The Role of Race, Ethnicity, and Cancer in the Time of COVID-19

As the latest wave of coronavirus disease 2019 (COVID-19) rises, the first day of the San Antonio Breast Cancer Symposium 2020 opened up with a session that examined how the pandemic is disproportionately affecting care for minority patients.

Deborah Doroshow, MD, PhD, assistant professor of Medicine, Hematology, and Medical Oncology at the Tisch Cancer Institute, opened the session with an anecdote from April when she was doing rounds at the institute and met a Black woman in her 60s who was hospitalized for COVID-19. Three years prior, the woman had undergone a lumpectomy and radiation for hormone-positive breast cancer; she was currently on hormonal therapy with an aromatase inhibitor.

While in the hospital, the patient was growing short of breath and showing signs of being tachypneic and hypoxic; this led Doroshow to ask a rapid response team for high-flow nasal cannula. However, Doroshow was met with a response of, “She was a cancer patient—why be so aggressive?”

The response, said Doroshow, rasied a larger question: “What role might gender and race also be playing here?”

It’s well documented that race and ethnicity carries weight when it comes to outcomes across a myriad of conditions, and COVID-19 is no exception. Doroshow gave the example of a 3600-patient cohort from Louisiana, of which Blacks accounted for 70.4% of the COVID-19 infections despite representing less than one-third of the population.¹ Similarly, among 28,000 tested patients in New York, 6000 tested positive for COVID-19, with Blacks accounting for nearly 1 in 4 infections and Hispanics accounting for 29% of infections while representing 19.2% and 12.8% of the population, respectively.²

Data from the CDC show that American Indians/Alaskan natives, Blacks, and Hispanic/Latinos are at higher risk of developing COVID-19, being hospitalized for the virus, and dying from COVID-19 infection.³ However, the agency does note that race/ethnicity are risk markers for other underlying conditions that impact health, such as socioeconomic status and access to healthcare.

Now, enter cancer. Having cancer or a history of cancer alone leaves a patient is at significantly higher risk of dying if they are infected with the virus. Data from nearly 4000 patients included in the COVID-19 and Cancer Consortium showed that 30-day all-cause mortality hit 14% overall and 23% among those hospitalized with the virus.⁴

So, both race/ethnicity and cancer on their own are associated with poorer COVID-19 outcomes, but what happens when you combine the 2?

Doroshow is an investigator in the COVID-19 and Cancer Outcomes Study, a multicenter, prospective study looking at the impact of the pandemic on cancer care delivery and outcomes among patients with active cancer or a history of cancer. The study includes 2300 patients who visited Mount Sinai Hospital or Dana-Farber Cancer Institute between March 2 and March 6, 2020. The team of researchers performed a 3-month retrospective analysis going back to December 2019 (baseline period), as well as a 3-month prospective analysis going through early June (pandemic period).

What they found was Black and Hispanic patients were less likely to have telehealth visits and were far more likely to be diagnosed with COVID-19, with an odds ratio of 1.86 and 3.19, respectively. When looking at pandemic-related delays in cancer care, Hispanic patients were far more likely to delay care, while Black patients had a trend toward this.

“Why these disparities?” questioned Doroshow. “One can certainly point to a variety of factors. One might say that increased vulnerability to COVID could be related to the fact that minority patients are more likely to be frontline workers or perhaps to live in multigenerational homes. Could the possibility of poorer outcomes be related to poorer baseline health or disparities in health literacy or insurance, leading patients to seek care later on?”

With a focus on the continuity of care, Doroshow outlined several focus points for closing these disparities. She argues providers should not assume all patients:

• Are able to engage in social distancing at work and at home
• Understand COVID-19 related public health recommendations
• Have a safe way to get to the clinic
• Have devices allowing them to participate in telehealth
• Speak English or are able to interact with an interpreter via a digital platform
• Have sufficient hearing or visual acuity to participate in telehealth
• Are open to telehealth

“We must be persistent in not losing out most vulnerable patients to follow up,” urged Doroshow. “Ask about living and social situations; educate and support safe public health practices to the extent they are possible; provide nonjudgmental, supportive education; help our patients get to the clinic and stress the importance of not delaying urgent care; ensure telehealth is provided to patients who are able to participate fully and who are open to this mode of care; and ask of patients what they need from us.”

References

1. Price-Haywood E, Burton J, Fort D, Seoane L. Hospitalization and mortality among Black patients and White patients with COVID-19. New Engl J Med. 2020; 382:2534-2543.

2. Wang Z, Zheutlin A, Kao Y, et al. Hospitalised COVID-19 patients of the Mount Sinai Health System: a retrospective observational study using the electronic medical records. BMJ Open. 2020;10(10):e040441.

3. COVID-19 Hospitalization and Death by Race/Ethnicity. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html. Updated November 30, 2020. Accessed December 8, 2020.

4. Assessment of clinical and laboratory prognostic factors in patients with cancer and SARS-CoV-2 infection: The COVID-19 and Cancer Consortium (CCC19). Presented at: ESMO 2020; September 19-21, 2020. Abstract LBA72. doi: 10.1016/annonc/annonc325