How Social Determinants of Health Affect Access to Breast Cancer Therapies

It is crucial to understand how social determinants of health (SDOH) are related to health literacy, so that patients can navigate a very complex health care system, says Lidia Schapira, MD, FASCO, professor of medicine at Stanford Medicine, medical oncologist, and director for the Stanford Cancer Institute and the Stanford Comprehensive Cancer Center.

This transcript was lightly edited; captions were auto-generated.

Transcript

What are some of the most prominent SDOH that impact timely access to breast cancer diagnosis and treatment?

That's a very thoughtful and comprehensive question. I think resources, of course, a person's insurance, which is often dictated for working adults by their employer; that's the first thing to think about. For people who are not employed, it's also their insurance. If they're above 65 [years], they have access to Medicare. If they are either disabled or have other extenuating circumstances in low income, they may also be eligible for support through programs like Medicaid or Medi-Cal. I think a person’s access is first of all determined by where they can go, have a consultation, and get treatment for their cancer. Their access may also be in some way determining or contributing to the stage at which their cancer is diagnosed. If they have access to preventative services and regularly get screening, they are more likely to be diagnosed—not always—but more likely to be diagnosed with an earlier stage breast cancer, which improves their prognosis.

I think it's the most important thing in the US to consider. Other social determinants of health are perhaps related to health literacy, how much a person knows about how to respond to a new symptom, to a new medical diagnosis, whether they feel any urgency, [and] whether they have any sort of idea how to navigate a very complex system. Other determinants of health have to do with lived experiences and family experiences with health care. If a person has had a very bad experience or family member or somebody in their community, they may be more reluctant to ask for help or to enter into the health care establishment. I think those are sort of the all the primary ones, access to both preventative care that may determine screening and stage of diagnosis and access to specialty care, which is often not the same as primary care, prior experiences, and their own understanding of what it means to be diagnosed with cancer and to need treatment.

What are the biggest challenges clinicians face in ensuring patients have access to the latest treatment options, including targeted therapies and clinical trials?

That's also a great question, because I think that oncologists in general think that they're in this fight together with the patient on the patient side, and often the perceived enemy is the insurer or the payer. We spend a lot of time, and certainly our members of our team spend a lot of time getting preauthorizations or fighting denials from insurers. I think that is that is a real issue. It's a few things. One is that the cost of some cancer therapies are so prohibitive that an individual can't afford it unless their insurance can pay for it, and therefore the insurance companies also contract with the medical establishments, and patients have to sort of abide by those rules, whether we're talking about getting a diagnostic test such as an MRI or paying for a new targeted therapy, which may be prohibitively priced. Even the copays may exceed a person's ability to pay. I think all those things are really important. A person's resources, their ability to sort of navigate the health care establishment, their insurance, which again depends for most working adults on their employer, are all important determinants. I think that for physicians, it puts us often in a bind when we think that there is a good treatment for somebody, but we find that for a number of reasons, they may not be able to access it.