How Can We Reduce Clinical Inertia to Improve Cancer Care Equity?

Dr. Nicole Rochester:

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 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: 

Absolutely. And so we really are talking about this idea of translating innovation into equitable evidence-based medical care, and both of you have given really great examples of how to actually operationalize that.

Dr. May, in your colorectal cancer research, you’ve talked about things like targeted screening reminders, and partnerships with community messengers and other things that can close gaps in prevention and early detection, in your experience, what’s the most effective ways, or are there other additional effective ways for providers and health systems to operationalize these equity goals that we’ve been talking about? 

Dr. Folasade May: 

What I find is that with many of these screening opportunities or treatment opportunities, It’s actually more of a stepwise process than a yes-no, did it get done or not. So, for example, we screen a patient. If that test is abnormal, did the patient give follow-up? If the follow-up is positive for cancer, did the patient get treatment?

And not only did they get treatment, did they get all of the treatments in the right order at the right time, and were there delays in treatment? So when you realize, that it’s actually stepwise care across maybe a series of, you know, 3 to 10 steps, depending on the disease, you realize that you have to have a longitudinal interventions as well. So things that I love, again, I love automization, because you can ping either the provider or the patient to remind them when they’re up for the next step. Did you order that follow-up test? You’re asking the provider. And then the provider remembers that they have to order it, and then you can ping the patient. Did you schedule your procedure, the follow-up procedure? I think the automization can be really helpful to close those equity gaps, especially in patients who have many adverse social determinants, maybe many challenges at home, many things going on in their lives that they can’t always prioritize their health. Which often we see in underserved populations are in our patients of color. 

So the automization, the reminders can be very helpful for patients and for their providers. And then the other thing that is really, really helpful is patient navigation. So we know whether you’re using promotoras and the Latino community, or whether you’re using traditional patient navigators and other communities. When you have an individual that the patient considers a partner with them in their care, who’s walking them through those steps, reminding them, addressing the barriers as they come up. We have very effective outcomes when we look at closing, screening our treatment gaps. These are very resource intense, so not all health systems have access to health navigators, or to patient navigators. But we know that they can be operationalized easily, and they can improve patient outcomes and also patient satisfaction. So if there are ways that we can think of models to improve patient navigation, I think that can help with our equity goals as well. Thank you, Dr. May.