Addressing Disparities in Breast Cancer – Where Do We Start?
Dr. Beverly Moy, from Mass General Cancer Center, presents during the 2022 Evolution Conference in Boston, MA.
At the recent ‘Evolution’ educational meeting held in Boston, Massachusetts, Dr Beverly Moy from Mass General Cancer Center discussed the evidence for racial disparities in breast cancer care, and outlined strategies to address these inequities. She noted that, while survival in breast cancer has been steadily increasing, there has not been a uniform improvement across all racial groups. Most notably, the incidence of breast-cancer related deaths remain approximately 40% higher among non-Hispanic black (NHB) individuals as compared to non-Hispanic whites (NHW), and the gaps in survival are most evident among patients who have more advanced (Stage III and Stage IV) disease. There is also an increased prevalence for more difficult to treat breast cancers in minority populations, specifically triple-negative breast cancers, which are twice as common among Black populations as compared to all other racial groups. Dr Moy further noted an increasing prevalence of breast cancers among Asian American women, and for immigrants, it is known that the prevalence will approach that of the overall US population within 1 to 2 generations.
Differences in breast cancer mortality can be quantitated using the Black to White breast cancer mortality ratio, which has been found to differ markedly by state in the US. In Louisiana, for example, the ratio is 1.66, whereas in Massachusetts, the ratio is quite low, only 1.08, indicating a very small difference in mortality. While the stage at diagnosis is a large contributor to the differences in mortality, it does not explain all of the difference. Access to quality care, on the other hand, appears to be a very important contributing factor. Massachusetts, for example, has achieved near-universal healthcare and Dr Moy noted this may have helped to eliminate some of the racial disparities in breast cancer mortality.
Dr Moy emphasized there are many studies showing racial disparities across the spectrum of cancer care, including such factors as delays in treatment, a lack of adjuvant treatment, lack of hormonal therapy, lack of surgery and/or radiation treatment when appropriate, and less adherence to survivorship care. She also noted that the poor of all races have similar patterns of disparate care. As such, Dr Moy emphasized that initiatives such as Medicaid expansion can go a long way to reducing racial disparities in cancer care and improving outcomes. As of 2022, Dr Moy noted there are a majority of states in the US which have adopted and implemented Medicaid expansion, whereas 12 states remain that have not adopted this policy.
In this regard, Dr Moy highlighted a 2020 study showing significantly lower incidence of breast, colorectal, and lung cancer mortality when comparing Medicaid expansion versus non-expansion states. Results showed, with an absolute difference of 0.4%, a total of 250 additional patients would need to gain Medicaid coverage to prevent 1 death. In addition, with a 2% decrease in the hazard ratio for death, a total of 1,384 lives could be saved yearly if Medicaid expansion was implemented. In another study examining the impact of Medicaid expansion on breast cancer stage in Louisiana, the percentage of overall patients with lower stage (Stage 0-II) cancers increased by 2.1%, while the percentage of patients with Stage III-IV cancer decreased by 2.1% with implementation of Medicaid expansion. Interestingly, these differences were more pronounced in Black patients (with 3.0% increase and 3.0% decrease, respectively). The results suggest that implementation of policies such as Medicaid expansion can help to reduce inequities in cancer care, and improve outcomes in our underserved populations.
In light of findings such as these, Dr Moy identified several key areas where advocacy can play an important role in promoting Medicaid reform. These include extending the clinical trial protections from the Affordable Care Act (ACA) to Medicaid patients. Also important is to ensure parity for Medicaid patients with oral cancer medications, requiring coverage for genetic testing without deductibles or co-pays, and reducing variability between Medicare and Medicaid physician reimbursement.
In order to drive advances in cancer care, clinical trial participation is imperative, and Dr Moy noted the importance of having trials that increase enrollment of our underserved populations, particularly in the modern era of more targeted and/or molecular-driven cancer therapies. For example, in one analysis of 85 industry, and 273 Southwest Oncology Group (SWOG) clinical trials conducted between 2003 and 2018 across 15 cancer types, the percentage of Black enrollment was only 3% and 9%, respectively. In this setting, if cancer drugs are approved, for example, based on only 1% African American enrollment, clearly the results are not generalizable to the overall population, so increased clinical trial participation for minority populations is another area for advocacy.
Yet another area where advocacy can make a difference is to prioritize funding for research on interventions that are designed to specifically address racial, and/or socioeconomic disparities, not simply to identify or report that the disparities exist. Dr Moy emphasizes that the disparities in cancer care are now well known, and that is imperative to prioritize and fund research that aims to correct the imbalances. In this regard, she notes that there are comparatively very few studies at present which outline promising interventions that work. Dr Moy cited examples of her own work in the Boston area with the TRIP (Translating Research Into Practice) collaborative, which aims to improve breast cancer care particularly among vulnerable populations using tools such as a shared registry, screening and referral for social determinants of health, and patient navigation. The goal is to help eliminate disparities in cancer care delivery and serve as a model for other centers to do the same.
In summary, Dr Moy listed her top 5 priorities to address disparities in breast cancer care, which included first, advocacy to increase access to care, mainly by promoting policy like Medicaid reform, second, to increase minority enrollment in clinical trials, and third, to prioritize funding on research for interventions designed to address disparities in care. Promoting education and awareness on disparities in care for both health professionals and the general public was also among her top priorities, as well as engaging the community to build a more team-based approach for cancer care in these populations.
See more from the 2022 Evolution Conference here.
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