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.
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.”
In an interview with OncLive®, 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.
Olawaiye: 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].
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.
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.
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.
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.
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.