Ryan Scott

Socioeconomic and genetic factors play a major role in disparities in cancer care, according to Alexander B. Olawaiye, MD, who added that combined efforts from academic and community oncologists are required to help address these disparities and create more equitable standards for all patients.

“We all need to be aware that there are severe cancer care outcome disparities,” Olawaiye said. “If our goal is to improve the cancer treatment outcomes of United States citizens, all of them would have to be given optimum care under all circumstances. The starting point is to acknowledge, be aware, and be conscious of the fact that disparities exist in cancer treatment outcomes. Awareness alone is going to generate a conscious attempt to address the problem.”

®, Olawaiye, director, Gynecologic Oncology Research Program, professor, Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Women’s Hospital, University of Pittsburgh Medical Center (UPMC), discussed how social and biological determinants can affect care outcomes across cancer subtypes and what steps community and academic oncologists can take to ensure these disparities are recognized.

®: How do disparities currently affect cancer care?

: Disparities in cancer care cannot be separated from disparities in health care in general. To set the stage, the United States leads the world in biomedical research, including all the research relevant to health care. The budget of the National Institutes of Health is more than double the biomedical research budget of the rest of the world put together. A lot of the science originates from the United States, because of the [available] resources.

[The United States has] cutting-edge technology that leads health care. With that in mind, if you look at the ratings [examining] the health care of citizens of different countries, it would surprise you that different ratings exist. The highest rating that we have in any of them is 18. In fact, some put [the United States] as low as 34. This is surprising, because we are world leaders in biomedical research and health care research. Why is that?

United States health care disparities are why we lag behind other nations. Social determinants of health, which [include] biology, behavior, genetics, and geography, affect cancer care. If you look at the outcomes of patients being treated for cancer, [they are] extremely uneven. The outcome you get state-to-state for the same cancer often depends on who you are, your race, your geography, your ethnicity, and so on. One can argue that that should not be [the case].

What factors contribute to the disparities seen across cancer care?

There are many factors that contribute to cancer care disparities. The number one factor is obstacles to access expedient care. For example, if somebody is having symptoms that may be related to cancer but they have no means of getting to where they can be evaluated [because they] live too far from the nearest health care [provider]. Even if patients have access to those places, some [patients] do not have insurance, which may be the reason why they do not want to [see a doctor] in the first place. By the time some of these individuals make their way to health care [institutions], their diagnosis is made at an advanced stage, which limits their therapeutic options. Therefore, an outcome that could have been good, will now be [poor].

There is an interplay between these factors. Socioeconomic status is an important factor. However, even people who have high socioeconomic status and insurance can still experience significant disparities. These may reflect the effects of factors like institutional racism, chronic stress related to that, [plus] conscious and unconscious bias.

[Disparities stem] not only from institutions and [health care] providers. There are also [instances of] mistrust from patients. Even when health care is available, based on history [and] what patients experience in society, they do not willingly trust the institution to take good care of them, and therefore, their care suffers, and they experience disparities.

How has the COVID-19 pandemic affected disparities in cancer care?

I would argue [COVID-19] did not do anything directly to cancer care disparities. It brought to the surface the magnitude of the problem. At the peak [of the COVID-19 pandemic], infection rates were similar between African Americans and Caucasians, but [African American patients] were 2 to 3 times more likely to die from COVID-19. That tells you that their preexisting reserve was very poor. The ability to cope when the unexpected happens is practically non-existent. When COVID-19 hit, African Americans suffered greatly [and disproportionately], both in morbidity and death.

If you look at cancer care, at that time, our schedules were functioning at the highest level possible, but the resources were being taken disproportionately by the care needed for [patients with] COVID-19. Therefore, other things had to go to the backburner. Every time that happens, preexisting problems get bigger.

I have not seen any direct data looking at the outcomes of cancer treatment during COVID-19, because [the pandemic is ongoing]. [I expect] when we dive into the data and look at what happened over the COVID-19 pandemic, the usual disparities that we see in cancer care will have been exaggerated over that time.

How can community and academic oncologists work together to help reduce disparities in cancer care?

We can improve care by being aware of these critical metrics. The fact [is] that cancer care outcomes are not uniform when comparing across ethnicity, race, social groups, and so on. If people are more aware of these disparities, then what is likely to happen is that conscious awareness will lead to us doing a better job when we come across these patients, especially the ones who are usually disadvantaged.

There are resources available that can help mitigate the social determinants of health that do not allow patients to get to help in time or to be able to comply with what is being done to help treat their cancer. As part of comprehensive care provisions to patients in the community, it would be great if medical cancer-treating offices were aware of these resources and made those resources available to patients.

Academic oncologists have more work to do because a lot us work in close partnership with our community colleagues. If things are happening that are cutting edge or changing treatment standards, we are often the first to be aware of those things. We deliberate with our partners in the community and make sure that all of us are doing the same thing. We should also make sure that whatever it is that we think is the optimum approach to therapy is applicable to all equally. [We must] offer those treatments to every person that we can offer them to and [ensure] that optimum care is not restricted to certain groups.

Academic centers can [also help with] accrual to clinical trials, which is one area that has been shown to be consistently different between groups. Clinical trials are [meant to improve] the standard. When clinical trials are available, they should be the preferred [recommendation] to the patient. One of the ways we can try to reduce disparities or eliminate them is by making sure that clinical trials are [made available] to all, especially [those patients] who are usually disadvantaged.

Regarding your specialty in women’s health, is there a significant area of need in this group that should be recognized?

Like all cancers, if you look at women diagnosed with endometrial cancer, ovarian cancer, or cervical cancer, the incidence, prevalence, and mortality from these cancers, are much higher in African American [women], Native Americans, Alaska Natives, and Hispanic populations [compared with Caucasian women].

The important thing to remember is that social determinants of health, institutional racism, conscious and unconscious bias, and the lack of trust are contributing factors to these disparities. However, not all disparities are accounted for by [these determinants].

When [African American women] are diagnosed with endometrial cancer, they tend to have higher grade, more dangerous cancer histotypes. This means that the risk to the patient from the cancer is higher from the beginning. Compared with [a patient] diagnosed with a garden-variety, low-grade, typical endometrial cancer, which sometimes is cured by surgery alone, these other cancers tend to recur early [and] they tend to be diagnosed at advanced stages. These cancers are more lethal. That is a biological [determinant]. That is not due to a disparity in health care dispositions or bias. When this happens, one must recognize that.

There are other areas of genetics that are becoming available to us that affect populations differently. These might affect either how the cancer is diagnosed or how the cancer responds to therapy, which are not related to bias. They are related to genetics and biology. We have to continue to work harder to get better at making sure everybody [receives optimal] cancer treatment.

Is there anything else you would like to highlight?

I would like to express my appreciation for societies such as the Society of Gynecologic Oncology, the American Society of Clinical Oncology, and all the institutions [that] have risen to the task over the past decade and consistently prioritized health care disparities. [These societies have ensured] that cancer care providers are aware of [disparities] and that clinical research takes account of this. The work that they are doing at society, research, and leadership levels are appreciated. I want to thank all of them and recognize the work they are doing and encourage them to continue.

This article was originally published on OncLive®. 

Articles

Alexander B. Olawaiye, MD, discusses how social and biological determinants can affect care outcomes across cancer subtypes and what steps community and academic oncologists can take to ensure these disparities are recognized.

Addressing inequities in cancer care starts with awareness

Black women are more likely to present with high-risk uterine cancers compared with White women, said Cortney Eakin, MD, who added that although obesity has been considered 1 of the potential underlying risk factors, more research needs to be done to define the variables that have caused the disparity.

“The risk of high-risk histologies in Black women is increasing at a very high rate, at 4% every year,” Eakin said. “If we don’t find a reason for this trend, and we don’t do something to abate it, we’re looking at Black women being at a 2.8 times higher risk of being diagnosed with a high-risk cancer compared with a low-risk cancer. These disparities that we’re seeing today are only bound to get worse if we don’t do something about it.”

 during the 2022 SGO Winter Meeting, Eakin, a gynecologic oncology research fellow at the University of California, Los Angeles (UCLA), discussed alarming trends in uterine cancer histologies in Black women and some of the potential underlying risk factors at play.

: What prompted this research into trends in uterine cancer histology in Black women in the United States?

: I have some phenomenal mentors as a fellow. John K. Chan, MD, [of the University of California, San Francisco] is certainly one of them. One of the things that is important for great mentorship is being able to challenge [existing] paradigms and to ask the [important] questions. One day, we were having a conversation about the dualistic approach to type 1 vs type 2 endometrial cancer, and we questioned how accurate that [paradigm was].

We have access to these national databases where we can see obesity and histology trends. If this paradigm really exists, shouldn’t we see that on a national scale? That question is what started this project.

What did you find when looking into this topic?

There have been several studies thus far that have showed that Black women tend to be at higher risk for high-risk histologies. That’s nothing new. What we really wanted to do was to [observe] what obesity trends are doing [in this population] and understand how they compare with those of White women. We also wanted to understand what happens if these trends continue.

We found that the rate of uterine cancer is not increasing significantly in White women, but it’s increasing very significantly—about 2.5% every year—in Black women. If those were all low-risk, grade 1, endometrioid tumors that typically have a good prognosis, that’s 1 [thing]. But we wanted to break down the histology to understand what cancers [these women] are getting. [It turns out Black women are getting] higher-risk cancers.

When you look at obesity, [Black women] are significantly more obese [compared with White women]. The main finding of the study was that Black women are significantly more impacted by those high-risk cancers [and] that they’re increasing at a high rate. If you look at all type 2 cancers, they’re increasing at about 4% annually, which is worrisome in and of itself. When you look at serous carcinomas in particular, they have been increasing over 6% every year for almost the past 20 years. If this trend continues over the next 10 years, when a Black woman gets diagnosed with uterine cancer, they’re going to be almost 3 times as likely to get a high-risk cancer compared with a low-risk, grade 1 tumor. That’s a trend that we have to pay attention to.

We know that these racial disparities exist. What can we do to modify them? When [a patient] gets diagnosed with uterine cancer, we can say it’s an access to care issue, and we can [ask] whether they are getting the best treatment available, but we can’t change the histology. The histology is what they present with, and there have to be some sort of modifiable risk factors out there that can account for some of these racial disparities. Maybe obesity is 1 of them.

What is the likelihood that obesity is responsible for these trends?

The main question we had with this study was whether obesity could potentially be a [risk] factor. Obesity is rising in both Black and White women. Obesity is rising [at a faster rate] in White women than it is in Black women, but Black women are also traditionally more obese.

By 2017, 47% of Black women were obese. Forty seven percent of an entire population is high. Ultimately, [we didn’t collect] patient-level data, so we can’t say [definitively] that obesity plays a role. All we can say is that when we look at the national trends, it’s a question that is worth proposing and looking into further in future studies.

Have any comparative studies been done on a global scale on this topic?

On a global scale, [there have not been any studies done on this topic]. Our study had over 778,000 endometrial cancers. The vast majority were endometrioid. Serous cancers made up about 6%, and clear cell and carcinosarcomas collectively made up about another 6.5%. Globally, you’re talking about [approximately] 10% of cancers. It’s hard for us to have studies that have the power to find these risk factors when endometrial tumors are traditionally much more common.

The studies that have been done that have proposed these questions are things like the Women’s Health Initiative. Some data are coming out of [that study]. There’s also the Epidemiology of Endometrial Cancer Consortium. Those studies have shown that body mass index [BMI] and obesity have more of an impact on type 1 tumors, but the impact that [obesity] has on type 2 tumors is also not 0.

The data are out there, and people are paying more attention to this now. Now it’s a matter of, on a national and global scale, what we do about it.

What are some of the next steps that should be taken to further this research?

One thing that we can do about it is ask: What is driving this? Race is not just Black and White. Genetically at our core, we’re much more similar than we think. Race is a proxy for so many other social determinants of health and environmental factors. Are there environmental factors, are there epigenetic factors, or are there biomarkers that are impacting this population at a higher rate than they’re impacting other populations that can explain why Black women are being diagnosed with higher-risk cancers? Those are the questions that we need to start asking ourselves so we can start to drive down this disparity.

At the end of the day, our job as oncologists is to ask the tough questions, go back to the original paradigms, and question whether there is a way that we can rethink them.

Ultimately, that’s all we’re proposing. Can we rethink the way that we have approached endometrial cancer that will allow us to improve the disparities that we’re seeing today? Hopefully, we can start to drive that conversation forward, and if that’s what happens, we’ve done our job.

This article was initially published by our sister publication OncLive.

Cortney Eakin, MD, discusses alarming trends in uterine cancer histologies in Black women and some of the potential underlying risk factors at play.

Ryan Scott

Articles

Addressing inequities in cancer care starts with awareness

Increase of endometrial cancer in Black women prompts questions into underlying causes