Study after study has demonstrated race-based differences in survival and other clinical outcomes for patients with cancer. But as health professionals, we are learning that these differences are less about a patient’s skin color and more about the legacy of racial inequality.1 This knowledge changes the conversation from one of genetic predisposition to a modifiable risk factor.
The implications of such a pivot are profound. Earlier this year, a collaboration of oncologists and researchers in Illinois reported the jaw-dropping results of a study into race-based differences in acute myeloid leukemia (AML) outcomes. Armed with robust race and ethnicity data for 822 patients, the team found that non-Hispanic Black patients had a 59% higher risk of dying than their non-Hispanic White counterparts.2
Although alarming, this result was consistent with past findings. The study’s true revelation came from how the researchers quantified the impact of structural racism—an innovative measure combining neighborhood factors such as affluence and segregation. After controlling for multiple other factors—age, sex, treating hospital, comorbidities, receipt of transplant—the researchers found that these neighborhood factors were the most significant predictors of death. If structural racism, as they measured it, were to miraculously disappear, the increased risk of death for Black patients would decline from 59% to 4%.2
Rethinking the Oncologist’s Role in Tackling Health Inequities
When I first processed the findings of this study, I felt disheartened. I have spent much of my career focused on improving access to specialty care and trying to ensure equitable receipt of gold standard treatment. Yet, for this cohort of Black patients with AML, that would have been grossly insufficient. Our standard, out-of-the-box approaches to reducing health disparities—such as focusing on access to a physician or patient education—would not have addressed the root cause of deaths. When I shared this article with colleagues, the initial line of questioning consistently reverted to asking about delays in diagnosis, insurance differences, and patient preferences.
“If structural racism, as they measured it, were to miraculously disappear, the increased risk of death for Black patients would decline from 59% to 4%.”— S. Monica Soni, MD
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We in health care are much more comfortable blaming the health-care system, patient health literacy, or even physicians for their conscious and unconscious biases than we are considering the structural societal ills that plague our patients from in utero. However, compelling studies like this one, as well as our collective lived experience watching COVID-19 ravage poor communities of color, are forcing us to reckon with our role as physicians in addressing these larger determinants of life and death.
Being an expert in autologous stem cell transplantation is not adequate if subgroups of patients in treatment will die because of conditions outside the hospital walls. As Dr. Irum Khan [Associate Professor of Hematology/Oncology at the University of Illinois College of Medicine], one of the authors of the previously mentioned study, stated: “We focus our energies on tailoring therapies to the patient’s physical health, as well as the molecular characteristics of the leukemia, but no one’s really paid attention to the third piece in that Venn diagram, which is the social determinants of health, both individual as well as the neighborhood, which represents the continuum of their experiences.”3
Addressing Health-Related Social Needs
There is a growing acceptance that this third piece of the Venn diagram is also within our scope of responsibilities as treating physicians. The duty of physician-citizens was nicely outlined in a 2004 article in JAMA in which the authors wrote: “Although physicians should not be discouraged from addressing any public issues, it is reasonable to ask where a physician’s responsibility ends.... Direct social determinants, such as smoking or wearing bicycle helmets, have a good evidence base connecting them directly with health outcomes and operate clearly through individual patients. They are issues in which physician advocacy, directed toward potential patients and policymakers, is likely to have some impact. They are issues on which society expects physicians to hold and articulate a public position.”4
Since this article was published, the evidence base has expanded, and the causal connection between social issues and patient outcomes has grown stronger. What then falls clearly within the scope of oncology practice, and what, as the authors write, “although laudable, are better considered aspirations”?
Food, housing, and transportation insecurity are commonly found in patients with cancer. As expected, patients with cancer who are focused on meeting their basic needs are more likely to miss appointments, delay or forgo care, and have worse outcomes, including lower survival rates. These poor outcomes are heightened for oncology patients with a low socioeconomic status.
The field of oncology has continued to lean into these findings and test iteratively what can be done to reduce inequities in cancer care. It is heartening to see studies have found that screening for and addressing health-related social needs can be done and, indeed, have a linear impact on patient outcomes.
For example, recent studies have shown meaningful results through the use of interventions to address food insecurity in patients with cancer, such as a reduction in length of hospital stays by 10% for oncology patients during the COVID-19 pandemic5 and an increase in cancer treatment completion rates of at least 90%.6 With such findings, it is no longer debatable that it is the professional obligation of oncologists both to screen for patients’ social needs and hardships that impact their care plan and to try to resolve them.
Advocating for Equitable Care
Although many of us think about the patient in front of us, perhaps even solving that individual patient’s food, housing, and transportation challenges, how many of us spend time on the upstream interventions that prevent these gaps from existing at all? Certainly, the federal government, through the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services, has committed to this challenge through policy changes that directly target the social determinants of health. At the state level, through Medicaid, progressive programs are being deployed to address unmet social needs at the population level.
Professional societies, including ASCO and the Society of General Internal Medicine, have developed educational programs that highlight the importance of whole-patient care to improve outcomes, but there is still the opportunity for us to throw our weight behind evidence-based upstream interventions. For example, studies have shown that the Affordable Care Act (ACA) led to an increase in cancer screening, diagnosis, treatment, and survival.7 With a now-clear fact base, oncology professional societies and specialty guilds should be exerting energy and advocacy efforts in states that have not expanded coverage for Medicaid and the ACA.
Even as individual physicians and clinicians, we have immense power and ability to advocate in a nonpartisan way for social change, which can meaningfully impact the health of our patients. Tactical examples of steps to take follow:
Know the facts: Keeping up-to-date on ASCO’s advocacy priorities (https://old-prod.asco.org/get-involved/advocacy/advocacy-agenda-initiatives/advocacy-priorities), including ensuring access to affordable health care for patients with cancer and subscribing to a state legislative bill tracker (www.ncsl.org/research/telecommunications-and-information-technology/ncsl-50-state-searchable-bill-tracking-databases.aspx), may help physicians find opportunities to get involved in advocacy efforts on their local level.
Educate learners: Creating and leading formal curricula about the social drivers of health and their impact on health outcomes signal to our pipeline of future physician leaders that this issue is as important as traditional biomedical knowledge.
Contribute to the research base: Ensuring adequate capture of patient sociodemographic factors in research will continue to advance our scientific understanding of the complex interplay between economic status and survival outcomes.
Reach out to elected officials: Sharing patient stories and bringing the physician perspective of caring for patients with cancer to legislators provide them with a more complete picture of the health consequences of inadequate and inconsistent research funding for cancer and the barriers patients face to accessing quality cancer care.
Serve on local commissions of health: Being an appointed or elected official in our local community can bring meaning and immediate influence over social issues that impact our patients.
Making Your Voice Heard
Daniel E. Dawes’ book, The Political Determinants of Health (Johns Hopkins University Press, 2020), makes the compelling case that social drivers that affect health stem first from political action (or inaction). Although neighborhood affluence, segregation, and socioeconomic disadvantage will not be solved through one ballot submission, civic engagement on these issues will improve health outcomes for our future patients. Thus, voting and advocacy are core activities for any physician committed to health equity. The physician voice is an important one. We must be willing to use our voice, loudly, on behalf of our patients. If we believe that one of our core responsibilities and competencies is to prevent avoidable death, we have no other choice.
DISCLOSURE: Dr. Soni is an advisor for Waymark.
REFERENCES
1. Best AL, Roberson ML, Plascak JJ, et al: Structural racism and cancer: Calls to action for cancer researchers to address racial/ethnic cancer inequity in the United States. Cancer Epidemiol Biomarkers Prev 31:1243-1246, 2022.
2. Abraham IE, Rauscher GH, Patel AA, et al: Structural racism is a mediator of disparities in acute myeloid leukemia outcomes. Blood 139:2212-2226, 2022.
3. Botterman L: Study shows structural racism can result in poorer leukemia outcomes. UIC Today, March 7, 2022. Available at https://today.uic.edu/study-shows-structural-racism-can-result-in-poorer-leukemia-outcomes/. Accessed March 28, 2023.
4. Gruen RL, Pearson SD, Brennan TA: Physician-citizens—Public roles and professional obligations. JAMA 291:94-98, 2004.
5. Kamaraju T, Atkinson D, Wright D, et al: Leveraging social determinants of health to reduce hospital length of stay: A pilot QI project for solid tumor oncology patients during the COVID-19 pandemic. WMJ 121:205-211, 2022.
6. Gany F, Melnic I, Wu M, et al: Food to overcome outcomes disparities: A randomized controlled trial of food insecurity interventions to improve cancer outcomes. J Clin Oncol 40:3603-3612, 2022.
7. Lee A, Shah K, Chino JP, et al: Changes in cancer mortality rates after the adoption of the Affordable Care Act. 2020 ASCO Annual Meeting. Abstract 2003.
Dr. Soni is Associate Chief Medical Officer of New Century Health in Los Angeles.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
