• Posted September 11, 2023

Cancer Care Tougher to Access in U.S. If English Second Language

Much has been made of how a lack of English proficiency can interfere with a patient's ability to interact with their doctor and get the best health care possible.

But language barriers can prevent cancer patients from even getting in the door for a first visit with a specialist, a new study reports.

English speakers calling a general information line at U.S. hospitals succeeded nearly 94% of the time in either getting the number for a cancer clinic or being directly transferred to the clinic, results show.

By comparison, Spanish speakers moved to that next step only 38% of the time, and people speaking Mandarin Chinese only 28% of the time, according to findings published Sept. 6 in the Journal of the National Comprehensive Cancer Network.

"Disparities in access to cancer care for many patients start prior to that physician-patient visit,"said lead researcher Dr. Debbie Chen, a clinical instructor at the University of Michigan. "I think there's a significant need for really understanding those barriers upstream of the first patient-physician visit."

This inability to proceed from even the most basic contact with a hospital can have a profound effect on millions of Americans, Chen said.

More than 60 million people speak a language other than English at home, and more than 25 million have limited proficiency in English, according to 2010 Census stats cited by Chen. That's a sizable chunk of the overall U.S. population, which now stands at more than 330 million.

Most research on language barriers in health care focuses on patient-physician interactions, but Chen and her colleagues reasoned that clear communication is important even earlier in health care.

"When we think about access to care, a lot of it starts well before you see a physician,"Chen said. "Studies have shown that the hospital general information line generally serves as an initial entry point for many individuals, when they're trying to understand where to go for clinics or what services are offered in the hospital. And so we felt like it was a highly relevant site to evaluate access to cancer care."

For the study, callers speaking either English, Spanish or Chinese rang up 144 hospitals across 12 U.S. states between November 2021 and June 2022.

Nearly 1,300 calls were made, evenly distributed between the three languages. The callers specifically asked about colon, lung and thyroid cancer -- three cancer types that disproportionately impact Hispanic and Asian people.

The goal was to see who could get past that first contact with a hospital.

"The next step would be one, the telephone number for the clinic that they're asking about, or two, for them to be transferred to the clinic or department that would provide this kind of care,"Chen said.

Nearly all English speakers proceeded to the next step, while Spanish and Chinese speakers were far less likely to get past the initial informational call.

This isn't good for anyone who needs health care, but is particularly dangerous for someone with a cancer diagnosis, Chen said -- not only due to access at all, but also to the type of access needed to treat a person's cancer.

"For many cancer types, including thyroid cancer, seeing a high-volume physician is very important for patient outcomes,"Chen said. "And if you can't get information about how to access this clinic or what clinic to go to, you may not be able to see those physicians or you may not be able to get care in a timely manner."

The study also found that non-English speakers calling an academic hospital were 57% more likely to be successful in moving to the next step, compared to non-teaching hospitals.

"It seems like there's specifically differences in how much and to what extent hospitals are able to access language resources,"Chen said.

Chen noted earlier research that had found teaching hospitals were more likely to have staff interpreters, external interpreting agencies, or language telephone services.

"There was also a discrepancy in terms of the reimbursement for language-based services, in that non-teaching hospitals that were less likely to receive reimbursement compared to teaching hospitals,"Chen said.

"When you think about it, if you have less resources, you're probably less able to provide services for a specific population,"Chen said. "At the same time, it's hard to know why do these discrepancies exist."

Chen and her colleagues suggest that automatic messaging on general information lines should be sure to include instructions for accessing the message in different languages. The line also should default to a live person instead of disconnecting in instances where no input is made.

They also recommend that people manning the general information number remain on the line when connecting callers to a language interpreter. That way, they can be available to provide answers about the hospital that the interpreter might not know offhand.

"If their role is to interpret, they need something to interpret,"Chen said. "Oftentimes these language interpreters, some of which are external agencies, they can't provide the information because they're not hospital staff."

These results "actually do not surprise me, sadly,"said Maria Lugo, senior director for health initiatives for the Hispanic Federation, a Latino nonprofit that promotes health equity as part of its overall mission.

"We have seen that there are disparities in accessing information about health care resources among communities of color,"Lugo said. "This has been going on for years now, and this is why Hispanic Federation is very much actively working to address these disparities and promote health equity for people of color nationwide."

Lugo agreed that hospitals can help by providing more hands-on guidance for people with limited English skills.

"We definitely do see that when you give someone just information, not necessarily they're going to accept that information or pursue it,"Lugo said. "Sometimes you have to hold an individual's hand and walk them through the process, because the health care system is very complicated.

"When we get a phone call or when we meet someone in the community, we don't just tell them, 'Hey, go to this center,'"Lugo added. "We actually pick up the phone, we call the center, we connect them with an actual person so that it's easier to navigate."

Lugo also recommended that people with limited English skills seek out a federally qualified health center in the community meant to focus on underserved populations.

"There are a lot of federally qualified health centers that provide a lot of these services -- early cancer detection, early detection of any other chronic conditions -- and they're not utilized,"Lugo said. "Sometimes community members themselves are afraid to pursue any care, thinking that either they don't have health insurance or they have health insurance, but it's limited. And many of these centers have doctors that speak their language."

More information

The American Medical Journal has more about language barriers to health care access.

SOURCES: Debbie Chen, MD, clinical instructor, University of Michigan; Maria Lugo, MA, senior director, health initiatives, Hispanic Federation; Journal of the National Comprehensive Cancer Network, Sept. 6, 2023