Review Highlights Gaps in Equity-Focused Cancer Care

Numerous gaps in US cancer care, including those pertaining to research on receipt of guideline-concordant care and interventions addressing multiple levels of structural and social determinants of health have been identified in a new scoping review published in Cancer Medicine.

“Health disparities in cancer care persist, and in some cases are growing, despite decades of research aimed at achieving equal outcomes for all Americans,” authors wrote. “There is growing consensus that reducing disparities will require a shift from aiming to provide care that is equal to aiming to provide care that is equitable.”

However, the current landscape of metrics and interventions that move beyond equality toward equity has yet to be systematically characterized, they said.

Overall, the findings demonstrate “the lack of clarity about how best to measure equity (or a lack thereof) in the various dimensions of the cancer continuum,” the authors wrote.

The review also aimed to identify cancer-specific health equity metrics and interventions explored within published literature. Results showed a major focus for the field has been cancer screenings and that strategies designed to improve outreach and follow-up can positively improve these rates, especially in at-risk populations.

By searching PubMed, Scopus, and other platforms, the researchers identified 40 articles published in English between 2012 and 2022 that included an intervention to advance health equity in cancer care. Timeliness of screening and treatment, receipt of goal-concordant care, and survival were among the metrics included in the studies.

The researchers defined health disparity as “a preventable difference in the burden of disease, outcomes of treatment, and opportunity to achieve optimal health that socially disadvantaged populations experience compared to the population as a whole.”

Inequities in cancer incidences and receipt of guideline-concordant care are especially prevalent in racial and ethnic minority groups. Other groups like asylum seekers, individuals with disabilities, and sexual and gender minorities also face hurdles when it comes to cancer screening and treatment.

Most of the articles included in the review addressed cancer screening. Of these, 13 focused on reducing inequities in colorectal cancer (CRC) screening, 1 focused on lung cancer screening, and 4 addressed breast cancer screening. Seven additional articles addressed cervical cancer screening or follow-up colonoscopies, the researchers said.

A major focus comprised efforts aimed at improving screening rate equity in different populations with cancer, especially CRC screening in rural and Black patients. Findings also underscored the importance of community engagement when it comes to building support for cancer screening in communities facing systemic inequalities, they added.

“These studies demonstrated that outreach using mailings, telephone, or text messaging to remind and encourage completion of CRC screening can be effective across populations,” authors wrote.

Fewer articles focused on interventions to improve equity in treatment. One such article evaluated the impact of providing clinicians with real-time warnings about missed appointments and procedures using the electronic health record, along with race-specific feedback on completion rates. In addition, just 2 studies described interventions to improve equity in outcomes for cancer survivors or family caregivers, the authors wrote, while “of the 5 studies employing methods for evaluating health equity, 4 examined the effect of policy level changes.”

Several studies in the latter group found policy changes, like screening eligibility expansions, were associated with reductions in disparities. One also found Medicaid expansion was linked with increased active surveillance for low-risk prostate cancers, especially among low-income patient populations.

Around 20% of studies only incorporated 1 level of intervention to address health disparities.

Along with strategies aimed at improving screening rates, these results suggest efforts aimed at increasing access to cancer specialists and resources needed to participate in clinical trials can also mitigate care gaps.

“While it is clear that equity has been a consistent focus for the field for decades, studies evaluating interventions specifically designed to address equity, or to evaluate the degree to which certain outcomes can serve as reliable ‘equity metrics’ in the cancer space, are lacking,” the authors concluded. “A majority of the research studies included in the scoping review were focused on cancer screening, suggesting that more interventional research is needed to advance equity in treatment and survivorship outcomes, especially among underserved populations.”

Reference

Starkweather A, Cohen B, Gray TF, Linder L, Zanville N. Cancer-specific health equity metrics in the United States of America: a scoping review. Cancer Med. Published online April 5, 2023. doi:10.1002/cam4.5881