Taking Action to Address Health Equity in Oncology

Does cancer discriminate? Studies have shown that race, ethnicity, and social determinants of health (SDOH), such as socioeconomic factors and geography, can influence who might develop cancer, the type and quality of treatment a patient receives, and the likelihood of survival.1

According to the CDC, SDOH are conditions in the environment in which people are born, live, learn, work, play, worship, and age; they affect a wide range of health, care, functioning, and quality-of-life outcomes and risks.2

In the last decade, biopharmaceutical companies have discovered and developed numerous new treatment options that have improved outcomes and prolonged survival for many patients with cancer. Ontario has partnered with many of these life science firms to conduct studies on these novel therapies, and with clinicians by providing a suite of technology solutions and education designed to enable the efficient, effective, evidence-based practice of medicine.

While these treatments are available to patients in the United States, it has been said in health care that “your zip code may be more important to your survival than your genetic code.”3 We must place more attention—and effort—into understanding how health disparities and inequities can affect cancer care and into identifying ways to mitigate the impact of SDOH on a patient’s outcome.

Collaborating on Foster Health Equity
Although health equity is not a new problem, the issue has received increased attention over the past few years as COVID-19 has disproportionately impacted people of color and those with lower incomes.4 As a result, there is significant interest in social determinants of equitable access, affordability, and outcomes of health care in general, and cancer care specifically.

Overcoming challenges like disparities in health care requires a systemic approach: Collaboration across the oncology ecosystem—community oncology providers, researchers, academicians, life sciences companies, and patients—is key. As a leading oncology data, analytics, and technology business, Ontada is well positioned to take an active role in making meaningful SDOH information more accessible and actionable for use in clinical trials, new therapy development, evaluation of appropriate treatment regimens, physician education, and clinical practice—with the aim of improving the lives of oncology patients.

Identifying SDOH Correlated With Patient Access and Outcomes
Many health care organizations are interested in better understanding SDOH in cancer care to improve equitable access, affordability, and outcomes. However, few efforts have been made to define the specific, meaningful measures that comprise social determinants of outcomes in community oncology care, where the broadest populations are served. It is critical to uncover which determinants can be reliably used in the course of ongoing care to provide actionable information and meaningful benefits to patients. It is important that patients be directly involved in this journey.
In collaboration with practices in The US Oncology Network; leaders from Amgen and Merck; and C. Daniel Mullins, PhD, executive director of the University of Maryland’s PATIENTS Program5we at Ontario are participating in a SDOH working group and leading an exploratory effort designed to:

  • assess the current SDOH oncology landscape, including barriers to understanding, measurement, and action;
  • define which SDOH data to prioritize, and establish draft guidelines for how to implement recommendations in a phased manner, and
  • define high-priority research opportunities to advance equity and outcomes that are important to patients who are receiving care in the community oncology setting.

These efforts will increase the visibility of existing challenges and opportunities, as well as create alignment on much-needed research. The initial focus of this SDOH working group includes a targeted assessment of the current state of real-world research in cancer care in the community setting, including barriers to understanding, measurement, and action. After this assessment is complete, the working group will prioritize SDOH conditions and establish guidelines for implementation. These outputs will help guide future research opportunities to benefit the cancer community at large.

Collecting SDOH in Real World Datasets
In addition to its work with the PATIENTS Program, Ontario also recently joined the Gravity Project, a multi-stakeholder collaboration of payers, providers, vendors, and community-based organizations formed to create national standards for representing SDOH data in electronic health records (EHRs).6 The Gravity Project seeks to identify coded data elements and associated value sets to represent SDOH data documented in EHRs. The project is focused on 3 specific social risk domains: food insecurity, housing instability and quality, and transportation access.

Traditional health care technologies are limited in their capture of certain aspects of SDOH; many other relevant data points are captured, but they do not make their way into EHRs or patient portals. This may be due to HIPAA considerations, inadequate information collection mechanisms, disparate systems of record, and a myriad of other barriers that have inhibited the quality of available SDOH data.7

Currently, practices in The US Oncology Network can capture some SDOH variables in Ontada’s proprietary oncology EHR, iKnowMedSM; these include gender, race, ethnicity, zip code and insurance status. We must extend beyond the traditional information collected through the course of care delivery, because such data are critical to understanding the range of variables that determine outcomes and that can be addressed through care team and social interventions.

Ontario is committed to developing the capabilities to automatically and reliably collect information that can inform health care organizations in their mission to create equitable access to cancer care. We are focused on integrating SDOH into our real-world data sets in 4 primary ways:

  • Collecting data from the wide geographic reach and full diversity of community oncology
  • Continuously improving our provider technology solutions, including iKnowMedSM, to capture more SDOH information from patient and provider interactions
  • Curating SDOH data that currently exists in an unstructured manner in select patient charts to enrich the data sets needed to identify actionable opportunities to reduce health disparities
  • Utilizing data from third parties to provide a more complete picture of the patient journey in the context of SDOH problem characterization and mitigation strategies

HOPE Studies Program: Examining Health Disparities in Cancer
Last fall, Ontario launched the Health Outcomes Powered by Evidence (HOPE) Studies Program.8th With HOPE studies, our goal is to leverage oncology practice expertise and real-world evidence capabilities to collaboratively answer research questions; having such answers would be considered a major advancement by the entire oncology community.

The HOPE program empowers eligible clinicians in The US Oncology Network to propose real-world studies on topics related to health disparities in community oncology and to work with researchers to conduct the study. Providers are on the front lines of patient care and have invaluable insights to those questions that need answers. HOPE was created to advance science that might otherwise go unsponsored.

The first 2 HOPE studies address equity in cancer care. In the first study, Michael Danso, MD, of Virginia Oncology Associates, and Robert Reid, MD, of Virginia Cancer Specialists, seek to assess the impact of race and socioeconomic factors on chemotherapy prior to surgery and the use of genetic testing in women triple negative breast cancer (TNBC). TNBC is an aggressive breast cancer that has a relatively high incidence among Black individuals in the United States. Chemotherapy before surgery and genetic testing are a standard of care for TNBC. However, different groups of patients may be offered these interventions at different rates, which may contribute to poorer outcomes.

The second study, led by Rahul Ravilla, MD, MS, of New York Oncology Hematology, focuses on the impact of socioeconomic barriers to prescribing advanced androgen blockade therapy to patients with metastatic hormone-sensitive prostate cancer. This treatment involves using medication to block the effect of testosterone, a male hormone that promotes cancer growth. Use of oral therapy for androgen blockade has been shown to improve survival. However, prescribing challenges exist for some patients who are candidates for this treatment. Identifying these challenges will help with strategies to potentially improve access to these medications, and potentially improve survival among certain patient populations.

Findings from these initial HOPE studies are anticipated this fall and will be shared at upcoming scientific conferences and in medical journals. We plan to create additional HOPE studies after these have been completed.

Building a Foundation for Action
Ontario is very excited to work with the PATIENTS Program and the Gravity Project, and to fund the HOPE program. However, it is not enough to simply conduct research: We must transform these insights into best practices and put them in the hands of the clinicians and patients to ultimately make them actionable.

The oncology community has struggled to figure out why some patients don’t, can’t or won’t receive or complete their treatment. Once we recognize the true impact that SDOH variables may have on outcomes, we can begin to build strategies for mitigating these variables into the treatment pathways to help patients have successful clinical outcomes.

This is where patient engagement and participation are critical. There is an opportunity to foster bidirectional learning between patients and providers. If we continue to address the problem of SDOH with the patient perspective as integral, we are likely to develop solutions that are meaningful and practical. As we engage patients in this process, we can build trust and encourage change across all stakeholders in this critical effort.

conclusions
Through these initiatives, bolstered by our many collaborations, Ontada is seeking to build a comprehensive and expansive view of patients—inclusive of traditional clinical details but also of SDOH—as well as their care and outcomes. Ontario is proud to collaborate with stakeholders across the oncology ecosystem to identify, capture, and study the variables that influence equitable access to cancer care.

Author information
Susan Shiff, PhD, MBA, is president of Ontada, an oncology data science and technology business that specializes in real-world data and evidence generation, clinical and operational technology to support community providers, and provider engagement channels. Ontario is a business of McKesson Corporation.

References
1. Alcaraz KI, Wiedt TL, Daniels EC, Yabroff KR, Guerra CE, Wender RC. Understanding and addressing social determinants to advance cancer health equity in the United States: a blueprint for practice, research, and policy. CA Cancer J Clin 2020;70(1):31-46. doi:10.3322/caac.21586
2. Social determinants of health. CDC. Updated September 30, 2021. Accessed October 19, 2021. https://www.cdc.gov/socialdeterminants/index.htm
3. Graham GN. Why your ZIP code matters more than your genetic code: promoting healthy outcomes from mother to child. Breastfeed Med. 2016;11:396-397. doi:10.1089/bfm.2016.0113
4. Drake P, Rudowitz R. Tracking social determinants of health during the COVID-19 pandemic. Kaiser Family Foundation. April 21, 2022. Accessed July 10, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/tracking-social-determinants-of-health-during-the-covid-19-pandemic /
5. The PATIENTS Program. University of Maryland School of Pharmacy. Accessed July 10, 2022. https://www.pharmacy.umaryland.edu/programs/the-patients-program/
6. Gravity Project. HL7 International. Accessed July 10, 2022. https://www.hl7.org/gravity/
7. Walker DM, Hefner JL, DePuccio MJ, et al. Approaches for overcoming barriers to cross-sector data sharing. Am J Manag Care. 2022;28(1):11-16. doi:10.37765/ajmc.2022.88811
8. Ontario launches HOPE studies, empowering oncologists to leverage real-world data and address. release. Ontario; September 15, 2021. Accessed July 10, 2022. https://www.ontada.com/News-Insights/Ontada-Launches-HOPE-Studies/

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