Forgotten No More: Bringing American Indians into the Narrative | Jessica Buck DiSilvestro, MD, Keely Krolikowski Ulmer, MD, and Amanda Bruegl, MD

Jessica Buck DiSilvestro, MD

Keely Krolikowski Ulmer, MD

Amanda Bruegl, MD

As of the 2020 U.S. Census, 9.7 million American Indians reside in the United States, comprising approximately 3% of the total population. There are currently 574 federally recognized American Indian and Alaskan Native (AI/AN) tribes. While many AI/ANs still live on reservations and tribal lands, the majority (71%) reside in urban centers.¹ Since colonization, AI/AN people have faced socio-economic and health disparities that persist to this day.

AI/AN women suffer from vast disparities in gynecologic cancers, with higher incidence and mortality rates for cervical cancer, later stage at diagnosis for ovarian cancer, higher mortality rates for uterine cancer, and younger ages at diagnosis for all gynecologic cancers compared to non-Hispanic white women.^2,3 Despite this, AI/AN women remain largely underrepresented in clinical trials. AI/AN involvement in NIH research between 2014-2017 was disproportionately low at only 1%.⁴ Cancer treatment clinical trials have increasingly reported racial distribution over the past decade; however, AI/AN continues to be rarely included as a unique demographic and is typically grouped into the “Other” category.^5,6 We urge that AI/AN be brought out of this umbrella category in order to build on the extremely limited data on the AI/AN population.

To tackle some of these disparities, Amanda Bruegl, MD, a citizen of Oneida Nation and a gynecologic oncologist in Oregon, has dedicated her research to addressing the startling rates of cervical cancer within the AI/AN tribes of the Pacific Northwest. With 1.5 times the incidence and over double the mortality rate, there is much work to be done. She has engaged the local tribes in her research as well as the Northwest Portland Area Indian Health Board, a non-profit AI/AN health advisory organization, in order to perform culturally appropriate and thoughtful research.

Disparities exist not only within the patient population, but also in the racial distribution of oncology providers. With less than a handful of AI/AN gynecologic oncologists in the country, mentorship is crucial. National organizations such as the Association of American Indian Physicians (AAIP) and the Association of Native American Medical Students (ANAMS) can help bridge the miles between AI/AN physicians and provide opportunities for mentorship, scholarship, and community. But this work cannot fall on the shoulders of a few. We must all look for ways to inspire, mentor, and bring all voices to the next generation of women’s gynecologic cancer healthcare force.

This upcoming November, American Indian Heritage Month, we urge you to remember that the land which we call home is that of the Indigenous people, a population largely forgotten in the greater discourse of health disparities. AI/AN people reside throughout this country, and we implore you to become involved and educate yourself on the specific issues this population faces. Lastly, as we gather this upcoming March for the SGO Annual Meeting, we want to give thanks to the tribes that once inhabited the Tampa Bay area—the Tocobaga, Calusa, Seminoles, Mocoso, Pohoy, and Uzita tribes, as well as the current Indigenous people residing in Florida.

Háwwih

Wopila tanka

Nia:wa

Thank you

References

1. Urban Indian Health – Urban Indian Health Institute. Accessed August 25, 2022. https://www.uihi.org/urban-indian-health/
2. Bruegl AS, Joshi S, Batman S, Weisenberger M, Munro E, Becker T. Gynecologic Cancer Incidence and Mortality among American Indian/Alaska Native Women in the Pacific Northwest, 1996–2016. Gynecol Oncol. 2020;157(3):686. doi:10.1016/J.YGYNO.2020.03.033
3. Singh SD, Ryerson AB, Wu M, Kaur JS. Ovarian and Uterine Cancer Incidence and Mortality in American Indian and Alaska Native Women, United States, 1999–2009. Am J Public Health. 2014;104(Suppl 3):S423. doi:10.2105/AJPH.2013.301781
4. Vigil D, Sinaii N, Karp B. American Indian and Alaska Native Enrollment in Clinical Studies in the National Institutes of Health’s Intramural Research Program. Ethics Hum Res. 2021;43(3):2-9. doi:10.1002/EAHR.500090
5. Scalici J, Finan MA, Black J, et al. Minority participation in Gynecologic Oncology Group (GOG) Studies. Gynecol Oncol. 2015;138(2):441. doi:10.1016/J.YGYNO.2015.05.014
6. Grant SR, Lin TA, Miller AB, et al. Racial and Ethnic Disparities Among Participants in US-Based Phase 3 Randomized Cancer Clinical Trials. JNCI Cancer Spectr. 2020;4(5):60. doi:10.1093/JNCICS/PKAA060

Amanda Bruegl, MD MCR, is a Citizen of Oneida Nation and descendent of Stockbridge-Munsee Band of Mohicans. She is an Associate Professor and Vice Chair of Diversity, Equity, and Inclusion in the Department of OB/Gyn at Oregon Health and Science University. Her research passion is cervical cancer prevention among American Indian/Alaska Native and Rural women. 

Jessica Buck DiSilvestro, MD, a member of the Caddo Nation of Oklahoma, is a current second-year Gynecologic Oncology Fellow at Brown University/Women & Infants Hospital. She completed her undergraduate studies at Harvard University and worked at an American Indian health center in New York City before earning her medical degree from Weill Cornell Medical College. During her training, she has received several teaching, surgical excellence, and research awards. She is passionate about cancer prevention, quality improvement and addressing American Indian health disparities. 

Keely Ulmer, MD. I was raised on the Pine Ridge (Oglala Sioux) Reservation in the Badlands of South Dakota outside of a town called Wanblee (Eagle). As many reservation kids do, I fell in love with the game of basketball and the sport took me to college at Black Hills State University in the Black Hills of South Dakota. I then attended medical school at the University of South Dakota followed by residency and now fellowship at the University of Iowa. 

This column is sponsored by an unrestricted grant from GSK. Sponsorship excludes editorial input. Content developed by the SGO Diversity, Inclusion & Health Equity Committee.