Breaking down barriers: Language and survival outcomes after transplant

From the Lee Lab, Clinical Research Division

Significant health disparities persist in healthcare across the United States (US). Patients from underrepresented communities who have faced marginalization and exploitation are less likely to have equitable access to high-quality healthcare, which reduces quality of life and can increase disease burden for these communities. One such barrier to access is language. Hundreds of languages are spoken across the US, and studies have shown that non-English speakers are faced with a multitude of challenges not necessarily faced in kind by English speakers. These challenges include reduced access to needed healthcare services and exclusion from clinical trials due to language or literacy barriers, although they are otherwise eligible, and a lack of adherence to after-care guidelines due to a decreased understanding of what is required. While the presence of patient-centered services (e.g., interpreter services, informed consent available in multiple languages, patient navigators) can aid in mitigating these disparities, significant issues remain. In the realm of hematopoietic cell transplantation, meaningful communication is essential after procedures to ensure the best possible outcomes and to reduce risk of treatment-related adverse effects.

A recent study led by Ahona Mukherjee a clinical research coordinator in Dr. Stephanie Lee’s Lab, part of the Clinical Research Division at Fred Hutch, sought to determine whether language barriers play a role in survival outcomes for patients who undergo hematopoietic cell transplantation. Specifically, the study assessed whether non-English speakers have poorer survival outcomes. While their study, recently published in Bone Marrow Transplantation, observed a greater risk of graft-versus-host disease (GVHD -  a disease state wherein donor cells attack the endogenous cells of the transplant recipient) in non-English speaking patients, this patient population did not have worse survival outcomes than their English speaking counterparts. Describing the goal of their study Mukherjee said “an important goal of healthcare is that there's equity in access and quality. Language barriers between patients and physicians can introduce obstacles to the physician-patient relationship, which can impact many steps of care - discussion of diagnosis, treatment, and follow-up, among others. One angle to look at this from is whether potential language barriers are negatively impacting treatment outcomes, which could result from the previously mentioned obstacles.” Elaborating further, Dr. Lee said “transplantation is such a complex procedure and language barriers could affect every interaction from talking about side effects, to discussing new symptoms, to giving instructions about taking a new medication, to scheduling appointments etc. Fred Hutch Cancer Center and UW have very good interpreter services but there could still be gaps in communication. It was reassuring to see that major outcomes like survival did not differ between non-English speakers and English speakers.”

Non-English speakers did not have worse survival outcomes after hematopoietic cell transplantation compared to English speakers.
Non-English speakers did not have worse survival outcomes after hematopoietic cell transplantation compared to English speakers. Figure provided by Ahona Mukherjee.

To address their question, the authors assessed all transplants that took place between 2015-2019 at Fred Hutchinson Cancer Center and divided patients into non-English and English-speaking groups based on their preferred reported languages and request for professional interpreter services. The authors employed Cox statistical models to determine differences in outcomes between these two groups, including overall survival, relapse, and rates of GVHD. The most frequent primary languages among non-English speakers were Spanish and Vietnamese. Notably, no differences in overall survival were observed between non-English and English speakers either in unadjusted models or in models that included an adjustment for clinical parameters such as type of transplant, disease stage or age. Further, no differences were observed between groups with regards to relapse rates, non-relapse mortality or time to discharge. Interestingly, a two-fold higher risk of acute GVHD was described by the authors for non-English speaking patients. The authors note that additional studies in multiple cancer centers with a broader patient population will aid in further elucidating these findings and addressing increased risk for this patient group.

Acknowledging barriers and providing equitable access to all aspects of the healthcare system will improve outcomes for patients. The authors are keen to point out that while in this study language did not appear to have a role to play in survival outcomes after transplant, significant health disparities remain commonplace, and they are focused on determining how to better understand and address the needs of patients who face them. “It is good news that we found no differences in survival outcomes, but that doesn’t necessarily mean the transplant process is equitable at every step. There are many more aspects of the treatment journey that could be impacted by a language barrier. Of those, an additional variable that we could not fully address is the caregiver, their language preference, and how it impacts care. We also hope that other institutions conduct similar research to broaden our understanding across many regions,” explained Mukherjee. Dr. Lee continued, “We still are trying to figure out exactly why disparities in outcome occur in hematopoietic cell transplantation and how to overcome them. If a different primary language doesn’t contribute to the worse outcome, then what other factors do and how can we better address them? Also, our study only looked at people who had a transplant – it doesn’t say anything about which patients were referred to consider transplant and which ones successfully underwent the procedure. We know there are a lot of disparities in who gets referred too.” Their team will continue to address existing disparities in hematopoietic cell transplant research in future studies. 

This work was funded by grants from the National Cancer Institute.

UW/Fred Hutch Cancer Consortium members Dr. Ted Gooley, Dr. Marco Mielcarek, Dr. Brenda M. Sandmaier, Dr. Kristine Doney, Dr. Leona Holmberg, Dr. K. Scott Baker, Dr. Rachel Salit, Dr. Elizabeth F. Krakow and Dr. Stephanie J. Lee contributed to this work.

Mukherjee A, Gooley T, Mielcarek M, Sandmaier BM, Doney K, Oshima MU, Holmberg L, Baker KS, Salit RB, Krakow EF, Shannon-Dorcy K, Davis C, Lee SJ. Outcomes after hematopoietic cell transplantation among non-English- compared to English-speaking recipients. Bone Marrow Transplant. 2022 Mar;57(3):440-444. doi: 10.1038/s41409-021-01557-7. Epub 2022 Jan 31. PMID: 35095100.