Social Determinants of Health in Metastatic Breast Cancer Care: A Podcast Exploring Challenges and Opportunities in the

00:00:00: You are listening to an

00:00:02: ADIS Journal podcast.

00:00:12: Hello and welcome to our podcast exploring the impacts of social determinants of health and breast cancer care that is hosted by the Oncology and Therapy Journal.

00:00:21: My name is Dr.

00:00:22: Monique Gary and I am a breast surgical oncologist in Bucks County, Pennsylvania in the US.

00:00:27: I am delighted to be joined today by Dr.

00:00:30: Karen Gelman for this important discussion of non-biological factors that may affect treatment choices and outcomes for patients with breast cancer and particularly those with metastatic breast cancer.

00:00:41: I have learned firsthand that gaining an understanding of our patient's circumstances beyond their diagnosis is essential to treating the whole patient and delivering optimal care.

00:00:51: Thank you, Monique.

00:00:52: It is wonderful to be here and to raise awareness on such an important topic.

00:00:57: My name is Dr.

00:00:58: Karen Gelman, and I am a medical oncologist from BC Cancer in Vancouver, British Columbia, with a special interest in breast cancer.

00:01:08: Social determinants of health, or SDOH as they are often called, are truly a global challenge that transcends borders and healthcare systems.

00:01:17: I became aware of the importance of SDOH early in my medical education when one of my mentors would stress the importance of knowing where our patients worked, how they got to the hospital, what their support system was, and about their lives in general.

00:01:34: As a result, I am passionate about promoting this approach and integrating SDOH considerations into the day-to-day care that we provide for patients with breast cancer.

00:01:47: Thanks, Karen.

00:01:49: Let's begin with a few definitions.

00:01:51: SDOH, as defined by the U.S.

00:01:53: Department of Health and Human Services' Healthy People, Twenty-Thirty Initiative and the World Health Organization, or WHO, are non-medical factors that can influence health outcomes, including the conditions in which people are born, grow, live, work, and age.

00:02:09: Healthy People, Twenty-Thirty, classifies these factors into five categories, which are economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context.

00:02:24: The WHO has recently updated their SDOH guidance with a renewed focus on promoting health equity.

00:02:31: Their twenty-twenty-five report now takes an expanded view of SDOH factors, describing macro-level structural determinants such as economic systems, conflict, and climate change, in addition to factors affecting daily life such as education, employment, food, housing, and transportation.

00:02:49: The picture that is emerging is that SDOH factors, which are in large part determined by the place where patients live, may have a greater impact on clinical outcomes than factors such as tumor type, age, and overall health.

00:03:02: In today's discussion, we aim to raise awareness among care providers of SDOH factors in support of more equitable treatment for patients with metastatic breast cancer in the U.S.

00:03:12: and Canada.

00:03:13: The SDOH considerations we will cover are primarily relevant to developed nations.

00:03:18: Patients in developing countries face overlapping but distinct SDOH factors that deserve a separate, dedicated discussion.

00:03:26: Even though new therapies have been developed for treating metastatic breast cancer in recent years, it unfortunately remains an incurable disease.

00:03:34: Therefore, we as a clinical community need to do what we can to provide the best possible treatments for all our patients while maintaining their quality of life.

00:03:44: On a basic level, it is intuitive that a patient lacking access to quality healthcare or struggling with food insecurity would experience greater challenges from their disease than those without these barriers.

00:03:58: And indeed, this is what the literature shows.

00:04:02: Studies have shown that low socioeconomic status is linked to premature mortality, increasing the risk of cancer-related death by twenty-six percent compared with patients with high socioeconomic status.

00:04:17: Other studies have demonstrated that food insecurity, which worsens health outcomes, is widespread, occurring in as many as fifty-five percent of patients with cancer in some U.S.

00:04:30: clinics.

00:04:32: Finally, the lack of health care access, be it screening diagnosis or treatment may also impact survival.

00:04:41: It is important to recognize that patients may be affected by more than one SDOH barrier, making it difficult to achieve optimal outcomes.

00:04:52: SDOH factors not only impact patients directly, but even before we discuss their impact on outcomes, which has been the topic of much research, these determinants can also, unfortunately, influence the treatment decision-making process.

00:05:06: Together with my colleagues, we recently explored how SDOH considerations affect treatment selection for patients with metastatic breast cancer by surveying physicians and advanced care providers in the U.S Echoing the research you just mentioned, Cary, we found that the patient's ability to afford medication-related treatment costs, along with the presence or absence of a caregiver at home, were the most often cited factors affecting breast cancer treatment selection in the metastatic setting.

00:05:34: I would agree with those survey findings as they align with my clinical experience.

00:06:04: and the rest of the world, STOH barriers must be identified and addressed.

00:06:10: I could not agree more.

00:06:11: Let's get into some specific STOH factors and how they may impact care.

00:06:16: While STOH challenges are broadly applicable to many diseases and conditions, the metastatic breast cancer setting brings these factors into a sharp focus for a number of reasons.

00:06:26: For example, patients with metastatic breast cancer may be older and may have a variety of comorbid conditions.

00:06:32: There can be a high degree of complexity to the diagnosis, the therapeutic regimen, and the careful monitoring that is necessary for standard of care treatments.

00:06:40: I have seen firsthand how being diagnosed with metastatic breast cancer can truly upend all aspects of a patient's life and profoundly stress not only the patient but their support system as well.

00:06:52: You're right, Monique, and those additional stressors can raise barriers to care and worsen outcomes.

00:06:59: Take,

00:07:00: for example, the patient's socioeconomic status.

00:07:04: A patient may have pre-existing financial challenges, and these may be exacerbated by job loss, loss of insurance coverage, and the costs of managing treatment side effects.

00:07:15: In more extreme cases, there may be nutritional concerns, an inability to keep working, or even loss of housing.

00:07:24: In Canada, even though the cost of primary anti-cancer treatment is almost always covered, costs associated with supportive care drugs, food, and housing may still impact outcomes for patients.

00:07:39: It's also important to recognize the costs of traveling to the many appointments that are often required in the advanced dermatostatic breast cancer setting.

00:07:49: Some persons may struggle with affording childcare.

00:07:53: when they come to appointments.

00:07:55: Collectively,

00:07:57: these economic pressures contribute to what is termed as financial toxicity, and there is now substantial literature on the negative impact that this situation can have on patient health.

00:08:12: Yes.

00:08:13: In fact, nearly half of cancer survivors in the U.S.

00:08:16: experience hardship related to treatment cost, including direct expenses, lost income, and psychological stress.

00:08:23: Such financial burdens are associated with poor treatment adherence and lower quality of life.

00:08:28: One study found that patients with breast cancer have a forty-eight percent higher risk of death if they declare bankruptcy.

00:08:35: Even in the early breast cancer setting in France, a country known for its universal health care and strong social safety net, lower socioeconomic status has been linked to poorer quality of life.

00:08:51: in a study published in twenty-twenty-four.

00:08:54: So if there is a lack of consistent access to the basic necessities, inability to travel to clinics regularly, or other cost-related obstacles, treatment effectiveness can be diminished.

00:09:09: Absolutely.

00:09:11: Financial toxicity is so damaging to patients' outlook, quality of life and outcome.

00:09:16: For patients young and old.

00:09:18: It impacts their earning years and affects their lifelong financial situation.

00:09:23: However, in my experience, financial navigators can provide a great deal of support to patients and treatment centers when they are available.

00:09:30: Another commonality between the US and Canada is the challenge of securing transportation to and from appointments as distances between the patient's home and the nearest cancer center can be vast in rural regions or can be expensive when relying on public transportation to commute to urban cancer centers.

00:09:47: Yes, and based on the frequency of visits required for specific therapy, transportation logistics may influence treatment options.

00:09:57: For example, choosing an oral therapy rather than an intravenous option, or a therapy with less monitoring may be a more practical option for a patient who has challenges getting to the treatment site.

00:10:12: Finally, transportation barriers are one of many possible reasons for the reduced enrollment in clinical trials observed among certain populations.

00:10:20: Participation in clinical trials is very important, not only for the individual as they can have access to new treatments, but also for patient groups that they represent.

00:10:29: For all of these reasons, assessing transportation barriers is essential to providing optimal care.

00:10:36: While telehealth solutions may be useful in some cases, even virtual care may have other potential barriers, such as lack of access to or understanding of the technology utilized in telehealth.

00:10:48: Another important factor that is strongly associated with SDOH that warrants our attention is health literacy.

00:10:56: Health information is very important to patients, their caregivers, and their support communities.

00:11:03: as it can help them understand their disease and treatment regimen.

00:11:07: Poor health literacy may impact treatment adherence and or persistence, especially given the complexities of metastatic breast cancer therapy, contributing to worse outcomes such as higher risk of death.

00:11:23: Language barriers may further complicate patient education.

00:11:28: Finally, Poor health literacy may be a barrier to clinical trial enrollment as patients may lack awareness or understanding of the benefits of participating in these studies.

00:11:41: Taking the time to talk with the patient and their caregiver.

00:11:46: using non-medical jargon and employing translation services as appropriate can go a long way towards establishing trust and can help persons understand their options and make informed treatment decisions.

00:12:01: Including caregivers in these types of conversations is crucial.

00:12:05: Caregivers can be helpful in promoting treatment compliance as well as monitoring for side effects.

00:12:10: As was mentioned earlier, the importance of a caregiver at home was highlighted in our recent survey and may affect what types of treatments are recommended for patients with cancer.

00:12:20: In fact, one study of patients with metastatic breast cancer reported that living with a spouse or partnered home was associated with a twenty percent reduction in the risk of breast cancer-specific death relative to those who were single.

00:12:33: However, not every patient has a caregiver at home, so the care team needs to be cognizant of this fact and consider other social supports their patient may have.

00:12:41: Some of the barriers we have mentioned may be difficult for patients to discuss, especially when they are meeting members of their care team for the first time.

00:12:50: They may also not understand why these personal questions are being asked.

00:12:55: Screening for these and other SDOH factors is necessary at diagnosis, but should also be reassessed on an ongoing basis.

00:13:05: Not only might patients be more forthcoming about their challenges over time, but also their circumstances may change during their cancer journey.

00:13:16: That is so true, Karen.

00:13:18: Establishing patient trust with the care team is absolutely essential to supporting optimal outcomes for patients with metastatic breast cancer.

00:13:26: We need to recognize that there is earned mistrust of the health care system by some populations in both our countries due to historical abuses and exploitation.

00:13:35: Affected populations include members of the Black, Indigenous and people of color or BIPOC communities or persons who identify as part of the LGBTQ community.

00:13:46: Even today, there are well-documented disparities in survival outcomes and cancer burden between some of these groups of patients with breast cancer and their counterparts.

00:13:54: Mis-trust of the healthcare system is a systemic issue.

00:13:58: But regaining the trust of these patients is a vital and ongoing effort and one that is necessary for them to disclose their SDOH-related challenges.

00:14:06: As providers, we need to be conscious of and address our own implicit biases that may contribute to disparities in care.

00:14:12: We have described some fairly large and far-reaching barriers for optimal care for certain groups of patients among those with metastatic breast cancer.

00:14:23: Whether the root cause of these barriers is macro, such as changes in the global economy, or micro, such as a patient's living situation, the scale of the challenges may seem overwhelming for individual clinicians and practices.

00:14:39: Further, we recognize that many clinics have resource constraints, be they financial, staffing, or infrastructure related, and that new initiatives may seem daunting.

00:14:52: So let's talk about some actionable steps that clinics can take to assess and address SDOH-related needs.

00:15:00: Well, I think we should acknowledge that individual care providers and clinics are not alone in this fight.

00:15:05: So many of us across the globe are facing similar challenges.

00:15:09: But first, we must ask our patients about their situations.

00:15:12: What gets measured gets managed, I'd like to say.

00:15:15: Asking patients about SDOH needs to be normalized.

00:15:18: None of these barriers to care can be addressed if we don't know they exist.

00:15:22: And the good news is that there are resources available to help clinics screen for SDOH that are available free of charge and we include links to these assessment tools as a supplement to this podcast.

00:15:33: Yes, those screening tools can be very useful for practices taking the first step towards SDOH informed care.

00:15:43: Based on my personal experience, I'd like to share a few suggestions for the screening process.

00:15:49: Foremost, I think care team members should do their best to avoid assumptions about patients regarding perceived barriers or lack thereof.

00:16:00: Using a screening tool can help alleviate the need to make such assumptions and standardizing this assessment can ensure that it is used with all patients.

00:16:11: I also feel that it is important to ensure that all members of the care team are SDOH aware.

00:16:18: For example, while a social worker may perform the initial formal assessment, other team members may have conversations that reveal important information that needs to be considered.

00:16:31: Finally, assessing for SDOH must be an ongoing process.

00:16:37: Patient social circumstances often change over the course of the disease, and events such as job loss or family support changes can have a profound clinical and personal implications.

00:16:50: While we are used to considering a patient's clinical status throughout the course of treatment, their SDOH needs and challenges are also important.

00:17:00: Those are excellent suggestions to augment the screening process.

00:17:04: But once we've identified SDOH barriers, we should explore and understand the available resources to address them.

00:17:10: I think it's critical that collaborative and effective solutions are shared so that individual programs don't feel compelled to reinvent the wheel.

00:17:18: Sharing what works leads to decreasing burden on social workers and navigators and supports greater sustainability across health systems.

00:17:26: Patient organizations and nonprofits can offer direct support to patients through peer mentoring, in-person and virtual appointment support, or volunteer drivers.

00:17:34: They can also provide training for staff or lay volunteers.

00:17:39: In my own experience, having trained nurse, patient, or financial navigators can help address multiple SDLH barriers.

00:17:47: Where possible, practices should attempt to focus on sustainable solutions instead of short-term transactional solutions.

00:17:54: Above all, clinics should look to be creative and flexible as they seek to meet these patient-centered needs.

00:18:00: These are great recommendations.

00:18:02: We should note that navigators as members of the CARE team are rarer in Canada, but their utility is well documented.

00:18:11: Our listeners may be surprised how many sources of support are out there, and we provide links to some of these resources in the podcast supplement.

00:18:21: Irrespective of a clinic's resources, screening tools should be deployed to help get a sense of the challenges patients are facing.

00:18:31: From there, it is a matter of identifying and securing resources to aid in providing the most equitable care possible.

00:18:39: And finally, I would like to add that it is important to recognize that the whole health care system cannot be changed overnight.

00:18:48: Incremental progress at the practice level is a worthy and achievable goal.

00:18:55: Very well said, Karen, and thank you so much for joining me for today's discussion.

00:18:59: As a community, we're still in the early stages of understanding how SDOH can affect patient outcomes and quality of life.

00:19:06: We know there are many challenges, but we encourage our audience to ask the tough questions that may lead to opportunities to support your patients with SDOH barriers.

00:19:16: Thank you all for listening.

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