COVID-19 adds urgency to fight against inequities in cancer care
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The COVID-19 pandemic has amplified inequities that historically underrepresented populations have faced for decades in the U.S. health care setting.
Disparities in COVID-19 cases and mortality emerged early during the pandemic in the United States, with mortality rates more than twice as high among Blacks than whites.
Source: John Wallace, Virginia Commonwealth University.
Such disparities already had been well-established in cancer care.
According to data from the American Cancer Society, Blacks have the highest mortality and poorest survival rate of any racial/ethnic group in the U.S. for the majority of cancer types.
Now, experts are concerned the pandemic will exacerbate disparities in cancer care among Blacks, Hispanics and other people of color.
Such concerns have revitalized efforts to address disparities in cancer care, research and beyond. Last month, ASCO released a policy statement on cancer disparities and health equity, with several recommendations that aim to increase access to high-quality care and research and to address long-standing structural barriers to equitable care.
This also was the topic of a scientific symposium during the American Association for Cancer Research Virtual Annual Meeting II, in which experts discussed these inequities and how to make use of this moment to undo them.
“COVID-19 has shown a light on what many of us had already known to be occurring in this country and throughout the world for the better part of 100 years,” Robert A. Winn, MD, director of Virginia Commonwealth University Massey Cancer Center, said during the symposium. “My call to action is that we do not retrench as we have in the past. I have never been more optimistic — cautiously optimistic, but optimistic — that we can make real change that is sustainable.”
HemOnc Today spoke with symposium participants about the disparities that have come to light during the pandemic, the pandemic’s impact on cancer care of historically underrepresented populations, and intensified efforts by the oncology community to eliminate barriers to equitable care.
Parallels between cancer, COVID-19
As data on trends in COVID-19 incidence and mortality emerge, researchers have observed striking similarities with historical cancer inequities.
Data from New York City, where the pandemic hit early and severely, have been especially revealing.
According to a viewpoint by Balogun and colleagues published last month in JAMA Oncology, race- and ethnicity-stratified COVID-19 data released by New York showed “two distinct trajectories and risk groups defined along the lines of race and socioeconomic status.”
Cases per 100,000 individuals in the Bronx, Queens and Brooklyn are twice as high as those in Manhattan and three to four times as high as in Staten Island, with the death rate twice as high among Blacks and Hispanics compared with whites across the city.
COVID-19 is yet another disease added to the already lengthy list of those that disproportionately affect Black and Hispanic Americans, Lisa A. Newman, MD, MPH, FACS, FASCO, director of the interdisciplinary breast oncology program at Weill Cornell Medicine, said during the AACR symposium.
“The effects of systemic racism and socioeconomic disadvantages on health care access as well as health care delivery are clearly dominating, pervasive factors in this complex picture,” she said. “Other potential contributing factors include biology of disease and environmental exposures, germline genetics and the epigenetic effects of lifetime stressors.
“The COVID-19 public health crisis has been heartbreaking in its impact on everyone, regardless of racial/ethnic identity, but given what we already know about health inequity in the United States, it was inevitable that Blacks and Hispanics would suffer disproportionately from morbidity and mortality associated with COVID-19,” she added.
Obesity, hypertension and cardiovascular disease are well-documented contributing factors to the cancer burden among communities of color and emerged early on as risks for poorer outcomes associated with COVID-19 infection, according to Newman.
Newman “took a deeper dive” into the burden of the novel coronavirus among the diverse New York City population — where nearly one-fifth of the nation’s COVID-19-related deaths occurred during the first few months of the pandemic — and described additional details regarding disparities that resulted from the pandemic based on data from the New York City Department of Health.
The highest mortality rates of COVID-19 occurred among Blacks and Hispanics across all five boroughs of New York City.
“On a national level during the early pandemic surge, the COVID-19 burden among Hispanics was only slightly higher than among whites but, in New York City, Hispanics experienced more COVID-19-related morbidity and mortality — much closer to the rates observed among Blacks,” she said.
COVID-19-related case and mortality patterns were reflective of the wealth and race/ethnicity patterns across the city’s boroughs — similar to what has been observed with the breast cancer burden, Newman added.
“For example, breast cancer has an earlier stage distribution and lower mortality rate in Staten Island, the borough with the highest median household income and the least diversity, with nearly 80% white residents,” Newman said. “This is compared with a higher breast cancer stage distribution and higher mortality rate observed in the Bronx, which is the borough with the lowest median household income and where whites account for only 30% of the total population. Similarly, COVID-19-related mortality also was substantially higher in the Bronx compared with more affluent communities of the city.”
Newman and colleagues are working to embed disparities lessons learned from breast cancer research into ongoing COVID-19 research efforts.
“We have been studying the frequency of triple-negative breast cancer in women with African ancestry, including African American and Ghanaian women. These women have high frequencies of triple-negative breast cancer compared with women of other ancestries,” Newman said during her presentation. “My colleague, Melissa Davis, PhD, is an expert on the Duffy gene, which is particularly interesting in disparities research because there is a variant of this gene, the Duffy null allele, that is linked to Western sub-Saharan African ancestry. We found that the inheritance of the Duffy null genetic variant is associated with risk for developing triple-negative breast cancer.”
The Duffy null variant appears associated with chemokine balance and inflammatory response, and the effects in pulmonary tissue might be influencing the cytokine storm associated with COVID-19-related pneumonia, according to Newman.
“Our group is now in the process of studying the role of the Duffy null variant in COVID-19-related research,” she said.
“By applying lessons learned to response and recovery efforts, there is the potential for prevention of some of the downstream COVID-19 consequences and to prevent one public health crisis from begetting many others,” Newman added, urging cancer clinical research groups to leverage their community engagement networks in support of diverse accrual onto COVID-19 vaccine and treatment trials.
Impact on cancer care
Given that both COVID-19 and cancer disproportionately affect the same racial and ethnic groups, experts worry the pandemic will have long-lasting effects on oncologic care and outcomes.
“During our medical response to managing the COVID-19 health crisis, mammography screening programs were placed on hiatus, and this will likely have worse public health impact on Black communities that were already more likely to have advanced breast cancer stage distribution,” Newman said. “Minorities were more likely to lose their jobs and insurance coverage as a consequence of the COVID-19-related recession, which will also impact breast cancer screening and treatment during COVID-19 recovery.”
Additionally, public safety net hospitals, which provide medical care to large proportions of Black and Hispanic patients with cancer in New York City, were disproportionately devastated by the financial toll of caring for patients with COVID-19, according to Newman.
There are a variety of reasons the oncology community “should absolutely care about health disparities created and worsened by the COVID-19 pandemic,” according to Amelie G. Ramirez, DrPH, director of the Latino-focused health equity advocacy organization Salud America! and professor and chair in the department of population health sciences at UT Health San Antonio.
During her presentation at the AACR symposium, Ramirez addressed the impact of COVID-19 on the Hispanic community and how the pandemic deepened existing inequities faced by Hispanic and Black individuals.
“The U.S. population continues to grow more diverse; thus, cancer patient populations are growing more diverse,” Ramirez told HemOnc Today. “U.S. Census Bureau data published in June show Hispanics comprise 18.5% of the U.S. population — behind only whites (60.1%) — representing a greater percentage than Blacks (13.4%), Asians (5.9%) and American Indians or Alaska Natives (1.3%).”
Still, minority groups are more likely to be diagnosed with certain cancer types and chronic diseases, with cancer cases among Hispanics expected to increase 142% by 2030, Ramirez added.
“Health disparities faced by minority populations have been worsened by the COVID-19 pandemic,” she said. She cited CDC data from Aug. 13 showing Hispanics represent over 30% of COVID-19 cases among adults aged 25 to 64 years and over 40% of cases among children and young adults aged 0 to 24 years, despite being a minority group in the United States (see Table).
“Barriers to health care — such as the cost of care, language complexities, having no health insurance, cultural myths and mistrust of doctors or clinical research — are at the heart of a lot of these disparities,” Ramirez said. “But even before they reach the need for care, minority groups are already starting at a health disadvantage due to inequities in income, early education, housing, transportation, food, physical activity, and exposure to pollution and toxins. We can’t simply treat these individuals without addressing their circumstances.”
Because COVID-19 led to the shutdown of many cancer screening programs, it is essential that minority communities be targeted for aggressive screening efforts once these services resume, Newman said.
“In an effort to catch up with cancer screening while continuing to adhere to social distancing protections, many believe that telehealth will be the answer. However, we must exercise caution here, as the digital divide is real,” Newman said. “Access to and utilization of the internet across different population subsets is not equal. Several studies have shown that Blacks and Hispanics are less likely to utilize telehealth technologies.”
A global experience
Much of the disparities in health care can be attributed to social determinants and structural racism on a global scale, Francis I. Chinegwundoh, MD, consultant urological surgeon at London Bridge Hospital in England, said during his presentation.
“We are a global community — what affects one affects all in one way or another,” Chinegwundoh told HemOnc Today. “Blacks are more than fourfold likely to die of COVID-19-related complications but, when considering sociodemographic characteristics — such as measures of self-reported health and disability, urban vs. rural living, living arrangements such as rental vs. owner and education level — the risk reduces to double.”
The impact of the COVID-19 pandemic on patients with cancer in the U.K. appears to mirror that of the United States.
“The negative impact was inevitable due to delays in diagnosis and treatment, which may lead to inoperable cancers. The general feeling is that this will disproportionately affect Black, Asian and Minority Ethnic [BAME] communities the most,” Chinegwundoh said. “Despite free equal access to health care in the U.K., not all communities experience the health care journey in the same way, including patients with cancer.”
Results of a U.K. annual national survey of patients with cancer showed BAME patients experience less satisfaction overall with health care, reporting lower confidence in and less understanding of health care professionals, Chinegwundoh said.
“On top of this, cancer treatments have been turned upside down during the COVID-19 pandemic and cancer services have taken a back seat. The expectation is that this will affect BAME communities disproportionately, given that even in the best of times they report worse health care experiences than their white counterparts,” he said.
Chinegwundoh said hospital services are now gearing up to reestablish the health care services lost and resume cancer clinical trial research.
“There is a need for research to value insights from BAME communities themselves, that researchers reflect the diversity of the communities they are studying, and to ensure that BAME participants are involved in such research efforts,” Chinegwundoh said. “The global community can ensure that access to cancer trials is available to all and not just high-income communities.”
To combat the added disparities in cancer care, the U.K. National Health Service posted messages on social media to encourage patients with symptoms to seek preventive care.
“The U.K. National Health Service recognized that BAME communities are more likely to take heed of public service messages if delivered by someone who looks like them, and I was therefore asked to record a 1-minute video to encourage patients to seek care,” Chinegwundoh said.
Access to cancer treatments should be unbiased, as well, he added.
“In the U.K., disparities are driven by a less favorable experience of cancer services by Black and other ethnic minorities,” Chinegwundoh said. “We have a national health service, where access to treatment is not by ability to pay. There needs to be increased access to clinical trials and access to the same cancer treatments as the white majority.”
Ongoing efforts
To help prevent these disparities from persisting, physicians should be willing to treat all patients while taking into consideration their environmental and social circumstances, Ramirez told HemOnc Today.
She gave the example of the diverse Southern Orchards neighborhood in Columbus, Ohio, which struggles with racism, lack of affordable housing, economic segregation, violent crime, poverty and high health care costs.
“Nationwide Children’s Hospital recognized these issues and took on the entire neighborhood as its ‘patient’ and listed ‘unsafe living conditions’ as the top symptom,” she said. “They diagnosed their patients with ‘unstable housing,’ which is known to cause many economic, social and health hardships, especially for Hispanics and other people of color.”
The hospital then prescribed a “housing intervention” and has spent the past decade revitalizing Columbus’s South Side and Southern Orchards neighborhoods through a Healthy Neighborhoods Healthy Families partnership in collaboration with faith-based, community and school organizations.
“During this time when COVID-19 has worsened housing and income issues, the health care workforce must go beyond disease and account for people’s external situations,” Ramirez said. “Oncologists can add socioeconomic factors, such as housing stability, access to transportation and healthy food, and other social issues to patients’ medical records. This could serve to enable clinicians to have a more holistic look at patients’ health history, including clinical, social and behavioral risks. This also will arm health care workers with information to connect patients with community services and reduce costly emergency visits.”
Given data that show the expansion of Medicaid through the Affordable Care Act has improved earlier detection of cancer, such a model might be important to address the financial impact of COVID-19 on historically underrepresented populations, Newman said.
“States that enacted Medicaid expansion saw notable improvements in the stage distribution of their patients with breast, colon and lung cancer compared with nonexpansion states,” she said. “It is reasonable to assume that comparable measures will assist in the health maintenance of populations financially impacted by the COVID-19 pandemic. Close collaboration is needed between the oncology community and public health professional communities. As we rebuild public health care in the post-COVID-19 era, we must be proactive in achieving health equity and mitigating further disparities by working together.”
Health care professionals should also become more aware of implicit bias they may unknowingly harbor, Ramirez added.
“Many studies have shown that physicians — especially white physicians — have implicit, subconscious preferences for white patients over those of color. Implicit bias can lead to false assumptions and adverse health outcomes,” Ramirez said.
Ramirez recommended physicians learn about implicit bias and bias testing, available at salud.to/biasone, and become acquainted with the work of other physicians who are helping overcome bias. For example, Jabraan S. Pasha, MD, FACP, has created a training workshop to spread awareness of implicit bias in health care.
Winn said that physicians, caregivers and researchers also need to reflect their patient populations.
“We need to talk about these equity issues, not just in the context of patients we take care of, but also the equity issues within our own academic structures,” Winn told HemOnc Today. “The number of Black oncologists is embarrassingly low. We need to work with medical schools and residency programs to increase the number of minorities in the oncology field. We also need to highlight the minorities in our field who are doing outstanding work, which is something that we can all do right now.”
Ramirez agreed that more efforts are needed to build the pipeline for a diverse health care workforce. She cited as an example the NCI-funded Éxito! Latino Cancer Research Leadership Training program, which recruits 25 Hispanic students and health care professionals annually for a culturally tailored curriculum that promotes pursuit of a doctoral degree and cancer research career.
“The program also offers internships and ongoing support,” Ramirez told HemOnc Today. “Of the 101 individuals who participated in the program between 2011 and 2015, 43% applied to a doctoral program and 29.7% were currently enrolled. We have proved that Éxito! is a strong model pipeline program that equips Hispanics for applying to and thriving in doctoral programs, with added potential to boost the pool of cancer health disparities researchers.”
‘Commit to action’
Despite these ongoing efforts, the experts with whom HemOnc Today spoke stressed more is needed to counteract the pandemic’s exacerbation of cancer care disparities and to remove their root causes altogether.
In ASCO’s policy statement, the society listed increased awareness and action as one of its recommended steps to improve health equity in cancer care.
“Achieving health equity requires efforts that inform, educate and empower all individuals,” Patel and colleagues wrote in the statement. “Continued efforts to ensure awareness are crucial for the general public, health care professionals, policymakers, health systems and other stakeholders. ... Although awareness of cancer health inequities has improved modestly over the past decade, educational efforts should extend to those policies, programs, activities and research that have proven successful at ameliorating cancer health inequities.”
Ramirez and colleagues have created an action plan — available at salud.to/endracism — that aims to help individuals get their cities and counties to declare racism a public health crisis and commit to specific actions as a first step toward lasting and meaningful change.
“Our hope is that there will be rapidity for movement to reevaluate existing policies and create new policies with a lens on achieving racial justice and health equity where everyone has a fair and just opportunity to live their healthiest lives,” Ramirez said. “This will require all sectors — public, private, business, health care, government and school systems — to work together to commit to action.”
Winn agreed.
“We must recognize that the demographic and public health aspects of disparities during the COVID-19 pandemic are real. As researchers, clinicians and physicians, we must stop playing around and understand that to stop these disparities, action is required now,” Winn said during the symposium. “Let us work together to keep each other healthy.”
Oncology clinical trials teams should leverage their resources to ensure accrual of appropriately diverse patient populations onto COVID-19 testing, treatment and vaccine trials, Newman added.
“Some of these resources involve social media outlets, others will involve manpower resources, such as connections with patient navigator and community-based cancer advocacy organizations,” Newman said. “We have learned the importance of embedding a priori research aims that are specifically designed to answer disparities research questions into cancer clinical trials. It also is essential to address diversity accrual targets into the statistical study design so that results can be generalized with confidence. These same principles should be followed in the design of COVID-19 studies.”
Winn said it also will take different dialogue and consistency of “showing up” before health care institutions gain the trust of underserved populations.
“In many ways, we are putting the cart before the horse in the sense that we want to benefit multiple minority groups of patients, but we do not do the hard work of showing that prevention is important,” Winn told HemOnc Today. “We should improve upon our community advocators and educators and hire people from the communities we are trying to reach. Discovering an effective cancer treatment is great in and of itself, but it is not enough to reduce the gap in health disparities among minority populations.”
References:
American Cancer Society. Cancer Facts & Figures for African Americans 2019-2021. Available at: www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf. Accessed Aug. 19, 2020.
Balogun OD, et al. JAMA Oncol. 2020;doi:10.1001/jamaoncol.2020.3327.
Minorities in Cancer Research Scientific Symposium: Health Inequities and Disparities in the COVID-19 pandemic and Impact on Cancer Care Among Racial and Ethnic Minorities and the Medically Underserved. Session VSS06. Presented at: American Association for Cancer Research Virtual Meeting II; June 22-24, 2020.
NHS England. National Cancer Patient Experience Survey. Available at: https://www.ncpes.co.uk/2019-results/. Accessed Aug. 19, 2020.
Patel MI, et al. J Clin Oncol. 2020:doi:10.1200/JCO.20.00642.
For more information:
Francis I. Chinegwundoh, MD, can be reached at London Bridge Hospital, 27 Tooley St., London SE1 2PR, United Kingdom; email: frank.chinegwundoh@nhs.net.
Lisa A. Newman, MD, MPH, FACS, FASCO, can be reached at Weill Cornell Medicine, 525 E. 68th St., New York, NY 10065; email: lan4002@med.cornell.edu.
Amelie G. Ramirez, DrPH, can be reached at UT Health San Antonio, 7411 John Smith Drive, Suite 1000, San Antonio, TX 78229; email: ramirezag@uthscsa.edu.
Robert A. Winn, MD, can be reached at Virginia Commonwealth University Massey Cancer Center, 907 Floyd Ave., Richmond, VA 23284.
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