Dr. Fredrick Ashbury, PhD and Dr. Kashyap Patel, MD
Fred Ashbury: There has been a lot of recent discussion regarding social inequalities and social determinants of health negatively affecting cancer outcomes. Given your experience, can you put disparities in cancer care into context?
Kashyap Patel: Despite ranking among the top six wealthiest economies in the world per capita, health disparities rooted in social, economic, and environmental factors persist in the US. Where you are born, for example, is more strongly associated with life expectancy than either race or genetics. Life expectancy between the most advantaged and disadvantaged of our citizens in the US differs by 15 years. This difference correlates with geography and health behaviors, influenced by historical and social factors. (1-3)
In the context of cancer, about one-third of cancer deaths in the 25-79 age group are attributed to socio- economic factors, gender, geography, age, race and ethnicity. Addressing disparities in cancer care is projected to save as much as $1trillion over 3 years through reductions in healthcare delivery costs and associated indirect savings (AACR CDR 2020). (4)
FA: What disparities are we are seeing in the oncology setting? How are these manifesting?
KP: We are seeing many challenges, including:
Insufficient access to treatment and supportive cancer care, in underserved areas
Uneven access to cancer screening services 5
Limited or no access to precision medicine testing.
Absence of data that would help predict the efficacy of drugs, for example, according to race and ethnicity
The financial toxicity of cancer care, especially for disadvantaged groups (6)
Limited or no access to clinical trials – moreover, there is even distrust of the clinical trial system by certain patient populations (8)
Implicit and explicit biases, including ageism and racism, from providers and healthcare teams. (9)
FA: It is fair to say that these disparities can be especially pronounced in the community oncology setting, where patients are more often located in rural/remote areas with poorer access to healthcare services and other resources, where age, race and ethnic diversity are more pronounced, and whose patients may often face greater financial pressures, not only related to treatment but also with respect to delivering effective supportive care and participation in clinical trials. At the societal level, what approach would you recommend to mitigate the negative impact of these disparities?
KP: A comprehensive approach is needed to bring a ground swell of resources. Public policy must be supported by all segments of the cancer eco systems (the private sector, Pharma, researchers, physicians, government, community groups, patient representatives), as well adequate funding is needed for federal and local initiatives, considerations of health must be top-of-mind in community planning and development, and finally, we must collect real-world data and evidence to evaluate the impact of these measures to address the disparities.
FA: What measures or interventions can community oncology practices put in place to mitigate inequalities in cancer care? After all, more than three-quarters of cancer patients are treated and supported in the community setting, and not in the large, academic centers.
KP: Staff and clinicians in community practices, I believe, recognize daily how geography, financial toxicity, the social determinants of health, including access to social support structures, socio-economic status, geography and the like have adversely affected patient outcomes. I think most are implementing strategies to try to mitigate these factors, however, some strategies, such as telehealth/digital health require financial investments that both the practices and patients struggle to be able to do. I believe many practices, however, need more and better tools to enable them to be, for example, more culturally sensitive or avoid systemic biases such as ageism and racism. Most community oncology practices don’t actively participate in clinical trials and this is a major loss to understanding whether novel therapies will help selected groups in our population who may not match the participants usually recruited to trials. This is where trial sponsors need to partner more effectively with community practices to provide the resources and tools to facilitate their ability to recruit, consent, manage, monitor and report on the patients enrolled in trials.
FA: We must clearly do better to ensure we eliminate processes and behaviors that disenfranchise people. Any final comments?
KP: Failure to address systemic bias in health-care provision and genetic databases will make existing disparities worse. We need to de-compartmentalize cancer care delivery and look at cancer from a much higher global perspective than on-the-ground transactional perspective.
1 National Cancer Institute. Available from: https://www.cancer.gov/about-cancer/causes-prevention/risk/age
2 Mohile SG et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 2018;36:2326-2347.
3 Akagunduz B et al. Assessment of abuse and related factors in older patients with cancer. Supp Care Cancer 2021; Jul 2. doi: 10.1007/s00520-021-06391-7
4 Popescu T et al. Challenges facing radiation oncologists in the management of older cancer patients: Consensus of the International Geriatric Radiotherapy Group. Cancers 2019, 11(3), 371; https://doi.org/10.3390/cancers11030371
5 Butler R. Ageism: Another form of bigotry. Gerontologist 1969;9:243-46.
6 Palmore EB. Ageism comes of age. Journals of Gerontology: Psychological Sciences & Social Sciences 2015;70(6):873-5.
7 Dharmarajan KV, Presley CJ and Wyld L. Care disparities across the healthcare continuum for older adults: Lessons from multidisciplinary perspectives. ASCO Educational Book 2021 :41, e215-e224
8 Olver I. Chemotherapy for elderly patients with advanced cancer: is it worth it? Aust Prescr 2000;23:80-2
Fredrick D. Ashbury, PhD
Chief Scientific Officer, VieCure Professor (Adj), Department of Oncology University of Calgary Professor (Adj), DLSPH, University of Toronto
Kashyap Patel, MD
Chief Executive Officer, Carolina Blood and Cancer Care Associates,
President, Community Oncology Alliance (COA).