Patierno, Barrett, Take to National Stage on Disparities

This has been an extraordinary labor of love by a nation-wide committee made up of experts in cancer disparities and cancer health equity, each with specific expertise in particular aspects of cancer disparities and particular areas of intervention towards achieving cancer health equity.

This trans-disciplinary effort is necessary because the drivers of cancer health disparities, similar to all health disparities, are multi-level in nature. This is further complicated by the growing concern of interactions between the various drivers, which can work additively or synergistically to exacerbate cancer disparities.

Disparities span the cancer control continuum, including in the areas of prevention, early detection, diagnosis, interception, treatment, survivorship and end-of-life care. Such disparities can be manifest in an earlier age of diagnosis, diagnosis of more aggressive disease, more rapid progression to more advance disease, and increased mortality because of poorer treatment or poorer therapeutic responses to the same treatment. As shown here, cancer disparities are driven by a complex interplay among societal factors such as structural and systemic racism, social factors such as socioeconomic status and educational attainment, lifestyle and environmental factors such as diet and pollution, institutional level factors that affect access to care, and individual level factors such as ancestry-related genetics and biology.

In the same way that the drivers of cancer disparities are multi-level, the interventions needed to mitigate cancer disparities must also address the multi-level drivers. This requires engagement by the entire spectrum of cancer research including basic, translational, population level, behavioral and clinical research, and even evidence-driven policy. In particular, there is great need to advance what I call “convergence science”: research focused on understanding how the multi-level drivers intersect with each other, and implementation of evidence-driven interventions at each level.

Oncology clinical trials is an area of research that is critical to advancing the future of cancer care. Unfortunately, as you just heard from Dr. Newman, clinical trial enrollments do not reflect the population demographics of our society, with gross under-representation of persons from marginalized or minoritized communities. The causes of the under-representation are complex, including medical mistrust due to historical atrocities, fear, or simply not being asked to participate due to implicit bias and/or structural racism embedded within our health systems. But the effect is clear: a severe limitation of real-world impact of each such trial.  

To address this, the Duke Cancer Institute has created a longitudinal program to address the causes of under-representation and in fact has helped pioneer oncology clinical trials that are equitably stratified by race.  In prostate cancer we and others have made exciting discoveries: for example, in general black men come into the trials with more advanced disease but respond better to several different modes of therapy.  This type of research has huge implications, not only in mitigating the disparity, but also in advancing the quality of care for all men diagnosed w prostate cancer.

Another intervention that you will read about in the report, one that is proven to help overcome cancer disparities is patient navigation.  Patient navigators engage in patient-centered culturally tailored assistance to help individuals find their way to a healthcare provider, and through a health care episode, including identifying and overcoming access barriers across the full heathcare continuum.  

The importance of navigation was highlighted in a recent study showing that Black patients with aggressive large B-cell lymphoma were just as likely as White patients to receive standard treatments, participate in clinical trials, and complete treatment with similar survival rates when they received care at a health care facility with navigator program. The navigators helped disadvantaged patients access care by guiding them through treatment, helping them with their practical needs such as transportation and lodging, and providing other nonmedical support.

Another study conducted here in North Carolina, the ACCURE study demonstrated that a multi-pronged intervention centered on patient navigation eliminated racial disparities in the likelihood of receiving curative therapy for lung cancer, equalized treatment completion rates, reduced the disparity in timeliness of surgery after diagnosis, and narrowed the disparity in 5-year survival rates between Black and White patients.

Finally, evidence-driven policy matters at both the federal and state levels. Equal access to quality cancer healthcare is impacted by a number of factors, including distance from and transportation to a cancer healthcare facility. But the most limiting factor is lack of health insurance and particularly lack of access to Medicaid expansion through the Affordable Care Act. Several major studies have been conducted showing that Medicaid expansion leads to more cancer survivors. Cancer mortality rates declined in states that underwent early Medicaid expansion compared to those that didn’t.  Moreover, cancer disparities were markedly reduced in states that underwent Medicaid expansion but were worsened in those that didn’t. Federal and state level policymakers could look to models that are working now, like patient navigation, to have a lasting impact on equitable cancer health care.

It is our sincere hope that this Progress Report on Cancer Disparities will serve as a roadmap for achieving the bold vision of health equity for all person and populations.