How Can We Prevent Innovation From Widening Cancer Disparities?

Dr. Nicole Rochester:

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 So, we’re gonna move to outdated practices and awareness gaps, and how they can limit patient options.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 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.