HCP Roundtable: Empowering Providers to Bring Cancer Innovation to Every Patient

Dr. Nicole Rochester:

Welcome to this Empowering Providers to Empower Patients EPEP program. I’m Dr. Nicole Rochester. EPEP is a Patient Empowerment Network program that serves as a secure space for healthcare providers to learn techniques for improving physician-patient communication and overcome practice barriers. In this Healthcare Provider Roundtable, we are exploring overcoming barriers to accessing innovative cancer care, with a particular focus on breast and colorectal cancers. 

Some of the topics we’ll explore today include barriers to timely access and adoption of innovative treatments, outdated practices and awareness gaps that sometimes limit patient options, addressing outcome expectancy and clinical inertia in care delivery, and translating innovation into equitable, evidence-based patient care.

Today, I’m honored to be joined by two leading voices who are breaking down barriers and advancing equitable cancer care across the continuum. First, we have Dr. Demetria Smith-Graziani, Assistant Professor, Department of Hematology and Medical Oncology at Emory University School of Medicine, and she’s a nationally recognized researcher focused on understanding and addressing racial and ethnic disparities in breast cancer outcomes. Dr. Smith-Graziani’s work examines how social determinants of health, systemic barriers and provider bias influence access to timely diagnosis and evidence-based treatment. Dr. Smith-Graziani is deeply committed to developing strategies that ensure every patient, regardless of background, receives equitable, high-quality cancer care. Thank you so much for joining us today, Dr. Smith-Graziani. Thank you for having me, I’m happy to be here.

We’re also joined by Dr. Folasade May, Associate Professor of Medicine and Director of Quality in Gastroenterology at the UCLA David Geffen School of Medicine and a practicing gastroenterologist at UCLA Health and in the Veterans Affairs. Dr. May’s research focuses on colorectal cancer prevention and community-engaged strategies to increase screening and early detection in underrepresented populations. Dr. May’s work bridges data-driven research with real-world implementation, bringing preventive care to communities that need it most. 

Thank you so much for being here, Dr. May.

Dr. Folasade May:

It’s a pleasure to be here, thank you for having me. 

Dr. Nicole Rochester:

So let’s start with barriers to timely access and adoption of innovative treatments. We know that across the cancer continuum, progress in screening, diagnostics, and treatment continues to accelerate yet, many patients still face barriers that delay or limit access to these advances, a reality that continues to disproportionately affect vulnerable and historically marginalized communities. While some challenges are shared across cancer types, others are deeply shaped by disease-specific factors and the communities most affected. 

So we’re gonna start with you, Dr. Smith-Graziani. From your perspective, in your research examining disparities in breast cancer outcomes, you’ve shown how social and structural factors can influence both diagnosis and treatment options. What key factors continue to limit timely access to new therapies? And how can providers begin to close these gaps in care delivery? 

Dr. Demetria Smith-Graziani:

Well, it’s a really good question, and so much of it is due to the effects of structural racism. And that really affects patients before they even get to see me, the oncologist, right? There are people who, because of where they live, because of their income, because of lack of insurance, may not have timely access to even get their screening mammogram in the first place and so when you think about the time it takes just to get the mammogram, if that mammogram is abnormal, they then need to come back for a biopsy. So there’s another opportunity for delay, and then if that biopsy does show that the patient has breast cancer, then they need to get to that appointment to see an oncologist.

And so there are a lot of different steps along the way before they even arrive at an oncologist’s clinic, where they can have delays in their care. And so much of that access can be related to just proximity to a hospital or a clinic, which is a result of the effects of redlining. Access to public transportation and then the affordability of all of that, once we actually get that diagnosis, their ability to miss work, to take that time off of work to get childcare. All of that is going to affect someone’s ability to receive timely, guideline-directed care. 

Dr. Nicole Rochester: 

Thank you so much for pointing that out. I think it’s important to make sure that the audience understands what redlining is, so would you mind just giving us a brief explanation of redlining so that they can appreciate how that disproportionately influences or impacts Black Americans?

Dr. Demetria Smith-Graziani: 

Definitely. So, redlining is the historical practice in the United States, where, the government was, segregating, racially segregating, neighborhoods, and that happened in practice by, not approving mortgages for Black families, for Black homeowners in certain neighborhoods, and it was a very purposeful process, this created very segregated neighborhoods and in those neighborhoods that were more likely to be Black, there then were less resources available. We see that today in what we call food deserts, in that people have less access to grocery stores, to fresh foods, and you can think about all the other resources that might exist in a neighborhood that was redlined versus one that was not.

We can sometimes measure that in what we call neighborhood deprivation, and the income, the average income of that neighborhood, and their access to various resources. 

Dr. Nicole Rochester: 

Thank you, thank you so much for sharing that. Dr. May, we’re going to turn to you. Much of your work focuses on improving access to cancer prevention, and early detection in diverse populations. What patterns do you see when it comes to barriers in screening and treatment adoption for patients facing a colorectal cancer diagnosis, whether they be logistical, financial, communication-related, or all of the above?

Dr. Folasade  May: 

Thank you for that question, it’s really interesting to hear Dr. Smith-Graziani, because you realize that regardless of the cancer type you’re talking about, there are common themes when we talk about inequities, access to care, disparities, and we certainly see them in colorectal cancer. I like to point out that colorectal cancer is a unique disease, and the reality that we actually can prevent most people from developing it. It’s a disease that starts in the form of a polyp, that over time develops into a cancer. So we have years to intervene before that transition occurs. 

Unfortunately, we aren’t able to do that in many patients, and that’s why it remains the number two cancer killer in the United States, and unfortunately, it’s one of the fastest-growing cancers in young people, people under age 50. I still believe in the power of screening. We can screen and prevent most people from getting this disease, as I mentioned, but that does require people to have knowledge that screening is available. that we can prevent it, that we can early detect it, and that that saves lives. And a lot of patients don’t even have that information. They’ve heard about breast cancer, or even the NFL celebrates breast cancer by having people wear pink in the month of October they’ve heard about prostate cancer, particularly males have a fear about that diagnosis. Women have been empowered to learn about pap smears and cervical cancer, but we don’t do it as well of a job in educating about colorectal cancer risk. People certainly don’t know that it’s the second most common cancer killer.

So, we have to improve knowledge about this disease among our patients. We also have to make sure that patients have access to screening. We’re very lucky in that there are several screening modalities for colorectal cancer, so we can screen with colonoscopy, but we even have screening tests that you can do in the comfort of your own home. These are stool-based tests. And we need to just make sure that patients know that they have an opportunity to pick between a colonoscopy, which is more invasive and which may have some stigma attached. Versus doing an at-home stool test, which I think a lot of patients find more convenient. So, empowering your patients with knowledge about the importance of screening, and also screening options, and making sure that all patients, regardless of background, regardless of those social determinants that we just heard about, have access to a doctor who can order these tests and provide follow-up care.

Dr. Nicole Rochester: 

Wonderful. Thank you, Dr. May. There definitely are similarities, as you stated, really, between all types of cancer. So, with that, Dr. Smith-Graziani, how do structural inequities and provider bias show up in everyday practice, because we know that those also contribute to the disparities. And then what are actionable steps that clinicians can take to counter these as treatment innovations evolve?

Dr. Demetria Smith-Graziani: 

Yeah, another great question, because, you know, when we talk about these big, you know, policies, these historical factors,sometimes it feels a little bit overwhelming for an individual provider to say, well, what can I do? And, you know, on the larger level, you can advocate for policy changes, you can make sure that your healthcare organization has appropriate support services to help patients navigate, and you can work with community organizations. But on a day-to-day level, an encounter with patients,I think one of the biggest barriers, that has been identified is, providers assuming who is going to be interested in a clinical trial, who is going to be interested in a particular treatment, and because of that, they may just not ask. Like, the research has really shown that there are just disparities, And who the same provider is going to ask about a clinical trial. And so there actually has been training underway at Emory and other organizations, with the goal of educating providers and encouraging them to really just ask every patient about clinical trials, because you may be surprised by who may have an interest. And I think we also get to that point of being able to ask about their interests and getting the appropriate treatment for someone by building rapport, right? We’re building trust with patients.

Patients are going to be more likely to open up and ask questions if they feel like they can trust you, and so I think it’s really important that we encourage questions from patients, that we explain the reasoning behind recommendations, and oftentimes we have to, I know in an initial oncology visit, we’re giving out a lot of information, it can be very overwhelming, and sometimes people get into a habit of delivering these recommendations without really explaining a why behind them and just because patients don’t have the specific medical training doesn’t mean that they can’t understand why a treatment applies to them. You just meet patients where they are, you give them the plain language, you develop that collaborative relationship, you respect their autonomy, and then from there, you can provide that additional knowledge that allows them to make their informed decision. 

Dr. Nicole Rochester: 

Thank you. Thank you so much, Dr. Smith-Graziani. Dr. May, do you have anything that you’d like to add to that?

 Dr. Folasade May: 

No, I love that answer, and I think what we see a lot of times, especially when we look at things like treatment disparities, We have patients who are Black patients, for example, and patients who are white patients. They’re walking into the same provider’s office, and they’re getting different information. And I think what’s happening is that we as providers sometimes think, maybe this patient, can’t handle this level of information or make these decisions for themselves. We can’t make those assumptions, those are biases that have built into our society, historically and over time, from the commercials we see, the movies we watch, even the medical training we’ve received, and we need to break away from that. We need to make sure that we’re providing patients with all of the information, helping them understand, maybe some patients need additional support, but it’s really our job to make sure we’re conveying all the options, whether it’s trials, or other treatment options, and letting patients and their families make the choice that’s best for them, instead of assuming.

Dr. Nicole Rochester: 

Absolutely. I really appreciate both of you holding that up, because I think because so much of medicine now is based on protocols and their algorithms. Many of us assume that we’re giving the same care to all of our patients, and you both have elucidated that, in fact, that is not always the case. 

Well, I want to talk about innovation, because we know that while innovation is great, it doesn’t reach all communities equally. So, Dr. May, as providers, can you speak to the moral and practical urgency of ensuring that innovation doesn’t inadvertently widen existing disparities? 

Dr. Folasade May: 

Absolutely. This is so important, because innovation is critical, innovation is why science is paramount, here in the United States, because we have incredible scientists that are making incredible discoveries, including, for cancer treatment every day. What we see, unfortunately, is that as we innovate, sometimes those disparity gaps widen. Because what happens is those who are the most affluent, who are the most connected, the most insured get access to those innovations, while other populations who don’t have the access, don’t have the insurance coverage, don’t get the access, and that broadens the differences or the variation that we see. So we need to work against that. We need to make sure that we are introducing innovation to all populations, all settings. It can’t only sit in academic centers. It has to be disseminated to community health centers, federally qualified health centers, and to other settings where patients who are underinsured, or uninsured also receive care. 

Example I’ll share is that with colorectal cancer specifically, we treat with surgery, chemotherapy, and radiotherapy, or radiation. And as we’ve had advances in the chemotherapies and radiations, we’ve had actually very specific guidelines about what patients at which stage should be treated with which treatments, we really strive to make sure that patients have guideline concordant care. But as we’re seeing, things like the newer radiotherapy or adjuvant chemotherapy, are not reaching populations that don’t receive care, at these quaternary tertiary care health centers, and they aren’t reaching people of color. We know, for example, if you look at minimally invasive surgery or robotic surgery, which now we know improve outcomes for our colorectal cancer patients, those surgeries are less likely to happen in Black patients for example. So we need to make sure that we push innovation in science, but we also need to make sure that we have dissemination of those innovations to all populations. 

Dr. Nicole Rochester: 

Thank you. Appreciate that. So, we’re gonna move to outdated practices and awareness gaps, and how they can limit patient options. We know that precision medicine continues to transform oncology from breast, colorectal, prostate and bladder cancers, and yet it’s heartbreaking that many patients still don’t fully benefit from these innovations, as you were just stating, Dr. May. When biomarker or molecular testing isn’t performed, patients lose access to the targeted therapies or the clinical trials that were designed specifically for their disease. So, Dr. Smith-Graziani, I’m gonna go to you first. In breast cancer care, what are some of the factors that continue to limit equitable adoption of precision testing?

Dr. Demetria Smith-Graziani: 

Yeah, you know, Dr. May have brought up a great point about the fact that this can’t just live in academic centers, right? This information really needs to be disseminated out into the community. And it’s really important that our community oncology partners are able to stay up to date and to be educated about what is really a fast-changing landscape in oncology in general, and in breast cancer specifically, you know, every year, we are getting new approvals for multiple drugs, and a lot of them are based now on this testing, right? One of the examples is that we are using not just the germline genetic testing, right, to understand if patients have a BRCA mutation, that can affect their care, but we are also using the somatic testing, the genomic testing, to figure out if certain mutations, driver mutations, in our metastatic or stage 4 patients can then qualify them for certain targeted therapies, some of which are FDA approved and some of which are in clinical trials. And as these new FDA approvals come out, that now changes the guidelines for when we should get this testing. And so, when you have this information that is sort of disseminated first within the academic community, and then out into our community oncology, our private practice partners, there can be a little bit of delay in adoption of that, right? 

And then it becomes a question of if that testing, you know, is done by a certain companies, right, and it has to be send-out labs, and so do these centers then have the relationship established with these companies to get this testing done in a timely fashion? And then, when those results come back, do we know that our providers have the most up-to-date information on how to interpret those results and how to use them? What new treatments have come up, what is actionable, what is not, and understanding how to best interpret that to the patient and help them understand.

All of that is really hard, and navigating that healthcare system, even when you have the information, is difficult. So, you know, one of the things I think that we try to do, at my academic institution, is develop, you know, create relationships with our community oncology partners to make sure that if there is a question that they have, if they want to refer someone for clinical trial eligibility, for a trial that might not be available, you know, closer to that patient’s home, that they can come in, that they can get that second opinion, that we maintain the relationship with the oncologist to keep that discussion going. And so it’s really just, you know, we all commit to lifelong learning, but in practice, it can be hard to keep up with what’s going on in oncology, and so we all just need to be helping each other to stay up to date with that. 

Dr. Nicole Rochester: 

Thank you so much, Dr. Smith-Graziani. It sounds like, you know, there’s a huge burden, as you shared, on the patient, and on the provider, but we know that ultimately there are system changes that need to take place. So Dr. May, in your work, to expand colorectal cancer prevention and screening, what are some system-level changes, whether within the health systems or through policy, that are needed in order to make evidence-based testing and care more consistent and accessible for diverse populations?

Dr. Folasade May: 

I think you actually bring up a really important point there, because when we talk about interventions to address inequities, I tend to break them up into groups. We have patient-focused interventions, we have provider-focused intervention, health system-focused interventions, and then we also have interventions that are more community or population-based. And, you know, ideally, you have interventions that are affecting all of those stakeholders, but my work actually very often focuses on those system-level interventions. How can you make small tweaks or changes within a health system to help close gaps or variation and address inequities?

There are two specific examples I’ll use of how I think health system-level changes can address variation in care. The first is using automation in a health system, and the other is using standard education or information in a health system. So, in my lab, part of our team focuses on quality improvement. And we do that at the health system level here at UCLA Health and what we’ve been able to do over time is make changes to our electronic health record and to our system that help offset the work that a primary care provider needs to do. A primary care provider is responsible for all health maintenance, which is overwhelming for them to do, sometimes in a 15-minute appointment. So what we can do is use things like the electronic health record to not only remind providers when critical things are due, but also directly interface with the patient.

So that automatization (sic) example at UCLA Health is that we automate our colorectal cancer screening tests. We actually asked patients, we tell them, you’re due for screening now, do you want a colonoscopy, or do you want us to mail you a stool-based test? And then we wait for the patient to answer through the patient portal, and we either schedule that colonoscopy, or we mail them that kit, to do the test at home. So that automation is really helpful because it helps remove a potential bias from a situation where maybe a provider is looking at a patient and making a judgment as to whether the patient will complete the screening test and not recommending it, which sometimes, unfortunately, we see with our patients of color. And it’s also helping offset the primary care doctor by removing that from the laundry list of things that they have to cover in a primary care appointment. So that’s an example of automation in a health system to reduce variation. The other example is standardized information or education. So, when a patient’s reach a certain age, i.e., they are eligible for breast cancer screening, are eligible for colorectal cancer screening, we can start automating information, our shared decision-making tools, or flyers to them, either through the mail or through patient portals. And that can help patients prepare for upcoming conversations with their provider, or even go ahead and take care of it without the involvement of the primary care provider. So, these are just two examples, automatization (sic) and standard education that we can use at a health system level to close those gaps and get patients on the same page with their access. 

Dr. Nicole Rochester: 

Those are phenomenal examples. Thank you. Thank you so much for sharing that. I feel like everybody should be doing that. Those are great examples. We’re gonna talk about outcome expectancy and clinical inertia, another challenge. that we have in this space. As the evidence base in oncology expands, it often takes, as you all have mentioned, years. For proven interventions to then reach the patients who can benefit. And sometimes that delay stems from system-level barriers, but other times, it’s rooted in subtle forms of clinical inertia or outcome expectancy. This assumption that certain patients or populations are less likely to benefit from newer approaches. Dr. Smith-Graziani, from your perspective, what helps shift these patterns, and how can care teams move from being aware of disparities to adopting consistent equity-focused practices in everyday settings? 

Dr. Demetria Smith-Graziani: 

Yeah, this is a common issue within the world of disparities in health equity, in that we put so much effort into describing the problem, and we seem to hit a roadblock when it comes to actually addressing the problem and coming up with solutions. This is really what we call implementation science, right? And that’s what we need to be doing. Implementation science is an iterative process, meaning that we test a certain intervention among a patient population.

We get information, both quantitative and qualitative, right, about how is it affecting outcomes, how is it reducing disparities, but also, how, uh, how easy or difficult was that process for the patient? What was their experience of it? Are they likely to do that again? And then we take that information, we go back to the lab, and we come up with something better, and we test that again. And so, I think it’s important for us not to rest on any of our laurels whenever we do create an improvement in this space. It starts with listening to patients, figuring out what we want, I think…you know, all of us now, as researchers, there is a real emphasis on including patients and patient advocates in the very design of the trial, right? At the very beginning, from the ground floor. And so, listening to patients from the beginning, and then continuing to get their input throughout the process, of their experience of it,  that is so important. 

And we also need to make sure that these trials are open everywhere. I work at an institution where we have both a large tertiary care academic center and also a safety net hospital, and a VA, and sort of a hybrid, and we have these other, you know, hospitals within that. And we really are attempting, when we are opening new trials, to open them at as many of those sites as possible, so that we are really capturing a cross-section of our patient population. So, it’s really important that we get the patient input, actually test a real intervention and then figure out how did that intervention work? How can we adjust it? 

Dr. Folasade May: 

I love that. 

Dr. Nicole Rochester: 

Yeah, you want to add something, Dr. May? 

Dr. Folasade May: 

No, I just… I love that answer, and I think that’s so critical for making sure that people have access to trials.

Dr. Nicole Rochester: 

Well, this has been amazing. I really want to thank both of you for joining us today. I’ve learned a lot. I’m sure our audience has learned a lot. As we close, I’d love for you to each share a closing thought, one thing that you want to leave the audience with. So, I’ll start with you, Dr. May. What’s one takeaway? 

Dr. Folasade May: 

Sure, first of all, thank you for having us. I think my biggest takeaway is I hope that our colleagues recognize that we are trying to help them, and we’re trying to help our patients. I think when people hear about bias, they automatically think that they’re not biased.

I’m a person of color, I have biases, and there are unconscious biases that many of us don’t even recognize about ourselves. This is just a call to action to recognize that there is evidence of bias, and it’s data-driven, the work that we do. But it’s also a call of action to maybe think about how we address our patients, and whether we intentionally or unintentionally treat them a little bit differently. It’s also a time to think about how you can help your health system or your practice, improve how we improve care for all of our patients. 

Dr. Nicole Rochester: Thank you, Dr. May. All right, Dr. Smith-Graziani, what’s your takeaway message? 

Dr. Demetria Smith-Graziani: 

Yes, and thank you for having us. This was a great discussion, some amazing points that were brought up today. I would say that, sort of piggybacking on what Dr. May said, you know, our North Star is our patients.

And we want to center them in all of these decisions that we’re making. I think so much of the change that we can do on a provider level comes when we really lean into that relationship with our patients. And the idea of really listening, actively listening to our patients, and listening to understand, and not to have a response. Right? I think that is… that is really key in where it all starts to really understand where your individual patient is coming from, then allows you to think about all of these different social determinants that have gotten your patient to where they are today, sitting in front of you and using all of that information that you learn about a patient by actively listening, beyond just the pure medical facts of their particular disease and their case, allows us to really, treat the patient as a whole person, and really get better results for them. 

Dr. Nicole Rochester: 

Thank you so much. Again, thank you, Dr. May. Thank you, Dr. Smith-Graziani. This has been incredible. Lots of great information to reflect on. And thanks to those of you who are tuning in, we are proud to present this Healthcare Provider Roundtable as part of the Patient Empowerment Network’s EPEP initiative. Empowering providers to empower patients. Helping providers support their patients every step of the way. I’m Dr. Nicole Rochester, and until next time, take care, and be well.