problems. “Prejudice and discrimination still lurk. We will not let the progress we fought for slip away. Pride is a celebration of the courage it takes to stand up for what’s right.”

The American Psychiatric Association applauded President Biden’s action. This executive order will “protect the mental health of LGBTQ+ people, particularly children. APA has long condemned the practice of so-called ‘conversion therapy’ and we welcome the federal government’s efforts to raise public awareness about its harms, alongside other practices that will help to end it.”

The goal of the order is to “improve the health, wellbeing, and safety of countless families across the country,” senior White House administration officials said in a June 15 media call. “And they will send a powerful signal from the president of the United States to LGBTQIA+ kids across the country – who may be feeling scared and hopeless – that their president has their back.”

Biden also called on Congress to pass the Equality Act “to enshrine the long overdue civil rights to protect all Americans.”

The event was held in the East Room of the White House at a Pride event attended by Vice President Kamala Harris and her husband, the first lady, Transportation Secretary Pete Buttigieg, and hundreds of LGBTQIA+ leaders.
 

Guidance on starting transgender treatment

In other LGBTQIA+-related news, an international group focusing on transgender health lowered the minimum ages they recommend for starting hormone therapy or surgery for transgender youth.

The World Professional Association for Transgender Health said that hormones could be started at 14, 2 years earlier than the group’s previous advice. The association also said some surgeries can be performed at age 15 or 17, a year or so earlier than their previous recommendations.

The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment, according to a report from The Associated Press.

Transgender treatment for teens has been a controversial issue, with experts disagreeing about whether teenagers can fully understand the ramifications of such life-altering decisions.

During the White House background media call, senior administration officials pointed to existing policy regarding transgender care. “We’ve already put out guidance through HHS about civil rights protections and making clear that the denial of medical care based on someone’s gender identity is discriminatory and have invited the members of the public to file complaints with the Office of Civil Rights.”

A version of this article first appeared on WebMD.com.

President Joe Biden issued an executive order on June 15 banning conversion therapy and offering other LBGTQIA+ protections as part of White House efforts to advance equality during Pride Month.

“My order will use the full force of the federal government to end inhumane practices of conversion therapy,” President Biden said in a speech before signing the order. “This is the first time the federal government is making a coordinated effort against this dangerous and discredited practice.”

Conversion therapy is any emotional or physical therapy used to “cure” or “repair” a person’s attraction to the same sex, or their gender identity and expression. Providers claim these therapies can make someone heterosexual or “straight.” But there’s no evidence to support this.

Medical and mental health experts have rejected conversion therapy practices as dangerous and discriminatory for decades.

The executive order also addresses:

• The LGBTQIA+ youth mental health crisis, in part by expanding suicide prevention resources for that at-risk population.
• Discrimination within the foster care system against LGBTQIA+ children and parents.
• Discrimination, poverty and isolation challenges faced by LGBTQIA+ seniors.
• Efforts to strengthen federal data collection in this population to counter homelessness, housing insecurity and barriers to health care access.

Enforcement of executive order will rely on legal experts, including the Justice Department.

President Biden’s order comes at a time when multiple states are promoting or passing anti-LGBTQIA+ laws.

“I don’t have to tell you about the ultra-MAGA agenda attacking our freedoms. There are more than 300 discriminatory bills introduced in states across this country,” President Biden said. “In Texas, they are knocking on front doors to investigate parents who are raising transgender children, and in Florida they are going after Mickey Mouse for God’s sake.”

First Lady Jill Biden, PhD, said the order will not solve all problems. “Prejudice and discrimination still lurk. We will not let the progress we fought for slip away. Pride is a celebration of the courage it takes to stand up for what’s right.”

The American Psychiatric Association applauded President Biden’s action. This executive order will “protect the mental health of LGBTQ+ people, particularly children. APA has long condemned the practice of so-called ‘conversion therapy’ and we welcome the federal government’s efforts to raise public awareness about its harms, alongside other practices that will help to end it.”

The goal of the order is to “improve the health, wellbeing, and safety of countless families across the country,” senior White House administration officials said in a June 15 media call. “And they will send a powerful signal from the president of the United States to LGBTQIA+ kids across the country – who may be feeling scared and hopeless – that their president has their back.”

Biden also called on Congress to pass the Equality Act “to enshrine the long overdue civil rights to protect all Americans.”

The event was held in the East Room of the White House at a Pride event attended by Vice President Kamala Harris and her husband, the first lady, Transportation Secretary Pete Buttigieg, and hundreds of LGBTQIA+ leaders.
 

Guidance on starting transgender treatment

In other LGBTQIA+-related news, an international group focusing on transgender health lowered the minimum ages they recommend for starting hormone therapy or surgery for transgender youth.

The World Professional Association for Transgender Health said that hormones could be started at 14, 2 years earlier than the group’s previous advice. The association also said some surgeries can be performed at age 15 or 17, a year or so earlier than their previous recommendations.

The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment, according to a report from The Associated Press.

Transgender treatment for teens has been a controversial issue, with experts disagreeing about whether teenagers can fully understand the ramifications of such life-altering decisions.

During the White House background media call, senior administration officials pointed to existing policy regarding transgender care. “We’ve already put out guidance through HHS about civil rights protections and making clear that the denial of medical care based on someone’s gender identity is discriminatory and have invited the members of the public to file complaints with the Office of Civil Rights.”

A version of this article first appeared on WebMD.com.

President Joe Biden issued an executive order on June 15 banning conversion therapy and offering other LBGTQIA+ protections as part of White House efforts to advance equality during Pride Month.

“My order will use the full force of the federal government to end inhumane practices of conversion therapy,” President Biden said in a speech before signing the order. “This is the first time the federal government is making a coordinated effort against this dangerous and discredited practice.”

Conversion therapy is any emotional or physical therapy used to “cure” or “repair” a person’s attraction to the same sex, or their gender identity and expression. Providers claim these therapies can make someone heterosexual or “straight.” But there’s no evidence to support this.

Medical and mental health experts have rejected conversion therapy practices as dangerous and discriminatory for decades.

The executive order also addresses:

• The LGBTQIA+ youth mental health crisis, in part by expanding suicide prevention resources for that at-risk population.
• Discrimination within the foster care system against LGBTQIA+ children and parents.
• Discrimination, poverty and isolation challenges faced by LGBTQIA+ seniors.
• Efforts to strengthen federal data collection in this population to counter homelessness, housing insecurity and barriers to health care access.

Enforcement of executive order will rely on legal experts, including the Justice Department.

President Biden’s order comes at a time when multiple states are promoting or passing anti-LGBTQIA+ laws.

“I don’t have to tell you about the ultra-MAGA agenda attacking our freedoms. There are more than 300 discriminatory bills introduced in states across this country,” President Biden said. “In Texas, they are knocking on front doors to investigate parents who are raising transgender children, and in Florida they are going after Mickey Mouse for God’s sake.”

First Lady Jill Biden, PhD, said the order will not solve all problems. “Prejudice and discrimination still lurk. We will not let the progress we fought for slip away. Pride is a celebration of the courage it takes to stand up for what’s right.”

The American Psychiatric Association applauded President Biden’s action. This executive order will “protect the mental health of LGBTQ+ people, particularly children. APA has long condemned the practice of so-called ‘conversion therapy’ and we welcome the federal government’s efforts to raise public awareness about its harms, alongside other practices that will help to end it.”

The goal of the order is to “improve the health, wellbeing, and safety of countless families across the country,” senior White House administration officials said in a June 15 media call. “And they will send a powerful signal from the president of the United States to LGBTQIA+ kids across the country – who may be feeling scared and hopeless – that their president has their back.”

Biden also called on Congress to pass the Equality Act “to enshrine the long overdue civil rights to protect all Americans.”

The event was held in the East Room of the White House at a Pride event attended by Vice President Kamala Harris and her husband, the first lady, Transportation Secretary Pete Buttigieg, and hundreds of LGBTQIA+ leaders.
 

Guidance on starting transgender treatment

In other LGBTQIA+-related news, an international group focusing on transgender health lowered the minimum ages they recommend for starting hormone therapy or surgery for transgender youth.

The World Professional Association for Transgender Health said that hormones could be started at 14, 2 years earlier than the group’s previous advice. The association also said some surgeries can be performed at age 15 or 17, a year or so earlier than their previous recommendations.

The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment, according to a report from The Associated Press.

Transgender treatment for teens has been a controversial issue, with experts disagreeing about whether teenagers can fully understand the ramifications of such life-altering decisions.

During the White House background media call, senior administration officials pointed to existing policy regarding transgender care. “We’ve already put out guidance through HHS about civil rights protections and making clear that the denial of medical care based on someone’s gender identity is discriminatory and have invited the members of the public to file complaints with the Office of Civil Rights.”

A version of this article first appeared on WebMD.com.

THE COMPARISON

A Nodular basal cell carcinoma (BCC) with a pearly rolled border, central pigmentation, and telangiectasia on the forehead of an 80-year-old Hispanic woman (light skin tone).

B Nodular BCC on the cheek of a 64-year-old Black man. The dark nonhealing ulcer had a subtle, pearly, rolled border and no visible telangiectasia.

Basal cell carcinoma (BCC) is most prevalent in individuals with lighter skin tones and rarely affects those with darker skin tones. Unfortunately, the lower incidence and lack of surveillance frequently result in a delayed diagnosis and increased morbidity for the skin of color population.1

Epidemiology

BCC is the most common skin cancer in White, Asian, and Hispanic individuals and the second most common in Black individuals. Squamous cell carcinoma is the most common skin cancer in Black individuals.²

Although BCCs are rare in individuals with darker skin tones, they most often develop in sun-exposed areas of the head and neck region.¹ In one study in an academic urban medical center, BCCs were more likely to occur in lightly pigmented vs darkly pigmented Black individuals.³

Key clinical features in people with darker skin tones

The classic BCC manifestation of a pearly papule with rolled borders and telangiectasia may not be seen in the skin of color population, especially among those with darker skin tones.⁴ In patient A, a Hispanic woman, these features are present along with hyperpigmentation. More than 50% of BCCs are pigmented in patients with skin of color vs only 5% in White individuals. ^5-7 The incidence of a pigmented BCC is twice as frequent in Hispanic individuals (FIGURE, A) as in non- Hispanic White individuals.⁷ Any skin cancer can present with ulcerations. So, while this is not specific to BCC, it is a reason to consider biopsy.

Worth noting

Pigmented BCC can mimic melanoma clinically and even when viewed with a dermatoscope, but such a suspicious lesion should prompt the clinician to perform a biopsy regardless of the type of suspected cancer. With experience and training, however, physicians can use dermoscopy to help make this distinction.

Note that skin of color is found in a heterogeneous population with a spectrum of skin tones and genetic/ethnic variability. In my practice in San Antonio (RPU), BCC is uncommon in Black patients and relatively common in Hispanic patients with lighter skin tones (FIGURE, A).

There is speculation that a lower incidence of BCC in the skin of color population leads to a low index of suspicion, which contributes to delayed diagnoses with poorer outcomes.¹ There are no firm data to support this because the rare occurrence of BCC in darker skin tones makes this a challenge to study.

Health disparity highlight

In general, barriers to health care include poverty, lack of education, lack of health insurance, and systemic racism. One study on keratinocyte skin cancers including BCC and squamous cell carcinoma found that these cancers were more costly to treat and required more health care resources, such as ambulatory visits and medication costs, in non-Hispanic Black and Hispanic White patients compared to non-Hispanic White patients.⁸

Final thoughts

Efforts are needed to achieve health equity through education of patients and health care providers about the appearance of BCC in skin of color with the goal of earlier diagnosis. Any nonhealing ulcer on the skin (FIGURE, B) should prompt consideration of skin cancer—regardless of skin color.

THE COMPARISON

A Nodular basal cell carcinoma (BCC) with a pearly rolled border, central pigmentation, and telangiectasia on the forehead of an 80-year-old Hispanic woman (light skin tone).

B Nodular BCC on the cheek of a 64-year-old Black man. The dark nonhealing ulcer had a subtle, pearly, rolled border and no visible telangiectasia.

Basal cell carcinoma (BCC) is most prevalent in individuals with lighter skin tones and rarely affects those with darker skin tones. Unfortunately, the lower incidence and lack of surveillance frequently result in a delayed diagnosis and increased morbidity for the skin of color population.1

Epidemiology

BCC is the most common skin cancer in White, Asian, and Hispanic individuals and the second most common in Black individuals. Squamous cell carcinoma is the most common skin cancer in Black individuals.²

Although BCCs are rare in individuals with darker skin tones, they most often develop in sun-exposed areas of the head and neck region.¹ In one study in an academic urban medical center, BCCs were more likely to occur in lightly pigmented vs darkly pigmented Black individuals.³

Key clinical features in people with darker skin tones

The classic BCC manifestation of a pearly papule with rolled borders and telangiectasia may not be seen in the skin of color population, especially among those with darker skin tones.⁴ In patient A, a Hispanic woman, these features are present along with hyperpigmentation. More than 50% of BCCs are pigmented in patients with skin of color vs only 5% in White individuals. ^5-7 The incidence of a pigmented BCC is twice as frequent in Hispanic individuals (FIGURE, A) as in non- Hispanic White individuals.⁷ Any skin cancer can present with ulcerations. So, while this is not specific to BCC, it is a reason to consider biopsy.

Worth noting

Pigmented BCC can mimic melanoma clinically and even when viewed with a dermatoscope, but such a suspicious lesion should prompt the clinician to perform a biopsy regardless of the type of suspected cancer. With experience and training, however, physicians can use dermoscopy to help make this distinction.

Note that skin of color is found in a heterogeneous population with a spectrum of skin tones and genetic/ethnic variability. In my practice in San Antonio (RPU), BCC is uncommon in Black patients and relatively common in Hispanic patients with lighter skin tones (FIGURE, A).

There is speculation that a lower incidence of BCC in the skin of color population leads to a low index of suspicion, which contributes to delayed diagnoses with poorer outcomes.¹ There are no firm data to support this because the rare occurrence of BCC in darker skin tones makes this a challenge to study.

Health disparity highlight

In general, barriers to health care include poverty, lack of education, lack of health insurance, and systemic racism. One study on keratinocyte skin cancers including BCC and squamous cell carcinoma found that these cancers were more costly to treat and required more health care resources, such as ambulatory visits and medication costs, in non-Hispanic Black and Hispanic White patients compared to non-Hispanic White patients.⁸

Final thoughts

Efforts are needed to achieve health equity through education of patients and health care providers about the appearance of BCC in skin of color with the goal of earlier diagnosis. Any nonhealing ulcer on the skin (FIGURE, B) should prompt consideration of skin cancer—regardless of skin color.

THE COMPARISON

A Nodular basal cell carcinoma (BCC) with a pearly rolled border, central pigmentation, and telangiectasia on the forehead of an 80-year-old Hispanic woman (light skin tone).

B Nodular BCC on the cheek of a 64-year-old Black man. The dark nonhealing ulcer had a subtle, pearly, rolled border and no visible telangiectasia.

Basal cell carcinoma (BCC) is most prevalent in individuals with lighter skin tones and rarely affects those with darker skin tones. Unfortunately, the lower incidence and lack of surveillance frequently result in a delayed diagnosis and increased morbidity for the skin of color population.1

Epidemiology

BCC is the most common skin cancer in White, Asian, and Hispanic individuals and the second most common in Black individuals. Squamous cell carcinoma is the most common skin cancer in Black individuals.²

Although BCCs are rare in individuals with darker skin tones, they most often develop in sun-exposed areas of the head and neck region.¹ In one study in an academic urban medical center, BCCs were more likely to occur in lightly pigmented vs darkly pigmented Black individuals.³

Key clinical features in people with darker skin tones

The classic BCC manifestation of a pearly papule with rolled borders and telangiectasia may not be seen in the skin of color population, especially among those with darker skin tones.⁴ In patient A, a Hispanic woman, these features are present along with hyperpigmentation. More than 50% of BCCs are pigmented in patients with skin of color vs only 5% in White individuals. ^5-7 The incidence of a pigmented BCC is twice as frequent in Hispanic individuals (FIGURE, A) as in non- Hispanic White individuals.⁷ Any skin cancer can present with ulcerations. So, while this is not specific to BCC, it is a reason to consider biopsy.

Worth noting

Pigmented BCC can mimic melanoma clinically and even when viewed with a dermatoscope, but such a suspicious lesion should prompt the clinician to perform a biopsy regardless of the type of suspected cancer. With experience and training, however, physicians can use dermoscopy to help make this distinction.

Note that skin of color is found in a heterogeneous population with a spectrum of skin tones and genetic/ethnic variability. In my practice in San Antonio (RPU), BCC is uncommon in Black patients and relatively common in Hispanic patients with lighter skin tones (FIGURE, A).

There is speculation that a lower incidence of BCC in the skin of color population leads to a low index of suspicion, which contributes to delayed diagnoses with poorer outcomes.¹ There are no firm data to support this because the rare occurrence of BCC in darker skin tones makes this a challenge to study.

Health disparity highlight

In general, barriers to health care include poverty, lack of education, lack of health insurance, and systemic racism. One study on keratinocyte skin cancers including BCC and squamous cell carcinoma found that these cancers were more costly to treat and required more health care resources, such as ambulatory visits and medication costs, in non-Hispanic Black and Hispanic White patients compared to non-Hispanic White patients.⁸

Final thoughts

Efforts are needed to achieve health equity through education of patients and health care providers about the appearance of BCC in skin of color with the goal of earlier diagnosis. Any nonhealing ulcer on the skin (FIGURE, B) should prompt consideration of skin cancer—regardless of skin color.

Photographs courtesy of Richard P. Usatine, MD (Figure A), and Tizita Yosef Kidane, MD (Figure B).

THE COMPARISON

A Nodular basal cell carcinoma (BCC) with a pearly rolled border, central pigmentation, and telangiectasia on the forehead of an 80-year-old Hispanic woman (light skin tone).

B Nodular BCC on the cheek of a 64-year-old Black man. The dark nonhealing ulcer had a subtle, pearly, rolled border and no visible telangiectasia.

Basal cell carcinoma is most prevalent in individuals with lighter skin tones and rarely affects those with darker skin tones. Unfortunately, the lower incidence and lack of surveillance frequently result in a delayed diagnosis and increased morbidity for the skin of color population.¹

Epidemiology

Basal cell carcinoma is the most common skin cancer in White, Asian, and Hispanic individuals and the second most common in Black individuals. Squamous cell carcinoma is the most common skin cancer in Black individuals.²

Although BCCs are rare in individuals with darker skin tones, they most often develop in sun-exposed areas of the head and neck region.¹ In one study in an academic urban medical center, BCCs were more likely to occur in lightly pigmented vs darkly pigmented Black individuals.³

Key clinical features in people with darker skin tones

The classic BCC manifestation of a pearly papule with rolled borders and telangiectasia may not be seen in the skin of color population, especially among those with darker skin tones.⁴ In patient A, a Hispanic woman, these features are present along with hyperpigmentation. More than 50% of BCCs are pigmented in patients with skin of color vs only 5% in White individuals.^5-7 The incidence of a pigmented BCC is twice as frequent in Hispanic individuals (Figure, A) as in non-Hispanic White individuals.⁷ Any skin cancer can present with ulcerations, so while this is not specific to BCC, it is a reason to consider biopsy.

Worth noting

Pigmented BCC can mimic melanoma clinically and even when viewed with a dermatoscope, but such a suspicious lesion should prompt the clinician to perform a biopsy regardless of the type of suspected cancer. With experience and training, however, physicians can use dermoscopy to help make this distinction.

Note that skin of color is found in a heterogeneous population with a spectrum of skin tones and genetic/ ethnic variability. In my practice in San Antonio (R.P.U.), BCC is uncommon in Black patients and relatively common in Hispanic patients with lighter skin tones (Figure, A). There is speculation that a lower incidence of BCC in the skin of color population leads to a low index of suspicion, which contributes to delayed diagnoses with poorer outcomes. ¹ There are no firm data to support this because the rare occurrence of BCC in darker skin tones makes this a challenge to study.

Health disparity highlight

In general, barriers to health care include poverty, lack of education, lack of health insurance, and systemic racism. One study on keratinocyte skin cancers including BCC and SCC found that these cancers were more costly to treat and required more health care resources, such as ambulatory visits and medication costs, in non-Hispanic Black and Hispanic White patients compared to non- Hispanic White patients.⁸

Final thoughts

Efforts are needed to achieve health equity through education of patients and health care providers about the appearance of BCC in skin of color with the goal of earlier diagnosis. Any nonhealing ulcer on the skin (Figure, B) should prompt consideration of skin cancer regardless of skin color.

Photographs courtesy of Richard P. Usatine, MD (Figure A), and Tizita Yosef Kidane, MD (Figure B).

THE COMPARISON

A Nodular basal cell carcinoma (BCC) with a pearly rolled border, central pigmentation, and telangiectasia on the forehead of an 80-year-old Hispanic woman (light skin tone).

B Nodular BCC on the cheek of a 64-year-old Black man. The dark nonhealing ulcer had a subtle, pearly, rolled border and no visible telangiectasia.

Basal cell carcinoma is most prevalent in individuals with lighter skin tones and rarely affects those with darker skin tones. Unfortunately, the lower incidence and lack of surveillance frequently result in a delayed diagnosis and increased morbidity for the skin of color population.¹

Epidemiology

Basal cell carcinoma is the most common skin cancer in White, Asian, and Hispanic individuals and the second most common in Black individuals. Squamous cell carcinoma is the most common skin cancer in Black individuals.²

Although BCCs are rare in individuals with darker skin tones, they most often develop in sun-exposed areas of the head and neck region.¹ In one study in an academic urban medical center, BCCs were more likely to occur in lightly pigmented vs darkly pigmented Black individuals.³

Key clinical features in people with darker skin tones

The classic BCC manifestation of a pearly papule with rolled borders and telangiectasia may not be seen in the skin of color population, especially among those with darker skin tones.⁴ In patient A, a Hispanic woman, these features are present along with hyperpigmentation. More than 50% of BCCs are pigmented in patients with skin of color vs only 5% in White individuals.^5-7 The incidence of a pigmented BCC is twice as frequent in Hispanic individuals (Figure, A) as in non-Hispanic White individuals.⁷ Any skin cancer can present with ulcerations, so while this is not specific to BCC, it is a reason to consider biopsy.

Worth noting

Pigmented BCC can mimic melanoma clinically and even when viewed with a dermatoscope, but such a suspicious lesion should prompt the clinician to perform a biopsy regardless of the type of suspected cancer. With experience and training, however, physicians can use dermoscopy to help make this distinction.

Note that skin of color is found in a heterogeneous population with a spectrum of skin tones and genetic/ ethnic variability. In my practice in San Antonio (R.P.U.), BCC is uncommon in Black patients and relatively common in Hispanic patients with lighter skin tones (Figure, A). There is speculation that a lower incidence of BCC in the skin of color population leads to a low index of suspicion, which contributes to delayed diagnoses with poorer outcomes. ¹ There are no firm data to support this because the rare occurrence of BCC in darker skin tones makes this a challenge to study.

Health disparity highlight

In general, barriers to health care include poverty, lack of education, lack of health insurance, and systemic racism. One study on keratinocyte skin cancers including BCC and SCC found that these cancers were more costly to treat and required more health care resources, such as ambulatory visits and medication costs, in non-Hispanic Black and Hispanic White patients compared to non- Hispanic White patients.⁸

Final thoughts

Efforts are needed to achieve health equity through education of patients and health care providers about the appearance of BCC in skin of color with the goal of earlier diagnosis. Any nonhealing ulcer on the skin (Figure, B) should prompt consideration of skin cancer regardless of skin color.

Photographs courtesy of Richard P. Usatine, MD (Figure A), and Tizita Yosef Kidane, MD (Figure B).

THE COMPARISON

A Nodular basal cell carcinoma (BCC) with a pearly rolled border, central pigmentation, and telangiectasia on the forehead of an 80-year-old Hispanic woman (light skin tone).

B Nodular BCC on the cheek of a 64-year-old Black man. The dark nonhealing ulcer had a subtle, pearly, rolled border and no visible telangiectasia.

Basal cell carcinoma is most prevalent in individuals with lighter skin tones and rarely affects those with darker skin tones. Unfortunately, the lower incidence and lack of surveillance frequently result in a delayed diagnosis and increased morbidity for the skin of color population.¹

Epidemiology

Basal cell carcinoma is the most common skin cancer in White, Asian, and Hispanic individuals and the second most common in Black individuals. Squamous cell carcinoma is the most common skin cancer in Black individuals.²

Although BCCs are rare in individuals with darker skin tones, they most often develop in sun-exposed areas of the head and neck region.¹ In one study in an academic urban medical center, BCCs were more likely to occur in lightly pigmented vs darkly pigmented Black individuals.³

Key clinical features in people with darker skin tones

The classic BCC manifestation of a pearly papule with rolled borders and telangiectasia may not be seen in the skin of color population, especially among those with darker skin tones.⁴ In patient A, a Hispanic woman, these features are present along with hyperpigmentation. More than 50% of BCCs are pigmented in patients with skin of color vs only 5% in White individuals.^5-7 The incidence of a pigmented BCC is twice as frequent in Hispanic individuals (Figure, A) as in non-Hispanic White individuals.⁷ Any skin cancer can present with ulcerations, so while this is not specific to BCC, it is a reason to consider biopsy.

Worth noting

Pigmented BCC can mimic melanoma clinically and even when viewed with a dermatoscope, but such a suspicious lesion should prompt the clinician to perform a biopsy regardless of the type of suspected cancer. With experience and training, however, physicians can use dermoscopy to help make this distinction.

Note that skin of color is found in a heterogeneous population with a spectrum of skin tones and genetic/ ethnic variability. In my practice in San Antonio (R.P.U.), BCC is uncommon in Black patients and relatively common in Hispanic patients with lighter skin tones (Figure, A). There is speculation that a lower incidence of BCC in the skin of color population leads to a low index of suspicion, which contributes to delayed diagnoses with poorer outcomes. ¹ There are no firm data to support this because the rare occurrence of BCC in darker skin tones makes this a challenge to study.

Health disparity highlight

In general, barriers to health care include poverty, lack of education, lack of health insurance, and systemic racism. One study on keratinocyte skin cancers including BCC and SCC found that these cancers were more costly to treat and required more health care resources, such as ambulatory visits and medication costs, in non-Hispanic Black and Hispanic White patients compared to non- Hispanic White patients.⁸

Final thoughts

Efforts are needed to achieve health equity through education of patients and health care providers about the appearance of BCC in skin of color with the goal of earlier diagnosis. Any nonhealing ulcer on the skin (Figure, B) should prompt consideration of skin cancer regardless of skin color.

Similar to other dermatologic conditions, barriers to early care in patients with vitiligo can exacerbate health disparities.¹ Delayed treatment of vitiligo is known to hamper successful disease stabilization and repigmentation, as therapies tend to work more effectively in early stages of the disease.²

To investigate the factors associated with treatment delays for patients with vitiligo, we conducted a retrospective chart review of 102 consecutive patients with vitiligo attending an academic outpatient clinic in Austin, Texas, over 36 months.

Methods

Our sample included 102 consecutive patients with vitiligo who attended an academic outpatient clinic in Austin, Texas, from January 2017 to January 2020. Demographic information, clinical characteristics of vitiligo, and treatment data were self-reported via a standardized questionnaire given to all patients with vitiligo and gathered from medical chart review. Patient characteristics are outlined in the Table. The delay to treatment was the time (in months) from the date the patient first noticed the lesion to the start date of first treatment. This retrospective chart review was reviewed by the University of Texas at Austin institutional review board and was determined to be exempt.

Statistical Analysis—The data were analyzed descriptively with a Wilcoxon rank sum test (type I error rate of .05).

Results

Of the 102 charts that were analyzed, 45 were females and 57 were males. More than half of the patients (54.9% [56/102]) were White. Sixteen were Asian, 13 were Hispanic non-White, 11 were Black/African American, and 4 were American Indian/Alaska Native. The median age of disease onset was 21 years, minimum age was 1 year, and maximum age was 83 years. The diagnosis of vitiligo was made by a dermatologist for 72 patients and by a physician of another specialty for 20 patients. Ten patients did not declare the specialty of the diagnosing physician.

Individuals older than 21 years when their disease started had a shorter delay to treatment than individuals who noticed their first lesion at an age younger than 21 years (median, 75 months vs 13 months; P<.01). Individuals diagnosed by a dermatologist had a shorter delay to treatment than individuals diagnosed by a physician of another specialty (median, 13 months vs 58 months; P<.05). White individuals had a shorter delay to treatment than individuals with skin of color (median, 13 months vs 31 months; P=.08), though this trend did not reach statistical significance. Individuals with 1% to 25% of body surface area (BSA) affected at time of presentation to clinic also had a shorter delay to treatment than those with a greater BSA affected (median, 13 months vs 74 months; P<.06), though this trend did not reach statistical significance. Type of vitiligo (P<.8), Fitzpatrick skin type (P<.6), and smoking status (P<.7) were not associated with differential delays.

Comment

Impact of Age on Vitiligo Treatment—Our data suggest that individuals who develop vitiligo at a younger age experience longer treatment delays compared to older individuals. Reasons for this are uncertain but could include access issues, medical decision-making agency, and younger patients not remembering being treated during their youth. Our data also could be influenced by some of the adult patients in our study first noticing their lesions many years ago when treatments for vitiligo were more limited. Nevertheless, detrimental effects on quality of life in children and adolescents with vitiligo suggest that motivating younger individuals with vitiligo to seek treatment or proactively making them aware of treatment opportunities may be beneficial.³

Diagnosis of Vitiligo by Nondermatologists—The increase in delay to treatment when a nondermatologist diagnoses vitiligo suggests that prompt initiation of treatment or referrals to dermatology by primary care providers may not routinely be occurring.⁴ Our data indicate the need to educate primary care providers on treatment opportunities for individuals with vitiligo and that early treatment generally is more effective.⁵

Impact of Race/Ethnicity on Vitiligo Treatment—Our data also show trends for longer treatment delays for individuals with skin of color. Although this did not reach statistical significance, we hope future studies will investigate this issue, especially because patients with skin of color experience more stigmatization and quality-of-life impacts by vitiligo than White patients.⁵

Impact of BSA on Vitiligo Treatment—Our data show that patients with a smaller BSA had a shorter delay to treatment than those with a greater BSA affected. This was a unique finding given it initially was hypothesized that patients with greater BSA would seek treatment earlier because of the associated increase in quality of life impact. This trend was not statistically significant, but further investigation would be helpful to analyze the reason behind treatment delays in patients with greater BSA affected.

Conclusion

The delay to treatment in our study population was correlated with the diagnosing physician’s specialty and patient age at disease onset, with trends also observed for race and BSA affected. These findings emphasize the need to investigate specific causes of barriers to early care to promote health equity among individuals with vitiligo.

Similar to other dermatologic conditions, barriers to early care in patients with vitiligo can exacerbate health disparities.¹ Delayed treatment of vitiligo is known to hamper successful disease stabilization and repigmentation, as therapies tend to work more effectively in early stages of the disease.²

To investigate the factors associated with treatment delays for patients with vitiligo, we conducted a retrospective chart review of 102 consecutive patients with vitiligo attending an academic outpatient clinic in Austin, Texas, over 36 months.

Methods

Our sample included 102 consecutive patients with vitiligo who attended an academic outpatient clinic in Austin, Texas, from January 2017 to January 2020. Demographic information, clinical characteristics of vitiligo, and treatment data were self-reported via a standardized questionnaire given to all patients with vitiligo and gathered from medical chart review. Patient characteristics are outlined in the Table. The delay to treatment was the time (in months) from the date the patient first noticed the lesion to the start date of first treatment. This retrospective chart review was reviewed by the University of Texas at Austin institutional review board and was determined to be exempt.

Statistical Analysis—The data were analyzed descriptively with a Wilcoxon rank sum test (type I error rate of .05).

Results

Of the 102 charts that were analyzed, 45 were females and 57 were males. More than half of the patients (54.9% [56/102]) were White. Sixteen were Asian, 13 were Hispanic non-White, 11 were Black/African American, and 4 were American Indian/Alaska Native. The median age of disease onset was 21 years, minimum age was 1 year, and maximum age was 83 years. The diagnosis of vitiligo was made by a dermatologist for 72 patients and by a physician of another specialty for 20 patients. Ten patients did not declare the specialty of the diagnosing physician.

Individuals older than 21 years when their disease started had a shorter delay to treatment than individuals who noticed their first lesion at an age younger than 21 years (median, 75 months vs 13 months; P<.01). Individuals diagnosed by a dermatologist had a shorter delay to treatment than individuals diagnosed by a physician of another specialty (median, 13 months vs 58 months; P<.05). White individuals had a shorter delay to treatment than individuals with skin of color (median, 13 months vs 31 months; P=.08), though this trend did not reach statistical significance. Individuals with 1% to 25% of body surface area (BSA) affected at time of presentation to clinic also had a shorter delay to treatment than those with a greater BSA affected (median, 13 months vs 74 months; P<.06), though this trend did not reach statistical significance. Type of vitiligo (P<.8), Fitzpatrick skin type (P<.6), and smoking status (P<.7) were not associated with differential delays.

Comment

Impact of Age on Vitiligo Treatment—Our data suggest that individuals who develop vitiligo at a younger age experience longer treatment delays compared to older individuals. Reasons for this are uncertain but could include access issues, medical decision-making agency, and younger patients not remembering being treated during their youth. Our data also could be influenced by some of the adult patients in our study first noticing their lesions many years ago when treatments for vitiligo were more limited. Nevertheless, detrimental effects on quality of life in children and adolescents with vitiligo suggest that motivating younger individuals with vitiligo to seek treatment or proactively making them aware of treatment opportunities may be beneficial.³

Diagnosis of Vitiligo by Nondermatologists—The increase in delay to treatment when a nondermatologist diagnoses vitiligo suggests that prompt initiation of treatment or referrals to dermatology by primary care providers may not routinely be occurring.⁴ Our data indicate the need to educate primary care providers on treatment opportunities for individuals with vitiligo and that early treatment generally is more effective.⁵

Impact of Race/Ethnicity on Vitiligo Treatment—Our data also show trends for longer treatment delays for individuals with skin of color. Although this did not reach statistical significance, we hope future studies will investigate this issue, especially because patients with skin of color experience more stigmatization and quality-of-life impacts by vitiligo than White patients.⁵

Impact of BSA on Vitiligo Treatment—Our data show that patients with a smaller BSA had a shorter delay to treatment than those with a greater BSA affected. This was a unique finding given it initially was hypothesized that patients with greater BSA would seek treatment earlier because of the associated increase in quality of life impact. This trend was not statistically significant, but further investigation would be helpful to analyze the reason behind treatment delays in patients with greater BSA affected.

Conclusion

The delay to treatment in our study population was correlated with the diagnosing physician’s specialty and patient age at disease onset, with trends also observed for race and BSA affected. These findings emphasize the need to investigate specific causes of barriers to early care to promote health equity among individuals with vitiligo.

Similar to other dermatologic conditions, barriers to early care in patients with vitiligo can exacerbate health disparities.¹ Delayed treatment of vitiligo is known to hamper successful disease stabilization and repigmentation, as therapies tend to work more effectively in early stages of the disease.²

To investigate the factors associated with treatment delays for patients with vitiligo, we conducted a retrospective chart review of 102 consecutive patients with vitiligo attending an academic outpatient clinic in Austin, Texas, over 36 months.

Methods

Our sample included 102 consecutive patients with vitiligo who attended an academic outpatient clinic in Austin, Texas, from January 2017 to January 2020. Demographic information, clinical characteristics of vitiligo, and treatment data were self-reported via a standardized questionnaire given to all patients with vitiligo and gathered from medical chart review. Patient characteristics are outlined in the Table. The delay to treatment was the time (in months) from the date the patient first noticed the lesion to the start date of first treatment. This retrospective chart review was reviewed by the University of Texas at Austin institutional review board and was determined to be exempt.

Statistical Analysis—The data were analyzed descriptively with a Wilcoxon rank sum test (type I error rate of .05).

Results

Of the 102 charts that were analyzed, 45 were females and 57 were males. More than half of the patients (54.9% [56/102]) were White. Sixteen were Asian, 13 were Hispanic non-White, 11 were Black/African American, and 4 were American Indian/Alaska Native. The median age of disease onset was 21 years, minimum age was 1 year, and maximum age was 83 years. The diagnosis of vitiligo was made by a dermatologist for 72 patients and by a physician of another specialty for 20 patients. Ten patients did not declare the specialty of the diagnosing physician.

Individuals older than 21 years when their disease started had a shorter delay to treatment than individuals who noticed their first lesion at an age younger than 21 years (median, 75 months vs 13 months; P<.01). Individuals diagnosed by a dermatologist had a shorter delay to treatment than individuals diagnosed by a physician of another specialty (median, 13 months vs 58 months; P<.05). White individuals had a shorter delay to treatment than individuals with skin of color (median, 13 months vs 31 months; P=.08), though this trend did not reach statistical significance. Individuals with 1% to 25% of body surface area (BSA) affected at time of presentation to clinic also had a shorter delay to treatment than those with a greater BSA affected (median, 13 months vs 74 months; P<.06), though this trend did not reach statistical significance. Type of vitiligo (P<.8), Fitzpatrick skin type (P<.6), and smoking status (P<.7) were not associated with differential delays.

Comment

Impact of Age on Vitiligo Treatment—Our data suggest that individuals who develop vitiligo at a younger age experience longer treatment delays compared to older individuals. Reasons for this are uncertain but could include access issues, medical decision-making agency, and younger patients not remembering being treated during their youth. Our data also could be influenced by some of the adult patients in our study first noticing their lesions many years ago when treatments for vitiligo were more limited. Nevertheless, detrimental effects on quality of life in children and adolescents with vitiligo suggest that motivating younger individuals with vitiligo to seek treatment or proactively making them aware of treatment opportunities may be beneficial.³

Diagnosis of Vitiligo by Nondermatologists—The increase in delay to treatment when a nondermatologist diagnoses vitiligo suggests that prompt initiation of treatment or referrals to dermatology by primary care providers may not routinely be occurring.⁴ Our data indicate the need to educate primary care providers on treatment opportunities for individuals with vitiligo and that early treatment generally is more effective.⁵

Impact of Race/Ethnicity on Vitiligo Treatment—Our data also show trends for longer treatment delays for individuals with skin of color. Although this did not reach statistical significance, we hope future studies will investigate this issue, especially because patients with skin of color experience more stigmatization and quality-of-life impacts by vitiligo than White patients.⁵

Impact of BSA on Vitiligo Treatment—Our data show that patients with a smaller BSA had a shorter delay to treatment than those with a greater BSA affected. This was a unique finding given it initially was hypothesized that patients with greater BSA would seek treatment earlier because of the associated increase in quality of life impact. This trend was not statistically significant, but further investigation would be helpful to analyze the reason behind treatment delays in patients with greater BSA affected.

Conclusion

The delay to treatment in our study population was correlated with the diagnosing physician’s specialty and patient age at disease onset, with trends also observed for race and BSA affected. These findings emphasize the need to investigate specific causes of barriers to early care to promote health equity among individuals with vitiligo.

NEW ORLEANS – In an unexpected finding, researchers discovered that Asian American adolescents had the highest rate of suicidal ideation, per a 2019 national survey of high-school students. According to a weighted analysis, 24% of Asian Americans reported thinking about or planning suicide vs. 22% of Whites and Blacks and 20% of Hispanics (P < .01).

“We were shocked,” said study lead author Esha Hansoti, MD, who conducted the research at UT Southwestern Medical Center, Dallas, and is now a psychiatry resident at Zucker Hillside Hospital Northwell/Hofstra in Glen Oaks, NY. The findings were released at the annual meeting of the American Psychiatric Association.

Dr. Hansoti and colleagues launched the analysis in light of sparse research into Asian American mental health, she said. Even within this population, she said, mental illness “tends to be overlooked” and discussion of the topic may be considered taboo.

For the new study, researchers analyzed the 2019 Youth Risk Behavior Survey, conducted biennially by the Centers for Disease Control and Prevention, which had more than 13,000 participants in grades 9-12.

A weighted bivariate analysis of 618 Asian American adolescents – adjusted for age, sex, and depressive symptoms – found no statistically significant impact on suicidal ideation by gender, age, substance use, sexual/physical dating violence, or fluency in English.

However, several groups had a statistically significant higher risk, including victims of forced sexual intercourse and those who were threatened or bullied at school.

Those who didn’t get mostly A grades were also at high risk: Adolescents with mostly Ds and Fs were more likely to have acknowledged suicidal ideation than those with mostly As (adjusted odds ratio [AOR] = 3.2).

Gays and lesbians (AOR = 7.9 vs. heterosexuals), and bisexuals (AOR = 5.2 vs. heterosexuals) also showed sharply higher rates of suicidal ideation.

It’s not clear why Asian American adolescents may be at higher risk of suicidal ideation. The survey was completed prior to the COVID-19 pandemic, which spawned bigotry against people of Asian descent and an ongoing outbreak of high-profile violence against Asian Americans across the country.

Dr. Hansoti noted that Asian Americans face the pressures to live up to the standards of being a “model minority.” In addition, “very few Asian American adolescents are taken to a therapist, and few mental health providers are Asian Americans.”

She urged fellow psychiatrists “to remember that our perceptions of Asian Americans might hinder some of the diagnoses we could be making. Be thoughtful about how their ethnicity and race affects their presentation and their own perception of their illness.”

She added that Asian Americans may experience mental illness and anxiety “more somatically and physically than emotionally.”

In an interview, Anne Saw, PhD, associate professor of clinical-community psychology at DePaul University, Chicago, said the findings are “helpful for corroborating other studies identifying risk factors of suicidal ideation among Asian American adolescents. Since this research utilizes the Youth Risk Behavior Survey, these findings can be compared with risk factors of suicidal ideation among adolescents from other racial/ethnic backgrounds to pinpoint general as well as specific risk factors, thus informing how we can tailor interventions for specific groups.”

According to Dr. Saw, while it’s clear that suicide is a leading cause of death among Asian American adolescents, it’s still unknown which specific subgroups other than girls and LGBTIA+ individuals are especially vulnerable and which culturally tailored interventions are most effective for decreasing suicide risk.

“Psychiatrists should understand that risk and protective factors for suicidal behavior in Asian American adolescents are multifaceted and require careful attention and intervention across different environments,” she said.

No funding and no disclosures were reported.

NEW ORLEANS – In an unexpected finding, researchers discovered that Asian American adolescents had the highest rate of suicidal ideation, per a 2019 national survey of high-school students. According to a weighted analysis, 24% of Asian Americans reported thinking about or planning suicide vs. 22% of Whites and Blacks and 20% of Hispanics (P < .01).

“We were shocked,” said study lead author Esha Hansoti, MD, who conducted the research at UT Southwestern Medical Center, Dallas, and is now a psychiatry resident at Zucker Hillside Hospital Northwell/Hofstra in Glen Oaks, NY. The findings were released at the annual meeting of the American Psychiatric Association.

Dr. Hansoti and colleagues launched the analysis in light of sparse research into Asian American mental health, she said. Even within this population, she said, mental illness “tends to be overlooked” and discussion of the topic may be considered taboo.

For the new study, researchers analyzed the 2019 Youth Risk Behavior Survey, conducted biennially by the Centers for Disease Control and Prevention, which had more than 13,000 participants in grades 9-12.

A weighted bivariate analysis of 618 Asian American adolescents – adjusted for age, sex, and depressive symptoms – found no statistically significant impact on suicidal ideation by gender, age, substance use, sexual/physical dating violence, or fluency in English.

However, several groups had a statistically significant higher risk, including victims of forced sexual intercourse and those who were threatened or bullied at school.

Those who didn’t get mostly A grades were also at high risk: Adolescents with mostly Ds and Fs were more likely to have acknowledged suicidal ideation than those with mostly As (adjusted odds ratio [AOR] = 3.2).

Gays and lesbians (AOR = 7.9 vs. heterosexuals), and bisexuals (AOR = 5.2 vs. heterosexuals) also showed sharply higher rates of suicidal ideation.

It’s not clear why Asian American adolescents may be at higher risk of suicidal ideation. The survey was completed prior to the COVID-19 pandemic, which spawned bigotry against people of Asian descent and an ongoing outbreak of high-profile violence against Asian Americans across the country.

Dr. Hansoti noted that Asian Americans face the pressures to live up to the standards of being a “model minority.” In addition, “very few Asian American adolescents are taken to a therapist, and few mental health providers are Asian Americans.”

She urged fellow psychiatrists “to remember that our perceptions of Asian Americans might hinder some of the diagnoses we could be making. Be thoughtful about how their ethnicity and race affects their presentation and their own perception of their illness.”

She added that Asian Americans may experience mental illness and anxiety “more somatically and physically than emotionally.”

In an interview, Anne Saw, PhD, associate professor of clinical-community psychology at DePaul University, Chicago, said the findings are “helpful for corroborating other studies identifying risk factors of suicidal ideation among Asian American adolescents. Since this research utilizes the Youth Risk Behavior Survey, these findings can be compared with risk factors of suicidal ideation among adolescents from other racial/ethnic backgrounds to pinpoint general as well as specific risk factors, thus informing how we can tailor interventions for specific groups.”

According to Dr. Saw, while it’s clear that suicide is a leading cause of death among Asian American adolescents, it’s still unknown which specific subgroups other than girls and LGBTIA+ individuals are especially vulnerable and which culturally tailored interventions are most effective for decreasing suicide risk.

“Psychiatrists should understand that risk and protective factors for suicidal behavior in Asian American adolescents are multifaceted and require careful attention and intervention across different environments,” she said.

No funding and no disclosures were reported.

NEW ORLEANS – In an unexpected finding, researchers discovered that Asian American adolescents had the highest rate of suicidal ideation, per a 2019 national survey of high-school students. According to a weighted analysis, 24% of Asian Americans reported thinking about or planning suicide vs. 22% of Whites and Blacks and 20% of Hispanics (P < .01).

“We were shocked,” said study lead author Esha Hansoti, MD, who conducted the research at UT Southwestern Medical Center, Dallas, and is now a psychiatry resident at Zucker Hillside Hospital Northwell/Hofstra in Glen Oaks, NY. The findings were released at the annual meeting of the American Psychiatric Association.

Dr. Hansoti and colleagues launched the analysis in light of sparse research into Asian American mental health, she said. Even within this population, she said, mental illness “tends to be overlooked” and discussion of the topic may be considered taboo.

For the new study, researchers analyzed the 2019 Youth Risk Behavior Survey, conducted biennially by the Centers for Disease Control and Prevention, which had more than 13,000 participants in grades 9-12.

A weighted bivariate analysis of 618 Asian American adolescents – adjusted for age, sex, and depressive symptoms – found no statistically significant impact on suicidal ideation by gender, age, substance use, sexual/physical dating violence, or fluency in English.

However, several groups had a statistically significant higher risk, including victims of forced sexual intercourse and those who were threatened or bullied at school.

Those who didn’t get mostly A grades were also at high risk: Adolescents with mostly Ds and Fs were more likely to have acknowledged suicidal ideation than those with mostly As (adjusted odds ratio [AOR] = 3.2).

Gays and lesbians (AOR = 7.9 vs. heterosexuals), and bisexuals (AOR = 5.2 vs. heterosexuals) also showed sharply higher rates of suicidal ideation.

It’s not clear why Asian American adolescents may be at higher risk of suicidal ideation. The survey was completed prior to the COVID-19 pandemic, which spawned bigotry against people of Asian descent and an ongoing outbreak of high-profile violence against Asian Americans across the country.

Dr. Hansoti noted that Asian Americans face the pressures to live up to the standards of being a “model minority.” In addition, “very few Asian American adolescents are taken to a therapist, and few mental health providers are Asian Americans.”

She urged fellow psychiatrists “to remember that our perceptions of Asian Americans might hinder some of the diagnoses we could be making. Be thoughtful about how their ethnicity and race affects their presentation and their own perception of their illness.”

She added that Asian Americans may experience mental illness and anxiety “more somatically and physically than emotionally.”

In an interview, Anne Saw, PhD, associate professor of clinical-community psychology at DePaul University, Chicago, said the findings are “helpful for corroborating other studies identifying risk factors of suicidal ideation among Asian American adolescents. Since this research utilizes the Youth Risk Behavior Survey, these findings can be compared with risk factors of suicidal ideation among adolescents from other racial/ethnic backgrounds to pinpoint general as well as specific risk factors, thus informing how we can tailor interventions for specific groups.”

According to Dr. Saw, while it’s clear that suicide is a leading cause of death among Asian American adolescents, it’s still unknown which specific subgroups other than girls and LGBTIA+ individuals are especially vulnerable and which culturally tailored interventions are most effective for decreasing suicide risk.

“Psychiatrists should understand that risk and protective factors for suicidal behavior in Asian American adolescents are multifaceted and require careful attention and intervention across different environments,” she said.

No funding and no disclosures were reported.