Undocumented Immigrants With Cancer Face Unique Care Challenges

The United States has a very long and often complicated relationship with immigration. Although Ellis Island is lauded as a uniquely American symbol of freedom and hope, those moving to this country seeking better economic opportunities or to escape oppression and violence have not always received a warm welcome. Even today, several studies show that immigration status is often associated with health care disparities.¹

The American Society of Clinical Oncology, the American Society for Hematology, and the American Association for Cancer Research, among other industry groups, have all established initiatives aimed at improving cultural competency among practitioners and diversity in clinical trials. As physicians at the beginning of their careers, fellows are singularly positioned to make cancer care more inclusive for all patients.

According to findings from the Center for Immigration Studies published in December 2021, the immigrant population includes 46.2 million documented and undocumented people, the highest total in US history. Overall, 14.2% of people in the United States come from somewhere else.²

Undocumented immigrants are foreign-born individuals who have migrated to the United States without authorization.² Contrary to conventional wisdom and anti-immigration policies, approximately 50% to 70% of the undocumented immigrant population pays federal and state taxes. Despite their contributions to the American economy, the undocumented population continues to face discriminatory policies.¹ Those who have been diagnosed with cancer and their loved ones, in particular, feel the sting of those disparities. These policies affect undocumented immigrants with cancer on emotional, financial, physical, and social levels.

Disparities Within the Health Care System

The Affordable Care Act is a federally funded initiative implemented in 2010 to allow more affordable health care options for millions of Americans. However, this initiative excludes many in the undocumented population.

Research shows that those who are undocumented are rarely able to attain full insurance coverage, whether it is private insurance from the marketplace or Medicaid. Multiple states have expanded Medicaid policies to cover service gaps for undocumented individuals (Emergency Medical Treatment and Active Labor Act), but this extended policy varies by state and solely covers emergency services. This affects individuals who are diagnosed with cancer for any type of treatment. Individuals who seek emergency services due to a diagnosis may receive emergency medical attention; however, it typically does not cover cancer treatment costs.

Thus, those who are undocumented and uninsured usually do not seek medical assistance or delay seeking care, for several reasons. Health insurance is closely linked to the number of times individuals seek medical assistance; this includes general checkups, annual physicals, and cancer screenings.³ Cancer screenings are typically delayed unless or until individuals experience extreme discomfort or a medical emergency. Undocumented individuals are likely to live with pain and discomfort to avoid receiving high medical bills. They may avoid seeking medical attention or put off annual physical exams to avoid fees and co-payments.¹

A delayed cancer diagnosis affects the prognosis and types of treatments that are available to patients. The quality of treatment is also compromised, as undocumented populations are more likely to be offered a less effective, more affordable treatment as opposed to the best available treatment, which is more expensive and linked to a higher survival rate.¹

Cancer: Financial and Emotional Consequences

Undocumented individuals facing a cancer diagnosis are at higher risk of struggling with the financial burden of cancer treatment. Because of the nature of diagnosis and treatment, most patients with cancer who are undocumented are unable to work, resulting in ineligibility to receive federally funded benefits such as extended family leave, paid time off, paid sick days, and short-term and long-term disability.

Furthermore, undocumented patients with cancer face unique traumatic experiences that increase stress and strain their mental health. Some of these traumatic experiences include discrimination because of immigration status, stigma related to status, language barriers, and racism. Such experiences can reduce the likelihood of patients seeking medical assistance for their cancer treatment or diagnosis.¹

Often undocumented individuals with a cancer diagnosis delay seeking medical assistance because of fear of deportation. It can be difficult for these patients to ask for help because, oftentimes, they are the ones supporting their families—financially and emotionally. Moreover, an extended illness can result in unemployment, a terrifying prospect for a person who may be the breadwinner for multiple generations of family members.

These experiences can be isolating for patients and are correlated with depression, anxiety, posttraumatic stress disorder, and other mental health conditions. Such conditions have a direct impact on a patients’ physical health as well as response to treatment and survivorship.¹

Navigating Health Care Disparities

Despite multiple challenges and barriers preventing undocumented immigrants with cancer from receiving adequate treatment, support, and information, there are a plethora of ways to help this population navigate the challenges.

• Cultural humility is defined as “a lifelong process of self-reflection and self-critique, whereby the individual not only learns about another’s culture, but one starts with an examination of their own beliefs and cultural identities.”⁴ Reflecting on one’s own core cultural identity and privileges one may hold allows the health care worker to empathize with structural and emotional challenges their patients may face. It also assists professionals with the emotional capacity of advocating for patients or assisting them with the tools to advocate for themselves.⁴
• Faith and spirituality are helpful factors at the micro-level that assist with coping skills and how individuals react to stressors and mental health challenges. Being connected with an outside force (whether it is religion or spirituality) assists patients to externalize traumatic experiences and can create a sense of hope and belonging.⁴
• Health and policy literacy is an important component in assisting this population. Most undocumented immigrants with cancer are unaware of policies that could assist them. Health care professionals who are informed about local and federal laws can help inform undocumented immigrants with cancer what they are eligible for. Because direct federal programs that assist financially are very limited, nonprofit organizations and Catholic charities are the main source of financial and emotional support for patients. These organizations do not include immigration status as a form of eligibility to receive financial and emotional support.

Although many factors affect health care in this population, creating a safe space and providing appropriate empathetic care are key to maintaining a patient’s sense of hope and faith in their treatment and their care team.

References

1. Olazagasti C, Duma N. Cancer care for all? tales of caring for undocu-mented patients with cancer. Oncologist. 2020;25(7):552-554. doi:10.1634/theoncologist.2020-0113
2. Camerota SA, Zeigler K. Immigrant population hits record 46.2 million in November 2021. Center for Immigration Studies. December 20, 2021. Accessed April 26, 2022. bit.ly/3vitcbq
3. Beck TL, Le TK, Henry-Okafor Q, Shah MK. Medical care for undocu-mented immigrants: national and international issues. Physician Assist Clin. 2019;4(1):33-45. doi:10.1016/j.cpha.2018.08.002
4. Tervalon M, Murray-García J. Cultural humility versus cultural compe-tence: a critical distinction in defining physician training outcomes in mul-ticultural education. J Health Care Poor Underserved. 1998;9(2):117-125. doi:10.1353/hpu.2010.0233