Amid Effort to Shrink Cancer Disparities, Authors Say COVID-19 Will Widen Them

Three clinicians from leading New York academic medical centers say coronavirus disease 2019 (COVID-19) will “exacerbate” cancer disparities, even as a leading professional society renewed its call to reduce the gaps in care.

Writing today in JAMA Oncology, Onyinye D. Balogun, MD; Vivian J, Bea, MD, MBS; and Erica Phillips, MD, MS, of Weill Cornell Medicine and New York Presbyterian Brooklyn Methodist Hospital (Balogun and Bea), say COVID-19 will put those from minority groups on “distinctly different trajectories along race and socioeconomic divisions for patients with cancer from the same city.”¹

This assessment comes a day after the American Society of Clinical Oncology (ASCO) published a position statement calling on members to move beyond raising awareness of disparities in cancer care and take “bold, aggressive steps” to achieve equity. The statement in the Journal of Clinical Oncology² makes recommendations to increase access to care, to improve access and diversity in clinical trials, and to remove “structural barriers,” including implicit bias in the oncology care work force.

COVID-19 and Cancer Disparities

The JAMA Oncology authors cite the greater likelihood that minority patients with cancer will need to work outside the home during the pandemic—in jobs that have little or no health coverage. In other cases, they write, patients may be underinsured and lose coverage when their job is eliminated. Their essay appears the same day that data show 963,000 people filed first-time unemployment claims last week, and another 489,000 sought benefits under a separate program for independent contractors.

For many of these patients, telemedicine will prove inadequate. “Barriers such as inequity in access to technology put minority patients at risk of fractured care and being lost to follow-up,” they write.

Having access to a smartphone is not sufficient if patients lack health care literacy and cannot advocate for themselves, the authors say. The result is stress that will likely worsen cancer outcomes, and COVID-19 will result in treatment delays. The authors call for the following:

• A commitment to complete cancer care for patients already diagnosed or who have a suspicious test result. Patient navigation and tracking systems must be fully deployed to keep patients on track.
• Expansion of tracking systems to include social workers and nonelectronic tools when needed so patients are not lost to follow-up.
• Efforts to address the psychological toll and anxiety patients are experiencing.

ASCO’s Call to Action

The New York clinicians cite ASCO’s effort to assess COVID-19’s impact on patients with cancer and urge colleagues to participate. ASCO’s new statement comes more than a decade after it first formed a Health Disparities Committee and follows presentations during its annual conference about the impact of disparities on care and outcomes.

The statement notes that the overall good news about declining cancer mortality is not spread evenly. “Black men and women, patients living in rural areas, and populations with lower income and education levels continue to experience worse survival for many cancers regardless of stage at diagnosis,” the statement read. “These disparate outcomes are compounded when examined through the lens of multiple social factors.

“For example, although lung cancer rates have declined among Black men overall, among those living in rural areas, incidence and mortality rates surpass those of all other populations,” the statement notes, appearing the same day as a major National Cancer Institute review of improving lung cancer survival, published in the New England Journal of Medicine.

The policy statement connects the cost of new therapies and the vagaries of benefit design to inequities in care—challenges that may increase as more workers lose employer-sponsored coverage. Financial toxicity hits hardest on those at lower income levels, the statement said.

“Rising health care premiums, high-deductible insurance plans, and narrowed networks are linked to delays in cancer care, delays that adversely affect cancer control and survival,” the statement said. “A similar pattern will likely emerge in conjunction with the discontinuity of employer-based insurance and short-term coverage for those who lose employment or are employed as ‘gig’ workers or temporary and/or independent contractors. The projected and unsustainable rise in total cancer costs and the resulting economic strain on society, patients, and families will exacerbate the barriers preventing access to high-quality cancer care.”

In an accompanying editorial, ASCO President Lori Pierce, MD, a radiation oncologist who is the vice provost for Academic and Faculty Affairs at the University of Michigan, said the “stunning progress” that has led to 17 million cancer survivors falls short if some Americans are left out.³ “We should not accept a world in which racial and ethnic minorities face poorer health outcomes and geography affects treatment outcomes. We should not rest until the opportunity to participate in clinical trials is available to—and represents—all patients with cancer, not just the 5% who enroll today. And we should lead the change toward a system of cancer care that serves the whole person, not just their disease.”

References

1. Balogun OD, Bea VJ, Phillips E. Disparities in cancer outcomes due to COVID-19—a tale of 2 cities. JAMA Oncol. Published online August 13, 2020. doi:10.1001/jamaoncol.2020.3327
2. Patel MI, Lopez AM, Blackstock W, et al. Cancer disparities and health equity: a policy statement from the American Society of Clinical Oncology. J Clin Oncol. Published online August 12, 2020. doi:10.1200/JCO.20.00642
3. Pierce LJ. A time to dig deeper and take meaningful action. J Clin Oncol. Published online August 12, 2020. doi: 10.1200/JCO.20.02158