Social Determinants of Health - Highlights from the 2021 ASCO Annual Meeting

Social Determinants of Health in Cancer Care

This episode was originally released July 21, 2021

In this episode of the Social Determinants of Health (SDOH) series, Dr. Shekinah Elmore (University of North Carolina at Chapel Hill) and Dr. Ramy Sedhom (Johns Hopkins University) provide research highlights in Social Determinants of Health topics from the recent 2021 ASCO Annual Meeting, provide context to the research, and discuss clinical implications. View episode slides and COI.

TRANSCRIPT

LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care, and is not intended for use in the diagnosis or treatments of individual conditions.

Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite Guests with a wide range of views and perspectives. Some of these conversations may be provocative, and some even uncomfortable.

But ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere. I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table-- voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high-quality, equity for cancer care. Thank you.

SHEKINAH ELMORE: Hi, and welcome to the seventh episode of the ASCO Social Determinants of Health Series. I'm Dr. Shekinah Elmore, and I'm an assistant professor of radiation oncology and urology at UNC Chapel Hill. With me is Dr. Ramy Sedhom, a medical oncology fellow at Johns Hopkins. We're happy to be joining you, wherever you are in the world.

RAMY SEDHOM: Yes, absolutely. This series is part of an initiative proposed by ASCO president Dr. Lori Pierce, focused on increasing oncologists' understanding of the social determinants of health, its impact on patients, and modifiable risk factors for cancer, inspired by Dr. Pierce's presidential theme of equity, every patient, every day, everywhere. In this episode, we will review highlights in social determinants of health topics from the recent ASCO annual meeting, provide context to the research, and discuss clinical implications.

SHEKINAH ELMORE: In the social determinants, some of us might need a refresher, and that's OK, too. So the social determinants, as most of us know, are really those things at the interpersonal, community, social, structural higher levels that pattern health outcomes and access. So it's education, it's health care, its neighborhood and built environment, social and community context, and economic stability in one model from Healthy People 2030. But what we'll be talking about in many ways is at the individual level-- so the individual social risk factors that are lower than the social determinants of health. And then we'll also be talking a lot about race and racism.

And so in terms of racism, the best definition that I have found is by Dr. Ruth Wilson Gilmore. She's a noted geographer. And that definition is that racism is the state-sanctioned or otherwise extralegal production and exploitation of group-differentiated vulnerability to premature death. And one of the benefits of the podcast format is that you can rewind, fix yourself on this slide, and read the definition a few times, like I did when I first came upon it, to just see how straightforward, but how all-encompassing, it is.

And so racism is really a structural determinant of health. It sits above even some of these social determinants that we talk about. It patterns health inequities directly. It also has these interactions with all of the social determinants of health. And I think that that will become clear with the abstracts that we're talking about.

RAMY SEDHOM: Really, really powerful definitions. And with regards to care access, almost 40 years ago, Penchansky and Thomas published their five As of access framework. And the five As, as you can see here, represents affordability. So thinking about what is the cost to patients.

And there's been a lot of work coming out over recent years showing that these costs are increasing for patients directly with time. Accessibility-- what is the distance to location or a particular service for patients throughout the country. Availability-- what is the access to specialists and specialty resources, accommodation, flexible scheduling, and acceptability.

And the reason why we bring up this framework is it's a context to discuss the first of the abstracts that we will discuss coming from Dr. Guerra and colleagues at the Penn Abramson Cancer Center. While published 40 years ago, these issues remain pertinent today. And we know that clinical trials do not operate in a vacuum, but instead mirror a lot of the problems within our current health care infrastructure. And that's what makes this work most impressive to me.

I do encourage all to listen to the oral presentation from the ASCO annual meeting, abstract number 100, titled "Accrual of Black Participants to Cancer Clinical Trials Following a Five-Year Prospective Initiative of Community Outreach and Engagement." So what was the problem they were tackling? The team identified a major gap for full inclusion of minoritized patients in their cancer clinical trials network. And their goal, as highlighted by this abstract, was to increase the accrual of Black participants in cancer clinical trials.

Importantly, they took a multilevel approach. But before thinking about any intervention, they went out into the local communities. They spoke to the patients, to the community leaders, pastors, community advocacy groups, and outreach groups to really listen to what the problems were. And by engaging with those most important stakeholders, did they really think about what were the most important interventions?

And what did these interventions look like? Well the team at the Penn Abramson Cancer Center focused on educational efforts in Black communities dispelling many myths about cancer clinical trials. They also increased touch points and access points for patients to access care. Most importantly, these came through breast cancer and colon cancer screening for both insured and uninsured patients.

One thing that really stuck out to me, very pragmatic and thoughtful in its design, was to make sure that culturally-tailored marketing strategies were also available for patients to see. They worked with pharma to make sure that Black patients were also shown on pamphlets discussing cancer clinical trials. And when thinking about access to care, we know that transportation is oftentimes a barrier, especially for our most vulnerable patients. So they had made sure to have contracts and connections with Lyft and other ride-sharing agencies to make sure that people can make it to the cancer center.

And from the health care infrastructure side, they established new requirements for minority accrual plans, and made sure to use community health workers and one-on-one patient navigation. And what was the ultimate impact of their work? Over a five-year effort, they reached more than 10,000 individuals through various venues. And when looking at their primary outcome, they more than doubled the number of Black patients who were accrued on cancer treatment trials. And they saw up to a four-fold increase in the accrual of Black patients in non-intervention treatment trials.

However, what is most important is they established a new level of trust with patients in communities that they were not before reaching. And they were able to remodel their organizational care delivery infrastructure to address this major gap in care delivery. So what was the hallmark of the strategy and how can we pragmatically implement it in our own institutions?

First, they focused on understanding local needs. Importantly, they established bidirectional relationships, and they made sure to acquire data to show the business case for why this is a return on investment for patients, their local city, and their health care infrastructure. I want to applaud Dr. Guerra and her team for making sure that this was a long-term investment in the Philadelphia area. What first started as a research grant later grew to involve the entire cancer service line, all the way with the director of the cancer center, and making sure to involve their entire organization.

And what is the lesson learned? Well, Black participants are significantly underrepresented in clinical trials. But it is not because they are resistant to participating. Instead, this is likely due to structural, clinical, and organizational barriers.

In our local communities, the underrepresented minoritized groups may look different. Perhaps they may be racial minorities. They may be rural dwellers, adolescents, or perhaps elderly patients, sexual and gender minorities, and so on and so forth. So I'd like to open this up to Dr. Elmore, and see if you have any other comments or thoughts from hearing about this.

SHEKINAH ELMORE: This is such tremendous work. And I agree. I think that it's a testament to so many things. I think that responsive development of interventions is so critical, and that truly, Black patients and Black people want to be included in the things that are meaningful to changing health outcomes. And there's so much here, and I really hope to see more efforts like this in both trial enrollment and for standard of care enrollment.

RAMY SEDHOM: Absolutely, and hats off for ASCO advocacy for really pushing forward the CLINICAL TREATMENT Act, which made sure to ensure that clinical trial costs were also covered. This was a landmark decision that came in December of this previous year. [AUDIO OUT] area. And we look forward to seeing this implemented on a larger scale through partnerships with ASCO in future years. And with that, I'd like to transition to our next abstract that Dr. Elmore will lead us through.

SHEKINAH ELMORE: Great, thanks. So this abstract, "Financial Toxicity, Symptom Burden, Illness Perceptions, and Communication Confidence in Cancer Clinical Trial Participants," the first author is Dr. Subha Perni and the last author is Dr. Ryan Nipp, both of which I know well from MGH. And so the problem here that they were trying to address and explore is that trial participants are at high risk for adverse effects from financial toxicity. But we don't really know that much about what the scope and type of those adverse events might be.

So with this study, they prospectively enrolled trial participants from MGH for about two years, and they saturated their sample with those that were already referred per their request for financial assistance. And so they assessed financial toxicity in these two ways, both asking these participants about financial burden overall of care, and then focusing in on trial cost concerns. And then they also asked, using standardized validated measures, about patient-reported outcomes. So physical and psychological symptoms, illness perception, and communication confidence. How confident are they in communicating with their care teams?

The results are interesting. 200 patients-- so 57% in this group noted that they had financial burden overall, and 41% with trial cost concerns. Those that noted financial burden were more likely to be young patients, which makes sense. And trial cost concerns, those were more frequent among patients with lower incomes. Both of these were significant, and I think that that speaks to the validity of these constructs of financial toxicity.

And then this is the most interesting part. Financial toxicity was associated with greater physical and psychological symptom burden, negative illness perception, and lower communication confidence. So the bottom line here is that financial toxicity was associated with worse patient-reported outcomes across all domains that were measured. Lots of future questions here.

So how might financial toxicity operate in different clinical settings? These are trial participants at a designated cancer center. How does that work in community oncology practices or among non-trial participants? How might financial toxicity moderate some of those other social risk factors or social determinants of health? We know from other health outcomes that if you look at Black Americans and white Americans with the health outcomes disparity, that disparity sometimes widens as you climb socioeconomic strata.

And then how might financial toxicity influence oncologic outcomes? More physical symptom burden, more psychological symptom burden, worse communication, that could all lead to worse oncologic outcomes. So lots of programmatic implications here. I think prospective identification of financial toxicity risk, those patients who are at risk for that, and then aligning that with social and economic interventions. But this certainly aligns with the previous abstract that we discussed, another lens on why people might not participate in trials, and just the financial burdens that care can bring to patients, and the fact that it impacts the very care that they're getting.

RAMY SEDHOM: Yes, absolutely. Such great work by Dr. Perni and Dr. Nipp and their team. I think we're just scratching the surface, as you mentioned, with financial toxicity and its implications on patient care and the caregiver experience as well.

So all in all, I think the concluding remarks we could probably make is that equity is a simple concept to grasp, but very complicated to execute and measure for success. We do want to thank our authors who did put time and effort in their careers to opening up our eyes, and Dr. Pierce for really making this the highlight and the theme of her tenure as ASCO president. So for those listening in, thank you for joining us for this episode of the ASCO Social Determinants of Health series.

To keep up with the latest episode, please click Subscribe. Let us know what you think about the series by leaving us a review or by emailing us at [e-mail]. On behalf of Dr. Elmore and I, thank you for listening in.

SHEKINAH ELMORE: Thanks.

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