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Expert Critique

FROM THE ASCO Reading Room

Christy Walters Haygood, MD Physician St. Dominic's Jackson Memorial Hospital, Gynecologic Oncology

Recent studies have shown that a negative perception of the patient鈥檚 disease can lead to lower quality care for many disciplines. This was recently demonstrated in a study by Dr. Jeff Stone and colleagues from the University of Arizona at Phoenix. They included 151 study participants from gynecologic oncology associations and evaluated negative emotions and prejudices, as well as negative beliefs and stereotypes. Ovarian cancer was used as the neutral comparison disease. More often, participants associated cervical cancer with anger and frustration and ovarian cancer with empathy. They also showed implicit stereotyping with associated cervical cancer patients with risky behavior. When separated out, nurses were found to be largely the cause of this implicit bias. This has been shown in other literature and reinforces the need for evaluation into why specific groups have higher bias than others. It is also prudent to note that providers who have participated in cultural competency courses scored significantly lower on stereotype test scores than those who had not.

In a similar vein, the poor uptake of the HPV vaccine may be due to implicit bias, or the lack of effective recommendations from physicians, according to Dr. Caitlin Hansen and colleagues at the Yale School of Medicine. This bias was typically in the form of three types of cognitive bias including anchoring bias where the patient's age or pubertal status seems to be a deterrent to further discussion of the vaccine. Optimism bias relates to clinicians conveying a patient鈥檚 low risk of HPV infection to allow for delaying the vaccine. The other form noted was present bias, that discussion of the vaccine would be uncomfortable with the parents in the room for an adolescent.

All of these forms of bias deserve further discussion with clinicians to discourage this behavior and potentially improve our vaccine rates as well as improving our patient care for this population.

Full Critique

Unconscious biases held by some clinicians about cervical cancer and the HPV vaccine could negatively impact quality of care and outcomes for patients, new research suggests.

"In the domain of healthcare, several studies show that providers hold negative implicit associations toward a variety of patient groups, and that these negative implicit associations relate to lower-quality care for patients," Jeff Stone, PhD, a psychologist at the University of Arizona in Phoenix, and colleagues noted in . They said they believe the study provides the first evidence that gynecologic oncology providers hold implicit biases related to cervical cancer, and the team urged interventions targeting specific groups to improve interactions with patients.

In related research, Stone and co-authors noted, suggested that some healthcare providers hold implicit negative attitudes toward patients with lung cancer, and found that implicit racial bias toward African-American cancer patients was associated with lower quality of care.

"This evidence, along with some research in social psychology, suggests that healthcare professionals with stronger negative emotions and beliefs about women with cervical cancer may engage in less friendly interpersonal behavior or make treatment decisions that could be influenced by such emotions and beliefs," study co-author Katherine Wolsiefer, PhD, told the Reading Room via email, cautioning, however, that the evidence so far remains correlational only.

Past research has shown that in the general public, the belief is common that "women are to blame for their cervical cancer," because the disease is linked to sexual activity. Stone, Wolsiefer, and colleagues investigated whether this attitude was also prevalent among doctors and nurses.

The study included 151 participants (93 physicians and 58 nurses) recruited from professional gynecologic oncology associations. Participants took two Implicit Association Tests: one assessed negative emotions and prejudices, and the other assessed negative beliefs and stereotypes.

The tests consisted of word-association tasks in which respondents' reaction times and error rates were used to calculate how strongly the professionals associated particular characteristics and attributes with cervical or ovarian cancer patients. Ovarian cancer was chosen as the neutral comparator. Words such as "reckless," "liable," "sensible," and "justifiable" appeared on a screen, and participants had to quickly indicate whether they associated the words with "cervical cancer and anger" or "ovarian cancer and empathy."

The measure of bias generated by these tests is called a d-score. The more significantly this score differs from 0, the stronger the implicit bias. Overall, participants showed a significant level of implicit prejudice toward cervical cancer patients (mean score=0.17, SD=0.47, 95% CI 0.10-0.25), the investigators said. "Providers associated cervical cancer with emotions related to anger/frustration and ovarian cancer with empathy to a greater degree than the reverse."

Participants also showed significant levels of implicit stereotyping of cervical cancer patients (mean score=0.15, SD=0.42, 95% CI 0.80-0.21) -- "suggesting that providers more strongly associated cervical cancer with words related to risky health behavior, and ovarian cancer with words related to lower risk behavior," Stone's group said.

However, further analysis revealed it was largely the nurses, and not the doctors, who were responsible for these results. Nurses scored significantly higher than doctors on the prejudice test (0.32 vs 0.08, P<0.01) and the stereotyping test (0.32 vs 0.04, P<0.001), the results showed.

"In our study nurses expressed significantly greater prejudice and stereotyping of cervical cancer patients compared to physicians, which is consistent with the current literature, and suggests the need to understand why specific groups report higher implicit bias than others," the investigators said. "For example, nurses may have more extended contact with cervical cancer patients than physicians ... through negative contact, more experience caring for cervical cancer patients may engender more negative emotions and beliefs."

Training to Reduce Bias

Another key finding in the research was that implicit bias and cultural competency training could mitigate prejudice and stereotyping. For example, stereotype test scores were significantly lower for participants with implicit bias training compared with those without (0.06 vs 0.21, P<0.05). In addition, "although providers with and without cultural competency training demonstrated significant implicit stereotypes, implicit stereotypes were stronger for providers who reported never having participated in such training," the investigators said.

Cultural competency and implicit bias training seminars are increasingly being offered by employers, Wolsiefer noted. The U.S. Department of Health and Human Services also offers an online, self-directed cultural competency that counts towards continuing education for physicians, nurse practitioners, and nurses. "I can't personally speak to the effectiveness of any of these programs, but our lab is currently exploring whether and how training may be used to improve patient care," she said.

"Although it may be reasonable to assume that healthcare providers are particularly motivated to be egalitarian, they hold intergroup implicit biases similar to those of the general public ... The role of training in countering bias and improving patient care remains an open question," Wolsiefer continued. "Several lab groups, including our own, are currently conducting studies to better understand what types of training and/or strategies might be most effective for mitigating biases. That said, some evidence from social psychology suggests that slowing down and taking a moment to individuate the patient (i.e., consider the person as an individual) may be particularly helpful."

Cognitive Bias and the HPV Vaccine

Uptake of the HPV vaccine remains poor. In 2017, less than half (49%) of adolescents were up to date with the multi-dose HPV vaccine series, which is much less than for other vaccines. A major barrier to better uptake is the lack of effective recommendations from clinicians, researchers led by Caitlin Hansen, MD, of the Yale School of Medicine in New Haven, Connecticut, wrote online in .

"Studies have shown that the recommendations clinicians provide for the HPV vaccine frequently deviate from these best practices: the HPV vaccine is often presented as optional, not urgent, and less important than the other vaccines that are routinely recommended for adolescents," the team said. "One potential influence on clinicians' recommendations for the HPV vaccine that has been relatively unexplored is that of cognitive biases, or errors in judgment that result from 'mental shortcuts' used to make decisions under uncertainty."

Hansen's group conducted in-depth interviews with 32 clinicians -- primarily physicians trained in pediatrics and in private practice. They analyzed transcripts of these interviews for evidence of specific cognitive biases. "Interview questions were not designed to elicit information about cognitive bias from clinicians explicitly," the researchers said. "Rather, we used their descriptions of experiences to identify emergent topics related to biases."

The investigators identified three frequent types of cognitive bias related to HPV vaccine recommendations and illustrated each with quotes from the interviews:

• Anchoring Bias: The study found many instances where an initial impression of a patient, such as age or pubertal status, were "anchored" by the clinician in the context of discussing HPV vaccination. For example, several clinicians reported they might deprioritize a discussion about HPV vaccination for patients who appeared to be "late bloomers" or socially immature adolescents. As one clinician said, "For the 13-year old who has never had her period ... and the parents are very squeamish about vaccines, I might focus on other issues that visit, and choose to bring it up at the next visit."

• Optimism Bias: Clinicians often felt optimistic about a patient's low risk of HPV infection. The belief the patient would not be at risk until later in adolescence allowed them to delay recommending the vaccine. One clinician said, "I'm not gonna really push it unless they're going to college ... or if I'm suspicious that they're sexually active."

• Present Bias: Clinicians often assumed that recommending the vaccine would lead to an uncomfortable discussion with parents about the sexual nature of the virus which could preclude discussions about other health issues. In other words, the anticipation of discomfort in the present moment weighed more heavily in their minds than the long-term consequences of the patient not being vaccinated. "I have a few patients that are religious ... sometimes I feel hesitant talking about these things, especially with the parents, like, 'What are you accusing my kid of being and doing?'" one physician said.

"These findings should prompt clinicians to examine their own assumptions and motivations behind their current HPV recommendations and can be used to develop interventions with greater likelihood of success in promoting higher vaccination coverage," Hansen and colleagues said.