Q&A: Patient communication crucial to reduce racial disparities in metastatic breast cancer
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Ethnic and racial disparities are a major challenge throughout the field of oncology, but especially when it comes to treating metastatic breast cancer.
Research has shown that in patients with some forms of metastatic disease — specifically HER2-positive breast cancer — survival rates are nearly twice as high for white patients as they are for Black patients, highlighting a multifaceted issue that touches on factors from the biologic to the socioeconomic.
Healio spoke with Rachel Freedman, MD, MPH, a medical oncologist and clinical researcher in Dana-Farber Cancer Institute’s Breast Oncology Program, about the causes and effects of these striking disparities, and how it’s on clinicians to better communicate with metastatic breast cancer patients in order to mitigate these effects.
Healio: How do racial disparities affect patients with metastatic breast cancer today?
Freedman: Unfortunately, we're still seeing disparities in outcomes when it comes to race — Black race in particular. But we also see disparities when it comes to limited access to care, certain geographic places around the U.S., those at risk for poverty or who are in poverty, and actually the extremes of age — the youngest patients and the oldest patients.
These factors can sometimes be cumulative, meaning that if you are young and you are of Black race, for example, your outcomes are probably are even more at risk. And although people with metastatic breast cancer are now living longer and they're living better — and that's true across the board — the pace of that improvement is different for different populations.
So, sometimes disparities widen even when things are getting a little bit better because the pace of that improvement isn't uniform. And I think that's very much the case when it comes to Black/white differences in outcomes. There's a lot that goes into the reasons this happens but some of it is their disease, right?
Black patients tend to have more what we call triple-negative breast cancer. They may have more of these aggressive subtypes. They tend to present with not more metastatic disease necessarily but more what we call locally advanced disease, so that when they start out with their diagnosis, they don't have the smallest tumors compared with other patients. This sets them up for potentially more risk. And then you throw in some sociodemographic factors, social determinant factors, age factors, insurance factors — severything can be really amplified. It's well known that patients have differences in their time to treatment, and delays in treatment matter. And there's just a lot of factors that go into these race effects that we see pretty consistently.
Healio: How can clinicians attempt to address these disparities and bring about more equitable outcomes?
Freedman: This is a huge problem. I think we are used to, in our clinical training, focusing on the medical aspects of somebody's illness. But I think increasingly we need to be aware of what's going on in that person's life outside of their cancer. And I think medical centers are getting better across the board at asking patients about difficulties with housing, paying their bills, transportation, parking upfront. But it is still not universally done. And even when patients answer those questions, it's not clear that it leads to bringing people those resources.
So, there's a lot being done in trying to do that. We have a study at Dana-Farber that's trying to link patients with resources when they report issues around some of these potential challenges. As a community, we need to do better about asking. If a patient's not showing up, why aren't they showing up? What can we do to get them here? How can we help? Don't put it on the patient — help the patient. We need to be doing better at that as a community — actually asking what the challenges are and doing our best to address them.
We can't address everything. And I think housing is the biggest one that's so difficult to address. I can address parking. I can address gas cards. I can address groceries. But I can't address housing. It's really, really difficult. You can get them on lists and all of that through our social work program, but we can still do other things. And I honestly think that's such a huge part of it — asking patients what their copay is.
If I'm about to prescribe something, I'll tell them if I think the copay might be high, call me if your copay is high because then I can help. If you just go and you either don't fill it cause it's too expensive or you're going broke because you bought it, we want to know. Giving patients that freedom and comfort to tell you about the challenges they're facing is a huge thing that we need to be doing better as a cancer community.
Healio: What kind of programs or initiatives are in use to combat these disparities?
Freedman: Every cancer center has its array of resources. Sometimes they're labeled different things. In our center at Dana-Farber, we have social work that is really paying attention to the emotional, psychosocial aspects around somebody's diagnosis when it comes to their relationships or coping. But they also have a lot of information, knowledge around options for disability and other forms of reimbursement and helping with human resources at one's work.
We also have resource specialists at Dana-Farber who really focus on the financial piece. If a person doesn't have transportation or can't pay for parking, needs a taxi voucher one day, that's all done through our resource specialist. And they also help connect people to foundations who will have patient aid, and they often require a little bit of an application process. And it's, in our center, the resource specialist. Those two positions are key.
We also have navigators who help coordinate care and also help coordinate some of that financial piece and kind of take on some of the resource specialists. In some centers, it's just social work doing all of that. And in other centers, it's called different things. But I think the key is trying to make sure you're addressing all those different elements. In our center, the financial piece is mostly outside of social work.
Healio: What’s the current state of research into the biologic components of racial disparities in metastatic breast cancer outcomes?
Freedman: This is a huge issue. If you look at clinical trial populations, every clinical trial is not honestly representative of the populations with cancer we treat. Unless you are a white middle-aged woman, you are not well represented in research.
That limits us because if you are trying to tell the person in front of you who isn't represented in that study how she's going feel on a medicine or how she's going do with her treatment, you're extrapolating, and you're doing the best you can. And we do OK. We do the best we can, but it is less than ideal. And there's a major push nationally to get more diversity in our clinical trials when it comes to not just race, but age.
Older patients are traditionally completely underrepresented despite it being the most common time when people develop cancer. We really have to do a better job at opening up access to trials — bringing them to the community where most patients get care, not big academic centers where a lot of people don't end up going. We have to make it easy for them. We have to make it approachable and understandable, and make sure that their voices are heard, and their experiences are heard so we can better inform their care.
In general, there's a lot of really cool stuff going on in clinical trials, and there's a lot of biomarker work — trying to figure out predicting who will benefit from something, who won't benefit from something. There's a lot of amazing technology and advancement going on.
I will say that sometimes we forget the basics. In breast cancer, sometimes we're celebrating a very small benefit of a percent or two in something that's really new and innovative, but we've actually forgotten some of the basic underlying care that people need to get who aren't getting it. And so how are they ever going to get that really advanced technologic therapy if they're not getting the basics? As we move ahead and have all of this really cool research and innovation, we have to remember the foundation of what we need to do to treat breast cancer.
Healio: What is the biggest unmet need in addressing these racial disparities?
Freedman: I wish that it was a single answer. It's just so complicated. If it was an easy solution, we'd all be celebrating it, and we'd be done by now. Paying attention to the individual and the challenges in that individual are key. Promoting early screening when people are of age, taking family histories to know if people are at risk at a particularly young age that screening can start. We need to be more proactive about the beginning and getting people screened and finding cancers as early as possible. And once a cancer is diagnosed, we have to be really proactive about making sure timely care is given and addressing the reasons it's not. Not every patient needs the same thing.
There’s a lot of discussion around equality and equity, and it may be that to get to a optimized outcome for breast cancer, somebody needs something different than someone else. We have to pay attention to the individual along the way as best we can and support them as much as possible.
Healio: What are the biggest lessons you want clinicians to take away from examining these racial disparities in metastatic breast cancer?
Freedman: Clinicians need to ask their patients questions. They need to talk about clinical trials and explain what they are. We have to make sure we have the right language support in our clinics. We have to make sure that we have resources in our clinics, and we should advocate for those things when we don't have them.
Clinical trials are a huge thing, and in our center we have so many of them. There's a lot of barriers to getting people on studies, but I think when you explain to patients what they are and how they can contribute to the future of breast cancer care and have their experiences included in that, it's hugely beneficial.
We're always thinking about clinical trials when we see a patient. Is there something for this person? Always have that in your mind. Don't assume that somebody doesn't want it or doesn't have time for it or want to hear about it. In general, don't make assumptions. Ask the patients their needs. Think about clinical trials and support them as best that you can in your practice and however your center can do that.
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