Lisa Hatfield:

Dr. Gamble, how do social determinants of health potentially influence the quality of care received by patients with gynecologic cancers?

Dr. Charlotte Gamble:

Yeah, another really wonderful question and an area of research that people have looked at for a long time. I think when we think about social determinants of health, we have to define what they are, right? So these are going to be aspects of people’s lives that might not be specifically health related, but absolutely influence the ability to access healthcare, the ability to complete treatment regimens, the ability to be able to get support and survive these treatment regimens and continue in survivorship.

So think when we, when I specifically think about social determinants of health and gynecologic cancers and encompassing the ovarian cancers, cervical cancers, endometrial cancers and vulvar cancers. We see multiple things. So in general, these cancers are affecting people who have the female reproductive tract. So this is going to be oftentimes people that identify as women, but also can include trans men.

And so there’s also like a gender component of this and how people identify. And for the trans community, there are barriers everywhere in terms of how they can access gynecologic care and the stigma that might be associated with providing trans healthcare in general that affect them specifically. When we talk about women or people who have identified as women and who also have a female reproductive tract, there comes into place how women in general and historically have been able to access healthcare and the barriers that they might face in communities.

Women generally tend to be the providers of healthcare or the providers of childcare and have several responsibilities in taking care of their families and communities. And in so far, doing tend to downplay their own healthcare and prioritizing their own well-being to be able to care for those who they love, who surround them and are stretched thin.

And so because of that, we oftentimes see delays in seeking access to healthcare because women tend to be pulled in so many different directions by their communities. Other times what we see is things that I’ve mentioned previously in terms of insurance barriers and either not having insurance. So for patients who are undocumented immigrants, this tends to be a massive issue. I’ve had patients myself that we’ve had to work tirelessly for, to be able to get them insurance. And this is in the nation’s capital where insurance, even for undocumented people, tends to be a little bit easier to access than in other places. And it’s been a huge challenge and delay their care by months. And this directly correlates with survival and how patients do on the back end of things. But even having insurance that is, that is, doesn’t, might not cover everything that’s needed, and there might be large copays associated with visits or treatment plans.

This is an area that there’s a lot of room to improve in the United States, and a real macro issue. But when it comes to also things like transportation and living in a food desert and not having healthy groceries and nutritional options that for patients who have endometrial cancer, that oftentimes if it’s a low grade non-aggressive cancer, they’re going to do fine from a cancer standpoint, but it’s the cardiovascular issues and the possible severe obesity they might suffer from. And that is an issue that patients who live in food deserts or live in places that they can’t access sidewalks and ability to live healthy lives in their neighborhood will really suffer from not being able to have those determinants of health work in their favor.

And then we also have issues within health systems. And we see that for patients who live in conditions that are historically considered impoverished, they might not be able to make it to the beautiful National Cancer Institute designated cancer center, seeing this most subspecialist and having access to five clinical trials and a case navigator and a care navigator and a social worker to help them through the social issues that they might be seeking care with a community practice that could itself be underfunded or not linked to strong cancer institute options.

And so that’s another kind of systems level that we see where patients are seeking care that they might not be able to actually get to the subspecialists that they need, or health systems that are resourced enough to help them in their lives. So that’s a very long-winded question, [laughter] because it’s such a massive issue. But it, social determinants of health affect everything in the cancer continuum from a timely diagnosis and being able to recognize abnormal symptoms to being able to get into a doctor’s office, to be able to get to a subspecialist that is has expertise in the area to be able to complete therapies on time and to be able to eat healthy food and have a healthy lifestyle after one has gone through all these major treatments. It’s a massive issue and something that we see in every single health condition in the United States.

That is the most excellent comprehensive response to barriers, obstacles, stigmas that I’ve ever heard regarding accessing quality of care for cancer patients. Any cancer patient is going to benefit from your response to that. So thank you.