Disparities of cancer care in the US will not go away ... unless we do something about it in an election year

Issue: March 25, 2016

ByDerek Raghavan, MD, PhD, FACP, FRACP, FASCO

I was disappointed to see the excellent work by Grubb and colleagues and Schmid and colleagues, covered in detail in this issue of HemOnc Today. These reports again have shown significantly impaired outcomes in black and Hispanic patients compared with non-Hispanic white patients receiving treatment for purportedly curable cancers (pediatric Hodgkin’s lymphoma and adult localized prostate cancer, respectively).

At a time when we are planning moonshots and other glorious concepts, it is a national disgrace that we seem unable to provide simple equity in curative care to each member of our population. That seems a target that our politicians should truly find to be interesting and achievable.

Rocket science

Speaking of moonshots, this problem is not new, and the available solutions do not constitute rocket science! In 2007, around the time that I took over as chair of ASCO’s Health Disparities Advisory Committee, I addressed potential strategies that included improving access to care; active collaboration with leaders of the minority communities; and addressing fiscal, cultural, educational, health insurance and social barriers.

My collaborators, Siran M. Koroukian, PhD, and Paul Bakaki, MD, PhD, and I reported some years ago a study that assessed outcomes for eight curable malignancies, comparing survival and 5-year mortality by Medicaid status in more than 12,000 adults, with data drawn from the Ohio Cancer Incidence Surveillance System and Ohio Medicaid enrollment figures.

There was a disproportionate increase of black patients receiving Medicaid in this cohort compared with non-Hispanic white patients, and it was clear that support from Medicaid was associated with an unfavorable survival status. Individuals who were receiving Medicaid prior to diagnosis had a HR of 1.52 (95% CI, 1.27-1.82), and those who initiated Medicaid in association with the diagnosis had a HR of 2.01 (95% CI, 1.7-2.38).

In 2009, ASCO released its position statement “Disparities in Cancer Care,” the work product of the Health Disparities Advisory Committee. In brief, it stated the commitment of ASCO to collaborate with the diverse community of stakeholders to undertake the following:

Develop policies to guarantee equal access to quality health care, with special emphasis on reducing insurance and economic barriers to cancer care;

Develop a comprehensive plan to increase awareness of racial and ethnic disparities in cancer care;

Execute a strategy to enhance the supply of minority physicians and to improve the training of the oncology workforce to meet the needs of racially and ethnically diverse patients with cancer;

Increase prioritization of public and private research on cancer care disparities;

Develop mechanisms to increase participation of racially and ethnically diverse populations in cancer clinical trials; and

Support initiatives to enhance patients’ involvement in their cancer care.

I am happy to note that ASCO has delivered on those goals that it could influence — ie, the oncology community has taken many of the necessary administrative steps to improve this situation.

To identify just a few examples, with support from the Susan G. Komen for the Cure, we were able to create specific training programs to attract young physicians of color into oncology training programs, and we also were able to encourage their acquisition into and retention within underserved geographical communities.

We also dramatically changed the educational programs of ASCO to add content and focus on disparities of care and supported increased involvement of underserved communities in their oncology experience.

Equity of care

One of the most disappointing aspects of this whole debacle is that this information has been made available to national leadership repeatedly. For instance, more than 5 years ago, I addressed the President’s Cancer Panel on disparities of cancer care, and emphasized the dangers of analysis paralysis and the associated need for the nation’s influencers to seek more data rather than simply rolling up their sleeves and tackling the problem.

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So once again, I remind us and our political leadership on both sides of both houses: Black patients, Hispanic patients and other underserved populations continue to suffer excessive mortality and morbidity from cancer. Although we consider all the clever long-term solutions to achieve victory via moonshots, let us take some time and expend the necessary resources and political capital to attain this simple target — equity of cancer care by 2020.

References:

Goss E, et al. J Clin Oncol. 2009;doi:10.1200/JCO.2008.21.1680.

Grubb WR, et al. Pediatr Blood Cancer. 2016;doi:10.1002/pbc.25802.

Koroukian SM, et al. Cancer. 2012;doi:10.1002/cncr.27380.

President’s Cancer Panel 2009-2010 Annual Report: America’s Demographics and Cultural Transformation — Implications for Cancer. NCI. Available at: pubs.cancer.gov/ncipl/detail.aspx?prodid=P239. Accessed Feb. 16, 2016.

Raghavan D. Oncology (Williston Park). 2007;21:493-496.

Schmid M, et al. JAMA Oncol. 2016,doi:10.1001/jamaoncol.2015.3384.

For more information:

Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.

Disclosure: Raghavan reports no relevant financial disclosures.