Equally distressing, even when their ages and general health were similar, her Black patients were far likelier than her white patients to die from the disease, which had a dismal five-year survival rate of 18 percent to begin with. It was a revelation and a life-changer. Dr. Guerra retooled her career to address the problem. Today, armed with a master’s degree in clinical epidemiology alongside her other medical credentials, she battles health disparities at a lung cancer ground zero: a West Philadelphia community where it’s often the environments in which people live, work, and otherwise function (also known as the social determinants of health) that threaten their health and well-being. As part of Closing the Cancer Gap, a continuing series on cancer disparities, Guerra explains how her own background — the environments in which she lived and learned — informed her lifelong mission: to bring the best, most equitable lung cancer screening and treatment to everyone. This interview has been edited for length and clarity. Everyday Health: Your family endured considerable hardships emigrating from Honduras. How did that affect you? Carmen Guerra: My family left Honduras for New York with limited resources, little familiarity with the United States, and no English. I remember being yanked out of my country and facing poverty, discrimination, and the feeling of being an outsider in America. For the first months in the United States, we experienced what is now called “housing insecurity” as my parents and I crashed on relatives’ sofas and crowded into small apartments in Queens, New York. The situation made accessing consistent family healthcare difficult. My father eventually found a job as a maintenance worker, and my mother worked as a house cleaner. Both had sixth-grade educations. Gradually, they saved enough to find an apartment and begin to dream about one day sending me to college. EH: How did your school experience lead to medical school? CG: In the beginning, I was constantly picked on because I didn’t speak English. I learned the language pretty quickly, but those early days always affected my self-confidence, even after I began to do quite well in school. I considered becoming, for example, the very first person in my family to go to college, but I wasn’t sure I could succeed. So I applied to the closest community college, a few blocks away. When my adviser found out, he scolded me. He said I could do better and should aim higher, since I was a good student. I applied to New York University, was accepted, and earned an undergraduate degree in psychobiology. Twenty years later, when I wanted a master’s degree in epidemiology, I attended the University of Pennsylvania. By then, I’d long ago finished medical school at the University of Rochester in upstate New York, which I discovered — would you believe — from a New York City subway tile, and I’d joined UPenn’s Perelman School of Medicine. EH: Why the focus on lung cancer inequities? CG: Partially because I grew up around a smoker, my father. When he was found deceased of unknown causes in Honduras, I suspected that smoking played a role. Partially because I was surprised about the percentage of my Black patients diagnosed with lung cancer. Even when their ages and general health seemed similar, these people had more lung cancers, were sicker, and had more advanced disease than white patients. I wanted to understand why and how to help. EH: How serious are lung cancers? CG: They’re deadly, accounting for almost one-quarter of all cancer mortality annually in the United States; more than for colon, breast, and prostate cancers combined. And they’re particularly devastating for Black Americans. The AACR Cancer Disparities Progress Report 2022 [PDF], from the American Association for Cancer Research, says lung cancers are the leading cause of cancer-related mortality among Black men, who have a 12 percent greater chance of developing lung cancer than white men. That’s whether they smoked or not. Lung cancer is also the second leading cause of cancer death among Black women. Because it doesn’t generally produce symptoms until quite advanced, it’s difficult to catch early. Insurance companies cover screening for adults ages 50 to 80 who smoked 20 packs a year, currently smoke, or have quit within the last 15 years. But this blanket recommendation doesn’t benefit Black Americans who tend to develop the disease earlier in life. It’s another reason we need to tailor screening to different people’s cancer realities. That’s what’s meant by equitable versus equal treatment. EH: How difficult is it to screen for lung cancer? CG: The good news is that the noninvasive, low-dose computer tomography scan is simple and effective. It can detect a cancerous lung nodule before it becomes deadly. That alone could increase survival rates by about 20 percent. But here’s the catch, as the cancer disparities report reveals: Black smokers are 3 times less likely than white smokers to be screened. EH: Why do these cancer health disparities persist? CG: Early in medical school, we learned that only 20 percent of healthcare occurs within a doctor’s office. The other 80 percent originates outside the medical setting, where social determinants of health — one’s home, work, shopping, and recreational environments — are far more influential. In low-income areas, those determinants, including the built environment of housing, transportation, open spaces, playgrounds, sources of drinking water and air pollutants, and other human-made factors, can put people at a healthcare disadvantage. For example, a study in the April 2020 issue of the American Journal of Public Health reported that Philadelphia has roughly twice as many tobacco retailers per 1,000 people (2.21) as other major cities. Because many are near schools, young people here tend to get hooked on tobacco early. Another example: West Philly is among 6,500 “food deserts” [PDF] in the United States, where affordable fresh, healthful foods are virtually nonexistent, while highly processed, salty, sugar-laden foods are abundant. Junk foods, the cancer disparities report notes, worsen obesity and diabetes, and promote inflammation, which increase cancer risks. In terms of screening, consider how difficult it is to get to a medical appointment when you don’t have a car and can’t afford the time and expense of a bus ride, taxi, or car service. Many people hold multiple jobs, with little or no insurance, paid time off, or sick days, while providing unpaid care for ill relatives. And by the way, there’s limited state funding for screenings. Also, most medical visits occur on weekdays, when it’s toughest to get around and to take time off. So you risk losing wages, spending hours in transit, leaving a loved one uncared for, and paying for services not covered by insurance — all for a disease you probably don’t know you have. We have to bring greater attention to the availability of these tests, make them more accessible, and build more trust into healthcare. EH: Trust — talk a bit more about that. CG: A major survey on race and health published in October 2020 found that some Black Americans feel that doctors don’t believe them, don’t take them seriously, and don’t prescribe adequate pain relief. Then there’s the still lingering suspicion of American healthcare created by the 1930s Tuskegee Airmen experiments, in which Black men were subjected to cruel medical experiments. And even in the 1960s, many hospitals in the United States were still segregated. Beyond historical abuses, structural racism has left some Black Americans reluctant to seek care and skeptical about the motives of medical professionals. Limited trust can lead to misconceptions. For instance, there’s this persistent fear that when a medical procedure exposes the lungs to the air, it disseminates disease throughout the body. That’s absolutely not true. Programs can address transportation and insurance issues, and regulate tobacco, but trust and faith in the system are harder to instill. EH: You’ve successfully emulated your role model, Harold Freeman, by launching a navigator program to try cutting adverse social determinants down to size. Tell us about that. CG: Harold Freeman, MD, is a preeminent cancer specialist and former head of Harlem Hospital. Following his lead, I launched a navigator program at UPenn for colorectal cancer screening, since that’s where I received initial funding from a donor, the American Cancer Society, and other organizations. Over the years, we’ve added breast and lung cancer navigation programs. Trained navigators follow patients throughout screening and treatment, helping them make appointments, find transportation, hire interpreters, locate caregivers — whatever it takes to get them to the doctor. The program started in 2011 and by its third year had helped 763 people complete doctor-requested colonoscopies. Today, 19 navigators eliminate whatever obstacles keep people from completing tests and treatments at West Philly’s UPenn health centers. EH: What’s next for the program? CG: It’s still evolving. We’re hoping for legislation that will allow us to bill federal health insurance programs for patient navigation services. The funds are needed to offset a drop in cancer testing during the pandemic. We’re also seeking grants to add navigators and possibly extend our services to other parts of Philadelphia. And we’d like to see college-level navigator training expanded. The Harold P. Freeman Patient Navigation Institute began preparing navigators at Harlem Hospital in 2008, and George Washington University in the District of Columbia offers navigation training, but we need more. Meanwhile, the Academy of Oncology Nurse and Patient Navigators brings professional oncology navigators together. It’s not yet a regulated industry, but we hope that changes. We’re using Dr. Freeman’s strategy and going to local churches, community organizations, housing projects, barber shops, and beauty salons to identify people eligible for screening. And my colleagues and I are writing a grant proposal to bring a specially outfitted “lung bus” for mobile appointments here to Philadelphia for people who can’t easily get to healthcare appointments. EH: If you had the wherewithal to eliminate lung cancer disparities, what would you do? CG: I’d secure more role models for younger people considering oncology. I’d build on the terrific mentorship programs for aspiring oncologists and help boost efforts to recruit minorities for clinical trials, which overwhelmingly have white patients. Given my history, my initial lack of self-confidence, I know how important it is to have people and networks to support and encourage you. My husband — he’s a cardiologist I met in college — has always been my biggest cheerleader. My parents reassured me that I wasn’t abandoning the family by attending medical school in Rochester, that my getting an education was the reason we came to this country. My mom moved in to help with our three children 21 years ago with our firstborn; she’s been another source of encouragement for me. I think of the oncologist who interviewed me at Rochester and took me on as a mentee. He demonstrated what it means to be emotionally intelligent, supportive, and kind — skills you need when giving someone a cancer diagnosis. People like these helped me become an expert on health disparities. I’m now sitting on the National Cancer Institute advisory board that’s evaluating liquid biopsies. These are low-cost, easy-to-administer blood tests that pinpoint DNA and RNA proteins released only by tumors, never by healthy cells. They might eventually detect lung cancers four years earlier than is now possible. In the past, new technologies often made health disparities worse. I’m in a position to help keep that from happening with this technology and to ensure that if its promise is ultimately realized, it will benefit all communities.
