Great progress has been made in the fight against cancer, but not all patients have benefited equally. Disparities exist among specific populations in terms of survival and cancer-related mortality, incidence and prevalence, as well as adverse health conditions, according to Karen M. Winkfield, MD, PhD, Director, Office of Cancer Health Equity, Wake Forest Baptist Medical Center Comprehensive Cancer Center, Winston-Salem, NC. Dr Winkfield discussed the topic at the 2019 ASCO Quality Care Symposium.
Cancer Outcomes Influenced by Affluence
She cited data from the Centers for Disease Control and Prevention, showing that African Americans have the highest incidence of, and mortality from, visceral cancers, based on race and ethnicity. And although genetic and biologic factors may influence these disparities, Dr Winkfield said, one of the biggest predictors of health outcomes remains the person’s socioeconomic status.
“When it comes to writing the right prescription, contouring the appropriate volumes, and ensuring that patients are making it to the treatment facility every single day, income, occupation, and education are really the underpinning factors,” said Dr Winkfield.
“Issues with respect to disparities are not just relegated to race and ethnicity. One of the common denominators in all marginalized groups, including the LGBT+ community and adolescent young adults, is lower socioeconomic status,” she added.
It’s imperative for providers to consider the social context of their patients, Dr Winkfield explained, because of the multitude of barriers they face in receiving adequate cancer care. Whether unemployed or hourly employed, these patients are not well-compensated for their work, and cancer treatment often requires long commutes to and from appointments, at the expense of potential income. These competing survival priorities are important to remember when discussing cancer disparities.
“Your patients’ health is not just about what happens when they come into a clinical trial,” said Dr Winkfield, noting that medical care only accounts for approximately 25% of what happens with respect to social determinants of health at the population level.
“Before patients even walk into your office, they have all the other influences in their environment that can impact their health and their outcomes, including economic stability, education, community and social context, and diet,” she said. “That’s why Medicaid and uninsured people don’t often see the same benefit. There’s this whole other world.”
One of the factors leading to financial toxicity is the rising costs of cancer care, particularly the exponential increase in drug costs. For example, the out-of-pocket costs for lenalidomide (Revlimid), an oral agent used for the treatment of multiple myeloma, can reach up to $15,000 annually per patient.
“Lenalidomide has done wonderful things for myeloma patients, but these costs simply aren’t tenable for poorer patients,” said Dr Winkfield.
Although oral chemotherapy parity laws have helped to ease this financial burden, by requiring health plans to cover oral cancer medications at a rate “no less favorable” than the standard intravenous chemotherapy, some states still have not adopted this legislation.
“At a time when the majority of our new therapeutics are oral medications, it’s disgusting that there are states that have not passed this legislation that has the potential to cut thousands of dollars in out-of-pocket costs for patients,” Dr Winkfield emphasized. “As we continue to develop new technology like precision oncology, it’s incumbent upon providers to ensure that all forms of cancer therapy are accessible and affordable.”
The first step for providers is awareness, according to Dr Winkfield, and not only of the legislative landscape where they practice, but also the institutions for which they work. Oncology providers can also advocate for their communities and their constituents, by becoming involved in resource allocation decisions at the institutional, state, and national level.
In collaboration with the American Cancer Society, 43 states and Washington, DC, have enacted oral parity laws that require patients to pay no more for oral cancer medication than they would for chemotherapy infusion. Still, much work remains.
“Talk to your friends and family about the importance of voting, and the importance of understanding these issues,” Dr Winkfield concluded. “By removing some of these barriers to care, we can continue to improve the landscape around health disparities.”