Interview with Professor Jenny Spencer: Reducing Gaps, Disparities, and Inequities within the Healthcare System

I interviewed Professor Jenny Spencer, an assistant Professor in the Department of Population Health and Department of Medicine at the University of Texas Austin. She researches a wide variety of topics, including cervical cancer, implementing more equitable health screenings, gender, and more. Her bio reads:

“Jenny Spencer’s work uses econometric and decision science methods to focus on improving health equity in cancer screening and prevention. Spencer completed her master’s and Ph.D. training at the University of North Carolina at Chapel Hill, where she was a predoctoral fellow in the Cancer Care Quality Training Program at the Lineberger Cancer Center. Her dissertation, which focused on modeling the impact of HPV vaccination on disparities in HPV cancers by area poverty in the U.S., was awarded the Marci Campbell Award for Excellence in Cancer Population Sciences. After completing her Ph.D., Spencer completed a two-year postdoctoral fellowship with the Training in Oncology Population Sciences program at the Dana Farber Cancer Institute and the Harvard School of Public Health, where she continued her work in developing HPV vaccination models and strategies to incorporate equity considerations into decision modeling. Spencer joined the Department of Population Health in 2021, where she has expanded her work on HPV vaccination to additionally study inequities in cancer screening and cancer prevention — including cervical, breast and colorectal cancer — by race, ethnicity, income and sexual orientation.” (bio and photo from UT Austin Directory)

Could you talk about how you personally got involved in the field of population health and medicine? What interests you about these topics?

When I was an undergraduate, my plan was to go to veterinary school. I really like dogs, and I really liked animals. I really liked science, and I thought that was the path I was going to go down. So, my undergraduate degree was in zoology. I worked in a vet hospital for a while and I also worked with animals in a couple of different capacities as well. For instance, I worked at a tiger rescue for a while, which is a very different story. But, as I was doing a lot of that, I really liked the science. I liked the problem-solving, and I started working in a research lab that was a basic science research lab. They did mouse-based studies on lung diseases, which I got really interested in. Eventually, I was getting kind of less interested in the structure of veterinary medicine, and started to realize that maybe the other parts were what I was actually interested in.

I also went to a really incredible presentation on what turned out to be public health (which I didn’t realize at the time), which looked at social determinants of health. They had been trying to assess the impact of crack cocaine during pregnancy, and they had all these issues with this study that turned into them discovering sort of all of the things. A lot of the things they were attributing to the study were actually confounded by the fact that the mothers that were in this hospital were just so poor and challenged. For the kids they were studying, they had to really consider all the impacts of maternal drug use. I’m summarizing their results badly, but it was a really powerful presentation. I had this call to get more involved.

We have this incredible technology now. I was working in a lab that was developing new treatments. But, none of that matters if we’re not actually getting care for people. It doesn’t matter, if we can’t solve these really basic problems of access, education, having health insurance, and more pieces.

So, long story short, I ended up going back to school at UNC for a master’s in health policy. I stayed there for a PhD in health policy, and I ended up doing cancer and health equity work because I think it’s such an interesting space for health equity. Because of the nature of the disease, involved people really get to see the inequities at a societal level really play out in cervical cancer. So, that’s how I got interested.

Can you please discuss your publication “Adapting a model of cervical carcinogenesis to self-identified Black women to evaluate racial disparities in the United States”? What were your motivations for writing this?

This was actually done as part of a larger project across a number of different cancer sites. This was part of a project funded by the National Cancer Institute that has a number of different modeling groups, and I was part of the cervical cancer modeling group. We’ve developed this elaborate model of cervical cancer. There are other models for breast cancer, colon cancer, lung cancer, prostate cancer, and maybe seven other models that I’m forgetting that are looking at different kinds of cancer. They funded a project within each of those models to look at Black race disparities in cancer and try to use their models to better understand what is going on, why disparities exist, and what we could do to reduce those disparities.

We started with these sorts of questions, and wanted to think about how we could adapt an existing model. This involved getting lots of data specific to race on all the things we think might be involved in the cervical cancer pathway and making sure to not change anything that we don’t think should be affected by race.

Race is a concept that we have decided on, and not a definable genetic component, as it was often thought for a long time. So, we wanted to think about what pieces are different. We were able to get all this data on things like mortality, cancer screening, follow up after cancer survival, etc,, and look at sort of how each of those differences added up to the total difference we see in both cervical cancer incidence and cervical cancer mortality.

I read about your work trying to implement equity considerations into decision modeling for HPV vaccines — can you please elaborate on this project?

Yeah, we’ve done some work in HPV vaccinations. My dissertation, when I got my PhD, was actually looking at high and low-poverty counties in the US and comparing places where the whole county has a fairly low rate of poverty to counties where the whole county has a pretty high rate of poverty. We know that high-poverty areas have higher rates of cervical cancer for reasons like lower screening and lower access to care. But, because the HPV vaccination is fairly new and reaching everyone at the same time, the hope was that this might decrease some of those disparities.

We actually did find in our data on vaccination rates that there weren’t big differences in vaccination rates by county. There is a lot of variation, but on average, high and low-poverty counties have very similar vaccination rates. So, the thought is that over time, those disparities may start to get smaller because vaccinations will have a similar impact in both places.

The goal is not to say we should be vaccinating certain populations more or less. The goal is to instead consider how we think about vaccination policy and vaccination outreach programs. If we’re doing something to increase HPV vaccination in a state, let’s say in Texas, and if we target just the big cities like Dallas, Austin, and Houston, we’re probably exacerbating some existing disparities. We’re making things worse by not reaching out to everybody. We need to think about how we can reach the rural populations in the state of Texas. How can we make our materials accessible in both English and Spanish, to make sure that Hispanic populations are able to access those interventions? This work is really about making sure that with everything we do, we’re thinking: is this going to make gaps in healthcare bigger or smaller?

Do you notice a notable impact of gender and race in your general studies of health and medicine? If so, what patterns are obvious? Are you constantly thinking about these two concepts across your projects, or only in some instances?

I think it’s worth thinking about in all projects. But, we don’t want to overemphasize it too much. I think some people are very worried that we make it out to be more about race than about underlying social inequities. What we care about is what the systems that result in unequal access are. So some people feel like focusing really strictly on race as the mechanism of that misses the underlying social mechanisms that divide people based on race or other social categories that are important.

But, I think it’s worth thinking about in every project. We should think about what the ways in which our societal barriers can introduce issues are. A lot of the work that I do is in cancers that mostly affect women, like cervical cancer and breast cancer. But in things like colon cancer, I think we know those can affect everyone. So, thinking about the way gender might play out is really important.

Then, the way race might play out is really important too. In Texas we have a large Hispanic population. So ethnicity is also really important in a lot of our data. So are language, country of origin, etc. They are all potentially important mediators of care, so they are really important.

The pattern that we notice is that very often, it’s not individual level things that are creating disparities. It’s really system-level problems. This means we need to think about what the systems that we have in this country for health insurance are. For most people, it’s through their employer. So if you are living in a society where women are less likely to work than men, that creates some challenges. Medicaid is differently available to pregnant people, differently available to parents of young children. These can create differences in who has care, who has access to care, and then where care is distributed in terms of where new facilities are set up.In some places, you’re able to go to a CVS Minute Clinic and get a flu shot quite easily, but in other places, it is really hard to do that. This division is also impacted by race. This occurrence ends up still having a racially disparate impact in ways that are really important to consider.

Can you please discuss your work as part of the Department of Population Health and studying race, ethnicity, and sexual orientation?

One thing I really love about my job is that I work on a number of different projects. My work is largely funded through research grants at the state or federal level. So, the racial disparities work that I mentioned before is funded by the National Cancer Institute. That’s a federal grant.

I am also looking at colorectal cancer screening across the state of Texas, which is funded by the state. We know that the screening rates are lower in Texas than we’d like, so we’re looking at different alternatives to improve screening.

I’m also funded by a federal grant through what’s called the National Institute of Minority Health and Health Disparities. It’s one of the centers at the National Institutes of Health. They have funded me on a five-year grant to study breast and cervical cancer screening in sexual minority women — so lesbian, gay, bisexual, queer women. We know these women have many reasons that are structural and societal that cause them to have lower access to care. These factors also make them less likely to get screened for breast and cervical cancer. Or their provider might perceive them to be at lower risk for breast or cervical cancer, and they may be less likely to get sort of timely, appropriate care. So, my work is using existing large survey data sets to try to better understand the use of care for this population as well as the barriers. Is it that people don’t have insurance? Or is it that a given person does have insurance, but doesn’t like going to the doctor because it’s very unpleasant as a sexual minority woman to answer invasive questions? Or does a person go to the doctor, but isn’t offered screening? I’m trying to understand where in the pathway women are falling off between existing and getting screening.

What are your goals for how you hope to see your research/work develop, specifically within the next few months or during this year?

I feel like normally people ask long term term goals so I love that you are asking about my shorter term goals! Each of those projects that I mentioned will hopefully progress forward over the next year or so. And I think the goal is a shift from being in this place where we’re really describing these health inequities to being in a place where we can start to make suggestions on how to address these health inequities.

This project I’m doing within Texas, looking at colorectal cancer screening, is really about identifying some interventions that could help improve it. We mail kits to people and they can test samples without even having to leave their house. It’s supposed to be very accessible. All that to say we’ve done some trials with that, with a mailed version of a test and we’re looking at kind of refining that. We are starting to ask how we people get the most benefit the most equally. I I’m hoping that each of those branches of my work will be able to start to move beyond just saying these are where all the barriers are and starting to identify the places where we can start to close those barriers to make the biggest difference. I want to ask people “If you were only going to fix one thing, what thing should you fix and how should you fix it?”

What advice do you have for those interested in fields similar to your areas of interest? Do you have blogs, podcasts, or books that you recommend students explore?

I think my recommendation is to follow your interests, which is maybe not super helpful. But I think it’s easy to say, “this is what I want to do,” but I think it’s easier to say, “this is what I’m interested in,” instead of deciding that you want to do medicine or public health. I think trying to think about what excites you, and then following that is the best way to go.

If you have the opportunity to get involved in research, I highly recommend it, even if you don’t know that you want to do research long term. I think it can be really valuable if you have the opportunity to talk with people about what they do. I didn’t know exactly what I wanted to do when I started undergrad and what I thought I wanted to do sort of changed as I discovered more things. It was really great to let myself kind of explore some avenues that I wasn’t sure were for me and then also have some that I ended up being more interested in, like public health.

As per book recommendations, there’s an excellent book called “Legacy” by Uche Blackstock. She discusses her experience as a Black woman physician. She talks a lot about social determinants and working within these broken and challenging systems, both as a person trying to fix the system and a person trying to exist in the system. I like her take on things a lot. The book is in a narrative style as well, so it’s certainly not a textbook or anything. If somebody’s trying to think about our healthcare system, I think she has a great take on what some of the challenges are.

Is there anything else you wanted to add to the discussion that we didn’t cover so far?

I want to say a couple of other things that I really love about my job.

I love being able to work, as I said, on multiple different projects. And I like the sense of working towards a difference. I know a lot of folks who are driven toward medicine, and I think that is wonderful. I wasn’t really driven towards medicine because the prospect of working day to day with patients wasn’t super appealing to me. But at the same time, I thought that the problem-solving and kind of thinking about all of these different systems and looking at all the pieces at once was really interesting and really satisfying. And I’ve found it nice. It’s nice to feel, on a day-to-day basis, that the things that I’m doing might actually help people. They might actually help improve our policies and our systems. I really like that piece. It’s been really nice.

I also enjoy that I get to work with a lot of really different kinds of scientists in my work, because building these kinds of models takes an understanding of, biologically, what’s going on with cancer, epidemiologically. It involves understanding, from a data science perspective, how to use the imperfect data that we get from a medical perspective, what things actually look like in the clinic, and more. This is so that I don’t just say that doctors should just offer more kinds of testing. Instead, I actually work with my physician colleagues who say that’s absolutely never going to work. I tell them “Here’s why you’ve never been in the room with a patient. This is what this process is like.” I think that a lot of what I do is really team-based, and I work with a lot of really different people. That’s really nice and helps build the projects further.