Social Determinants of Health - Beginning the Conversation

Social Determinants of Health in Cancer Care

This episode was originally released October 26, 2020

In ASCO eLearning’s first Social Determinants of Health (SDOH) series episode, Dr. Ramy Sedhom, MD moderates a discussion with ASCO President, Lori Pierce, MD, FASTRO, FASCO; Abenaa Brewster, MD, MHS; and Katie Reeder-Hayes, MD, MBA, MS on why understanding SDOH’s impact on patients is critical to providing equitable care. We hope you enjoy this episode.

TRANSCRIPT

ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

RAMY SEDHOM: Hello, and welcome to ASCO's newest podcast focused on the social determinants of health. My name is Ramy Sedhom, and I'm a medical oncology fellow at Johns Hopkins. Today, I am joined by ASCO president Dr. Lori Pierce, professor of radiation oncology at the University of Michigan.

We are also joined by Dr. Katherine Reeder-Hayes, associate professor of oncology and health services researcher from UNC Chapel Hill, also chair of the ASCO Health Equity Committee. And finally, we are also joined by Dr. Abenaa Brewster, chair of the ASCO Prevention Committee, medical oncologist, and professor of epidemiology at MD Anderson. All our distinguished health researchers focused on disparities work.

We are excited to launch this theme in light of the theme as highlighted by Dr. Pierce, equity, every patient, every day, everywhere. Dr. Pierce, why are the social determinants of health relevant? How do they relate to our work at ASCO and to the theme of equity?

LORI PIERCE: Thanks, Dr. Sedhom. Yes, the ASCO theme this year is based on equity, and treating patients with equitable care is at the very heart of what ASCO does. It's what ASCO stands for.

But we know there are factors, including social determinants of health, that can significantly affect the quality of health care that our patients receive, so we're hoping that this series of talks will increase awareness to many of those factors so providers can understand even better what some of the barriers are that our patients are experiencing. So we feel that understanding what they are, that's an important first step in terms of determining meaningful actions that we can take.

RAMY SEDHOM: Thank you, Dr. Pierce. Dr. Reeder-Hayes, any additional comments?

KATHERINE REEDER-HAYES: So I would just add that the reason I think oncologists inherently do care about the social determinants of health is that we care who gets cancer, and we care about the survival of that cancer. That's what we do as physicians. And as we follow cancer outcomes and cancer registries over time, what we realized is that there are a lot of biological things about cancers that determine their outcomes, but there are also many things that determine that outcome of a person's cancer that aren't biologic, and we have put those things together in a large group and use labels like the social determinants of health to understand what those non-biological factors are. But as physicians, as people who want to cure cancer, I think that it's just as important for us to have a good understanding of those non-biologic factors and how they're going to influence our patient's chance of the best outcome from their disease as it is for us to have a good grasp on the biologic determinants that are going to influence our patient's outcome.

RAMY SEDHOM: Thank you. And I think this is a really good time to emphasize that the series is at the intersection of work through the Health Equity Committee and the Prevention Committee as being put forth by ASCO, and the ASCO Education Committee as well. And Dr. Reeder-Hayes, how would you importantly define the social determinants of health?

KATHERINE REEDER-HAYES: So that's a pretty broad range of definitions, because there are a lot of people in health care who have talked about this concept of non-biologic determinants of how patients do for a long time, both in cancer care, and in other fields, like primary care, diabetes, and hypertension research. And so there are several organizations that have put forth definitions. The first one that I would point people to as the World Health Organization. So these patterns occur globally, not just in the United States. And the WHO describes the social determinants of health as the circumstances in which people are born, grow up, live, work, and age, and the systems that are put in place to deal with illness.

So there's this idea that the circumstances that people find themselves in, as well as the structure of the health care system are part of this conversation about social determinants of health. The Robert Wood Johnson Foundation has done a lot of work to help put these concepts into more understandable and everyday language. And so the definition they use is that health begins where we live, learn, work, and play. So the social determinants of health include factors that operate on a few different levels.

So there's the level of societal conditions, social conditions, economic conditions, physical conditions of where and how people live, and where and how people work, and then there are also psychosocial levels, like the patient-level psychosocial factors. And Centers for Disease Control also focus a lot of their work on social determinants at this idea of psychosocial factors at the patient level. So even though the concept is simple, it's actually also very broad. And when people talk about social determinants of health, they can be talking about things that are operating at several different levels, from the structure of the health care system, on down to the structure of the apartment complex where your patient lives. And so you have to think broadly, I think, when you're thinking about analyses for research or how to talk to your patients about social determinants of health.

But the American Cancer Society has recently also put out a paper that tried to help people put these social determinants into appropriate buckets, particularly the ones that really seem to impact cancer care. And so the three categories or domains that they've suggested are structural inequities, so things that happen in a larger society and in the structure of the health care system that impact our patients and how they access care. Secondly, institutional environments. What do the places where we treat cancer look like? What are their structures? And how does that impact our patients outcomes?

And then, finally, living environments. Where do our patients go back to when they go away from the health care setting? So those are some of the ways that we can think about the finding and talking about the social determinants of health.

RAMY SEDHOM: Thank you for sharing that. That's a lot to think about and to consider. Dr. Brewster can you comment on the impact of those social determinants of health in disparate groups beyond race and ethnicity?

ABENAA BREWSTER: So I agree that we're really used to thinking about social determinants of health as explaining some of the race-ethnic disparities that we see in cancer incidence and outcome. But we know that there are other groups that also experience differences in outcomes based on these determinants. For example, characteristics of sex, gender identity, sexual orientation, geography, immigration status, these are all characteristics that are impacted by social determinants of health.

An example that I like to give for the race-ethnic disparity is the 40% increase in mortality that African-American women experience who are diagnosed with breast cancer compared to white women, and that, for a large part, is due to socioeconomic poverty and insurance differences. And in fact, then those characteristics then explain decreased screening, later stage of diagnoses, and then leads to disparate delays and receipt of treatment. There was a really nice paper published in JCO by Jamal and others which showed that insurance alone accounted for about 37% of that 40% increase in mortality that Black women experience who are diagnosed with cancer. And so you can see the great opportunities that are there to make care more equal if you're able to improve access.

And so examples of other groups, for example, we have registry data showing that urban populations, although they have higher cancer incidence, the rural populations actually have a higher incidence of the cancers that are related to tobacco use or HPV. And we also know that rural populations also have higher mortality than urban populations when it comes to cancer, and that's largely driven by poverty, under insurance, socioeconomic status, isolation. And so that's another group that is impacted by those social determinants of health as outlined by Dr. Reeder-Hayes.

And then, lastly, the LGBT community. Although there haven't been a lot of large studies looking at the impact of cancer incidence and outcomes in that community, there have been lots of survey studies that have shown that these determinants of health tend to cluster within those communities. Once again, social isolation, negative patient-provider relationships, under insurance, poverty, and so that's another group where this becomes very meaningful.

And I think kind of what cuts across all of these groups are really characteristics that have been linked to historical discrimination. And so that's something that we see very clearly. And then, we also see it reflected in our oncology population, right? Only about 2% of oncologists are African-American. And so these social determinants of health not only impact our patients, but they impact what our workforce looks like, and then, that, in turn, leads to differences in terms of the patient-provider relationships.

RAMY SEDHOM: Absolutely. And this is a great question to direct towards you as the chair of the Prevention Committee. How do the social determinants of health-- how are they relevant for our cancer patients and our cancer survivors?

ABENAA BREWSTER: Social determinants affect the trajectory of cancer care. And so we've talked about the impact of social determinants of health on cancer mortality and cancer outcomes, receipt of treatment, timing of treatment. So those are all impacts that our oncology patients face. But I would say, in terms of the field of cancer prevention, over the past four decades, there have been significant advances in cancer prevention, vaccine, preventive therapies, high-quality screening. And unfortunately, there are populations that are being left out of those advances that we've seen in cancer prevention.

We also know that maintaining a healthy weight, having a physically active lifestyle, having a nutritious diet with fruits and vegetables also play a key role in cancer prevention. But those are impacted by where our patients live. And so patients who live in disadvantaged neighborhoods may have less availability for these nutritious food choices, and they may have less safe spaces to engage in physical activity. And so while we advance our prevention knowledge and our prevention strategies, we are leaving behind groups of individuals who, based on where they live, and where they work, and how they're educated, are not being able to access those types of advances in cancer prevention, and as a result, we see increasing cancer incidence.

RAMY SEDHOM: And Dr. Pierce, how does having this context or understanding make us better researchers, clinicians, and administrators? And also, how does it benefit our interactions with our patients and our colleagues?

LORI PIERCE: So understanding the social determinants of health, it will make us better researchers, then clinicians, and just better doctors, because it allow us to see how the cancer world looks to our patients, kind of look at the cancer world through their lens. And an example, we have all these groundbreaking therapies, but if the patients don't have transportation and they can't come in, then those therapies are for naught. And I'm going to echo what Dr. Brewster said a few minutes ago. Another example is if we're advocating for patients to maintain a healthy weight, and a part of that is to do exercise, but they can't go out in their communities because they're not in a safe community, then we need to come up with other strategies. So I think it's very important that we understand these issues so we can advise, we can advocate, and we can act once we truly understand the barriers that our patients are facing everyday.

RAMY SEDHOM: And Dr. Reeder-Hayes, can you comment on how the Health Equity Committee is seeking to understand the social determinants of health, their effects on populations, and the actions that can be taken to improve cancer care?

KATHERINE REEDER-HAYES: Sure, so one of the things that the Health Equity Committee has been really excited about and working with Dr. Pierce on, her presidential theme, and also, in entering this conversation about the social determinants of health, is getting more of our members engaged with the idea of knowing our patients and their non-biologic characteristics as a way of being better doctors, as Dr. Pierce said. So the most simple way I can explain the concept is that every patient has a backstory. We know this as doctors. Every patient brings this unique story into their cancer care experience.

And we know intuitively that that story that they bring with them into cancer care is going to impact what their cancer journey looks like. But we also need to acknowledge that it's going to impact their cancer outcome. We already know that it's going to impact how we interact together as a team, patient and provider, but we need to raise awareness that it's also going to impact how the cancer turns out. Because I think that's something our members naturally care about, and I think our members want to understand their patients' cancer care stories,

So as researchers, and as folks on the Health Equity Committee, we would like to help people understand how to obtain the most relevant information about their patient's backstory in the most respectful and efficient and effective way, and then to integrate that well into how they care for their patients, as well as how they shape their research and their administrative roles. So we're excited to be doing that. Now, some of these circumstances are not immediately changeable, and they certainly aren't within the patient's individual power to change, but some of them, at least in terms of how they impact our patient's access to care, are modifiable, either by us as their physician, or by someone else in the health care system, or by someone in an organization that comes alongside the health care system to help, like a private foundation or a philanthropic organization.

If our patient has a barrier to care because of transportation, like the example that Dr. Pierce gave, and they can't get a ride to cancer care, there are actually some ways that we can intervene on that. And there are even people in our health care system who are expert on how to intervene on that, as well as organizations that have volunteers that can help intervene on that. But if we don't obtain the information, we're not going to know, and then we can't bring the strategy to bear to get our patient to that groundbreaking therapy that they get. If they could make it to us, or if we could make it out to them, thinking about innovative ways to deliver care. So those are some of the things that we're excited about in the Health Equity Committee.

RAMY SEDHOM: Thank you for sharing with us a lot of the great work that you're doing, and the ASCO team. On a similar note, Dr. Brewster, can you review with us some of the key contributions related to the social determinants of health from the Prevention Committee?

ABENAA BREWSTER: Sure. Well, first of all, I'm so proud of the ASCO Cancer Prevention Committee for the work that they've done over the years to raise awareness, not only about cancer prevention to the public, but also within the oncology community. And ASCO's Cancer Prevention Committee has really spearheaded ASCO's work in tobacco control and cessation over the past 20 years, including supportive position statements on tobacco cessation and control, and also, for the electronic nicotine delivery device systems. And the committee continues to educate providers on the importance of addressing smoking cessation among their patients before and after a diagnosis of cancer.

Also, within the area of obesity and energy balance, the committee has issued a position statement, because, actually, the majority of Americans are not aware of the impact that obesity has on cancer risk and cancer prognosis, and just raising the awareness of that issue, particularly around underserved populations, is important, because those are the populations that actually have some of the higher rates, but also lack that knowledge. And so the committee has conducted surveys of not just oncologists, but also patients, to try to really understand how that information is being disseminated, and then what are the barriers to be able to address the issue of obesity? And so that's important work that's going on.

And a few years ago, the Prevention Committee also issued a statement on the association between alcohol and cancer risk and outcomes, and that's kind of all still a risk factor that has very little public awareness of its importance, and that's really driven a lot of the media and other publications that have come out really showing that association. And so raising that awareness is important. And the good news is that there are strategies and interventions and policy changes that can be brought to bear to impact some of these modifiable risk factors. And so that's a very exciting avenue for research and practical applications.

RAMY SEDHOM: Thank you, Dr. Brewster. That's actually a wonderful shift toward policy and advocacy. And I, myself, participated on the Hill with ASCO. And Dr. Pierce, can you share with us or discuss some of the advocacy efforts from ASCO for our patients and lawmakers who can help in critical ways as it relates to the social determinants of health?

LORI PIERCE: Thanks for the question. It's a great question. Advocacy is so important. So important that we advocate for our patients, because they often can't advocate for themselves.

And we advocate to lawmakers, that's on a local level, on state level, and a national level, because it really can highlight to our lawmakers some of the barriers that our patients face and things that they can do to remove those barriers. And I'll give you a great example, HR 913, the Clinical Treatment Act. For those of you who don't know what that is, it's the following.

Medicaid is the only insurer that does not cover routine care costs for patients, Medicaid patients who go on clinical trials. They're the only insurer that doesn't do that. And you talk about routine costs, we're talking about doctor visits, we're talking about x-ray tests, routine blood tests. The irony is Medicaid will cover these same costs if patients were not on a clinical trial, but they won't cover it on a clinical trial.

And of course, we know there are a lot of minority patients that are on Medicaid. And so this is the disincentive for minority patients to go on clinical trials, which is exactly what we do not want to see. And so ASCO has been spending quite a bit of time advocating to the legislation about how important it is to cover these costs in clinical trials.

And so the House has legislation, and just last week, the Senate now has parallel legislation. So we are moving the needle. We are going in the right direction. And it's a very important example of just what advocacy can do in terms of improving care for our patients.

RAMY SEDHOM: That's great to hear, and we hope things continue to move forward. Dr. Pierce, also would like to direct this question to you. What is your vision for the future of this podcast series? And what do we really want our listeners to take home from this?

LORI PIERCE: So I'm so excited about this series, and I am so appreciative to everyone, those who are on the series, and everyone in the background for getting this going. It's my hope that the series of broadcasts will be an important educational tool to really understanding the social determinants of health and how they impact our patients and society at large. And so this series will contain a lot of aspects, a lot of podcasts and videos on social determinants of health that our task force, which you are a key member of, is helping us to design. So our task force is made up of fellows and junior faculty, the future leaders of ASCO, and the future leaders of oncology in general. So thanks to your enthusiasm, thanks to your feedback, we are launching this, and I am super, super excited.

RAMY SEDHOM: Thank you, again, everybody. The conversations today are really a reminder of all of our shared experiences. I remember as an oncology fellow, oftentimes, the hardest part of care in the clinic was not the science or the biology of cancer, but actually, all of the things discussed today, especially the social determinants and how they impact our patients.

Again, we want to thank all of our wonderful faculty for serving as change agents. The planning of this podcast series is a joint effort through all of the wonderful ASCO volunteers who are fellows, junior faculty, ASCO leadership, and importantly, cancer survivors and ASCO staff. We do want everyone to look forward to next month's episode, where we will discuss and look at what ASCO can do as a professional society to address equity as a part of its mission.

Again, thank you to all of our listeners, both locally and abroad, for joining us for this episode of the ASCO podcast series on the social determinants of health. To keep up with the latest episodes, please be sure to subscribe. Let us know what you think about this series by leaving a review or by emailing us at [e-mail]. Again, thank you, and we look forward to seeing you in the next episode. ANNOUNCER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive eLearning Center at elearning.asco.org.