Seeking equity in cancer care for women, at home and abroad

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During the first day of the 2021 American Society of Clinical Oncology annual meeting, a discussion of disparities in cancer care in women highlighted challenges in the United States and internationally.

From Botswana to Bangladesh to Alabama, disparities in care are a global problem for women with gynecological cancers, whether it is a delay in starting treatment that allows the disease to progress , the poverty that puts drugs out of reach, or what one commenter called the systemic racism that prevents black patients from participating in clinical trials.

“Equal Care for All Women: Addressing Disparities in Gynecological Malignancies,” took place on the first day of the 2021 annual meeting of the American Society of Clinical Oncology. Health equity will be a theme throughout the 5 day virtual meeting. Moderated by Surbhi Grover, MD, MBA, University of Pennsylvania, the session also featured Arunangshu Das, FCPS, MBBS, from Square Hospital in Dhaka, Bangladesh, and Jennifer Young Pierce, MD, MPH, FACOG, from Mitchell Cancer Institute at the University of Southern Alabama.

Botswana

Grover developed a global radiation oncology practice at Princess Marina Hospital in Gaborone, Botswana, and presented data showing that disparities in care in Africa begin with the limited number of machines in the central part of the continent, resulting in treatment delays for women with locally advanced cervical cancer.

Botswana has high rates of HIV: around 20% of adults are HIV positive and rates among women of childbearing age are higher. Most people know their HIV status and receive treatment. “Over 95% of those who are on treatment are actually virally suppressed,” Grover said.

But this immunosuppression increases the risk of cervical cancer. “These are the patients who will need radiation therapy,” she said. “The overall survival for all patients at 2 years is close to 67%; at 5 years, it is nearly 56%.

The challenge is to get patients treated within a reasonable time. It might take 25 days from a clinic visit to get the pathology report, and by the time the patient arrives for the first radiation therapy conference, 40 days have passed. Government-funded care doesn’t mean it’s fast, Grover explained. “During this time, many patients are at risk of getting lost or becoming sicker. And that has a huge impact on their results, ”she said.

In 2015, work began at a clinic with Grover Hospital to set up care navigation to speed up the process, connect different doctors and lab staff, and reduce the number of days between diagnosis and treatment. “A simple intervention allowed us to reduce the [time] from biopsy to 120-day to 60-day processing, and we’re re-analyzing that data because it was last reviewed in 2017, ”she said.

Other interventions include solving problems with electronic medical records and using phone apps to track patients, which has allowed the hospital to register “every patient” in one app, eliminating paper and facilitates patient follow-up. She said, “90% of patients as well as providers found this really helpful” and patients are allowed to send free messages if they need to reschedule their appointment.

Other projects include using technology to understand why some women do not have radiation therapy for their cervical cancer, improving screening rates, and adjusting screening guidelines, given what they see from patients in their clinic.

International disparities

Das said the “striking disparities” in cancer management between rich and poor countries affect all aspects of care, whether it is surgery, chemotherapy, radiation therapy or pathology service. “Almost 100% of these components are available in the public sector in high income countries. But if we look at low income countries, we can see that only 40% of these essential components are available in the public sector, ”he said.

A large number of patients with major gynecological cancers – of the cervix, endometrium and ovary – live in Africa and Asia, Das explained. But the global burden of where deaths occur does not match where resources are.

Each year, he said, about 300,000 women die of cervical cancer and 207,000 die of ovarian cancer, and 80% of new cervical cancer diagnoses and deaths. occur in Asia and Africa. “The management of cervical cancer has 3 important elements: vaccination, screening and treatment. Vaccination against HPV reduces a person’s risk of cervical cancer. However, huge disparities persist in the distribution of the HPV vaccine across the world, ”said Das, pointing to maps and data from the New England Journal of Medicine to show that low- and middle-income countries are not keeping pace.

Other data shows that 19% of eligible women are screened for cervical cancer in low-income countries, compared to 63% of women in high-income countries. Access to the most modern therapies is often limited by price – the cost of bevacizumab, he said, is usually beyond the reach of an employee in a country like Bangladesh. And technologies like next-generation sequencing, which are essential for today’s precision medicine strategies, may not even be available in some parts of the world, or even for some poor patients in developed countries.

Das noted how COVID-19’s exposure of disparities in care had become a political issue. “Collaboration to close the gap is needed,” he said. Access to resources and “the commitment of companies and international organizations is necessary to ensure equality”.

Disparities at home

Pierce has been blunt in addressing the “paradox of ongoing disparities and emerging technologies,” showing a map of the United States to highlight the variation in cervical cancer rates by state. “Specifically, by race, we are seeing higher death rates among black, Hispanic and Native American women,” she said, noting that disparities have narrowed and that access to guideline-based care is ‘is improved.

“However, race is not the only category where we see persistent disparities. In every state there are a myriad of differences that every county within a state can have,” she said. Using Alabama Maps, she showed the overlap in the incidence of cancer associated with HPV and poverty.

“We know that in the United States, race is only a marker for other social determinants of health due to systemic racism. And yet this may also be true in other parts of the world, ”she said. “Differences in economic stability, housing, education, food, community and access to the health system all play a role in our access to cancer care and our risk of contracting cancer. “

Pierce discussed several realities of vaccination:

  • HPV vaccination ranges from 39% to 60%, and Pierce said absorption may be affected by cultural concerns that vaccinating adolescents is an invitation to premarital sex.
  • In Alabama, people with public insurance are more likely to get an HPV vaccine than those with private coverage

Guidelines that call for HPV screening, testing, and PAP testing and that take into account the patient’s history and short- and long-term risks can be helpful. Such factors “ultimately result in a specific recommendation for that patient that day,” Pierce said, but they may not be helpful in other countries.

Social determinants play a role in everything from lack of transportation, to not having child care leading to missed appointments, to not participating in clinical trials. “It is important to note that the differences in screening explain the differences in mortality, with up to 50% of women dying from cervical cancer without recent screening. However, these do not take into account the disparities, ”said Pierce.

Why, she asked, do women of different races with cervical cancer in the same stage receive different surgical recommendations? It’s a big deal if patients are given guideline-based care and yet, even in a high-volume hospital, the disparities are not completely eliminated, she said.

“Genetic alterations may contribute to these disparities, and a growing body of evidence supports tumor-level molecular differences by race and other cancers. This doesn’t mean that a breed is good or bad, but rather, these genetic differences may play a role in the treatments we offer patients and their response to treatment, ”said Pierce.

The problem: White women make up the majority of patients in the studies used to develop the guidelines.

“If we are to find different treatments that can work differently, we have to look further,” she said.


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