Social Determinants of Health in Cancer Care

This episode was originally released August 23, 2021

In this Social Determinants of Health (SDOH) episode, Dr. Narjust Duma (DFCI) moderates a talk with Dr. Danielle McCarthy (University of Wisconsin-Madison) and Dr. Erica Warner (Harvard Medical School & MGH) on tobacco cessation as a modifiable risk factor and how clinicians can respectfully engage with their patients on this topic. View COI.

TRANSCRIPT

LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care and is not intended for use in the diagnosis or treatments of individual conditions.

Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals. Every patient, every day, everywhere.

I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high-quality equitable cancer care. Thank you.

NARJUST DUMA: Welcome to the eighth episode of ASCO Social Determinants of Health Series. I'm Dr. Narjust Duma, and I'm the associate director of the Cancer Care Equity Program at the Dana-Farber Cancer Institute. With me is Dr. Danielle McCarthy, associate director for research and the Center for Tobacco Research and Intervention at the University of Wisconsin-Madison. I also have the pleasure of having Dr. Erica Warner assistant professor of medicine from Harvard Medical School and assistant investigator for Massachusetts General Hospital.

In this episode, we will discuss tobacco cessation as a modifiable risk factor and how clinicians can respectfully engage with their patients on this topic. I would like to thank Dr. McCarthy and Dr. Warner for being here today.

ERICA WARNER: Thank you.

DANIELLE MCCARTHY: My pleasure.

NARJUST DUMA: Moving forward, we address Dr. McCarthy and Dr. Warner by their first name. We're colleagues and friends, and this is a friendly conversation about a very important subject. So we're going to start with a few questions, and they're going to give us their great insightful comments.

First, we want to speak about the stigma with tobacco use. There's a lot of stigma associated with tobacco use and subsequently with lung cancer. This affects all patients, but it can be worse in some communities versus others. Dr. Warner, can you speak to us about this stigma with tobacco?

ERICA WARNER: Yes, certainly. I think stigma is a really important issue. And I'm doing some work around this right now with cancer patients. I think that anti-smoking campaigns have been amazingly effective really at spreading the message that smoking is associated with a long list of negative health outcomes.

I think the most well-known being the link with lung cancer risk. And over time, as smoking rates have declined in the United States-- focus is mainly on the United States, but I think some of these comments are relevant for other places. As smoking rates have declined, you've seen that the populations that continue to have the highest rates of smoking are largely lower socioeconomic populations in the US now.

And so I think this combination of the sense that messaging has told us that smoking is, quote, unquote, "bad," that marginalized populations tend to have higher smoking rates currently, coupled with this idea that smoking is just a poor choice, a bad decision that any given individual is making, leads to smoking and ultimately people who smoke being stigmatized in our society today. And I think there's a lot that we can do to try and combat this, but really focusing on this idea that smoking is a poor personal choice that someone is making.

We know that there has been lots of advertising that has been targeted at specific communities to try and get them to smoke and even now that we're not allowed to have smoking advertisements on TV and on billboards in the way that they used to be, there are still many ways in which these communities are being targeted, as well as recognizing that smoking is an addiction. So there are plenty of people who smoke, who recognize that it can have bad consequences for their health. They don't wish to continue to smoke but are struggling for smoking cessation.

And so I think that really all of us, and as we'll talk later about providers, need to approach smoking and individuals who smoke with more empathy.

NARJUST DUMA: And connected to that question, we have seen marketing that is targeted to certain populations. So while living in the Midwest, I have a very close contact with Native Americans. And the amount of mail these populations receive about smoking, like you turn 16, and you get an advertisement in the mail about here's your first Marlboro package for free.

And this can be for the two of you, how is this targeted marketing that also affected women in the 1970s and '60s in which is smoking was associated with weight loss, like if you want to stay thin or slim, you need to smoke. So how this has affected tobacco in the past and currently now with this targeted marketing to populations.

DANIELLE MCCARTHY: Yeah. I can certainly speak to that in Wisconsin. We see, it's not just marketing at point of sale. There is direct marketing, as you mentioned. There are also just a greater concentration of tobacco retail outlets in certain communities. So there's just more access.

And the Wisconsin African-American Tobacco Prevention Network has done a lot of really great work reaching out to retail sites, convenience stores, corner markets, to try to encourage them to verify a customer's age before they sell tobacco and also gotten them to agree to no menthol Sundays. Like they've had some days where they just won't sell menthol cigarettes because menthol has been so aggressively marketed to African-American communities.

And they've gotten these retailers to agree to this and to buy into this, that this is a social justice issue. It's not just a matter of commerce. It's a matter of equity. And it's really exciting to see that even people who make a little profit on selling tobacco are willing to modify their conduct to address these issues, at least in a small way. And so if we see a menthol ban enacted on a broader scale, that could have a big positive impact.

NARJUST DUMA: Thank you for your comment, Dr. McCarthy. We have seen some changes at the corporate and institutional level, such as made by CVS to stop to sell tobacco. And this is very linked to your comment. What has been the role of health care institutions in promoting tobacco cessation? I know we have talked about also being reactive to be more proactive, but what has changed and what can change still?

DANIELLE MCCARTHY: Right. A lot has changed. We now assess smoking status along with height, weight, and blood pressure. It's now considered a vital sign because it's the leading preventable cause of death. So knowing your patient's tobacco use status and addressing it is really important. Knowing it and doing nothing with that information is not very helpful. And so the next step is really important.

And we know that from population studies that only about half of patients who walk out of a doctor's office walk out and say, yeah, the doctor talked to me about my smoking and offered me something. And so we want to get that up to 100%.

And we think that health systems can implement changes to make that happen. And we've shown that if you integrate some prompts and reminders into the electronic health record, that that can greatly increase the rates at which treatment is offered and that about 12% or so of people who come in off the street for another reason to your clinic will agree to set a quit date within the next 30 days and accept treatment. So that's pretty impressive, right?

So even though the majority of people say they want to quit smoking, that doesn't mean that they want to do it today. But if you ask them today, more than 1 in 10 will probably say, yes, I will agree to treatment. Sign me up. I'm willing to quit within 30 days. So you really can intervene. Health systems can support that by creating workflows that are efficient and effective and connect the patients who smoke with cost low-barrier treatments.

For example, State Tobacco Quit Lines that don't charge for their services and now offer pharmacotherapy and free phone coaching or counseling. So that's something that we've been working on here in Wisconsin. And multiple health systems have now adopted electronic referral to the State Quitline as one of their standard options that they provide for patients who smoke.

The other thing is that 52 cancer centers in the country are now part of an NCI-funded initiative called the Cancer Center Cessation Initiative to more proactively address smoking in cancer settings. And so if you're working in a cancer center, odds are that they're participating in this program and that they're developing some sort of initiative to try to improve the rates of addressing tobacco use among people who present with cancer.

NARJUST DUMA: And the follow-up question, which is a little bit out of script, is have we seen differences in smoking cessation counseling across racial/ethnic groups and across gender? And you can spend a little bit more on this, Dr. McCarthy, if you would like.

DANIELLE MCCARTHY: Yeah. Sadly. We have. And even though we see that motivation to quit is higher among minoritized racial groups in the US and that more quit attempts are actually made among minoritized groups than among white people who smoke, that the rates of achieving cessation are historically lower.

What I think is really exciting about these proactive system changes is we actually have seen higher uptake of treatment among African-American patients, among Hispanic patients in some models, not all models, and especially high uptake among Medicaid-eligible patients, where smoking rates can be as high as 30%, compared to about 14% in the general population.

So where there is great need, there's also great interest in treatment and great receptivity to treatment. And I think that's incredibly exciting and encouraging, that maybe if we were to universally offer cessation treatment, we would see that the treatments were getting where they have not gotten before.

If you just wait for a patient to bring it up, it's not going to be the patient who has the greatest economic stress, greatest social stress who's going to say, you know what's on the top of my agenda today is quitting smoking, it's going to be the most resource to patients who do that.

And so if you want to address these inequities, I think you have to bring it to the patient where they are. And I think that's what's exciting about these system changes. So far, what we've seen is that they seem to enhance equity rather than exacerbate disparities.

ERICA WARNER: I think that's such an important point. And I think it resonates across all of our health equity work, is that if you leave it up to the patient or the provider that has to at each point of interaction make the decision about whether or not to offer something, whether or not to ask for something, that's when disparities creep in. And so we have to make it automated. We have to make it standard of care.

NARJUST DUMA: And that's a very important point. And to our listeners, there are preconceptions that certain populations will not be interested, when in fact, the data has shown the opposite. There are several psychosocial aspects associated with smoking. It is an addiction.

And I think providers should consider that. And this question goes to our guests. How can our understanding of these psychosocial aspects help providers and their conversations about cessation with patients? And now we start with Danielle.

DANIELLE MCCARTHY: It is an addiction. It is a powerful addiction. Untreated, the relapse rates are higher than 90%. It is a relapsing and remitting chronic condition. And there are neuroplastic changes that happen with just a few exposures to nicotine that can be long-lasting. Now, some of those can be reversed by quitting, but they take a long time.

The other thing that is really tricky about tobacco that led us to be confused about whether it was addicting or not for a while is it's not as frankly intoxicating as some other substances. So you don't see a clear intoxication. And the withdrawal symptoms are marked primarily by two things, negative mood and craving. And you don't see the same kind of withdrawal that you see with opioids or even alcohol.

And so for a long time we thought, well, this is just a habit. It is not a habit. There are neuroplastic changes that we know happen and that make it really challenging to quit. And we're asking people to quit in environments in which tobacco is incredibly easy to access. It's still fairly cheap, even considering taxes and price increases. And it's available in the grocery store or the pharmacy and at every gas station.

So it is just embedded in the environment in a way that makes a reliance on willpower and self-control not a great way to go. And so that's why we really advocate for pharmacotherapy to help manage the withdrawal and give the self-control a chance to win in this environment that's really challenging to quit.

ERICA WARNER: I would echo all of that and just add that I think that up front we have to be open and honest with patients, that we recognize that it's an addiction and that it's hard to quit. And that it may take multiple attempts to be successful. And that's not failure. That's a process that you're going towards for a goal.

Because I think it can be disheartening for people who have an earnest desire to quit and find it hard and are not able to on their initial attempts. But we don't want that to be a barrier to continuing to try. And we can support that, as was just described, with medications to help ease some of the symptoms and also trying to provide referrals or other support that can help them address some of the social factors that are associated with smoking.

So if you are trying to quit smoking, and you have someone in your household or multiple people in your household that also smoke, that's going to make it more challenging for you to quit. So to the extent that we can involve the household or the family in smoking, I think that that can help and particularly helps marginalized populations to try and quit.

NARJUST DUMA: Thank you for those comments. And some of the basis for these episodes and podcast is that many of us did not receive training about social determinants of health or how to obtain the information appropriately without being biased or making the patient feel bad about their behavior. So what are some of the comments or questions that providers should completely leave out when addressing smoking cessation or just smoking status? I would start with Danielle.

DANIELLE MCCARTHY: So we like to not start with a yes or no question. Do you want to quit smoking? That's too big an ask. You're going to get too many nos because that sounds scary. That sounds like, are you talking about today?

I don't want to do it today. So we advocate starting it as a conversation. Let's talk about your smoking. I have some resources that I can offer you. I can help you with your smoking. I can offer you medication. I can connect you with counseling. Would you be interested in changing your smoking.

So we're not necessarily saying, let's go from 0 to 60 in three seconds right now, because I got to go to the next patient. We're saying, let's have a conversation. I have something to offer you. Now, let's talk about whether you're interested. So make sure that you get the message across that you have treatment options to share before you ask, are you ready to do this? And sometimes even offer treatment with people who are just willing to cut down.

You could offer treatment to people who are willing to try treatment, even if they're not sure they're ready to quit. That is where we're going with treatment is to say, you don't have to know that I'm setting a quit date on October 1, and that's definitely when I'm going to quit smoking, you could start treatment and see how it goes and then make a decision about whether you're able to go to 0 or whether you just want to cut down by half.

NARJUST DUMA: Erica, which other comments or questions do you think your providers should leave out when addressing smoking cessation?

ERICA WARNER: Yeah I think that there's been a fair amount of work done that shows that positive messaging that emphasizes the benefits of quitting can be more effective than negative messaging that's focused on scare tactics and emphasizing the harms.

I think many people are well aware of the potential harms of smoking, but I think emphasizing that quitting sort of no matter where you are in your experience of quitting, no matter where you are in your cancer journey, for example, among individuals diagnosed with cancer, that there are benefits to quitting. And that, again, we have ways in which we can help support you with medication, with counseling, with other supports that can facilitate this for you.

NARJUST DUMA: Well, thank you to the two of you. We are shortly running out of time. But we want to finish this podcast with tips, because it's very important to share little pearls of wisdom for two of you, experts in the field. I'm no expert. I'm a lung cancer doctor, and I have learned tremendously from the two of you.

So what are some of the tips for providers and also patients or family members to help get these conversations started? And why are we asking for these tips? Because often patients with cancer are not offered smoking cessation counseling. So Danielle, what are one or two tips that you recommend for a provider to get that conversation started?

DANIELLE MCCARTHY: So I would refer people to the National Cancer Center Network Smoking Cessation Guideline, which provides really helpful algorithms. So what do I do if my patient tells me they quit two days ago? So that doesn't mean that they're quit for life? So what do I do with that?

What do I do with someone who's willing to quit within 30 days versus who isn't? And it has a great list of resources and treatment recommendations. These are the pharmacotherapies that are recommended as a first-line, and here are some special considerations for people who are on chemotherapy, et cetera. It's a really great resource.

And also know that there are Tobacco Quit Lines in every state. Every state has a free Tobacco Quit Line available. And that can offer coaching, which can be a great adjunct to the pharmacotherapy that you might provide.

NARJUST DUMA: Erica? A few tips for our listeners.

ERICA WARNER: I don't know that I have that much more to add than what we've said thus far. I would just emphasize this idea of approaching conversations with empathy. I think that we just did some focus groups around women smokers and lung cancer screening.

And we asked them about their interactions with providers around smoking. And many of them described a kind of adversarial interaction, where they felt like the provider was just mainly focused on the fact that they smoked and that was bad and they should quit. And they couldn't really get past that. And I think that's a barrier. It makes patients shut down.

I think providers feel uncomfortable if a conversation is approached that way. And it doesn't end up being useful, I think, for either party. And so, again, I think some of the tips we've shared around empathy, around acknowledging that it's challenging, around making it a conversation about a process as opposed to a one-time let's do it now kind of thing, would all be very helpful.

NARJUST DUMA: Well, thank you for those tips. To our listeners, it's important that we know that we're not doing a good job while addressing smoking cessation with our patients with cancer. We all can do a better job. It is important to practice empathy, like Erica mentioned, and also to avoid yes and no questions, like that Danielle mentioned. Come from a place of cultural humility because it's an addiction more than a choice.

So thank you for joining us for this episode of the Social Determinants of Health at ASCO. To keep up with the latest episodes, please click Subscribe. Let us know what you think about the series by emails to [email protected]. Thank you, everyone.

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SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning Weekly Podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning Center at elearning.asco.org.

This episode was originally released July 21, 2021

In this episode of the Social Determinants of Health (SDOH) series, Dr. Shekinah Elmore (University of North Carolina at Chapel Hill) and Dr. Ramy Sedhom (Johns Hopkins University) provide research highlights in Social Determinants of Health topics from the recent 2021 ASCO Annual Meeting, provide context to the research, and discuss clinical implications. View episode slides and COI.

TRANSCRIPT

LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care, and is not intended for use in the diagnosis or treatments of individual conditions.

Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite Guests with a wide range of views and perspectives. Some of these conversations may be provocative, and some even uncomfortable.

But ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere. I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table-- voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high-quality, equity for cancer care. Thank you.

SHEKINAH ELMORE: Hi, and welcome to the seventh episode of the ASCO Social Determinants of Health Series. I'm Dr. Shekinah Elmore, and I'm an assistant professor of radiation oncology and urology at UNC Chapel Hill. With me is Dr. Ramy Sedhom, a medical oncology fellow at Johns Hopkins. We're happy to be joining you, wherever you are in the world.

RAMY SEDHOM: Yes, absolutely. This series is part of an initiative proposed by ASCO president Dr. Lori Pierce, focused on increasing oncologists' understanding of the social determinants of health, its impact on patients, and modifiable risk factors for cancer, inspired by Dr. Pierce's presidential theme of equity, every patient, every day, everywhere. In this episode, we will review highlights in social determinants of health topics from the recent ASCO annual meeting, provide context to the research, and discuss clinical implications.

SHEKINAH ELMORE: In the social determinants, some of us might need a refresher, and that's OK, too. So the social determinants, as most of us know, are really those things at the interpersonal, community, social, structural higher levels that pattern health outcomes and access. So it's education, it's health care, its neighborhood and built environment, social and community context, and economic stability in one model from Healthy People 2030. But what we'll be talking about in many ways is at the individual level-- so the individual social risk factors that are lower than the social determinants of health. And then we'll also be talking a lot about race and racism.

And so in terms of racism, the best definition that I have found is by Dr. Ruth Wilson Gilmore. She's a noted geographer. And that definition is that racism is the state-sanctioned or otherwise extralegal production and exploitation of group-differentiated vulnerability to premature death. And one of the benefits of the podcast format is that you can rewind, fix yourself on this slide, and read the definition a few times, like I did when I first came upon it, to just see how straightforward, but how all-encompassing, it is.

And so racism is really a structural determinant of health. It sits above even some of these social determinants that we talk about. It patterns health inequities directly. It also has these interactions with all of the social determinants of health. And I think that that will become clear with the abstracts that we're talking about.

RAMY SEDHOM: Really, really powerful definitions. And with regards to care access, almost 40 years ago, Penchansky and Thomas published their five As of access framework. And the five As, as you can see here, represents affordability. So thinking about what is the cost to patients.

And there's been a lot of work coming out over recent years showing that these costs are increasing for patients directly with time. Accessibility-- what is the distance to location or a particular service for patients throughout the country. Availability-- what is the access to specialists and specialty resources, accommodation, flexible scheduling, and acceptability.

And the reason why we bring up this framework is it's a context to discuss the first of the abstracts that we will discuss coming from Dr. Guerra and colleagues at the Penn Abramson Cancer Center. While published 40 years ago, these issues remain pertinent today. And we know that clinical trials do not operate in a vacuum, but instead mirror a lot of the problems within our current health care infrastructure. And that's what makes this work most impressive to me.

I do encourage all to listen to the oral presentation from the ASCO annual meeting, abstract number 100, titled "Accrual of Black Participants to Cancer Clinical Trials Following a Five-Year Prospective Initiative of Community Outreach and Engagement." So what was the problem they were tackling? The team identified a major gap for full inclusion of minoritized patients in their cancer clinical trials network. And their goal, as highlighted by this abstract, was to increase the accrual of Black participants in cancer clinical trials.

Importantly, they took a multilevel approach. But before thinking about any intervention, they went out into the local communities. They spoke to the patients, to the community leaders, pastors, community advocacy groups, and outreach groups to really listen to what the problems were. And by engaging with those most important stakeholders, did they really think about what were the most important interventions?

And what did these interventions look like? Well the team at the Penn Abramson Cancer Center focused on educational efforts in Black communities dispelling many myths about cancer clinical trials. They also increased touch points and access points for patients to access care. Most importantly, these came through breast cancer and colon cancer screening for both insured and uninsured patients.

One thing that really stuck out to me, very pragmatic and thoughtful in its design, was to make sure that culturally-tailored marketing strategies were also available for patients to see. They worked with pharma to make sure that Black patients were also shown on pamphlets discussing cancer clinical trials. And when thinking about access to care, we know that transportation is oftentimes a barrier, especially for our most vulnerable patients. So they had made sure to have contracts and connections with Lyft and other ride-sharing agencies to make sure that people can make it to the cancer center.

And from the health care infrastructure side, they established new requirements for minority accrual plans, and made sure to use community health workers and one-on-one patient navigation. And what was the ultimate impact of their work? Over a five-year effort, they reached more than 10,000 individuals through various venues. And when looking at their primary outcome, they more than doubled the number of Black patients who were accrued on cancer treatment trials. And they saw up to a four-fold increase in the accrual of Black patients in non-intervention treatment trials.

However, what is most important is they established a new level of trust with patients in communities that they were not before reaching. And they were able to remodel their organizational care delivery infrastructure to address this major gap in care delivery. So what was the hallmark of the strategy and how can we pragmatically implement it in our own institutions?

First, they focused on understanding local needs. Importantly, they established bidirectional relationships, and they made sure to acquire data to show the business case for why this is a return on investment for patients, their local city, and their health care infrastructure. I want to applaud Dr. Guerra and her team for making sure that this was a long-term investment in the Philadelphia area. What first started as a research grant later grew to involve the entire cancer service line, all the way with the director of the cancer center, and making sure to involve their entire organization.

And what is the lesson learned? Well, Black participants are significantly underrepresented in clinical trials. But it is not because they are resistant to participating. Instead, this is likely due to structural, clinical, and organizational barriers.

In our local communities, the underrepresented minoritized groups may look different. Perhaps they may be racial minorities. They may be rural dwellers, adolescents, or perhaps elderly patients, sexual and gender minorities, and so on and so forth. So I'd like to open this up to Dr. Elmore, and see if you have any other comments or thoughts from hearing about this.

SHEKINAH ELMORE: This is such tremendous work. And I agree. I think that it's a testament to so many things. I think that responsive development of interventions is so critical, and that truly, Black patients and Black people want to be included in the things that are meaningful to changing health outcomes. And there's so much here, and I really hope to see more efforts like this in both trial enrollment and for standard of care enrollment.

RAMY SEDHOM: Absolutely, and hats off for ASCO advocacy for really pushing forward the CLINICAL TREATMENT Act, which made sure to ensure that clinical trial costs were also covered. This was a landmark decision that came in December of this previous year. [AUDIO OUT] area. And we look forward to seeing this implemented on a larger scale through partnerships with ASCO in future years. And with that, I'd like to transition to our next abstract that Dr. Elmore will lead us through.

SHEKINAH ELMORE: Great, thanks. So this abstract, "Financial Toxicity, Symptom Burden, Illness Perceptions, and Communication Confidence in Cancer Clinical Trial Participants," the first author is Dr. Subha Perni and the last author is Dr. Ryan Nipp, both of which I know well from MGH. And so the problem here that they were trying to address and explore is that trial participants are at high risk for adverse effects from financial toxicity. But we don't really know that much about what the scope and type of those adverse events might be.

So with this study, they prospectively enrolled trial participants from MGH for about two years, and they saturated their sample with those that were already referred per their request for financial assistance. And so they assessed financial toxicity in these two ways, both asking these participants about financial burden overall of care, and then focusing in on trial cost concerns. And then they also asked, using standardized validated measures, about patient-reported outcomes. So physical and psychological symptoms, illness perception, and communication confidence. How confident are they in communicating with their care teams?

The results are interesting. 200 patients-- so 57% in this group noted that they had financial burden overall, and 41% with trial cost concerns. Those that noted financial burden were more likely to be young patients, which makes sense. And trial cost concerns, those were more frequent among patients with lower incomes. Both of these were significant, and I think that that speaks to the validity of these constructs of financial toxicity.

And then this is the most interesting part. Financial toxicity was associated with greater physical and psychological symptom burden, negative illness perception, and lower communication confidence. So the bottom line here is that financial toxicity was associated with worse patient-reported outcomes across all domains that were measured. Lots of future questions here.

So how might financial toxicity operate in different clinical settings? These are trial participants at a designated cancer center. How does that work in community oncology practices or among non-trial participants? How might financial toxicity moderate some of those other social risk factors or social determinants of health? We know from other health outcomes that if you look at Black Americans and white Americans with the health outcomes disparity, that disparity sometimes widens as you climb socioeconomic strata.

And then how might financial toxicity influence oncologic outcomes? More physical symptom burden, more psychological symptom burden, worse communication, that could all lead to worse oncologic outcomes. So lots of programmatic implications here. I think prospective identification of financial toxicity risk, those patients who are at risk for that, and then aligning that with social and economic interventions. But this certainly aligns with the previous abstract that we discussed, another lens on why people might not participate in trials, and just the financial burdens that care can bring to patients, and the fact that it impacts the very care that they're getting.

RAMY SEDHOM: Yes, absolutely. Such great work by Dr. Perni and Dr. Nipp and their team. I think we're just scratching the surface, as you mentioned, with financial toxicity and its implications on patient care and the caregiver experience as well.

So all in all, I think the concluding remarks we could probably make is that equity is a simple concept to grasp, but very complicated to execute and measure for success. We do want to thank our authors who did put time and effort in their careers to opening up our eyes, and Dr. Pierce for really making this the highlight and the theme of her tenure as ASCO president. So for those listening in, thank you for joining us for this episode of the ASCO Social Determinants of Health series.

To keep up with the latest episode, please click Subscribe. Let us know what you think about the series by leaving us a review or by emailing us at [email protected]. On behalf of Dr. Elmore and I, thank you for listening in.

SHEKINAH ELMORE: Thanks.

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VOICEOVER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

This episode was originally released June 9, 2021

In this Social Determinants of Health (SDOH) episode, Dr. Randy Vince (University of Michigan) moderates a talk with Dr. Robert Winn (VCU Massey Cancer Center) and technology innovator and cancer survivor, Sylvie Leotin (Equify Health) on solutions for rebuilding patient-provider trust and communications, with insights from the clinician and patient perspective.

TRANSCRIPT

LORI PIERCE: Hi. I'm Dr. Lori Pierce, president of the American Society of Clinical Oncology. Thank you for tuning in to this discussion on social determinants of health and their impact on cancer care. The purpose of this podcast is to educate and inform. It is not a substitute for medical care, and it is not intended for use in the diagnosis or treatment of individual conditions.

Guests on this podcast express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative, and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere. I have dedicated this vision to my term as ASCO president.

These conversations bring many voices to the table, voices that we need to hear in order to move forward and find solutions. We hope you learned new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what they look like, receives high-quality, equitable cancer care. Thank you.

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RANDY VINCE, JR.: Hello, and welcome to the sixth episode of the ASCO Social Determinants of Health series. I'm Dr. Randy Vince, Jr., a fellow of urologic oncology at the University of Michigan. Today, I'm joined by Dr. Robert Winn, the director of the Virginia Commonwealth University Massey Cancer Center, and Dr. Sylvie Leotin, who is a technology innovator, cancer survivor, and a recent recipient of a $750,000 Health Equity Innovation Award.

This series is part of a new initiative proposed by ASCO president Dr. Lori Pierce, focused on increasing oncologists' understanding of social determinants of health, its impact on patients, and modifiable risk factors for cancer, inspired by Dr. Pierce's presidential theme of equity, every patient, every day, everywhere. During the fifth episode of this series hosted by Dr. Smith-Graziani, there was a deep dive into the impact of structural racism on medicine, both historically and contemporarily.

As a country, we find ourselves at a point of inflection. Many citizens and health care providers are starting to grapple with the fact that both interpersonal and structural racism impacts various aspects of our daily lives. As health care providers, it is imperative that we understand this history and how this affects our patient-provider interactions. To build on episode five, we will discuss the importance of patient-provider relationships and eliminating cancer disparities.

So the first question goes to you, Dr. Winn. I know you have made community engagement an essential pillar at the Massey Cancer Center with the goal of reducing and ultimately eliminating cancer disparities. This initiative is a critical step. But many times when we discuss social determinants of health, we talk about factors outside of the health system. But I'm wondering if you can comment on how patient-provider communication influences cancer disparities.

ROBERT WINN: No, absolutely, and thank you for that. And I think that the work that's happening at the ASCO right now is just outstanding. I wanted to actually also go back to making sure that we don't conflate individual needs with social determinants of health, because there sometimes is muddying of individual needs with social determinants.

And I want to make sure that as we talk about it, and through the lens of social determinants, that we understand that that's built on structure. And part of that structure is the doctor-patient communication, but also the medical community's communication to communities, which is frequently very one direction.

And even when we talk about being patient centered, frequently we don't have the patient at the center of our discussions. It becomes almost this very colonial-like— but benevolent colonialism, right? It starts from a good place. But it becomes this very benevolent, colonial flavor to it where we're talking for people, we're talking at people, but we're not talking with folks, nor with communities.

And so I think that to keep my answers short, we are going to have to, as a health profession, have a little bit of grace and a little bit, just a touch more of humility to understand that where we have— although well meaning, and certainly we're armed with knowledge, but they are too in communities.

And I'll end with saying that while we also talk about our patient-centered approaches and communities as being illiterate— health delivery system illiterate or scientifically illiterate, they'll remind you that we are, too, illiterate. And so trying to talk at people in this unidirectional way will give us some results, but not the best results. And I think there's many more, much more productive results to come if we have a little bit more humility of making sure that we are not just engaging but involving community.

RANDY VINCE, JR.: So the next question I'll pose to you, Dr. Leotin. First, I'll say this. You have an impressive background that spans multiple disciplines. And so I have a two-part question for you. First, with your expertise as an innovator and your personal experience as a cancer survivor, I wonder if you can share your thoughts about what can be done broadly to improve cross-cultural patient-provider interactions.

And the second part of the question is, you were recently awarded a large grant to collaborate with Emory School of Medicine. Can you share some information about your project and the innovative solutions you're developing to help reduce cancer disparities?

SYLVIE LEOTIN: Thank you for your question, Dr. Vince. First, I would like to stress, [INAUDIBLE] the patient first, that cross-cultural patient-provider communication is worse than many health providers imagine. And this directly affects disparities. There was a recent study, as an example from Genentech, that showed that 50% of Black, Latinx, and LGBT patients have delayed or discontinued their care because they didn't feel understood by their providers.

So second, to answer your question, I agree with Dr. Winn, and I applaud your leadership in transforming community engagement. As you said, I think that it's also part of the solution. I think that another part of the solution is really improving patient-provider relationship inside the hospital. And I see that a lot of providers are not looking at this when, as a patient, I can tell you that it is really an essential component of reducing disparities. And I'm going to try to unpack that.

So we talk about trust, we talk about mistrust, and we talk about patients needing to trust the health care system. But we have to realize that trust is a two-sided process. And it's not incumbent upon the patient to trust the health care system if the health care system keeps perpetuating mistrust. So my position is really that providers need to step up.

As Dr. Vince was so eloquently saying, they need to step up to inspire trust. And more than inspire trust, they have to stop fueling and perpetuating mistrust in their day-to-day interactions with patients. So I think that the providers are not equipped today to build trust and have good relationships with cross-cultural or racially discordant patients. I don't see this taught in medical school, and I don't see it in continuing education today.

So people will tell me that now we are starting to see anti-bias trainings and why this is a positive thing. I do not think that these trainings are sufficient to really have an impact on the patient experience of Black and Brown patients. I think that we need something that is a lot more practical, a lot more pragmatic, experiential, and, as Dr. Winn was saying, patient centered to really transform cross-cultural patient-provider relationships, which leads me to my grant.

So I'm happy to share that I recently won a $750,000 Health Equity Innovation Grant from Genentech in collaboration with Emory School of Medicine. And the grant is going to fund some research with Black patients and oncology providers at Emory Winship Cancer center, but also at the Grady Hospital in Atlanta. And we are also going to pilot an innovative training, which I designed, which is going to help improve cross-cultural patient-provider communication.

This training is coming from my background as a multicultural cancer patient, but I also have 20 years of experience in innovation and in human-centered design. And before I got cancer, I developed a model that is really the underpinning innovation about this training that will really give providers an experiential understanding of what it's like to be a Black patient in the health care system. So I'm not going to take the whole time.

RANDY VINCE, JR.: No, that's amazing. That's amazing. Thank you. And I'm looking forward to seeing the research that comes out of this and really provide some useful techniques for providers to implement in their daily interactions with patients. So I'm definitely going to be looking out for that, Dr. Leotin.

For my next question, I'm going to pose it first to you, Dr. Winn. And then, Dr. Leotin, you can weigh in on this as well. So we know that the history of structural and interpersonal racism can influence these patient-provider interactions. And so I wonder if you can provide thoughts on how, specifically, providers can establish a trusting relationship with their patients of color, given that this history we just discussed is so ingrained in so many of our daily interactions.

ROBERT WINN: Yeah, I think on the practical [INAUDIBLE] patience matters. And I mean that. So I think this is where, sometimes, well-meaning physicians get very frustrated, that they will say, well, I've been decent to you, and I've been pleasant to you, and I'm not getting your trust. Martin Luther King once said it best when he says, let's not get decency confused with equality.

And there is a level where just because you're decent, doesn't mean that you're building trust. Decency should be expected as a health profession. So I'm sometimes confused when people say, well, I've been nice, and I'm trying to be nicer. What does that mean? So it goes beyond just decency.

So trust is built up over time, number one. And I think I heard it once best from one of my mentors who says, trust is gained drop by drop by drop. But trust is lost, and when it's lost, it's lost in buckets. And I'll say that there's been reasons why we need to have more patience as health professions to understand that just because you've been good to someone for a year or two years, doesn't gain their trust. It may actually gain you some decency back, but that's not the same as trust.

So I'm going to say that people want me to give them a protocol because, as academics, everything is protocolized, right? And they want me to give them a protocol for, how do I build trust? And I'm going to tell you the following, that your mom and your grandmother probably taught you this a way long time ago.

Be nice. Have grace, have humility, and patience. Show up and show out every time. And do it whether there's— whether you feel that there's being trust built or not. Do it anyways. And if you do it anyways just because it's the right thing, over time you'll get people and communities' trust.

RANDY VINCE, JR.: Dr. Leotin, your thoughts?

SYLVIE LEOTIN: So I really love this answer. I would like to add my perspective because in the training that I'm developing, and I will be piloting at Emory University, we are addressing some of this from a different vantage point. I'm a patient. I'm an innovator. I'm not an MD, so I think differently.

And my belief is that in addition to what you were describing, Dr. Winn, there is an element of empathy and cross-cultural empathy that is often missing. And this is not about the health care industry. This is our society at large. And I think this is happening because we have a hard time taking the perspective of someone else without projecting our own projections, filters, biased assumptions on top of them and thinking, oh, this is what I would do if I were them, instead of really what it's like to be someone else.

And I love this quote from Harper Lee that said, you never really understand a person until you consider things from their point of view, until you crawl under their skin and walk around in it. So I developed a training to actually do this in a simulated environment. What I'm seeking to do is to give this really groundbreaking perspective to providers on what it is like.

What does it feel like at the visceral level to be a Black patient in health care undergoing and constantly facing biased interaction? And I think that until we really understand what it's like, it's hard for us to fix it, because racism and bias— they operate below the level of our consciousness, many times. And yes, I'll stop here. I'll say more later.

RANDY VINCE, JR.: Yeah, yeah, but I'd like to build on that a little bit. Because I know many of you have spoken prior to recording this podcast, and you said that in your interaction with many other Black oncology patients, there was often a feeling of being unheard or feeling dismissed by their providers.

We often talk— and Dr. Winn mentioned this earlier— about illiteracy when it comes to health care information. And often, people cite health insurance as a barrier to health equity. But we know that a lot of these disparities exist even in insured, educated patients. And so I wonder if you can share some thoughts on why you think this disparity exists, again, even when Black patients are insured and well educated, like yourself.

SYLVIE LEOTIN: Yes, I'm glad that we're making this point today. I personally interviewed several— many— Black patients with cancer. And I have to tell you that all those people had insurance. Many had great insurance. Many were educated. And they were still experiencing disparities in cancer care. And I would like to give you some concrete examples.

So there was a woman that I spoke to with stage II cancer. She stopped to take a hormone therapy drug because she didn't know what it was for, and the side effects were bothersome. The oncologist had not even explained what this drug was for, and he had been so disrespectful in their interaction that she never wanted to speak to him again. What happened a few years later is her cancer metastasized.

I spoke to another Black woman who complained of migraines and headaches for two years. The doctor dismissed her and said that, it must be stress. Your work is stressful. It became really bad, and one day she had a colleague at work who told her, did you get the blood test? So she went to get the blood test, and she found out that she had advanced melanoma spread to multiple spots in her body.

There was a Black woman that had, also, breast cancer, who was given a choice between a lumpectomy and a mastectomy. But she wasn't able to get the pros and cons from her surgeon, who was really rushing her to make a decision without information. She decided to take a mastectomy because she was thinking, oh, I'm going to be done faster, and I won't get to do chemo.

Well, after she got a mastectomy, she went to see a medical oncologist. And the medical oncologist ordered an Oncotype DX type test. And it turned out that she had to do chemo. So she was really mad at herself for not answering her question and rushing her into surgery. She felt that if she had been a white patient, she wouldn't have been treated that way.

Fast forward several months, she goes into chemo treatment, and she had many problems. She told me that they didn't want to give her a port for chemo. They said that she had good veins and she didn't need a port. She kept complaining, and nobody listened to her. Those are the stories that are happening. I had my fair share myself.

I'm an Ivy League-educated Black woman. I have four degrees. And I had an instance, I had a core breast biopsy. I was miserably butchered by a barbaric radiologist. He took so many, so many, an insane number of samples on me. And it was the equivalent of getting a lumpectomy without anesthesia. I had horrible post-surgery complications, and many other stories I will share in my book, which I'm finishing and should be published at the end of this year. But as you can see, it's not pretty.

RANDY VINCE, JR.: Yeah, thank you for sharing those experiences because these stories need to be told more because we can learn from them. And really, these stories constantly need to be promoted so we can make progress. So in closing, Dr. Winn, I'm going to post this last question to you. And I just wonder if you can provide your thoughts on how, collectively, a combination of better patient-provider interactions as well as community outreach can help reduce cancer and other health disparities.

ROBERT WINN: Yep, just quickly, I think, again, all data, great and small, is valued in my world. Why community? Because I think that the community— by being honest, by having the humility, by actually doing things differently, we'll be able to better serve our communities because they will give us some better information to help us literally refine our approaches and maybe even refine our questions.

The other thing I would actually add is that we have an obligation to not just— to really serve the community. It also means we should be thinking about, how do we actually have them not at the table but gainfully employed if we want to build trust?

So how do we do it? I think by totally, really engaging with the grace and humility that I know we're capable of, I think we will move the next 50 years— as we have the first 50 years as NCI-designated cancer centers, the next 50 years, I think, we'll do even better because we'll take the community along with us on the ride. As opposed to actually doing things to them, we'll start doing things with them.

RANDY VINCE, JR.: Absolutely. That was a great answer.

SYLVIE LEOTIN: Can I just add something?

RANDY VINCE, JR.: Sure, really quickly.

SYLVIE LEOTIN: Yes, I think that in addition to— in collaboration with talking to the community, I believe that the training that I'm building is going to equip doctors to be a lot more efficient in their conversation with communities. So it's both inside and outside the hospital.

RANDY VINCE, JR.: Great. Thank you. So this conversation has been incredibly enlightening. I want to thank both Dr. Winn and Dr. Leotin for being with us today. So as we conclude, I think it's important to say that while conversations like this are vital to impacting change, words alone won't bring about a kind of change that's needed. So it's of the utmost importance that we all back our words with actions and really engage the community and engage with our patients.

So I want to thank everyone for joining us on this episode of the ASCO Social Determinants of Health series. To keep up with the latest episodes, please click Subscribe below. Let us know what you think about the series by leaving a review or emailing us at [email protected]. That's all one word. And again, it's [email protected]. Also, to access any sources mentioned on the show or to read on Dr. Leotin's recent grant and her company, Equify Health, please check out the show resources.

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LORI PIERCE: Thank you for listening to this week's episode of the ASCO e-learning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

This episode was originally released May 27, 2021

Dr. Demetria Smith-Graziani (University of Texas) moderates a discussion with Ericka Hart, an activist and sexuality educator, and Dr. Kemi Doll (University of Washington) on the historical and structural reasons for patients' mistrust of the healthcare system due to systemic racism in medicine, with insights from both the clinician and patient perspective.

TRANSCRIPT

LORI PIERCE: I'm Dr. Lori Pierce, the President of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care, and is not intended for use in the diagnosis or treatments of individual conditions. Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed an ASCO position or endorsement. For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative, and some even uncomfortable, but ASCO is committed to advancing equitable cancer care for all individual – Every Patient. Every Day. Everywhere. I have dedicated this vision to my term as ASCO president. These conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what they look, receives high quality, equitable cancer care. Thank you.

DEMETRIA SMITH-GRAZIANI: Welcome to the fifth episode of ASCO Social Determinants of Health Series. I'm Dr. Demetria Smith-Graziani, and I'm a clinical fellow at M.D. Anderson Cancer Center. I'm joined today by Ericka Hart, an activist and sexuality educator, and Dr. Kemi Doll, a health equity researcher and gynecologic oncologist from the University of Washington.

This series is part of an initiative proposed by ASCO President Dr. Lori Pierce focused on increasing oncologists' understanding of social determinants of health, its impact on patients, and modifiable risk factors for cancer. Inspired by Dr. Pierce's presidential theme of equity every day, every patient everywhere, in this episode, we'll discuss the historical and structural reasons for patients mistrust of the health care system due to systemic racism in medicine within the clinician and patient perspective. So it's important to know that race is a social construct that continues to affect the health of marginalized populations. We have laws and practices that date back to chattel slavery, and clinicians really need to understand each patient's identity within the appropriate historical context in order to provide optimal care and engage in meaningful research to improve outcomes.

The health care system has not proven itself to be trustworthy in the past. It's still not trustworthy today. And there's a long history of institutional discrimination against racial and ethnic minorities, sexual and gender minorities, people with disabilities, and other marginalized groups that continues today and affects the patient-provider relationship. We'll focus today on anti-Black systemic racism within health care, and this will provide a foundation that we hope will encourage further discussion about other forms of discrimination within health care.

Thank you both so much for joining me today. We'll start with the first question, and that's that conversations about trust and health care among the Black community are usually centered around the Tuskegee study of untreated syphilis in the Negro male. But there are many other instances of clinicians and researchers engaging in unethical medical neglect and experimentation on African-Americans. So what other historical and current events should clinicians know about and what resources should they be using to stay informed? And we can start with Dr. Doll.

KEMI DOLL: SURE. So I think history is vital because without understanding our history, it's very hard for us to make sense of what's happening around us. And I think that the US study of untreated syphilis is-- in many ways, a medical education obscured the contemporary racism and the contemporary exploitation and mistreatment of Black people in the health care system. And so my first-- in terms of what else do people need to know-- is that they need to know that horrors as terrible as the syphilis experiment continue today all the time. I don't think you have to look far to find these incidences.

I will point out Dr. Susan Moore, a Black woman doctor, who died just a few months back being mistreated in a hospital system in the region where she practices and could not get care to the point where she was able to verbalize, I'm going to die. Because I am being mistreated, I'm not going to make it, and she didn't. So I want to gently remind us that to have to pull back to the syphilis experiment is demonstrating a willful not seeing, a willful choice not to see what's happening to us every single day.

The other thing that I would say for clinicians or researchers that want to stay abreast is that everything impacts health care. So the current trial of Derek Chauvin right now for the murder of George Floyd is an example of racism and how we value Black life. And so we need to understand as clinicians that when you walk into a room-- and now thinking about the oncology world that I'm in, the cancer world that I'm in-- and you are for example, trying to have a discussion with somebody about the risks and benefits of a certain treatment and survival and their life and maybe even trying to have a conversation that maybe it's time to stop treatment because I don't think you're going to make it and that patient is Black, you need to understand that that's happening in the context of us understanding that our lives do not matter to the same extent that other people's do just walking around on a daily basis.

DEMETRIA SMITH-GRAZIANI: Great point. Great point. Ericka, anything to add?

ERICKA HART: Yeah, for sure. Thank you for saying that, Kemi. That's brilliant and I do think it's important to be thinking about how this is continuing to show up contemporarily as folks will hearken back to the past as if we are now in a new day, and we are 100% not. But I do think what's important to talk about is whose stories get told. The focus now is on the Derek Chauvin trial due to the murder of George Floyd, but there wasn't this much attention, I would say, around Breonna Taylor's case and the fact that it wasn't actually addressed.

And even again, another marginalized community is Black trans people. When Black trans women die, what then is the national conversation? It doesn't exist. And I think that has a lot to do with the bodies that we are saying are worthy to be considered. And so what we talk about when I get so frustrated about the Tuskegee experiment being repeated over and over again is the erasure of Black femmes.

So J. Marion Sims is a pseudo medical provider who operated on countless Black femme people without anesthesia and then was named the father of gynecology. And then we come into the 1920s with Margaret Sanger and the experimentation of birth control experiments and the sterilization that continues to happen to this day. And what was happening is that Margaret Sanger used Black folks to say W. E. B. Du Bois was on-- I always say, "DeBwa"-- Du Bois is their name. They're from Massachusetts, so I'm going to give them spice.

W. E. B. DuBois really worked alongside of Margaret Sanger's eugenics project to essentially eradicate disabled folks and Black people and also went all the way to Puerto Rico to essentially attack and harm Black Puerto Ricans to create this birth control for white people. And then coming to the 1950s, we have Henrietta Lacks and the experiment on her body when she went to John Hopkins for actual care and the lack of informed consent. So I get frustrated when the focus is always on the Tuskegee experiment just as much as I get frustrated when we talk about police brutality being focused on Black cisgender man. There are so many folks who get impacted by the state, and often times we don't even hear their names because the media has construed who we see as important. And beyond the media, whiteness says whose identities are most important.

And it's important that when folks are studying medicine that you understand that you are also indoctrinated in this idea that certain people's identities are more valuable than others. And oftentimes, I'm told that there isn't much conversation around racial and social justice, gender justice at all in medical spaces. And I would say my resource is Medical Apartheid by Harriet A. Washington. It is necessary reading for anyone who wants to do anything in the world that relates to people's bodies beyond the medical spaces. I think it's important that you understand how folks bodies have been regarded in this country.

Another book I just got is called Medicalizing Blackness-- hold on, let me give you the author-- by Rana A. Hogarth. This is the book. Also, highly recommend-- it's just you have to do your research and really be applying this. Again, like Kemi said, it is not a function of the past.

It is happening currently. We can look to maternal mortality to really get the continuation of medical experimentation. I'm not a linguist, but even the word experiment has a lot to do with using someone to prove something.

So even inside of that, there is so much that we don't know that's not even really covered in these books. There's so much that has been buried. So yeah, that's what I would say.

DEMETRIA SMITH-GRAZIANI: Great [INAUDIBLE].

ERICKA HART: Thank you.

KEMI DOLL: May I have one more book Deirdre Cooper Owens, Medical Bondage, which focuses on the history of-- I love the pseudo. I love pseudo-physician. I'm going to start using that. Thank you, Ericka. A pseudo-physician J. Marion Sims, so thank you.

ERICKA HART: You're welcome.

DEMETRIA SMITH-GRAZIANI: This transitions well into a question about how does medicine as an inherently racist institution actually address these failings? One of the things that's been focused on recently is increasing diversity, increasing representation within medicine.

ERICKA HART: Yeah, so diversity and inclusion is ineffective. And what it does is it creates this idea that if you have cookie dough-- cookie dough without the chocolate chips is already kind of brown, right? But let's just imagine that it's mostly white.

So you have cookie dough, and then you're like, OK, you're not going to make chocolate chip cookies without chocolate chips, so you throw in the chocolate chips. That's diversity and inclusion. The basis, the foundation of it, is still white. You haven't done anything to uproot or change or acknowledge the harm that has been caused. What you are now doing is throwing Black people and non-Black people of color into the space to say, OK, look we got some Black doctors here.

But then, how do you address the fact that most medical schools are impossible to get into? The barriers that set up to actually get into medical school are incredibly financially impossible. And when Black doctors are practicing, they get so much racism that they experience from patients-- patients saying things like, I don't want that doctor. I don't want to work with them. What then is the impact on the doctor?

And then, can a Black doctor actually be politicized in their highly political position? Or do they have to essentially have-- I don't want to say minstrel show-- but perform Blackness in a way that's palatable to white people so they can keep their job? It has to go beyond identity. Identity will not save us. I want to know what your politic is, and diversity and inclusion is consistent with doing that as a way to absolve white institutions of their racism.

KEMI DOLL: If I could plus one, heart, like everything Ericka said times 10. I 100% agree especially regarding the point about identity. And it's not just about, I think, Blackness. It's about, I mean-- I don't know how to say this word-- but visible blackness, I'll just say. I mean, it's about the--

We are very hypervisible. Black physicians are hypervisible, especially in academic places. And I have to speak there because that's my experience.

So what happens is you walk in the door, and 30 seconds after you walk in the door, your face is on a poster. Somewhere, you in marketing materials, girl. You're already there.

And then on top of that-- so you're very visible. You just started. The scrutiny about what kind of doctor you are and the quality of care that you can provide is ramped up immediately even up and over what would be for a normal person starting.

Then you add on the layer of exactly what Ericka is talking about, which I have certainly experienced, is the also higher bar that patients have for you. Because they walk in, they're like, oh, you're my doctor. Now all of a sudden, you're reciting your pedigree, you're reciting how many cases of X you've done, you've done all of this stuff, plus the microaggressions that happen on a daily basis from staff who are supposed to be reporting to you but feel a type of way about reporting to a Black woman or a Black femme in a certain kind of position.

So you add on all of that. And so then, I say you add on all that, and then you turn to the Black doctor and you say, you're the solution to medical racism. It's ridiculous, it's insulting, and it's actually just racism. I agree 100% that simply having a Black doctor is not going to fix racism, and my perspective also is that it's necessary but not sufficient.

So we're definitely not getting anywhere without Black doctors. However, I personally did not get into my politic and understand race, gender, and the intersection of race, gender, and health and racism as it applied to my particular area, GYN oncology and endometrial cancer, until I was through medical training, through subspecialty training, and deliberately spent years consuming sociology and anthropology and equity frameworks, which just gives you a sense. Because I'm a Black woman watching all of this happen in front of me as a trainee.

If you do a four-week course in the summer on racism, you're not doing anything because it's about the embeddedness everywhere. It's about how we talk about Black bodies. It's about how we talk about race as a risk factor instead of racism as a risk factor. And I can just speak personally it's a journey out of that and then to turn around and look at it and then to say, now I am deliberately staying because I am deliberately trying to deconstruct.

And I do think that that saves lives. I do know that being in my position and a Black woman walking in with the politic and understanding that I now have is the difference between her getting the care she needs and not getting the care she needs. I've had people come to me as their third or fourth opinion because they can't have a respectful conversation with an oncologist who can listen to them and their concerns and who understands that everything isn't black and white. The things that we measure aren't always the things that matter to everybody.

And so it's both/and for me. We do have to grapple with the problem that Black people in medicine can obscure the progress towards anti-racism in medicine and towards deconstructing these things when all they are is identity and there's no effort to understand and define a politic. And I understand that makes us vulnerable, but it's always going to make us vulnerable until we remake the system. So that's what I would add.

DEMETRIA SMITH-GRAZIANI: Yeah. Thank you. It's really, really important points. So building off of all of that-- so let's say people are saying, OK, I'm learning to look through this lens where we're going to infuse the practice of learning about racism throughout medical training.

OK, now what do I do now? I'm a physician. I'm a nurse. I'm a health care practitioner. How do I use the power and privilege that I have to then to combat racism in medicine when I see it to help my patients? Who's going first this time? Maybe we can start with Kemi this time.

KEMI DOLL: It's-- OK. So what can I do is a hard question to me because there's a billion things to do, and so I just want to acknowledge that that question is sometimes used to not do anything. There's always something to do.

If the issue was you had high infection rates after all of the surgeries, people would have 30,000 things that they would try immediately tomorrow. So the first thing I just want to-- I have to say is stop asking that question. And in addition to reading something-- you got book recommendations already-- start doing something different. Just try. Iterate. Do that first.

Secondly, I would say that look in your own house. So what we know-- I'm going to quote a study and it's going to be terrible I can't tell you where it was. I can't remember anything about it. But it was about-- I think it was cardiologists, and they surveyed the survey cardiologists. And they were like, there was a study that came out that demonstrated that specifically-- getting to the intersectionality point-- specifically Black women, when reporting cardiac symptoms suggestive of a heart attack, are not referred to get cardiac catheterization to literally save their lives compared to white men and women and Black men.

After this, there's a study that asks cardiologists they say, OK, well, where do you think racism exists in the health care system? And it's like, out in the health care system, at my own hospital, in my own practice with me and my patients. And you might imagine what that looks like.

Oh, it's definitely out there. Maybe it's in my hospital. It could be in my practice, but not with me.

And so my answer to that question is acknowledge that there's racism in your practice because you literally live and breathe white supremacy. So acknowledge that it exists. We're not fighting that question.

And then because I am a research person-- I apologize-- get your data. Pull your-- stop assuming. Pull your data right now and look and see who's not doing well.

To Ericka's point about trans, non-gender binary people. Where are they? Are you asking people? Do you even have that data?

And then going on-- race, ethnicity, ethnicity breakdowns within the Asian population. Are you even looking to see how are we doing on these metrics? Who's getting care and who is not?

That is like the bare minimum of what you would do if you said, today, I am trying to change something. You would go get your own data. You wouldn't keep asking people, what should I do? So that's my answer. But also, just listen to Ericka.

DEMETRIA SMITH-GRAZIANI: Yes. Yes. [INAUDIBLE] kind of ruled this into how this affects your day-to-day experience as a patient, tying that together, hopefully. Yes. [INAUDIBLE]

ERICKA HART: Yeah, sure. I'll tie it together as well. I think everything that can be said and what I'll add is the lack of intersectionality, the lack of looking at intersecting identities that influence how folks receive or don't receive health care. One point that I feel like when we're having these conversations about medical institutions is that we leave out insurance companies, and insurance companies are a major barrier to actually accessing health because it is politicized in this country. It is connected to the government, which it should never be.

Folks should have access to health care. That should not even be a radical statement. Everybody should have access to health care, and we don't. I'll tell you right now-- and this is not an exaggeration-- I pay $660 a month for health insurance, and that is just because I don't want to leave my oncologist.

I don't want to have to search for another oncologist. I want to stay with this oncologist for the next-- I've been with them for five years. $660, right? And I'm in a privileged position where I can afford that, but it is still a lot of money. That is ridiculous.

So addressing the barriers-- my breast cancer surgeon actually saw me when I did not have health insurance. I don't know that-- I won't say his name because I don't know what you all to be finding him or doing nothing to him. That's my homie.

He really saved my life. He was willing to see me even though I did not have health insurance. Stop putting up the barriers of red tape. Right now, what we're seeing in states like Arkansas and Mississippi are racist and transphobic governors and politicians who are trying to stop trans young people from accessing health care.

The government is going to do what the government is going to do. What are you going to do when folks come into your office? Are you going to tell a trans young person, oh, the government says that I can't treat you? Hell no.

So my suggestion to medical providers, to folks who work in any field that serves people, is to risk losing your job. Put your job on the line for somebody else. Do not not give me care so you can continue to collect a check. How do you sleep at night?

What needs to happen is that medical institutions need to go away. They are consistent with supporting-- they work with the state clearly. They are informed by the state. Therefore, they are also informed by police. We are inside of a police state.

All of these things are connected. As a Black queer non-binary femme who has to navigate medical institutions on a regular basis, it is terrifying. And it is exhausting how most even when I get at the door and I fill out the copious amount of paperwork that ask me for everything besides how much butt hair do I have.

There's nothing on there that ask me my pronouns. There's nothing on there to ask me my gender identity. There's most likely to be an assumption of who my partner is or who I love or how I love, which is now triggering. I'm now stressed out to be at the doctor.

I'm also a person of size. I am inside of fat activism spaces I am considered a small fat. So any time I go to the doctor, there are some sort of correlation made with my health connected to my fatness.

It's pseudo-science. Anything you're talking about in terms of race has then a function of anti-Black racism, how I have been harmed in terms of racism, how my body is weathering due to the constant racism and transphobia and classism and fatphobia that I have to navigate. Don't contribute to that. Cut it out.

DEMETRIA SMITH-GRAZIANI: Yeah, it's kind of-- it seems complex, but it is kind of simple, right?

ERICKA HART: It's so simple. That complexity is a function of white supremacy as well-- to make it complex, so we could constantly be, like Kemi said, what do we do? And what do we do? It's nonsense.

You know what to do. You are unwilling to do it because it could eventually, hopefully lead to this institution falling apart. Great.

I want to go to the doctor underneath a tree. I don't care if the red tape to get to the technology has to be addressed. And that's all I mean.

DEMETRIA SMITH-GRAZIANI: All those barriers.

KEMI DOLL: Exactly. I just want to point that out though because I think in medical discursive spaces when people hear Ericka saying, we don't need the institution. We don't need all of this stuff. We need to dismantle it.

That gets skewed into we don't need anything, like all of this-- we're going to go back to bloodletting. That's not what we're talking about. But what we're talking about is we don't have to couple those things together.

We don't have to couple innovation and knowledge together with power and class and exclusion. Those can be decoupled. And I don't know, I'm like-- I don't know. My view is always like that is the goal. And then, what am I doing today?

What am I doing today that is disruptive? If you're doing something today disruptive, you're disrupting, and you're disrupting every day. Sometimes, that disruption is in the form of how you're talking to somebody as the first person who's talking to them as a person, as a whole human being, as a whole non-defective human being, and seeing everything that's on top of them not as something intrinsically wrong with their body, but as a function of the experience that they've had.

But in addition to that, in addition to an individual disruption of thinking about people as problems to solve, then disruption can also look like, for example, not allowing the same appointment length of time for a patient who speaks your language and a patient who doesn't. Just think about that. If all of your appointments are 30 minutes and you see-- or 15-- and you know somebody is coming to see you that y'all don't speak the same language, that means that you have to have a translator.

By definition, by the structure, that person gets half as much time with their doctor. They pay the same amount, they have to deal with the same insurance, all of those things, and yet they get half the amount of time because you're spending time going back and forth. That is a systematic disruption that's available to you right now.

To say, schedulers, an hour every time somebody comes in who does not speak my language? Double the appointment time because that's the bare minimum of equity. I mean, there's more things. I don't want to pretend like that's the solution. But there's an infinite number of things that you can do while still choosing to be in a system that disrupts that system is how I think about it.

DEMETRIA SMITH-GRAZIANI: I think we're always afraid of rocking the boat. But really, we have to think about, well, what are the consequences? And sometimes the consequences aren't really that bad, and that all depends on your personal identities and how you might be [INAUDIBLE] within a larger institution. But a lot of times the consequences aren't that bad if you push that boundary.

I wish I could continue this conversation all day. There are so many gems here, but I know this is just the beginning of the conversation. I really hope this is something that continues among oncologists, among other clinicians, health care providers, researchers. But we'll end there.

But thank you so much for sharing your time with me. This was amazing. And thank you all for joining us on this episode of ASCO Social Determinants of Health Series. To keep up with the latest episodes, please click Subscribe. Let us know what you think about the series by leaving a review or emailing us at [email protected].

SPEAKER 4: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive e-learning center at elearning.asco.org.

This episode was originally released February 24, 2021

In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Dr. Hala Borno (University of California San Francisco) moderates a discussion with Dr. Fumiko Chino (Memorial Sloan Kettering Cancer Center) on understanding the cost of care and ways care providers can help patients and caregivers mitigate financial toxicity.

TRANSCRIPT

[MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

[MUSIC PLAYING]

Welcome to the fourth episode of the ASCO Social Determinants of Health Series. I'm Dr. Hala Borno. I'm an Assistant Professor of Medicine at the University of California, San Francisco, and a genitourinary urinary medical oncologist. I have the pleasure today of being joined by Dr. Fumiko Chino, who's a radiation oncologist for Memorial Sloan Kettering.

This series is part of a new initiative proposed by ASCO President Dr. Lori Pierce, focused on increasing oncologists understanding of social determinants of health, its impact on patients, and modifiable risk factors for cancer. Inspired by Dr. Pierce's presidential theme of equality every day, every patient, everywhere.

In this episode, we will look at issues of financial toxicity and related barriers to cancer care. Again, thank you Dr. Chino for joining us today. First, I thought I would ask what do you consider to be financial toxicity and how can it be a barrier to access to care.

FUMIKO CHINO: Thank you so much for having me. I am very passionate about this topic. I have dedicated my life to it. And it's actually the reason why I am in medicine. I think financial toxicity is a very-- it's a hot topic nowadays, especially with the rising cost of cancer care and then I think highlighted by the COVID pandemic.

But financial toxicity is really a patient-facing problem, meaning it's how patients deal with the cost of their cancer care and how that affects the quality of their care, their access to care, and ultimately can affect their survivorship from cancer. Personally, interested in it because of my own experiences with financial toxicity. And it's really the reason why I ended up in medical school at all.

I think realistically, it's like the old adage where you haven't-- unless you ask about a problem, you're not going to identify it. And from my own experiences, I know that there are patients that you will see in your clinic that are having problems with financial toxicity, but they won't necessarily talk to you about it until they're given permission. And so I think this topic is increasingly important. And it's something that I'm really happy that we're spending some time with today.

HALA BORNO: Dr. Chino, thank you again. You really have been quite open about your personal experience, a very powerful experience to highlight this critical problem. Do you mind sharing a little bit about that story. And how does that impact the way that you interact with patients in your own practice and also inform your research?

FUMIKO CHINO: I think that my story, my husband's story, and ultimately our struggle through the health care system really highlights a lot of what this whole issue is about the social determinants of health. And I think the lens I bring to it is someone who's been on both sides of the stethoscope so to speak.

So my husband was diagnosed with cancer at a very young age, when he was in his 20s. And unfortunately, we dealt with some very poor quality health insurance, which did not have a lot of coverage for cancer. And we had a lot of out-of-pocket expenses for care.

Ultimately, I had to quit my job to help take care of my husband. And when he died from cancer, when he was less than 30, it left me with an incredible burden of debt related to his cancer treatment.

I think the flip side of the access problems, in terms of insurance, is that I have a very privileged background. Unlike a lot of patients with cancer and families with cancer, I am from a pretty wealthy family. So I was able to rely on the support of my family to help me get me back on my feet. And even, again, when we are suffering these great costs, we had people who could loan us money.

And I think that privilege that we had really helped us stay at least minimally afloat with our struggles with financial toxicity, instead of completely going under. And I think that really highlights some of the disparities that for patients that don't have wealth in their family, or people that they can rely on to loan them money, or flexibility within their jobs, financial toxicity of cancer treatment really hits them so much harder.

HALA BORNO: Yeah, that's certainly a really powerful experience. And I do in a moment want to hear how that informs the research questions you ask, but I do want to first highlight that you brought up two really important points.

So the first point is this notion of coverage, where access to insurance doesn't necessarily mean access to affordable insurance. And that this issue of cost sharing and out-of-pocket costs that patients bear can be quite burdensome and compromise their circumstance. And I think your story certainly highlights that.

The other piece that your story highlights is this notion of wealth versus household income and how different individuals enter their cancer journey from a different circumstance. And that circumstance of wealth versus household income can have huge ramifications on their experience of financial toxicity. So I think that that's a really critical point to make.

Could you share a little bit about how that experience now has become really the cornerstone of the research questions you're asking in your academic career? And then have you carved out certain solutions to identifying these among patients that you're seeing?

FUMIKO CHINO: I think that the experience that we had in terms of navigating the health care system, and the obstacles, and the rat race that cancer care treatment is for everyone, especially coming from a background of having-- a high educational and a family in medicine, and just how difficult it was for us really highlights for some patients how it can be insurmountable. And these problems of access, or even getting the right diagnosis.

So my husband was given, I think, three false diagnoses before he was actually told he had cancer. And then from cancer, he was originally told he had non Hodgkin's lymphoma. And he ultimately ended up having a high-grade neuroendocrine carcinoma.

So realistically, those barriers to even getting the right diagnosis are even worse for patients that may have a lower education standard or may have built-in racism within the system, which is holding them back from being able to trust their health care team and being able to get the proper diagnosis and the proper treatment for their care.

I think our experience has really focused me on trying to think about highlighting the populations that really could benefit the most from an intervention, and then piloting specific interventions that may actually help people receive the high quality, high value cancer care that everyone really deserves. I think within the United States, we are-- we like to think of ourselves as being leaders. And I think that to call ourselves leaders, we need to lead.

We cannot live in a society where a quarter, a third of our patients are really suffering huge burdens related to the cost of their cancer care. In highlighting a little bit about what you said before about wealth, we already know that, for example, Black families have one tenth of the wealth that white families have in the United States. There was a really compelling Brookings evaluation of that.

So if you think about just the out-of-pocket burden for cancer care eroding wealth, what we're talking about with financial toxicity is something that can really be durable within families. So not just eroding the financial security of a patient, but also potentially compromising the educational success of their children or causing housing instability within the family. That affects the entire family unit.

So thinking about these issues are really what has galvanized me to consider what are the next steps to actually getting people the care that they need in a facilitated way. And I think-- again, not to bring up COVID again, but that's really highlighted the gaps in the US health care system and the patients that are disproportionately affected by burden.

So if you think about someone who has now potentially lost health insurance, or does not have the job flexibility, or paid sick leave to deal with a cancer diagnosis, we're talking about an entire group of patients that are now going to have even worse cancer outcomes.

And we know that, for example, patients that do have-- the working poor, actually, those with essentially borderline private insurance, that they really do suffer the most in terms of financial toxicity in terms of their out-of-pocket costs, and their coverage gaps in terms of-- what their insurance insufficiently covers in terms of their cancer treatment are the highest.

And that's really, in terms of the people to really think about how do we help them, how do we get them the care that they need, that's really what I'm most interested in pursuing.

HALA BORNO: Really important points that you brought up. I think we can't ignore our context, the COVID context. And certainly, this current pandemic has shone the spotlight on the relationship between disease and our financial circumstance and in a variety of ways.

And so I think it emboldens us to understand and to evoke change in our clinics, in our health systems, in our communities to have conversations around financial toxicity and the relationship between financial toxicity and cancer care. And also emboldens us to start operationalizing, assessing patients for financial toxicity.

So when I have conversations with my colleagues and done my own research in this space, I've observed that clinicians often feel ill equipped to manage issues and problems around financial toxicity that they may identify in clinic. And, of course, when you feel ill equipped to navigate a problem that you identify, it may, of course, make you reticent to even identify it.

And so what are some potential solutions that our colleagues who might be listening to this may be able to take with them in their clinics and practice in order to start unpacking and addressing this problem?

FUMIKO CHINO: No, I think that's a really good question, because I think that's the most common concern that I have from providers when I talk to them about financial toxicity. And I am so pumped in terms of like we need to address it, and we need to be asking patients.

And it's funny, we did a survey of our patients-- this is actually before COVID-- to ask about some things that would actually help their financial situation related to their cancer care. And some of the solutions were honestly very, very basic.

Minimizing wait times so that people could actually get back to work and not have to take a whole day off of work. Having a food or a snack in clinic so that people would be able to actually get some food in them so that they could maybe go back to work. And I think MSK has really highlighted the idea of having a food bank embedded in certain clinics to try to help with food insecurity.

Providing things like parking vouchers, or bus passes, or metro tickets to patients to try to help with transportation. Really basic, fundamental access problems. And I think that the larger issues, outside of just the mechanical issues, is that to realize that we are part of a multidisciplinary team.

I would never treat someone-- I'm a radiation oncologist, I would never just start zapping someone without talking to the medical oncologist, and potentially also the surgeon, to really think about, well, how do we coalesce a good treatment plan for someone.

And I think you can really think of financial toxicity in a similar way, which is we need to bring in all of our potential assets. We really need to think of our assistance within social work, or the social work team, or patient financial services to really rally all of the available resources for our patients.

And I think the thing I would say is that we can lower costs for patients. We can't necessarily lower them to zero. And we can't lower them for every single person, but we can really make a meaningful difference. And it's a matter of getting people the help that they need or sometimes just that little bit of-- I'm going to miss my rent this month-- a little bit of philanthropic funds that can actually tide them over so that they don't fall into a larger hole related to their cancer diagnosis.

The study that I quote most commonly is actually one by Reshma Jagsi from the Michigan group, which found that 1 in 20 Black or Latinx women who are treated for in early-stage breast cancer actually became housing unstable related to their treatment. So they had in early-stage breast cancer, totally curable, totally treatable, and yet ultimately ended up homeless related to the cost of their treatment.

And you cannot help but think that some of that would be preventable if we could just provide people with some acute assistance when they're in need. And again, rally all of the resources around them. And it's not just social work and patient financial services. There's a national initiatives to try to think about how do I lodge patients during their cancer treatment from, for example, the Hope Lodges?

How do I get them to their treatment so that they're not paying for taxis, or they're not trying-- they don't have a car, so how do they get to their radiation treatments? Or how do I rally philanthropic funds to think, well, what about that extra $300 I just really need to pay my light bill?

And there are resources. They're not again infinity resources. But they can actually help our patients. And we just need to facilitate them getting them.

HALA BORNO: I think that's an incredible point. I think what I'm hearing from you is, why don't we look within our own clinical environment, the way that we deliver care, and identify areas that generate burden and areas that could be streamlined? Because while there are some opportunities to address indirect costs associated with care, such as travel, lodging, and there's a lot of innovation in that realm, this notion of economic opportunity loss.

The loss of wage as you receive care is difficult to measure, not measured operationally, and can be quite burdensome. And so if we streamline that health care delivery experience, perhaps we can start addressing the costs that we're making our patients bear in order to receive care. So I think that's a really important point.

And it brings me to a question, is we all acknowledge in the era of COVID-19 there has been a rise in utilization of telemedicine, which may be addressing a lot of these different issues around receipt of care, parking, travel time, waiting in the waiting room. Do you-- tell me a little bit about how you've thought about that approach. And do you think that it's a solution that we should be carrying forward in order to address this notion of financial toxicity?

FUMIKO CHINO: I think that we were all forced to rapidly implement telemedicine because of COVID-19. And I think one of the few benefits of COVID was that it forced us to really think about what are the barriers to telemedicine? What are the potential ways to deliver high-quality, high-value cancer care from a distance? And how-- what are the real true assets and potential risks of that?

And we, actually, within our own group, just recently published something in JNCCN. And specifically my question about the role of telemedicine was, how much was it actually saving patients? And the majority of patients did say, you know what, telemedicine helped. It helped reduce my treatment costs.

I think the flip side of that is that we know that, based on some research that's already been presented, at least in abstract form, that telemedicine has not been rolled out evenly. And so that there are potential racial, ethnic disparities, and socioeconmic disparities in terms of the capacity for someone to get a telehealth appointment to feel that is a trusted conversation and to have just the-- again, the technical capacity, video phone, Wi-Fi, to actually get telehealth in.

So I think that telehealth does present some really good opportunities to improve value within cancer care and to increase affordability. But the pitfalls, I think, are also true, which is that we can't just say, oh, well this is great, everyone I know has an iPhone, so I'll just Facetime all of my patients and neglect the patients that are really struggling.

They don't have Wi-Fi. They're not able to have a fast connection. They're not able to hear you. And they would really benefit from an in-person visit because communication may be a difficulty or trust may be a difficulty. And those are patients that, again, we need to tailor our interventions and make sure that we're using the right tool for the right patient.

The implementation of telemedicine is like precision medicine. We need to actually deliver the best care for the person who's in front of us. And it's not one size fits all.

HALA BORNO: I absolutely agree. I think the social determinants of health, integrated precision medicine, how do you individualize your intervention is key. And if you do use this one size fits all approach, you will likely widen the treatment gap in who we are serving. So I absolutely agree with that. And I think your points are well taken.

I think for our listeners, I really want there to be a tool that they can use in their own clinic as they interact with patients. How do you approach this with patients in your conversation? What is a takeaway that they can have that they can carry with them in their clinical practice?

FUMIKO CHINO: I think that drawing from my own experience and realizing that we were suffering greatly from our cost, and yet afraid to speak about them to our provider, just realizing that sometimes patients just need the OK. So they need you to ask them, are you having problems related to the cost of their care.

And then, you do need to have some small investment, at least, in terms of knowing what the resources are available. And that could be a simple conversation with your patient financial services group or your social work team, and know what resources are available within your own institution.

I think, shockingly, we found that we have great resources here at MSK, and we also have patients who are really suffering. And yet, there's this disconnect, where patients are not being appropriately referred to the resources that we have. And they're suffering in silence. Patients aren't bringing up the topic. Providers aren't bringing up the topic. And so there's this missed opportunity to actually provide the best quality of care tailored to that patient.

So just asking the question and then knowing what potential resources are available, even something as simple as a parking pass. Like, hey, do we have parking passes that we can give patients? You'd be surprised how much that-- just a small piece of paper-- it's 20 bucks-- can really make a difference to some of our patients.

Or even asking, how do we coordinate your care so that you can have a minimal amount of time off of work? How do we facilitate you actually maintaining your health insurance through your job so that you're not worried about not just the lack of health insurance for you, but also for your young kids?

How do we maintain your job related to your-- I again treat with radiation, so it's a daily treatment, typically for a period of weeks. How do we treat you at the right time of day, so that you actually don't have to take more time off of work? So that you actually have income coming in to offset the debts in the bills that are then-- because if you just have debts and no income, it digs you deeper into a hole.

So I think all of these things are part of, again, this idea of precision medicine, which is not necessarily next generation sequencing, but actually generating the right plan for the person in front of you. And I think the first question is always just asking.

HALA BORNO: Absolutely, precision medicine isn't just about genomics and targeted therapeutics. It's also about identifying the unique challenges of patient experiences. And I think you've given me a lot of lessons about what I can carry in my own clinical practice. And hopefully, that can also have a ripple effect on other listeners today.

[MUSIC PLAYING]

Thank you for joining us for this episode of the ASCO "Social Determinants of Health" Series. To keep up with the latest episodes, please click Subscribe. Let us know what you think about the series by leaving a review or by emailing us at [email protected].

[MUSIC PLAYING]

SPEAKER 1: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning Center at elearning.asco.org.

This episode was originally released January 21, 2021

In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Dr. Jacquelyne Gaddy (University of North Carolina Chapel Hill) moderates a discussion with Dr. Reginald Tucker-Seeley (University of Southern California) and Dr. Katie Reeder-Hayes (University of North Carolina Chapel Hill) on how to take a social history, with a focus on cultural humility and addressing implicit bias. Read more about this topic in Dr. Gaddy's recent ASCO Connection article.

TRANSCRIPT

PRESENTER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

JACQUELYNE GADDY: Welcome to episode three of the ASCO Social Determinants of Health Series. My name is Dr. Jacquelyne Gaddy, and I'm a fellow in the Division of Hematology and Oncology at the University of North Carolina at Chapel Hill. Today, I am joined by Dr. Reginald Tucker-Seeley, Assistant Professor of Gerontology at the University of Southern California, and Dr. Katherine Reeder-Hayes, Associate Professor of Oncology and a Health Services Researcher at UNC Chapel Hill.

This series is a part of a new initiative proposed by ASCO president, Dr. Lori Pierce, focused on increasing oncologist's understanding of social determinants of health, its impact on patients and modifiable risk factors for cancer inspired by Dr. Pierce's presidential theme of equity, every day, every patient, everywhere. In this episode, we will look at how to take a social history with a focus on cultural humility and addressing implicit bias. Dr. Reeder-Hayes, I think I will start by asking, why do you think the social history and the taking of it is so meaningful and impactful?

KATHERINE REEDER-HAYES: So to me, as a provider, it has always felt that the social history really is serving a dual purpose. One of those purposes is simply the development of rapport and relationship, learning about your patient as a person, learning about maybe points that the two of you have in common or that you may be able to connect about, just as we would in social conversation with any other human being. But the other purpose is to identify social factors that may impact the journey that your patient is starting out on, assuming that you're meeting a new patient. We know that social determinants of health have a huge impact on a patient's ability to stick with their treatment plan, their ability to navigate their way through the health care system, and have direct impacts actually on their physical health. So those are all reasons why the social history really may be as important as any other part of a new patient history and physical exam.

JACQUELYNE GADDY: I want to Pose this next question to both you, Dr. Reeder-Hayes, and Dr. Tucker-Seeley. What are key questions that you guys believe should be asked of your patient when completing the social history? Or Dr. Tucker-Seeley, just for you, like, what are just meaningful things that you should be able to walk away knowing about your patient?

REGINALD TUCKER-SEELEY: Well, I think it's important to understand that, as Dr. Reeder-Hayes mentioned, the things that impact how a patient navigates health care and their ability to adhere to treatment, those things may be happening outside of the doctor's office. So getting an understanding of your patient's life outside of that 10 to 20 minutes that you see them is really important.

So for example, I'm working with some colleagues-- and I'll be talking about this throughout the conversation today-- with some colleagues at the Los Angeles Department of Health Care Services, and we've decided to focus on three key areas. One is housing insecurity, food insecurity, and transportation needs. And so those are three key factors that have been shown to impact how folks are navigating health care, and also, to impact their ability to adhere to treatment.

KATHERINE REEDER-HAYES: So I would add to that the kinds of approaches that Dr. Tucker-Seeley is talking about and the kinds that are pretty natural to folks who work in a public health situation are not the same-- [AUDIO OUT] we were taught in medical school, right? So we were taught to ask about risk factors. It's really an epidemiology-based understanding of what the social history is for.

What have you been doing? Have you been smoking? Have you been drinking a lot of alcohol, doing illicit drugs, sitting around being sedentary instead of exercising, and how did that lead to the health state that you're in now? That's how we were taught as physicians to obtain a social history.

Now, some of these things are still relevant. I'm not saying that they're not relevant. But you can imagine, if this is the first interaction you have with your provider, first of all, it might be kind of off-putting to be intimate about your health habits as the very first encounter with the person, especially when it's the only focus. So you need to move to a more complex model. As Dr. Tucker-Seeley was saying, that focuses on actionable items.

When was the last time we were taught in medical school to ask about how our patient got to the appointment and how reliable their transportation is, and it's highly actionable. And it's also an approach to the social history that's really multilateral. The physician probably can't make the best come on time to pick up the patient for his appointment. There might be a social worker who can get the patient a Lyft coupon or help the patient find public transit or get a volunteer to give them a ride. There are lots of things that a social worker on the team might be able to make that actionable information.

And then, finally, I think the models that we need to move to for social history need to be much more patient-led and patient-centered, so open-ended questions. Tell me something about yourself outside the hospital. What's been your biggest challenge since you got this diagnosis? Let the patient tell us which parts of their social Story. Are most important or most challenging rather than assuming that we have a checklist that's going to hit the right pieces of information if we just go down the checklist.

REGINALD TUCKER-SEELEY: I think Dr. Reeder-Hayes is highlighting that the difference in training from those of us who come from a more public health background-- I trained in public health, specifically, social epidemiology and health and social policy, and we've been talking about the social determinants for a very long time. And so I think making sure that, in addition to having physicians at the table, having social work at the table, having someone from social epidemiology or medical sociology at the table to help the team come up with the best set of questions that are most relevant for that particular practice environment.

KATHERINE REEDER-HAYES: Absolutely. And the last thing I would say is that we are in the era of the electronic health record. Not everything about it is great for patients. But one thing we can do is we can build social history over time.

So if the chart tells you the patient's smoking history you can go deeper in a small amount of time. You can say, hey, Mr. Jones, I saw it mentioned in your chart that at some point, you were a smoker. Have there been some times you tried to quit smoking? That shows respect for the patient, respect for time, and the fact that they maybe already answered this question many times, and it also allows you to get to a point in the social history that's more actionable than just repeating the same questions over and over again.

JACQUELYNE GADDY: Dr. Tucker-Seeley, you mentioned something earlier that I wanted to ask, and I know, Dr. Reeder-Hayes, you'll be able to add to this also. Who do you believe is the best person on the care team to ask these questions? Who should be initiating this conversation?

REGINALD TUCKER-SEELEY: That's a very good question. And I think we often see this in the financial hardship and cancer space where patients want to talk about cost, but physicians may not necessarily want to talk about cost because you aren't aware of what everything is going to cost, so trying to think about what is the best framework or model for thinking through this process. In the project that I mentioned earlier, we developed this framework and it's called Screen, Navigate, Connect, Address, Evaluate.

And so it takes you through the entire process. So not just thinking about am I checking something off of a list that I'm required to do, but also thinking about, how do I help the patient navigate through the process? How do I then connect the patient to the social service that will eventually address that social need? And then investigating whether or not that need was actually addressed, and then an evaluation component that then determines, did addressing this particular need actually impact outcomes or help facilitate the navigation of health care?

It can be a challenge to figure out who on the team should be asking these questions. And I think with this particular framework, you can decide who's going to be responsible for screening. Who's going to be responsible for navigation? Who's going to be responsible for connecting? And thinking within the scopes of practice of the members of the care team, who's best suited for those particular roles?

KATHERINE REEDER-HAYES: That is a great thought. And I think it connects to what I would call the need for professional humility as physicians to realize that-- we have been taught that we have to do it all, but we're not necessarily very good at doing it all. When we walk into the room with the patient, we're faced with a lot of different competing priorities, including the care of their cancer.

I think we can learn something here from the patient-reported outcomes field where what many years of painstaking research have eventually really strongly shown is that doctors and patients in a room together with the doctor trying to figure out what the patient's are in a short space of time, maybe not in real-time as the symptoms are happening, is a way to get accurate information about reported outcomes. You put in a system, patients are able to report this remotely, where they're able to report it in a systematic way, and where there are those screening and navigation components where team members are responsible for responding to those symptoms, making sure they're taking care of, not only does that patient experience get better, but survival gets better.

Cancer survival actually improves when we use the whole team, systematic, and we do screening, navigation, response, evaluation. I think there were some patient-reported outcomes for physical symptoms. It's likely to work in terms of the social components of their illness as well.

REGINALD TUCKER-SEELEY: And two, I want to make sure to point out we know that system change is hard. Doing something new is going to be a challenge. So there was a recent report by the National Academy of Medicine, a consensus study focused on integrating social care into health care delivery. And they introduced a framework as well that really focuses on the awareness within the organization of the importance of social needs, adjusting the clinical workflow to the integration of these new social factors. So I think that report can be quite helpful for any department or organization that's looking to attempt to integrate social care into their current clinical workflows.

JACQUELYNE GADDY: Dr. Tucker-Seeley and Dr. Reeder-Hayes, something that both of you just mentioned makes me think about when we're in medical school, we're taught this format. You do this, you go from A, you get to Z. You don't make any detours. If you get to a different stop before you were supposed to, that's the wrong thing.

So Dr. Reeder-Hayes, at what point in the history do you think it's important to start taking the social history? Do you do it when you first meet the patient? Do you do it at the end? Where do you think that should be structured?

KATHERINE REEDER-HAYES: So I think where we tend to put it is where it has come in the traditional format of an office visit notes or a history and physical, which is kind of down towards the bottom of when you're talking to the patient maybe right before you get to the physical exam, so you're distracted. You've already asked them about 85 things. And I would really challenge folks to think about putting social history up front and changing that standard flow.

I think there are a lot of advantages to putting social history up front. The big one is that it follows the conversational norms that we have outside of medicine. So if you walk into a bank to talk about getting a loan or you're getting to know a new neighbor, you're not going to start with the business. You're going to start by getting to know the person a little bit. And so that may feel more natural in the interaction.

And it also has an opportunity-- if we view the patient as a whole person and we give them a chance to share something that they think is meaningful or interesting about themselves, that they can just open up. I had a fellow come in last week in my clinic-- we were seeing a male breast cancer patient, and sometimes, these patients feel really awkward in our clinic. This is a clinic that's not particularly built for men. All the other patients in the waiting room are usually women. Things just sometimes don't feel culturally welcoming to them.

And he said, well-- he just told me about his encounter with the patient before I even met the patient and he said, he was kind of stiff and he wasn't saying much and his wife was doing much of the talking, but then I just switched gears and I ask him what brought him to the area, and he said, a grandchild had been born and they moved here for that, and I asked him about his granddaughter and his face lit up. He showed me pictures on his phone, and that changed the whole character of our encounter with the patient because he was able to share that. So that's one practical thing.

Also, there may just be barriers to care that will come out in the social history that are going to-- at first, I started to say derail the conversation, but not derail it. Really take it in the direction that's necessary to get anything else done with the patient's care, whether that's that they're actually having overwhelming worry about how they're going to do this care that's making them so anxious that they really can't even absorb complex medical information. I recently saw a patient who it turned out her financial worries about how she was even going to pay for the care she had already gotten and her diagnostic workup were so large that most of the options I was going to offer she didn't see options for her. And so if we had spent five minutes talking about them without my being aware that we needed to incorporate cost and financial help into the conversation we would have wasted all our time. So I think there are ways that even if using the social history up front isn't what we were taught, it may, in the end, make the visit more effective and time better spent for both the patient and the physician.

JACQUELYNE GADDY: In that same topic, what are other things that I would say mainly focused towards trainings, what can they do to become more comfortable when interacting with patients on this particular level?

REGINALD TUCKER-SEELEY: I think it's going to be important for moments of personal introspection because I think this can be very challenging given how you describe medical training is for physicians to get comfortable talking about these issues. So first, recognizing, what are some places where we're not comfortable?

So my personal research program focus is on financial hardship and cancer, and I know that one of the things that we as a country don't like to talk about are finances. And that's like-- I used to start talks with, if I asked everyone in the audience what your annual salary is, who's going to tell me what that is? No one's going to talk about it. So realizing what are the areas that you are personally not comfortable, sort of getting to the heart of how can I become more comfortable, or at least comfortable enough to be having these kinds of conversations with patients. I think also thinking about this needs to take a systems perspective, so thinking about where in the clinical workflow do I feel most comfortable having this conversation, but also, thinking about where in the clinical workflow do the patients feel most comfortable having this conversation, and trying to figure out sort of where is the happy medium for where these kinds of conversations need to happen as patients are navigating cancer care.

JACQUELYNE GADDY: What are potential challenges that one may experience when taking a detailed social history? And this is a twofold question. With that same part of the question, how can one address specifically cultural humility and implicit bias?

REGINALD TUCKER-SEELEY: So I think I've shared with both of you briefly about how I approach navigating health care as an African-American gay man. So I trained at Harvard. So I have master's and doctoral degrees there. So it's part of the sort of you're there, you're going to get multiple Harvard T-shirts, Harvard sweatshirts and everything, and sweatshirts and tee shirts for your family.

But I am conscious of when I enter a health care facility, how I'm going to be perceived. And so I will make sure I'm wearing a Harvard sweatshirt or a Harvard T-shirt, and I'll make sure that I tell the physician what I do for work. And I realize that that changes the conversation.

It changes how the physician talks to me. I think it makes the physician view me more as a partner in the interaction as opposed to several preconceived notions that she or he may have about how I'm going to approach care and how I'm going to navigate care. And so I think from the physician perspective, sort of figuring out what can you do so that those of us that have to navigate care are not trying to adorn ourselves with the symbols that will garner respect from you so that you will treat us with respect as a patient.

KATHERINE REEDER-HAYES: And I think I would just mirror that story by saying that when we walk into the room as a provider, there are a lot of things that patients are going to assume about us on our appearance, perhaps what we're wearing and how we interact, whether we stand or sit, eye contact we make, and those things are not only informed by what's happening in the present moment, but also, by this person's previous experience, positive or negative. What were there experiences with other people in white coats been? Do they see a white coat as a message that I took effort to make sure that I wasn't bringing germs from my home to them and that the things I was wearing were clean to take care of them, or do they see it as a symbol that I'm trying to make myself an authority in the conversation with them?

So it could mean either of those things, and neither of those things is necessarily completely right or wrong. But I need to be conscious of all those possibilities. And those listening skills are really important, both the listening to the verbal cues, and also to the non-verbal cues.

Is a patient looking down on the floor? Are they avoiding eye contact with me? Are there some cues here that something about our interaction in that room is making them uncomfortable or not feeling like they can share?

I think a simple rule of thumb for trainees is ask more questions-- [AUDIO OUT] more statements. If you're asking questions, assuming that you're asking them in a polite and respectful way, you're going to continue to elicit information. You don't elicit a lot more information by making declarative statements.

And it may be that your declarative statements need to wait a little bit until you've asked enough questions to really understand where the patient is coming from. Patients will usually tell you the extent to which they might feel comfortable discussing something if you ask, how deep they want to go on that, or how much information they want to receive about a certain topic, or whether they're open to help on a certain topic, whether it be smoking cessation, or help with financial barriers or transportation barriers. I think if you ask, most patients are willing to tell you, and they're also going to communicate to you how much they want to share and how much, at this time, they're still going to hold back. So we just work on our communication skills, not only the talking ones, but the listening ones.

JACQUELYNE GADDY: I think this topic is so important. I know we're getting close to time for our viewers, but one last question. I want to know, how do you think that you can correct inaccurate and/or damaging information so that other care providers can access this?

KATHERINE REEDER-HAYES: So I think that's a challenge of the electronic health record. To the extent that systems and organizations can work to make the social history structured, I think that enables us to go back and fix structured information that may then be shared into or pulled into others notes. If others have documented unstructured information in their notes that is clearly not our information to correct, that can be really problematic.

I think if it's truly an egregious error or an error that might impact significantly on the patient's care, for instance, their spouse has recently died and the person has documented that their spouse is living, something like that, they've documented that the patient is a smoker and needs to stop, and in fact, the patient is a non-smoker and they're just going to continue to be asked about that. You can contact your colleague and say, hey, usually, these notes are editable for a long time. Do you mind going back and correcting that? That's inaccurate. We may not be able to correct every small inaccuracy, but we can make our own documentation appealing enough that maybe others will borrow from our accurate information and not from the previous inaccurate information.

JACQUELYNE GADDY: As we come close to time, Dr. Reeder-Hayes and Dr. Tucker-Seeley, I want to thank both of you for spending time and educating all of those in our viewers, and I want to thank you for joining us for this episode of the ASCO Social Determinants of Health Series. To keep up with the latest episodes, please click Subscribe. Let us know what you think about the series by leaving a review or by emailing us at [email protected].

PRESENTER: Thank you for listening to this week's episode of the ASCO e-learning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive E-learning Center at elearning.asco.org.

This episode was originally released October 26, 2020

In ASCO eLearning's first Social Determinants of Health (SDOH) series episode, Dr. Ramy Sedhom, MD moderates a discussion with ASCO President, Lori Pierce, MD, FASTRO, FASCO; Abenaa Brewster, MD, MHS; and Katie Reeder-Hayes, MD, MBA, MS on why understanding SDOH's impact on patients is critical to providing equitable care. We hope you enjoy this episode.

TRANSCRIPT

ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

RAMY SEDHOM: Hello, and welcome to ASCO's newest podcast focused on the social determinants of health. My name is Ramy Sedhom, and I'm a medical oncology fellow at Johns Hopkins. Today, I am joined by ASCO president Dr. Lori Pierce, professor of radiation oncology at the University of Michigan.

We are also joined by Dr. Katherine Reeder-Hayes, associate professor of oncology and health services researcher from UNC Chapel Hill, also chair of the ASCO Health Equity Committee. And finally, we are also joined by Dr. Abenaa Brewster, chair of the ASCO Prevention Committee, medical oncologist, and professor of epidemiology at MD Anderson. All our distinguished health researchers focused on disparities work.

We are excited to launch this theme in light of the theme as highlighted by Dr. Pierce, equity, every patient, every day, everywhere. Dr. Pierce, why are the social determinants of health relevant? How do they relate to our work at ASCO and to the theme of equity?

LORI PIERCE: Thanks, Dr. Sedhom. Yes, the ASCO theme this year is based on equity, and treating patients with equitable care is at the very heart of what ASCO does. It's what ASCO stands for.

But we know there are factors, including social determinants of health, that can significantly affect the quality of health care that our patients receive, so we're hoping that this series of talks will increase awareness to many of those factors so providers can understand even better what some of the barriers are that our patients are experiencing. So we feel that understanding what they are, that's an important first step in terms of determining meaningful actions that we can take.

RAMY SEDHOM: Thank you, Dr. Pierce. Dr. Reeder-Hayes, any additional comments?

KATHERINE REEDER-HAYES: So I would just add that the reason I think oncologists inherently do care about the social determinants of health is that we care who gets cancer, and we care about the survival of that cancer. That's what we do as physicians. And as we follow cancer outcomes and cancer registries over time, what we realized is that there are a lot of biological things about cancers that determine their outcomes, but there are also many things that determine that outcome of a person's cancer that aren't biologic, and we have put those things together in a large group and use labels like the social determinants of health to understand what those non-biological factors are. But as physicians, as people who want to cure cancer, I think that it's just as important for us to have a good understanding of those non-biologic factors and how they're going to influence our patient's chance of the best outcome from their disease as it is for us to have a good grasp on the biologic determinants that are going to influence our patient's outcome.

RAMY SEDHOM: Thank you. And I think this is a really good time to emphasize that the series is at the intersection of work through the Health Equity Committee and the Prevention Committee as being put forth by ASCO, and the ASCO Education Committee as well. And Dr. Reeder-Hayes, how would you importantly define the social determinants of health?

KATHERINE REEDER-HAYES: So that's a pretty broad range of definitions, because there are a lot of people in health care who have talked about this concept of non-biologic determinants of how patients do for a long time, both in cancer care, and in other fields, like primary care, diabetes, and hypertension research. And so there are several organizations that have put forth definitions. The first one that I would point people to as the World Health Organization. So these patterns occur globally, not just in the United States. And the WHO describes the social determinants of health as the circumstances in which people are born, grow up, live, work, and age, and the systems that are put in place to deal with illness.

So there's this idea that the circumstances that people find themselves in, as well as the structure of the health care system are part of this conversation about social determinants of health. The Robert Wood Johnson Foundation has done a lot of work to help put these concepts into more understandable and everyday language. And so the definition they use is that health begins where we live, learn, work, and play. So the social determinants of health include factors that operate on a few different levels.

So there's the level of societal conditions, social conditions, economic conditions, physical conditions of where and how people live, and where and how people work, and then there are also psychosocial levels, like the patient-level psychosocial factors. And Centers for Disease Control also focus a lot of their work on social determinants at this idea of psychosocial factors at the patient level. So even though the concept is simple, it's actually also very broad. And when people talk about social determinants of health, they can be talking about things that are operating at several different levels, from the structure of the health care system, on down to the structure of the apartment complex where your patient lives. And so you have to think broadly, I think, when you're thinking about analyses for research or how to talk to your patients about social determinants of health.

But the American Cancer Society has recently also put out a paper that tried to help people put these social determinants into appropriate buckets, particularly the ones that really seem to impact cancer care. And so the three categories or domains that they've suggested are structural inequities, so things that happen in a larger society and in the structure of the health care system that impact our patients and how they access care. Secondly, institutional environments. What do the places where we treat cancer look like? What are their structures? And how does that impact our patients outcomes?

And then, finally, living environments. Where do our patients go back to when they go away from the health care setting? So those are some of the ways that we can think about the finding and talking about the social determinants of health.

RAMY SEDHOM: Thank you for sharing that. That's a lot to think about and to consider. Dr. Brewster can you comment on the impact of those social determinants of health in disparate groups beyond race and ethnicity?

ABENAA BREWSTER: So I agree that we're really used to thinking about social determinants of health as explaining some of the race-ethnic disparities that we see in cancer incidence and outcome. But we know that there are other groups that also experience differences in outcomes based on these determinants. For example, characteristics of sex, gender identity, sexual orientation, geography, immigration status, these are all characteristics that are impacted by social determinants of health.

An example that I like to give for the race-ethnic disparity is the 40% increase in mortality that African-American women experience who are diagnosed with breast cancer compared to white women, and that, for a large part, is due to socioeconomic poverty and insurance differences. And in fact, then those characteristics then explain decreased screening, later stage of diagnoses, and then leads to disparate delays and receipt of treatment. There was a really nice paper published in JCO by Jamal and others which showed that insurance alone accounted for about 37% of that 40% increase in mortality that Black women experience who are diagnosed with cancer. And so you can see the great opportunities that are there to make care more equal if you're able to improve access.

And so examples of other groups, for example, we have registry data showing that urban populations, although they have higher cancer incidence, the rural populations actually have a higher incidence of the cancers that are related to tobacco use or HPV. And we also know that rural populations also have higher mortality than urban populations when it comes to cancer, and that's largely driven by poverty, under insurance, socioeconomic status, isolation. And so that's another group that is impacted by those social determinants of health as outlined by Dr. Reeder-Hayes.

And then, lastly, the LGBT community. Although there haven't been a lot of large studies looking at the impact of cancer incidence and outcomes in that community, there have been lots of survey studies that have shown that these determinants of health tend to cluster within those communities. Once again, social isolation, negative patient-provider relationships, under insurance, poverty, and so that's another group where this becomes very meaningful.

And I think kind of what cuts across all of these groups are really characteristics that have been linked to historical discrimination. And so that's something that we see very clearly. And then, we also see it reflected in our oncology population, right? Only about 2% of oncologists are African-American. And so these social determinants of health not only impact our patients, but they impact what our workforce looks like, and then, that, in turn, leads to differences in terms of the patient-provider relationships.

RAMY SEDHOM: Absolutely. And this is a great question to direct towards you as the chair of the Prevention Committee. How do the social determinants of health-- how are they relevant for our cancer patients and our cancer survivors?

ABENAA BREWSTER: Social determinants affect the trajectory of cancer care. And so we've talked about the impact of social determinants of health on cancer mortality and cancer outcomes, receipt of treatment, timing of treatment. So those are all impacts that our oncology patients face. But I would say, in terms of the field of cancer prevention, over the past four decades, there have been significant advances in cancer prevention, vaccine, preventive therapies, high-quality screening. And unfortunately, there are populations that are being left out of those advances that we've seen in cancer prevention.

We also know that maintaining a healthy weight, having a physically active lifestyle, having a nutritious diet with fruits and vegetables also play a key role in cancer prevention. But those are impacted by where our patients live. And so patients who live in disadvantaged neighborhoods may have less availability for these nutritious food choices, and they may have less safe spaces to engage in physical activity. And so while we advance our prevention knowledge and our prevention strategies, we are leaving behind groups of individuals who, based on where they live, and where they work, and how they're educated, are not being able to access those types of advances in cancer prevention, and as a result, we see increasing cancer incidence.

RAMY SEDHOM: And Dr. Pierce, how does having this context or understanding make us better researchers, clinicians, and administrators? And also, how does it benefit our interactions with our patients and our colleagues?

LORI PIERCE: So understanding the social determinants of health, it will make us better researchers, then clinicians, and just better doctors, because it allow us to see how the cancer world looks to our patients, kind of look at the cancer world through their lens. And an example, we have all these groundbreaking therapies, but if the patients don't have transportation and they can't come in, then those therapies are for naught. And I'm going to echo what Dr. Brewster said a few minutes ago. Another example is if we're advocating for patients to maintain a healthy weight, and a part of that is to do exercise, but they can't go out in their communities because they're not in a safe community, then we need to come up with other strategies. So I think it's very important that we understand these issues so we can advise, we can advocate, and we can act once we truly understand the barriers that our patients are facing everyday.

RAMY SEDHOM: And Dr. Reeder-Hayes, can you comment on how the Health Equity Committee is seeking to understand the social determinants of health, their effects on populations, and the actions that can be taken to improve cancer care?

KATHERINE REEDER-HAYES: Sure, so one of the things that the Health Equity Committee has been really excited about and working with Dr. Pierce on, her presidential theme, and also, in entering this conversation about the social determinants of health, is getting more of our members engaged with the idea of knowing our patients and their non-biologic characteristics as a way of being better doctors, as Dr. Pierce said. So the most simple way I can explain the concept is that every patient has a backstory. We know this as doctors. Every patient brings this unique story into their cancer care experience.

And we know intuitively that that story that they bring with them into cancer care is going to impact what their cancer journey looks like. But we also need to acknowledge that it's going to impact their cancer outcome. We already know that it's going to impact how we interact together as a team, patient and provider, but we need to raise awareness that it's also going to impact how the cancer turns out. Because I think that's something our members naturally care about, and I think our members want to understand their patients' cancer care stories,

So as researchers, and as folks on the Health Equity Committee, we would like to help people understand how to obtain the most relevant information about their patient's backstory in the most respectful and efficient and effective way, and then to integrate that well into how they care for their patients, as well as how they shape their research and their administrative roles. So we're excited to be doing that. Now, some of these circumstances are not immediately changeable, and they certainly aren't within the patient's individual power to change, but some of them, at least in terms of how they impact our patient's access to care, are modifiable, either by us as their physician, or by someone else in the health care system, or by someone in an organization that comes alongside the health care system to help, like a private foundation or a philanthropic organization.

If our patient has a barrier to care because of transportation, like the example that Dr. Pierce gave, and they can't get a ride to cancer care, there are actually some ways that we can intervene on that. And there are even people in our health care system who are expert on how to intervene on that, as well as organizations that have volunteers that can help intervene on that. But if we don't obtain the information, we're not going to know, and then we can't bring the strategy to bear to get our patient to that groundbreaking therapy that they get. If they could make it to us, or if we could make it out to them, thinking about innovative ways to deliver care. So those are some of the things that we're excited about in the Health Equity Committee.

RAMY SEDHOM: Thank you for sharing with us a lot of the great work that you're doing, and the ASCO team. On a similar note, Dr. Brewster, can you review with us some of the key contributions related to the social determinants of health from the Prevention Committee?

ABENAA BREWSTER: Sure. Well, first of all, I'm so proud of the ASCO Cancer Prevention Committee for the work that they've done over the years to raise awareness, not only about cancer prevention to the public, but also within the oncology community. And ASCO's Cancer Prevention Committee has really spearheaded ASCO's work in tobacco control and cessation over the past 20 years, including supportive position statements on tobacco cessation and control, and also, for the electronic nicotine delivery device systems. And the committee continues to educate providers on the importance of addressing smoking cessation among their patients before and after a diagnosis of cancer.

Also, within the area of obesity and energy balance, the committee has issued a position statement, because, actually, the majority of Americans are not aware of the impact that obesity has on cancer risk and cancer prognosis, and just raising the awareness of that issue, particularly around underserved populations, is important, because those are the populations that actually have some of the higher rates, but also lack that knowledge. And so the committee has conducted surveys of not just oncologists, but also patients, to try to really understand how that information is being disseminated, and then what are the barriers to be able to address the issue of obesity? And so that's important work that's going on.

And a few years ago, the Prevention Committee also issued a statement on the association between alcohol and cancer risk and outcomes, and that's kind of all still a risk factor that has very little public awareness of its importance, and that's really driven a lot of the media and other publications that have come out really showing that association. And so raising that awareness is important. And the good news is that there are strategies and interventions and policy changes that can be brought to bear to impact some of these modifiable risk factors. And so that's a very exciting avenue for research and practical applications.

RAMY SEDHOM: Thank you, Dr. Brewster. That's actually a wonderful shift toward policy and advocacy. And I, myself, participated on the Hill with ASCO. And Dr. Pierce, can you share with us or discuss some of the advocacy efforts from ASCO for our patients and lawmakers who can help in critical ways as it relates to the social determinants of health?

LORI PIERCE: Thanks for the question. It's a great question. Advocacy is so important. So important that we advocate for our patients, because they often can't advocate for themselves.

And we advocate to lawmakers, that's on a local level, on state level, and a national level, because it really can highlight to our lawmakers some of the barriers that our patients face and things that they can do to remove those barriers. And I'll give you a great example, HR 913, the Clinical Treatment Act. For those of you who don't know what that is, it's the following.

Medicaid is the only insurer that does not cover routine care costs for patients, Medicaid patients who go on clinical trials. They're the only insurer that doesn't do that. And you talk about routine costs, we're talking about doctor visits, we're talking about x-ray tests, routine blood tests. The irony is Medicaid will cover these same costs if patients were not on a clinical trial, but they won't cover it on a clinical trial.

And of course, we know there are a lot of minority patients that are on Medicaid. And so this is the disincentive for minority patients to go on clinical trials, which is exactly what we do not want to see. And so ASCO has been spending quite a bit of time advocating to the legislation about how important it is to cover these costs in clinical trials.

And so the House has legislation, and just last week, the Senate now has parallel legislation. So we are moving the needle. We are going in the right direction. And it's a very important example of just what advocacy can do in terms of improving care for our patients.

RAMY SEDHOM: That's great to hear, and we hope things continue to move forward. Dr. Pierce, also would like to direct this question to you. What is your vision for the future of this podcast series? And what do we really want our listeners to take home from this?

LORI PIERCE: So I'm so excited about this series, and I am so appreciative to everyone, those who are on the series, and everyone in the background for getting this going. It's my hope that the series of broadcasts will be an important educational tool to really understanding the social determinants of health and how they impact our patients and society at large. And so this series will contain a lot of aspects, a lot of podcasts and videos on social determinants of health that our task force, which you are a key member of, is helping us to design. So our task force is made up of fellows and junior faculty, the future leaders of ASCO, and the future leaders of oncology in general. So thanks to your enthusiasm, thanks to your feedback, we are launching this, and I am super, super excited.

RAMY SEDHOM: Thank you, again, everybody. The conversations today are really a reminder of all of our shared experiences. I remember as an oncology fellow, oftentimes, the hardest part of care in the clinic was not the science or the biology of cancer, but actually, all of the things discussed today, especially the social determinants and how they impact our patients.

Again, we want to thank all of our wonderful faculty for serving as change agents. The planning of this podcast series is a joint effort through all of the wonderful ASCO volunteers who are fellows, junior faculty, ASCO leadership, and importantly, cancer survivors and ASCO staff. We do want everyone to look forward to next month's episode, where we will discuss and look at what ASCO can do as a professional society to address equity as a part of its mission.

Again, thank you to all of our listeners, both locally and abroad, for joining us for this episode of the ASCO podcast series on the social determinants of health. To keep up with the latest episodes, please be sure to subscribe. Let us know what you think about this series by leaving a review or by emailing us at [email protected]. Again, thank you, and we look forward to seeing you in the next episode. ANNOUNCER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive eLearning Center at elearning.asco.org.

This episode was originally released December 9, 2020

In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Narjust Duma, MD, moderates a discussion with ASCO CEO, Clifford A. Hudis, MD, FACP, FASCO and Sybil R. Green, JD, RPh, MHA, Director of Strategic Initiatives in ASCO's Policy and Advocacy Department, on what ASCO is doing as a professional society to address equity as part of its mission.

TRANSCRIPT

PRESENTER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

NARJUST DUMA: Welcome, everybody, to the second episode of ASCO's Social Determinants of Health series. My name is Dr. Narjust Duma. I am an assistant professor at the University of Wisconsin and also a thoracic oncologist. Today I'm joined by ASCO's CEO, Dr. Cliff Hudis, and Sybil Green, Director of Strategic Initiatives in the policy and advocacy department for ASCO. This series is a new initiative proposed by ASCO president, Dr. Lori Pierce. It focuses on increasing oncologists' awareness about the social determinants of health through the cancer care and how impacts our patients' outcome, including modifiable risk factors. This series is inspired by Dr. Pierce's presidential team of equity, every day, every patient, everywhere. In this episode, we look at what ASCO is doing as a professional society to improve health equity and cancer care.

Welcome, Dr. Hudis. Welcome, Mrs. Green. First I would like to us what is ASCO doing as an organization in the matter of health equity and cancer care?

CLIFF HUDIS: So I guess I'll start here. Thank you very much for spending some time with us on this. If you look at ASCO's mission, it is conquering cancer through research, education, and the promotion of the highest quality and equitable cancer care. So the idea of equity and our responsibility to address disparities is really in our organizational DNA.

I have to point out something that many people may not realize. But when ASCO was founded in 1964, one of the seven founders was a black woman, Jane C. Wright. Dr. Wright died in February of 2013. But her father was among the first African-American graduates of the Harvard Medical School. His father was also a physician. And he was educated at what became Meharry. So I remind everybody of this as often as I can, to make the point that not only do we have an opportunity to advance equity and to deal with disparities in health care, but it's my perspective as a leader of ASCO that we have a special obligation and responsibility to do all of that.

So we can talk more about it. But I'll just introduce maybe the answer by saying there are really two broad themes at work for us at ASCO. One is externally facing. And one is internally facing. The externally-facing work includes a range of projects and output that we can talk about a little more, but for example our position papers describing disparities and then identifying potential steps to take to address and solve them. But it also includes support for targeted research that is meant to narrow those gaps. It includes our educational efforts, both for our members and for legislators, advocacy for policy, and so on.

And then on the internal side-- and here I'll ask Sybil to talk a little bit-- I think we've recently recognized our opportunity, and again responsibility, to think about the workplace itself and to think about our staff and to think about the activities and actions we can take and the roles we can model to create a better world. So I know I've been high level in my initial answer here. But the two domains again are external and internal. And then we can talk about some of the specific projects as we go on.

NARJUST DUMA: Mrs. Green, I think it's very important to share about these internal aspects of ASCO because many of us are now aware as members, we see the surface. But ASCO is a large organization with many staff and members. So it would be great that you can share that with us.

SYBIL GREEN: Absolutely. And thank you for allowing us to share that. I think Dr. Hudis pointed out some of what we've done since ASCO's establishments and really charging everyone on staff to really live out that obligation of equity, diversity, and inclusion. And so through our programs, our staff have to do their work, make sure that we are creating equitable opportunities for patients and physicians, but it starts at home.

And so we have to make sure that internally, we are offering those same opportunities for our staff to engage because what we know is that when staff are engaged, and they have the opportunity to bring their true selves to work every day, they bring their personalities. They bring their lived experiences. And that all plays out in the work that we're doing on behalf of members, in their patients, but also for staff.

I think if I were sum up where our program is going, similar to what Dr. Hudis has done, the three components are really enabling staff success. We ought to be able to do that for our staff internally. Every day we ought to provide opportunities for them to succeed. And then making sure that our partnerships-- those that we work with, whether it's in our publications, our meetings-- making sure that our partners goals and ideals align with ASCO's values and ideals. And all of this, of course, is in support of the greater ASCO enterprise, which is our members and the patients and of course, ASCO staff.

NARJUST DUMA: And I think that it's really important-- I had the pleasure of interacting with several staff members with diverse backgrounds. And I think as we develop the mentorship program and other things, their input is diverse. It means we also are able to cover the trainees needs because every trainee's needs are different. And because I cannot give a talk or do a podcast without mentioning my grandma, [INAUDIBLE], I have to say that it's important to clean your house first before you go and try to clean other people's houses. I do promise it's beautiful in a Spanish. But I think it's important that everybody knows that internally ASCO is doing a lot of work.

And I think it's important to talk about the grants in health equity. And I'm mentioning this because I haven't been doing health equity since I was a med student. And sometimes you find yourself not having enough grant opportunities. Now there is an increase. But when you compare it to other areas of oncology, you may be more competitive because there are less grants. And I think it would be great to hear from the both of you about the new health equity grants, the breast cancer disparity grant, and beyond.

CLIFF HUDIS: Well I would just point out something to build on your comment, first of all. Since we were founded in 1964 til now-- so just over 55 years-- we've made unbelievable advances, I think, in oncology in general. Indeed the reason I as an old man chose to go into an oncology in the 1970s was that the vision ahead was that this was going to be an exciting field. And it has not disappointed.

However there's a dark that I think we should acknowledge. The advances have not been fairly or evenly distributed. And indeed in some cases when we make massive improvements in outcomes in terms of what's possible with state-of-the-art care, we increase disparities because not every group catches up. And I say all that because it's important to understand that this is not about abstraction. These grants that address that gap are as or more important than the basic science grants that actually advance the biology and understanding in the first place. One without the other is incomplete.

So I can't agree more that this is important. And actually from an investment or return on investment point of view, in some ways, these grants are an even better deal because we can rest many of these gaps in care delivery and in knowledge pretty quickly and narrow the gap. And we've seen it. I'm going to give you some examples in a moment. Whereas funding basic science, honestly, is a much higher risk proposition, if you think about it. So I don't mean to set up a false competition here. But I want to point out that there's a big reward.

So here's an example. The plenary session abstract at ASCO two years ago now-- abstract number one, if you recall, was no moral less than an analysis of the impact of Medicaid expansion. And what did it show? It showed that with Medicaid expansion, those states that implemented it quickly narrowed the gap in time to initiation of therapy for curable colon cancer. It's a simple take-home point. I care passionately about this personally because these are differences in outcome that have been labeled as associated with race for many years or other specific ethnic facts. But really what they're about is nothing except unfair, uneven access to care in the first place on the basis of race. And it's something that we can address.

So we are building out programs to address this through a number of granting mechanisms. For 2020 alone, there are going to be two Young investigator awards that are earmarked for underrepresented populations. And there's a career development award and another YIA, Young Investigator Award, in health disparities specifically. But this is just, I think, part of the issue.

The other issue for us-- and actually a commitment going back for years-- is to do something about the workforce itself. And I don't have to tell you, but of course, there is a huge disparity playing out when we look at makeup of medical students in America. And it gets accentuated to the extreme when we look at black men. They are the most disproportionately underrepresented group right now.

So how are we going to address that? And we're really proud this year to be launching a program that is aimed at newly-matriculating medical students building on a successful program in Boston that's been running for a couple of years already with Bob Mayer is the founder. And our goal is to the interest of specifically targeted populations, not just in medicine but specifically in oncology.

NARJUST DUMA: Mrs. Green, you would like to add something about the grant and what is happening to support health disparities various research at ASCO?

SYBIL GREEN: I'll just add the importance of any grant opportunity in any program being one to two. So it's one thing to be able to address bringing in the right medical students to be able to mirror the populations that they serve. It's something else to continue to support them along the way, and so not just stopping at the students, not just stopping at the research, but also making sure that was they're in practice they're supported.

And a couple of grants that we've had for some time focus on quality, not just in ensuring that quality services are delivered, but actually helping practices to determine how to identify gaps in [INAUDIBLE] populations that are underserved because we may not be able to identify those same gaps that we would identify in majority populations. And so by giving them the tools to some of the other programs that ASCO has to be able to identify those gaps and then to support them along the way is really important.

NARJUST DUMA: And I want to add to what Dr. Hudis mentioned about workforce diversity because this is one of my areas of research and passion. And it's extremely important to have a diverse workforce to represent the patients we're caring for. It's not only having a diverse workforce, but having a workforce that practices cultural humility. We cannot assume that we are proficient or we are competent in somebody's culture.

I'm a Latina. And there are so many Latinos in so many different backgrounds that I cannot learn them all. And I think it's important that early interventions are-- because when you get exposed to a specialty early on during the training, that would change your pathway. I'm the daughter of two surgeons. I'm supposed to be a plastic surgeon. But a patient with cancer changed my life and my pathway. So we're able to support those students that have less resources and less access-- and that also includes rural students-- they may don't be black or Latino, they may be white, but they come from rural areas with limited resources-- we are sure that we meet the patient needs because there are aspects I don't understand.

Like I'm in Wisconsin, and there are some aspects to farming I didn't know. Now I know when harvest is. And all of that allows us to plan appropriately. So I can see how important it is. And there's a task force that is run by Dr. Winfield, which I'm lucky to be part, that focuses on the workforce diversity.

Along those lines, as a minority in medicine, I have seen up and downs of the interest in workforce diversity and health equity. I think many events in 2020 helped a lot of people open their eyes or be more conscious like, oh, that's not isolated. That happens in my back yard. It happened in Kenosha, Wisconsin. But we want to hear how is ASCO making these things long term, how the internal and external changes are going to be long term? And I will start with Mrs. Green and then go to Dr. Hudis.

SYBIL GREEN: So in terms of making it long term, it can't be one and done. I think quite often when we focus on equity and diversity issues, we always look at diversity first. And so whether it's workforce or whether it's increasing opportunities for access, you can't just look at the numbers. You have to also think a little bit deeper. You have to think about culture. And so culture with humility, like you mentioned, Dr. Duma, is important, but making sure that attitudes are changing along the way.

And that happens through self-awareness. That happens through understanding. And I think that ASCO plays a real role in making sure that our members understand what the issues are and how to dig past those things and provide them with the tools to be able to [INAUDIBLE]. ASCO I think, is not unique. And the idea that this is all new to us has gotten a lot of attention because of some of the social and racial injustice. But what that means is that our members now are probably more interested in ensuring equity than ever before.

But we have to teach them how to do it. We have to teach them how to speak the language. We have to teach them how to be more aware, both in their own organizations, at ASCO internally, and for their patients. And so it's a cultural change. It's not going to happen overnight. It's gradual understanding of the dynamics, gradual understanding of different peoples goals, and meeting them where they are, so that we can help them to move along, so that we can come to a more equitable and just [INAUDIBLE].

CLIFF HUDIS: I think one of the things Sybil and I spoke about this summer is we launched our internal EDI effort-- relates to this. And that is this is not about identifying a leaky pipe and patching it and saying, well, we're done now. This is actually, in my view, a permanent change in the way we see work and the way we see our growth. So the goal is to reach a specific landmark. The goal is to change how we think about our work and how we think about our role in the world, so that we're constantly improving.

And it's a journey, not a destination, I think, which sounds trite. But that's the spirit of it. And it gets to your question about how we make sure that the commitment is continuous and not just while it's [INAUDIBLE] and exciting. And I think we are committed and dedicated to that.

I do want to present a related challenge because it's something you said really sparked this thought for me. As a physician, when did you know that you wanted to be a physician? How old were you?

NARJUST DUMA: I was 5.

CLIFF HUDIS: And, Sybil, when did you know what your career path was going to be?

SYBIL GREEN: I was 9.

CLIFF HUDIS: That doesn't support my thesis [LAUGHS] [INAUDIBLE]. So here's the issue. The issue of burnout in medicine right now is getting a lot of attention. And one of the reasons for it, frequently given, is that doctors on average decide to commit to their careers a decade younger than most people on average commit to other careers. You're an exception, Sybil, so I should have pretested the question.

But the issue is we're not here to talk about burnout today, even though that's really important. The issue is this. In order to ultimately address the makeup of the population of physicians, we need to reach deeper and further into precollege communities. And we need to show people that they could have lives in science and health care and in medicine and maybe specifically oncology.

And I'm just pointing out to you that that's a daunting challenge for a professional society like ASCO. That's not our audience. We don't have a natural connection there. And one of the things that we're working on right now is identifying programs that have worked, that exposed high school students from previously excluded populations or communities to medicine, so that we can spark that passion before college, not during college, and therefore have the commitment that it takes to go far into medicine.

And I'll just close by saying something that you hinted at but needs to be said. The reason to have diversity in our workforce is not that an Asian patient needs an Asian doctor. It's that an Asian patient needs a practice that has Asian doctors in it, so that the practice as a whole is able to be culturally sensitive and able to relate and communicate and support them because I think sometimes this issue gets oversimplified as well.

SYBIL GREEN: So Dr. Hudis, your theory is not completely [INAUDIBLE] I think it's relevant to this conversation because while I knew what I wanted to do at 9, what I didn't have was the representatives in the community. I didn't have the mentor. Interestingly enough, I had more mentors in pharmacy than I had in law because I saw pharmacists who looked like me. I happened to live in a town where there was a historically black college with [INAUDIBLE]. And so I saw people look like me. And it made it a lot easier for me to reach out to them, for them to mentor me, for them to start talking to me about what equity in health care looked like. That really wasn't until I was in college.

But the truth of the matter is for most diverse students, most minority students, that doesn't exist. And I think that that's where ASCO's mentoring programs are really rich. You have the opportunity to do that.

NARJUST DUMA: And I think this is important because you can do what you can see. And that has been proven over and over again. We unfortunately are running out of time. But I want to ask the final question. Like a manuscript, like a study, everything has limitations. And I think it's important that we talk about the limitations of ASCO doing this work because realistic expectations are helpful so we don't get disappointed when we have big expectations that may not be met. So Dr. Hudis, what are some of the limitations of ASCO to help equity work now?

CLIFF HUDIS: You're right, it's a huge issue. If you think about where our scientific focus is, we can measure the disparities or the difference in outcomes. And we can write a paper about that but when you really get to addressing the reasons for it, it extends far beyond what we can do. So I guess our limit is we can call attention and rally colleagues and collaborate across the House of Medicine and broadly into Congress, where we can make a difference-- or to the United Nations and World Health Organization. But we can't do this heavy lift alone. We need other colleagues who agree who are willing to invest time and money to make the change.

SYBIL GREEN: And I would add partnerships because as much as we're talking about social determinants of health, we recognize that all social determinants of health are not health related. They're not [INAUDIBLE]. And many of them live and operate outside of the realm of health care. But what we can do is bring our expertise to the table about the impact of those things, so that our partners stand in their own world, in education, in criminal justice, in financial assistance, how that can help really change the outcomes for patients. I think at ASCO, we've got that expertise. And we can do that.

NARJUST DUMA: Thank both of you for your time. Thank you, everybody, for joining us for the second episode of ASCO Social Determinants of Health series. Please keep up with us. You can subscribe. You can see this on Facebook, YouTube-- when it becomes available. We'll continue to explore the social determinants of health and cancer care. You can leave feedback or emails, any questions to the professional development, at asco.org. And I thank you for your time. And have a wonderful week.

PRESENTER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the comprehensive eLearning center at elearning.asco.org.