The COVID-19 pandemic has demonstrated that personalized medicine should consider social determinants of health disparities as well as genomic factors.
To ensure that patients with cancer receive optimal care, the definition of personalized medicine needs to be broadened to include social determinants of health, according to Karen Winkfield, MD, PhD.
“Unfortunately, the COVID-19 pandemic has shown that in the United States, we don’t quite have the public health infrastructure that we need, not yet,” said Winkfield, executive director of the Meharry-Vanderbilt Alliance, the Ingram Professor of Cancer Research, and professor of radiation oncology at Vanderbilt University Medical Center, during the Greenspan Lecture at the 39th Annual CFS®, a program hosted by the Physicians’ Education Resource® (PER®), LLC.1
“However, we have an opportunity to think about it in a way that impacts communities at large, and, more specifically, the individual patients that are walking through our doors. What ways can we impact what is happening to the people that we serve?” Winkfield asked during her presentation entitled: “Precision Medicine: Ensuring every patient gets the right treatment at the right time.”
Precision vs Personalized Medicine
The field of precision oncology has grown significantly in recent years with the integration of broad molecular testing, identification of new prognostic markers, and understanding of mechanisms of resistance. With the development of targeted therapy, many patient populations can receive care that directly reflects unique characteristics of their tumor genomics and personal genetics.
However, Winkfield advises the field to further broaden the role of precision medicine to include not only genomic factors, but microbiome features, patient exposures and behaviors, clinical tests, and patient-contributed data to create a knowledge network that will allow for precision medicine to become more personalized.
“There are components of both [precision and personalized medicine] that we really need to think about today as we are talking about all the innovations that are being made in terms of how we manage chemotherapeutics. It is important to think about what we mean when we talk about precision oncology. Are we doing our best to personalize medicine?” Winkfield questioned.
Factors of Health Disparities in Cancer Care
Despite the downward trends in cancer-related deaths observed across all racial and ethnic patient populations, health disparities still exist, Winkfield explained.2 For example, one of the most widely known disparities in cancer care exists between White and African American patients.
There has been a decline in disparity for overall cancer death between African Americans and Whites from 33% in 1990 to 14% in 2016.2 However, achieving health equity remains a key goal in cancer care, Winkfield said.
Although biologic determinants like genetics, biology, and comorbidities inevitably have a role in creating these disparities, Winkfield hypothesized that social determinants, such as socioeconomic status, access to care, and sociocultural barriers, are the main contributors to these gaps.
Social determinants of health include economic stability, neighborhood and physical environment, education, food, community and social context, and health care system factors. Negative social determinants, such as low income, lack of access to transportation, food, and social support, literacy challenges, and limited health care provider availability, are associated with poor health outcomes, including increased mortality and morbidity, lowered life expectancy, increased health care expenditures, decreased health status, and functional limitations.
“The social determinants go beyond just food; it is transportation, employment, literacy, and health literacy. These are all issues we have to think about when we ask ourselves how we design personalized medicine programs and holistic care to the person who is right in front of us,” Winkfield said.
Lessons Learned from COVID-19 Pandemic
Although social determinants of health are becoming more understood, significant efforts from a socioeconomic and political context are needed to address them and provide precision medicine to all patients.
Notably, the COVID-19 pandemic required rapid integration of many technologies that may start to bridge some of these gaps that are influenced by social determinants of health, such as accessibility. The utility of telemedicine during the height of the pandemic is one lesson that can be taken away. Winkfield underscored that the pandemic showed feasibility with localized or virtual care for certain procedures and patient conversations. Additionally, even without the context of COVID-19, clinical trial consent forms are likely able to be signed virtually rather than having patients come into the clinic.
Importantly, adding virtual elements to cancer care can significantly lower the burden of treatment for patients, particularly for those who live in rural communities or who must rely on public transportation.
“Our ability to innovate the way that we have done with COVID-19 where telehealth is being compensated, these are the sorts of things we need to advocate for because, frankly, it makes it much easier for patients. This is what patient-centric care is about,” Winkfield said.
A study published in the International Journal of Radiation Oncology, Biology, Physics stated that achieving health equity is of critical importance for patients receiving radiation therapy and that the renewed passion to protect vulnerable patients observed during the COVID-19 pandemic should continue to address the disparities in care.3
Winkfield advised oncologists to be advocates of bringing more equitable cancer care in clinical trials and policy implications to their institutions and communities. Additionally developing a diverse workforce and working in direct collaboration with community-engaged researchers is a great start at addressing these gaps.
Specifically, Winkfield called attention to the need for redesigned and inclusive clinical trials. She highlighted the example of multiple myeloma where although African Americans comprise 20% of the multiple myeloma population in the United States, they comprise only 5% of FDA registration trials in multiple myeloma.4
In addition to African American patients, adolescent/young adults, older adults, other racial/ethnic minorities, LGBTQ+ individuals, individuals in rural areas, and patients of lower socioeconomic status are some of the patients at the greatest risk for exclusion from clinical trials.
“If we are only getting the clinical trials in the spaces at the places that are very homogenous or have not done a good job at being inclusive, are we really moving the needle?” Winkfield asked.
Developing an actionable framework for stakeholders to address cancer care disparities within medically underserved populations is of paramount importance to ensure population-health care is implemented.5
Ultimately, developing an understanding of the cross-cutting issues that span the entire cancer care continuum from prevention to detection, diagnosis, and treatment to survivorship and end of life is critical. In addition to health equity, some of these issues include quality of care, communications, and decision making.
“We need to figure out how we can create an environment where we provide precision oncology, but we provide it for every patient so that every patient gets the right treatment at the right time,” Winkfield concluded.