Equity in cancer care must remain top priority in COVID-19 era, beyond, presenters say
Although much has been achieved within the past year in addressing inequities across the U.S. health care system, it is only the tip of the iceberg, according to panelists at the COVID-19 & Cancer Consortium Scientific Retreat.
Experts who participated in a session on equity and patient engagement discussed the importance of being intentional in working to ensure adequate representation of minorities across all aspects of health care.
“It is our responsibility and duty to support people of all backgrounds,” Narjust Duma, MD, assistant professor at University of Wisconsin School of Medicine and Public Health, member of the medical oncology and lung cancer clinics at UW Carbone Cancer Center, and a HemOnc Today Next Gen Innovator, said during her virtual presentation. “Diversity has been proven repeatedly to improve productivity. It allows us to view problems with a different set of eyes, and it makes us better able to work with people who come from different backgrounds and have different ideas to offer. We want a cheeseboard with lots of diversity, and the same can be said for the medical field — this will help improve our research and allow us a better overall experience. It is time to diversify.”
Inequities in access, delivery
Data from the COVID-19 and Cancer Consortium have suggested common factors associated with worse COVID-19 outcomes include older age, male sex, smoking status, poor ECOG performance status, presence of comorbidities, hematologic malignancies and active cancer.
In a study published in March in Annals of Oncology, Grivas and colleagues gathered data from the consortium on 4,966 patients with COVID-19 and active cancer or a history of cancer. Among the 695 patients who died within 30 days of COVID-19 diagnosis, common risk factors associated with death included older age, male gender, Black race and Hispanic ethnicity.
“In addition, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes, worse ECOG status and hematologic malignancies were all associated with worse COVID-19 severity. There are definite major take-home messages with these findings,” Corrie Painter, PhD, researcher at University of Massachusetts Medical School, said during her presentation. “Of note, and in particular relevance to this panel, is the fact that higher COVID-19 severity was observed among Black and Hispanic people, with higher 30-day mortality among Black patients specifically. This suggests that there are disparities in health care access, delivery and research.”
Painter said the findings were reminiscent of previous data from the COVID-19 and Cancer Consortium.
“Research had shown that remdesivir [Veklury, Gilead] reduced mortality compared with untreated controls. Even though it was not enough to reach statistical significance, the numbers were there and Black patients were approximately half as likely to receive the therapy as their white counterparts,” Painter said. “It is disheartening to know that this is still happening today. This is a clear indication of where we are in medicine and we must do better. We must put the gauntlet down to figure out how we can come together as a community. One of the things I am hoping will surface during this retreat are the steps that we can take as a community to do better by our patients.”
Drivers of disparities
Racial disparities that have been observed since the beginning of the COVID-19 pandemic are strikingly similar to the disparities observed in oncology for decades, Sonya Reid, MBBS, MPH, breast oncologist at Vanderbilt University, said during her presentation.
“It is well-known that Black patients with cancer have higher mortality rates compared with all other racial and ethnic groups,” Reid said. “With this in mind, we chose to evaluate clinical characteristics and outcomes among Black patients with cancer and COVID-19 using the COVID-19 and Cancer Consortium, which is a diverse cohort with upwards of about 20% of Black patients included.”
Reid and colleagues examined data of 3,500 patients — including more than 2,000 white patients and 1,000 Black patients — that showed Black patients had higher COVID-19 disease severity, including higher hospitalization rates, ICU admissions and mechanical ventilation use.
“This is in addition to having higher 30-day mortality rates and even after adjusting for clinical and demographic factors,” Reid said. “This is highly disturbing. As we know, we have seen these disparities in cancer care and now we are now seeing the disparities in COVID-19, and it may be worse.”
Factors driving the disparities are wide-ranging and complex, according to Reid.
“They likely do overlap with some of the same factors that have been contributing to cancer health disparities, such as social determinants of health,” Reid said. “We know that racial minorities have difficulty with social distancing, and some reside in small apartments with high numbers of occupants. Minorites are also more likely to be essential workers and work in grocery stores and hospital settings and have preexisting conditions. All of these factors translate into higher COVID-19 disease severity and mortality among Black patients.”
Access to health care is another factor contributing to the disparity.
“As soon as we know there is inequity in access to quality health care — a key factor contributing to higher levels of underlying health conditions — that increases the risk for severe COVID-19 and mortality,” Reid said. “We also know that Black patients are less likely to receive novel anti-COVID therapies, such as remdesivir, compared with their white counterparts. This is one of those ‘access-to care issues’ that translate into other areas that were not clearly studied within this analysis.”
Regarding COVID-19 vaccine hesitancy, Reid said it is important to understand and respect that a general mistrust in health care has existed for decades among certain minority communities.
“We need to start by being silent and ask patients why they are hesitant to get vaccinated, and responses may differ,” Reid said. “If we did this, we would get a lot farther on this journey in trying to increase vaccine uptake. We have to be intentional about listening to our patients and understand that their ‘why’ may be different from others.”
Physician equity
Work also is needed to address inequities experienced by physicians in oncology and hematology, according to the presenters.
Duma and colleagues conducted the HOLA COVID-19 study to evaluate the effects of the COVID-19 pandemic on hematology and oncology practices across limited-resource settings in Latin America.
“Most of the data so far on COVID-19 had come from the U.S., Europe and Asia,” Duma said. “In the HOLA COVID-19 study, more than 700 oncologists practicing in Latin America completed a survey, and one thing that we learned was that access to telemedicine is significantly different in Latin America compared with the U.S. and because the frequency of telemedicine is low, the comfort level of telemedicine is low.”
Nearly 30% of oncologists practicing in Latin America were deployed to COVID-19 floors and were tasked with procedures and responsibilities that they had not handled in years and, in some cases, even decades, Duma said.
“Cancer centers across Mexico became COVID-19 hospitals, which made oncologists become hospitalists overnight,” she said. “These findings will publish soon and additional research from the HOLA COVID-19 study will examine the degrees of burnout among oncologists and hematologists in Latin America. These oncologists and hematologists in Latin America now have a voice.”
Last year was particularly challenging for physicians of color, according to Duma.
“We had two pandemics going on in 2020 — COVID-19 and racism,” Duma said. “We have known about structural racism, we have faced many barriers and we often encounter microaggressions and more. For many of us, it does not matter how many titles we have, our race precedes us before anything else. When this happens to us as physicians, it multiplies and affects our patients.”
Duma, who has accepted an assistant professor position at Harvard Medical School and also will serve as associate director of the Center for Cancer Equity and Engagement at the Dana-Farber/Harvard Cancer Center, is involved in another study currently recruiting participants to evaluate how COVID-19 affected racial and ethnic minority members of the COVID-19 and Cancer Consortium. In addition, members of the consortium created a disparities interest group early in the pandemic, with several manuscripts now moving through the publication process.
“We meet frequently and for me, this group has provided an environment to meet with my colleagues during this very hard time where we share some of our fears and support each other morally,” Duma said. “As a Latina, I have many family members who were affected by COVID-19, including myself. While the group is very productive in terms of research, it has also provided moral support to my colleagues and I, which is very important.”
References:
Grivas P, et al. Ann Oncol. 2021;doi:10.1016/j.annonc.2021.02.024.
Tsevat J, et al. Health care equity and patient engagement. Presented at: COVID-19 & Cancer Consortium Scientific Retreat (virtual meeting). March 26, 2021.
Collapse
Tsevat J, et al. Health care equity and patient engagement. Presented at: COVID-19 & Cancer Consortium Scientific Retreat (virtual meeting). March 26, 2021.