ASCO forum: Accountability, investment needed to address inequity in precision cancer care
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As precision medicine continues to play an increasingly important role in cancer care, racial and ethnic disparities in access to this innovative treatment approach have emerged.
To address obstacles to precision medicine at every stage of treatment, ASCO held a virtual roundtable featuring experts and thought leaders from oncology care, clinical research and patient advocacy.
“As an oncology community, we have seen incredible progress and advancements in cancer treatment, and precision medicine has been at the forefront of this progress,” ASCO President Lori J. Pierce, MD, FASTRO, FASCO, said during her introduction. “According to NIH, there have been more than 250 targeted therapies approved for use in cancer treatment by the FDA as of April this year. We have also seen the development of multiple immunotherapies that stimulate the immune system to fight cancer cells in some patients. These very hopeful and sometimes curative therapies are no longer the exception — they have become the standard of care for a large and growing share of cancer types.”
Pierce said the topic of the roundtable discussion reflected the theme of her term as ASCO president: “Equity: every patient, every day, everywhere.”
“Equity is so important for us as we observe the 1-year anniversary of the death of George Floyd,” Pierce said. “Achieving health equity has been a longstanding personal commitment for me. This focus includes working to achieve equity in precision cancer care so that all our patients have the best outcome for their disease.”
With innovation comes inequity
During the discussion, Otis W. Brawley, MD, FACP, Bloomberg distinguished professor of oncology at Johns Hopkins University School of Medicine and a HemOnc Today Editorial Board Member, noted that major advancements in cancer care often engender or emphasize racial, ethnic and socioeconomic disparities.
“Whenever we have an improvement in diagnosis, screening or treatment for cancer, we create disparities in who gets the advancement,” Brawley said. “The Black/white differences in mortality for colorectal cancer and breast cancer didn’t exist in the 1970s. It was only in the 1980s, after we learned how to screen and treat these diseases, that we started having disparities between Black and white patients. As we move into an era of precision medicine, I think we’re going to see the same thing. We’re going to have a group of people who don’t get these wonderful treatments or don’t get them as much.”
Brawley said he believes one important step toward narrowing these gaps in care is to make payment for health care the same for everyone.
“I think of Medicaid as a form of institutional racism,” Brawley said. “There are hospitals that will not take Medicaid and they provide very high-quality care, and there are hospitals that do take Medicaid and they are overrun, overwhelmed and resource-challenged.”
Brawley cited a study that showed most Black individuals only had six lymph nodes resected after colon cancer surgery, whereas most white individuals had about 18 nodes resected.
“It’s not that the pathologists are racist,” he said. “It’s that the pathologist working in the hospital where most Black patients are treated had five or six cases to deal with in her day, whereas the pathologist working in the hospital where white patients are treated had one or two cases to deal with and had time to dissect out the 18 lymph nodes. So, I am very concerned about where we get care and how care is being paid for.”
Biomarker-informed diagnosis
One of the first obstacles Black and other minority patients might face along their cancer journey is a lack of complete diagnosis through biomarker testing. Pierce noted a recent study that showed Black patients diagnosed with non-small cell lung cancer were less likely than their white counterparts to have their tumors tested for EGFR mutations.
“Not surprisingly, these patients were less likely to be treated with EGFR-targeted therapies,” Pierce said.
Panelist Olufunmilayo I. Olopade, MD, FACP, Walter L. Palmer distinguished service professor of medicine and human genetics and director of clinical cancer genetics and global health at The University of Chicago, discussed the importance of understanding the specific features of a patient’s cancer.
“Cancer is not one disease. In my field of breast cancer, I need to know if we are dealing with an HER2-amplified cancer [for which] targeted therapies [are] available,” Olopade said. “So, it’s very important to know what kind of cancer it is. Even if it’s metastasized, we are finding drugs that can get cancer that has spread everywhere to melt away. The standard of care should be telling me [not only] ‘I have cancer,’ but also what type of cancer and what drugs would target that type of cancer. A proper diagnosis that is biomarker-informed should be available to every patient, everywhere. That’s what we mean by making it personal to the patient.”
Equity as a quality metric
Another important approach to addressing disparities in precision medicine for cancer is to make equitable care a metric for quality care, according to panelist Blase N. Polite, MD, MPP, FASCO, associate professor of medicine, deputy section chief for clinical operations and executive medical director for cancer accountable care at The University of Chicago, as well as a HemOnc Today Editorial Board Member.
“We have a fragmented system where patients are often not connected with larger cancer centers that provide comprehensive care,” he said. “We need to hold ourselves accountable for patients who are falling through the system. If we’re serious about health equity, then health equity should be an outcome metric that we pay attention to, and that has consequences if we don’t achieve it.”
Polite added that Medicaid programs — and specifically, the managed care organizations that predominantly provide care for Medicaid patients — should incorporate health equity as a major quality metric.
“States should be using these metrics to decide where they’re sending patients. States have a choice on how they set up panels,” he said. “You shouldn’t be getting more Medicaid patients if you’re failing to achieve health equity outcomes. Similarly, I think the federal government, which is paying 55% to 65% of the bill for Medicaid programs, should also use that leverage to have health equity as a metric.”
Meeting these targets should be mandatory and the consequences for failing to meet them should be enforced, according to Polite.
“In my opinion, the first thing you do is say, ‘Here’s what we expect you to do, here’s how you’re actually doing, and here’s how you need to improve if you want to receive funding and expand your patient base,’” he said. “If we incentivize it and make it a high-stakes metric, I guarantee you, people will find solutions, because there are solutions if you prioritize it. Until we do that, it’s just talk.”
‘Normal was what got us here’
Journalist Ysabel Duron, a cancer survivor, patient advocate and founder of Latino Cancer Institute, discussed the disparities facing the Latino community.
“According to the American Cancer Society, one in five Latino deaths are due to cancer; it is the number one cause of death among Latinos, and breast cancer is the number one cause of death among Latinas,” Duron said. “Although the Latino community is smaller than the Black and white communities, cancer is cancer. Death is death, and that word drives such fear in the communities that live with myths and misinformation, and don’t even have access to standard care, much less quality care.”
Duron said the need for clear information and prompt screening inspired her to work on a bilingual genetic breast cancer toolkit with a colleague at University of California, San Francisco.
“This community needs knowledge and awareness. They need access to standards of care,” she said. “Then they need to work in systems that are integrated from the federally qualified health care system into the public health care system, where they have all of the sophisticated and advanced diagnostics. First, though, they need to understand it. They need not to fear it, and they need to utilize early screening for intervention.”
When asked what needs to be done to overcome health care disparities, Duron pointed to the need for funding.
“Invest, invest, invest,” Duron said. “We need dedicated dollars to invest in community-based organizations, which are utilized by all of our communities. We can’t wait for systems that are completely broken, that have huge cracks. We cannot go back to normal, because normal was what got us here in the first place.”
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ASCO virtual roundtable. From diagnosis to treatment: Ensuring equity in precision cancer care; May 25, 2021.
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