Breast Care With Pride

[00:00:00] Adam Walker: From Susan G Komen, this is Real Pink, a podcast exploring real stories, struggles, and triumphs related to breast cancer. We’re taking the conversation from the doctor’s office to your living room.

[00:00:17] Happy Pride Month, y’all. If you’re a member of the LGBTQ plus community, finding culturally responsive, affirming healthcare in general can be challenging. But when you add a breast cancer diagnosis or even finding a provider who understands the importance of screening for this community because of unique risks, it becomes even more daunting.

[00:00:39] Our guest today is Dr. Chandler Cortina, a breast surgical oncologist and clinical outcomes researcher with the Cancer Center Frederick Hospital and the Medical College of Wisconsin Health System. As an openly gay man himself and an oncology provider, he has a passion for ensuring that safe breast health spaces exist for members of the LGBTQ plus community and that outcomes are similar to those To that of their cisgender heterosexual peers.

[00:01:06] Dr. Cortina. It’s a pleasure to have you on the show. Welcome 

[00:01:11] Dr Chandler Cortina: Thanks for having me Adam. I’m very happy to be here this afternoon 

[00:01:14] Adam Walker: me too, and i’m happy to have this conversation I think it’s a conversation. We don’t really think about nearly enough And so I appreciate the perspective you’re going to be able to bring to it for me and for our listeners So, before we begin I’d like to, you just sort of ground us in some definitions.

[00:01:31] So we’re all talking about the same thing. For those that may not know, can you talk about what LGBTQ plus stands for? 

[00:01:38] Dr Chandler Cortina: Yep. So this acronym has been developed over the years and the letters each stand for a different word. So LGBTQ plus has been the usual word or the usual acronym that people use.

[00:01:50] And that stands for lesbian, gay, bisexual, transgender, queer, and others, or questioning individuals. 

[00:01:59] Adam Walker: Okay, got it. And now that there are, I know there are further nuances that folks may not understand as well, and they include terms such as sexual and gender minorities. So can you tell us kind of what are those terms and what are the differences between those two things?

[00:02:17] Dr Chandler Cortina: Absolutely. So I think it’s really important for listeners to understand there’s a difference between sexual identity and gender identity. The sexual identity is who you’re attracted to or not attracted to. So that might be in your, you know, I’m a gay man. I’m a man who’s attracted to other men. So that means that I’m gay, but I’m cisgender, meaning that I, my gender is the same as the sex that I was assigned at birth.

[00:02:43] So, so sexual identity is who you’re attracted to. Gender identity is how you see yourself on the gender spectrum between You know, woman this and man this or some results in between on that spectrum. So gender identity and sexual identity are very different things, but they often kind of get lumped together as part of the, you know, LGBTQ plus sexual and gender minority group.

[00:03:07] But they’re, you know, they’re actually different things. 

[00:03:11] Adam Walker: You know, it’s funny hearing you describe that is so simple. I don’t know that I’ve ever actually thought of it directly in those terms before. I think maybe if you’d asked me, like, maybe I could have described it that way. But like the way you put it was so, it’s so simple, so well done.

[00:03:25] And it sort of frames the conversation really well. I appreciate you, you doing that. So with that understanding, can you talk about how folks in the LGBTQ plus community. Might experiences challenges with breast cancer screenings and breast health care in general. And what does that look like? 

[00:03:43] Dr Chandler Cortina: Yeah, so we know, unfortunately, that members of the LGBTQ plus community have a lot of different challenges around health care.

[00:03:51] And that’s been exemplified as well in the breast care space. So there’s really great national survey data where a group of researchers are a few years ago sampled national group of women, some of which were identified as. Cisgender heterosexual women, some who identified as cisgender, lesbian, or bisexual.

[00:04:13] And what we found is that about 80 percent of cisgender heterosexual women reported getting a mammogram in the past year or two. But that number was less than 60 percent for lesbian and bisexual women. And so we know just when we’re looking at screening amongst straight women and lesbian and bisexual women, there’s this huge gap in terms of who’s actually showing up and getting a mammogram.

[00:04:37] And we know that mammograms are, you know, that they’re life saving. They cut breast cancer at a much earlier stage. Allowing for much better outcomes and long term prognosis. Additionally, you know, there’s data showing around you know, how this might impact survival outcomes as well.

[00:04:58] So so, you know, a group last year at Stanford, and this study was published in JAMA Oncology, I actually looked at about 100 women who are either lesbian, bisexual, or identified as trans. And they compared them to some patients who had similar age, similar, similar age, similar race, similar tumors, that were cisgender.

[00:05:22] And they actually found that patients who are non heterosexual, non cisgender, We’re more likely to be diagnosed with breast cancer at a later stage, and more likely to have a breast cancer recurrence or die from breast cancer. 

[00:05:37] Adam Walker: And I’m assuming that’s a direct reflection of the earlier statistic you said.

[00:05:41] I think you said 80 percent of cisgender heterosexual women were getting screenings, and 60 percent of cisgender bisexual lesbian women. Is that what you said? 

[00:05:51] Dr Chandler Cortina: Yeah, that’s exactly correct. And so 

[00:05:53] Adam Walker: because they’re not getting the screenings when they finally do get the screenings, they’re catching the breast cancer at later stages and they’re having poor outcomes by because of that, right?

[00:06:03] Dr Chandler Cortina: Exactly. So breast cancer screening, the goal of it is to detect disease that, you know, we can’t detect as physicians on physical exam or that patients we can’t, you know, no one can feel them. So the goal is to catch these things really early before anyone has any symptoms or anyone can notice them. And so we know that if you, if people are not getting screening mammograms and are being diagnosed with breast cancer, it’s usually because someone felt it.

[00:06:30] And usually that means that it’s a little bit larger. Usually it means that it’s a later stage of diagnosis. 

[00:06:36] Adam Walker: Yeah. Now, has there been any research or around why that there’s that disparity between 60 percent and 80 percent at all? 

[00:06:46] Dr Chandler Cortina: Yeah, so there’s been a lot of research around, you know, what are the challenges that sexual and gender minority groups are facing in terms of getting breast cancer screening, as well as other health care measures, and a lot of it has to do with fear of discrimination.

[00:07:02] So a vast majority of LGBTQ plus persons. Whenever they go to the doctor, go to the hospital, go to clinics, report having some sort of discriminatory action against them. Sometimes these things can be like overt discriminatory things, but sometimes they can just be microaggressions, right? So not using appropriate names, not using appropriate pronouns you know, facial cues, body language.

[00:07:28] So really subtle things that just make people feel uncomfortable and that show some of the biases that do exist. And so. That, in and of itself, has led to a lot of people not really wanting to go see doctors, not really wanting to go to clinics or to hospitals, because you just never know how you’re going to be treated or be viewed and, you know, there’s been a lot of strides in healthcare nationally over the past couple of decades to make medicine a more inclusive space for patients and for providers and for everyone but, you know, it’s not, still not where it should be.

[00:08:04] Adam Walker: I hate hearing that. That’s just, that’s not how it should be. You’re right. That’s not. 

[00:08:10] Dr Chandler Cortina: You’re right. And you know, there’s been progress. Adam, there’s still a lot more work to do. And so I think it’s important that we acknowledge the progress that has been made. 

[00:08:18] Adam Walker: Right. 

[00:08:19] Dr Chandler Cortina: But there’s still a long ways to go. 

[00:08:21] Adam Walker: I just hate for anybody to feel bad when they’re going to get, healthcare.

[00:08:24] I mean, they, you know, like, okay, well, moving on to the next question. That’s just it’s upsetting. I hope it’s upsetting to our listeners too, but so, so what can patients do to find culturally responsive providers and advocates and to advocate for themselves in the process of trying to get screened and or managing a diagnosis?

[00:08:48] Dr Chandler Cortina: Yeah, so I think I think one of the easiest ways that people can find providers who can you know, who are educated and want to provide inclusive and safe spaces is to ask around, right? If you have friends, family members, neighbors, other people in your community who identify as LGBTQ or don’t know of providers who are welcoming, inclusive.

[00:09:14] I think that’s a great way to just figure out who in your community, your health systems, you know, cares for LGBT plus patients in a safe space. You know, sometimes you can just pop online, look at different for different providers. Some of them will list. You know, that they care for LGBTQ plus patients or that they identify as an ally or sometimes really simple things to like, does this person include their pronouns, you know, on their face sheet or, you know, whenever they’re you know, if you go to a community event, how do they present themselves?

[00:09:49] Like, do they seem like someone who would be a welcoming sort of provider? And I think those are the sorts of things that I encourage patients to do. And then also, you know, if you have a good relationship with a primary care provider, whether that’s a nurse practitioner, physician assistant, medical doctor, an OBGYN, whoever that is, you know, say, you know, who would you recommend that I go see?

[00:10:14] And if they say a name, say, well, you know, are they going to. The accepting of who I am and are they gonna, you know, see me as a whole person and a lot of times, you know, physicians are in primary care providers. We’ll be really honest with you about that. And they, a lot of times, you know they’ll send you in the right direction.

[00:10:32] Adam Walker: Yeah. Oh, that’s great advice. And from the providers perspective, like let’s say there’s a provider, they want to learn and better understand how to care for the LGBTQ plus community. Where, like when it comes to breast health, like where would they go? What will they do? 

[00:10:48] Dr Chandler Cortina: That’s a really great question, Adam.

[00:10:49] So, you know, I was in med school, you know, a little over a decade ago, and LGBTQ plus health was not something that we really learned about. No one really talked about it. But over the past decade, there’s been huge strides in medical schools, allied health schools to make this part of the curriculum in terms of, you know, what are the challenges?

[00:11:11] How are things the same? How are things maybe different? And so I think it’s I think I just want to highlight the progress that is being making in medical education nowadays. But for those of us who are out of school and in clinical practice, finding those sorts of resources are going to be really important.

[00:11:29] integral to providing truly inclusive care. And so, you know, the National LGBTQIA plus Health Education Center is available online. It has a lot of really great resources and information about just general health for LGBTQ plus patients. The human rights campaign as well has a section about, you know, being a patient, what questions to ask, what to look for.

[00:11:53] And as providers, you know, there is a huge responsibility for us to read medical journals, to go to conferences, to ask these questions, and for these international conferences to include LGBTQIA plus initiatives as part of those discussions. I know this past year, you know, some of our meetings for the Society of Surgical Oncology, American Society of Breast Surgeons, you know, there were whole sessions dedicated to.

[00:12:22] sexual and gender minority patients and how we can be doing a lot better for them as providers, both from providing clinical care today, but also which sort of research questions, which sort of clinical trials we need to be thinking about and designing to move that information forward in the future. 

[00:12:39] Adam Walker: Dr.

[00:12:39] Jim Hawkins That’s great. And I understand you’re doing research in this area. So could you tell us about what type of research are you doing to better understand and improve these outcomes? Dr. Jim Hawkins 

[00:12:49] Dr Chandler Cortina: Yeah, so, you know, I’ve been really lucky. I’m here at the Medical College of Wisconsin. We have a really great clinical team and research team, and in 2018 our hospital system established the first independently standing inclusion health clinic in the state of Wisconsin.

[00:13:05] really focused on providing broad care for the LGBTQIA plus population. And a lot of my research is trying to understand how gender affirming care, so gender affirming hormones with estrogen and testosterone, as well as gender affirming operations such as top surgery, might affect how we think about screening for breast cancer in the future, might affect breast cancer risk, or how we treat breast cancer. 

[00:13:31] Trans or gender diverse patients who do develop a breast cancer. And so we’ve been really lucky. We actually just completed a study last year funded through the Advancing a Healthier Wisconsin Endowment looking at how if someone’s assigned female sex at birth, and it’s thinking about having top surgery, but looking at, well, what’s their baseline breast cancer risk?

[00:13:55] And, you know, should we think about conventional top surgery or should we think about maybe doing formal? Risk reducing mastectomies to really minimize future breast cancer risk. We’ve also been really lucky that we have funding from PCORI. It’s the Patient Centered Outcomes Research Institute to form a community collaborative.

[00:14:14] So we have researchers, healthcare providers, community members who come together a couple times a month to kind of think about What are some research questions that we can be asking that really affect trans healthcare from a policy to biology to clinical level to start trying to figure out, you know, how can we eliminate these disparities, but what sort of questions do we need to be asking to get us there?

[00:14:41] And then, you know, we also have a a prospective breast cancer screening study for trans and gender diverse patients. So there’s not really any great data at all, especially prospectively on how we should be thinking about screening trans and gender diverse patients for breast cancer. And so this study just opened up earlier this year, will be open to, will be open for the next four years.

[00:15:08] And this is funded through the National Cancer Institute. And we’re really hoping that the data we get from this screening study will help to better inform. breast cancer screening guidelines specifically for trans and gender diverse persons. 

[00:15:24] Adam Walker: Wow. Sounds like you’re you’re doing a lot. That’s all sounds fantastic.

[00:15:30] Dr Chandler Cortina: Yeah, it’s great work. It keeps us busy. But, you know, the thing that, that I think, you know, really keeps us going really keeps us driving is, you know, we really, we talk about cancer equity a lot. And, you know, for over the past couple of decades, there’s been some really great work done primarily about around race and ethnicity.

[00:15:49] But I think people have really not thought about or asked questions about the LGBTQ plus population. And part of that is because, you know, You know, skin color, someone walks into the clinic, you can usually tell if they’re white, black, Asian. But you can’t always tell if someone comes in if they’re gay or if they’re maybe trans.

[00:16:13] And so it’s been kind of this, you know, lack of visibility that I think has led to us kind of falling behind as cancer researchers and clinicians and moving the needle forward. And so I think if I think it’s really important as part of cancer equity and providing equitable care for everyone. That we really think about all the different diverse populations that exist and how we can make sure that everyone has the best outcome If they have a cancer diagnosis, 

[00:16:39] Adam Walker: that’s right.

[00:16:40] That’s right. I really I really admire that and I admire the work that you’re doing It’s so important so I guess my last question What advice would you offer for someone that’s listening to this or maybe know someone that’s listening, that should listen to this that feels their healthcare provider is not affirming or particularly responsive to their needs as an LGBTQ plus individual?

[00:17:02] Dr Chandler Cortina: Yeah. Well, first of all, I would say, I’m sorry that they’re facing that sort of challenge nowadays. I think there’s a couple of things they can do. They can challenge their provider and ask them, you know, are you uncomfortable treating for me? Are you uncomfortable treating me? Is there something that maybe you don’t know that I could help you find out? 

[00:17:24] And don’t be afraid to ask, you know, do, you know, someone else that might be a better fit for me from a as a provider, and I think sometimes, you know you know, I’m as part of this community work group that we have, you know, it’s interesting because, you know, a lot of times we think about providers being you know, kind of being really comfortable being very confident people.

[00:17:54] But sometimes, you know, if a provider is faced with a LGBTQIA plus patient sometimes the provider on their side can sometimes be a little bit nervous to make sure that they’re being affirming and inclusive. And sometimes that means that they’re nervous that they might say the wrong thing. They might not know what the right thing to say is.

[00:18:16] And so sometimes, you know that can sometimes come off to others as, you know, Then being uncomfortable when in all actuality, it’s not that you as a patient’s making them uncomfortable. They’re uncomfortable with their own lack of knowledge, lack of how to appropriately, you know, say things.

[00:18:35] And so I would also encourage people to to try and take that lens a little bit and look at through the, look through the provider’s eyes sometimes. Because having these conversations with some of the people, even here where I work, You know, they say, I want to do better. I want to be great, but I’m nervous.

[00:18:53] I don’t know enough. And I think that can sometimes come off as uncomfortable or annoying to patients when in all actuality. The provider wants to do a good job, they just don’t quite know how, unfortunately. 

[00:19:07] Adam Walker: And that also would have never occurred to me, that maybe they’re uncomfortable and awkward because of themselves rather than because of the patient at times.

[00:19:18] Dr Chandler Cortina: Yeah I know one oncologist here who is caring for a trans patient. And they were like, I’m just so nervous and say the wrong thing. I want to make sure they’re comfortable. I want to make sure that they know that I care about them. And I was just like, just tell them that and say, you know, I use the wrong pronoun or use the wrong name.

[00:19:34] It’s not intentional. And as long as you’re trying your best and being. Honest, because, I mean, at the end of the day. We’re all people. We all just want to take care of each other. And I think it’s important for people to be open and honest and vulnerable and humble. And that’s what I really encourage physicians who come to me with these sort of questions or these sort of feelings to do.

[00:19:56] And then I try and steer them in the right direction of, okay, let’s figure out how we can get you some better education on. understanding what different gender terminology is, you know, what is appropriate anatomical descriptions, what’s probably not. So anyway. 

[00:20:13] Adam Walker: Wow. Okay. That was a great discussion.

[00:20:16] I really appreciate all the things that you shared. Do you have any final thoughts that you’d like to share with our listeners before we go? 

[00:20:23] Dr Chandler Cortina: No, but, you know, my final thoughts are, you know, it’s pride month. It’s a great time to celebrate being an LGBTQ plus person or being an ally. I want to thank Komen for the opportunity and for highlighting this.

[00:20:35] And I really want to encourage that. Anyone out there who is nervous to see your provider nervous about getting a screening mammogram don’t be. I want to really encourage you to, you know, put yourself first and put your health first. And, you know, get your screening mammograms. If you have questions, notice something different, bring it up to your provider.

[00:20:56] Be an advocate for yourself and know that there are a lot of resources out there and a lot of people out there who care about you and want to make sure that you get the best health care possible. 

[00:21:06] Adam Walker: That’s right. That’s why we’re having this discussion because we do care and a lot of people, a lot of people care.

[00:21:11] Well Dr. Cortina, thank you so much for your time today. Thank you for everything you shared. 

[00:21:16] Dr Chandler Cortina: All right. Thanks for having me, Adam.

[00:21:23] Adam Walker: Thanks for listening to Real Pink, a weekly podcast by Susan G Komen. For more episodes, visit realpink. komen. org and for more on breast cancer, visit komen. org. Make sure to check out at Susan G Komen on social media. I’m your host, Adam. You can find me on Twitter at AJ Walker or on my blog, adamjwalker.

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