Coverage of Health Equity: August 2023

Strategies Are Needed to Facilitate Breast, Ovarian Screening Tool Implementation

The findings of a recent qualitative study underscore the need to develop multilevel implementation strategies to overcome barriers and leverage facilitators to improve access to genetic counseling and testing (GCT) for those at risk of hereditary breast and ovarian cancer (HBOC). The results were published in the Journal of Genetic Counseling.

The study results can also inform the development of implementation toolkits for community-based organizations (CBOs) to implement HBOC screening tools to advance health equity, authors wrote.

Variants in BRCA1 and BRCA2 are most strongly associated with HBOC, though variants in other genes also are linked with a heightened risk of HBOC. Because of this, participation in GCT can yield critical information to inform risk management in women both with and without cancer, the authors wrote.

Community-based organizations provide health care to a large portion of the medically underserved, who are also more likely to belong to racially and ethnically diverse communities. The United States Preventive Services Task Force recommends primary care clinicians use a validated familial risk assessment tool to assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 variants. Those with a positive result should receive genetic counseling and consider genetic testing, authors explained.

In the United States, CBOs provide health care to a large portion of the medically underserved, who are also more likely to belong to racially and ethnically diverse communities. “Given the health disparities Latina women encounter in accessing GCT for hereditary cancer risk including lack of referrals, CBOs have the potential to serve as bridges between Latinas at risk for HBOC and GCT services by identifying potentially at-risk women through screening tools,” the investigators noted.

In the current study, investigators assessed focus groups at 2 academic centers that were partnered with 4 CBOs in the Washington, DC, metropolitan area and Virginia. These centers planned to implement a validated questionnaire for HBOC risk screening. The investigators then analyzed CBOs’ preferences for screening tools, along with barriers and facilitators anticipated for future implementation.

Data showed:

• All CBOs chose the Family History Screen 7 (FHS-7) over prior screening methods and other short screening tools.
• Participants had positive attitudes toward implementing the screening tool, stressed that the culture of the organization positioned them to reach the target population, and noted barriers in different Consolidated Framework for Implementation Research domains (eg, low knowledge about HBOC and GCT referrals; scarce available resources).
• Participants pointed to barriers related to health equity domains such as limited access to GCT and follow-up care for uninsured and underinsured populations, challenges obtaining accurate family history, and immigration-related barriers
• CBOs highlighted the importance of partnering with other stakeholders to overcome barriers. Participants had an average age of approximately 50 years, and just under 50% self-identified as Hispanic or Latino. All individuals worked or volunteered at a CBO that served the Latino community. Participants included nurses, patient navigators, community health workers, health care providers, directors, and administrators.
  

Because the study only included CBOs from the mid-Atlantic region, findings may not be generalizable to other regions, marking a limitation. “Future studies should expand the number and type of CBOs engaged in research to further examine potential differences and properly tailor implementation strategies based on CBO characteristics,” the authors wrote.

Overall, “community-based organizations are uniquely positioned to connect underserved diverse populations to genetic services due to the long lasting trust, shared culture and language, and commitment to the community” they wrote. “Findings from this study can inform the development of a HBOC screening needs assessment and an implementation strategies toolkit that could be tailored for different types of CBOs.”

Reference
Bowen A, Gómez-Trillos S, Curran G, et al. Advancing health equity: a qualitative study assessing barriers and facilitators of implementing hereditary breast and ovarian cancer risk screening tools in community-based organizations. J Genet Couns. Published online March 13, 2023. doi:10.1002/jgc4.1705

SPOTLIGHT: Travis Brewer Discusses Payer Initiatives to Improve Oncology Patient Outcomes

Brewer

Travis Brewer, vice president of payer relations at Texas Oncology, spoke with Evidence-Based Oncology (EBO) recently about how collaboration between primary care providers and oncologists can improve population health outcomes by focusing on payer initiatives and strategies. He said aligning public health with payer initiatives is a challenge, especially in states with high rates of uninsured individuals.

EBO: How do payers address disparities in access to high-value oncology care and ensure equitable outcomes for diverse patient populations?

Brewer: That’s really a work in progress right now. I will say that the payers have done a better job. You hear the old cliche that a lot of health care is local. There are some payers that have done a very good job partnering with local community organizations to help with things such as food insecurity, housing issues, and transportation. But it’s kind of a mixed bag. Different payers do different things in different markets.
We’re seeing a lot more of it, which is a positive thing, and we do try to assist in those programs where we can. We have social workers in a lot of our sites who can help coordinate access to different community resources that might be out there, and we do that in conjunction with the payers and their programs as much as we can.

EBO: What are the challenges and opportunities in aligning public health strategies with payer initiatives in oncology care to improve population health outcomes?

Brewer: Public health is a little tougher. Being in Texas, the [state with the most uninsured individuals], and coupled with the fact that we have a lot of our current Medicaid population in danger of losing that coverage, the alignment with public health becomes a touch more difficult.

I think the payers do what they can, but they are somewhat reticent to do a lot of work in the specialty space, in our experience, simply because the nature of patients jumping from health plan to health plan year over year, or [patients switching] from an employer-based plan or through the health care exchange; they tend not to want to invest as much because they may be losing that patient as a member in a subsequent cycle. So they don’t necessarily, in their mind, see the benefit of the work that goes into it. But it’s a slow process. And until we probably do a better job as a state around provision of access to care for some of the lower-income populations and stabilize the Medicaid population, I think we’ll continue to struggle in that space.

EBO: How is Texas Oncology partnering with primary care providers to improve patient outcomes while managing cost?

Brewer: That really is the key. The payers do a better job of value-based care if they start with the primary care as the foundation vs trying to start something in any one specialty space. [They are] partnering with those primary care organizations that are large and sophisticated enough to handle risk, to handle capitation, and who understand what it takes to manage care in a total cost of care environment, and partner with the right specialists in order to manage the cost effectively. It’s very important to find those primary care organizations that have established ACOs [accountable care organizations] and partner with them. And we have had some success in that space.

Every opportunity we get, we will talk to anybody who’s willing to do the work. And it is that: It’s work. But I do believe ACOs are better positioned to begin with primary care as the foundation and then allow those more sophisticated risk-bearing entities to decide who the specialty providers that they work with should be, and then collaborate together for the best possible patient outcomes.

Panelists Spark Hope for New Liver Cancer Treatments, Clinical Trial Improvements

“Needs and Challenges of Innovating and Advancing Research in Liver Cancers,” a June 2023 webinar hosted by the Global Liver Institute, featured 3 panelists who discussed successes in liver cancer research and where the research community needs to go from here.

Panelists were Ahmed O. Kaseb, MD, professor and program director of hepatocellular carcinoma and the Department of Gastrointestinal Medical Oncology at The University of Texas MD Anderson Cancer Center in Houston; Mark A. McNiven, PhD, director of the Center for Biomedical Discovery at Mayo Clinic in Rochester, Minnesota; and Bruno Sangro, MD, head of the hepatology unit and internal medicine specialist at Clinica Universidad De Navarra in Pamplona, Spain. The moderator was Sarah Manes, MS, director of the liver cancers program at the Global Liver Institute.

Panelists started by discussing their roles and involvement in research projects, the type of research being conducted, and their projects’ goals. Kaseb described the multidisciplinary approach of MD Anderson, where teams work together to help patients in the clinic and to conduct research. This allows him to introduce research to the patients and include them in clinical trials, illustrating how the multidisciplinary approach, clinical activities, and research ultimately benefit patients, he said.

Sangro explained that his research has an immediate benefit for patients through collaborations with drugs and therapies, as well as translational research where samples are collected. Sangro works with the Specialized Programs of Research Excellence (SPORE) program, which was created by the National Cancer Institute (NCI). According to the NCI website, SPORE programs “are designed to enable the rapid and efficient movement of basic scientific findings into clinical settings, as well as to determine the biological basis for observations made in individuals with cancer or in populations at risk for cancer…and promote collaborative, interdisciplinary translational cancer research.”1 Sangro and his team collaborate to promote knowledge that can lead to better therapies in the coming years.

McNiven, whose institution has a SPORE program, noted, “Just to back up 5 or 6 years, when we got involved with SPORE, we noticed that, despite the fact that liver cancers are on the rise and will become the second leading cause of cancer deaths within the next 5 years or so, of the 30 to 40 different SPORE programs, there were none focused solely on hepatic biliary cancers.”¹

Designing clinical trials with hematologists and scientists for specific risk factors in hopes of preventing underlying disease is also a goal of clinical trials, Kaseb said.

“If we do research on the process that leads to cancer, we may find ways of preventing it, which will be very beneficial,” Sangro emphasized.
Manes asked the panelists about gaps in research results and the marginalization of certain communities. Kaseb replied that barriers such as patients with different cultural backgrounds, different levels of health care access, insurance, and cultural understanding of clinical trials exist in the treatment of liver cancer. He continued by highlighting that his experience in medical school and medical training did not prepare him to understand cultural differences and barriers to inclusion in medical trials, not just because of access to insurance and health care, but also in patient understanding.

Sangro continued, saying that more community education on the relevance of medical research is needed. That is “the only way to move forward,” he said.

McNiven was able to pinpoint 2 ways in which research trials have unintentionally excluded minority population: the first was that liver cancer studies have tended to focus on White men, and the other is insurance accessibility. Furthermore, he highlighted the need for trust in diverse communities. He noted that the barrier of stigma persists in the treatment of patients with liver cancer, such as perceiving that someone damaged their liver through intravenous drug use or alcohol use.¹

Added Sangro, “Stigma is behind delayed diagnosis, more difficult access to care, etc. But [it] also impacts funding. I’m sure if you plot the different tumor types and the number of funding activities, nongovernmental funding activities, you’ll see liver is at the bottom and the stigma around liver diseases in general.”¹

McNiven said that a diverse workforce and diverse array of scientists, nurses, and physicians who interact which such communities can better represent those individuals and hopefully help those community members “feel more comfortable toward our interactions.”

Finally, the panelists ended with a conversation on the future of improvements of liver cancer treatments. Sangro specifically highlighted the power of the immune system in fighting liver cancer:

“I think what we have learned over the past decade is that building upon the strength of the immune system gives us the opportunity because this is just the beginning. Immune checkpoint inhibitors, the drugs we now use, [are] just one form of enabling the immune system to fight against cancer. And I’m sure in the next decade [we’ll] see a bloom in immunotherapies other than immune checkpoint inhibitors.”¹

References
National Cancer Institute. Specialized Research Programs of Excellence (SPOREs). Updated May 10, 2022. Accessed July 5, 2023. https://www.cancer.gov/about-nci/budget/fact-book/extramural-programs/spores