1. Samson, Kurt

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Changes in cancer clinics' support structures can help early-stage lung and breast cancer patients complete treatment, improve survival rates, and offset racial disparities, according to the first prospective study designed to uncover influencing factors and erase gaps in cancer treatment completion and survival among African-American and White patients.

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By identifying and addressing obstacles that kept patients from finishing radiation treatments for cancer, a targeted intervention improved 5-year survival rates for all patients and erased the survival gap between African-American and White patients. Findings of the trial were presented at the 2021 American Society for Radiation Oncology (ASTRO) Annual Meeting (Abstract 53).


"Thousands of studies have looked at racial disparities in health care, but until recently, very few studies have implemented interventions to eliminate those disparities," said lead author Matthew A. Manning, MD, a radiation oncologist and Chief of Oncology at Cone Health in Greensboro, N.C. "This study shows that it can be done."


He presented the findings from the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) clinical trial, which involved multiple changes to the way patients were provided support while receiving cancer treatment.

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The research included four components: 1) an electronic health record with automatic alerts to flag missed or unmet milestones in expected care; 2) using a nurse navigator trained in race-specific barriers to help patients overcome obstacles to care when alerts are flagged; 3) a physician "champion" to engage health care teams with race-related feedback on treatment completion; and 4) health equity education training sessions for staff.


Previously published results showed the ACCURE intervention greatly reduced disparities in treatment completion rates during curative radiation therapy or surgery for early-stage breast or lung cancer, Manning noted.


Study Details

In the study, researchers compared 5-year survival rates among 1,413 patients with Stage 0, I, and II lung and breast cancer who were treated after the intervention began, with 2,016 patients treated prior to the system changes.


Before the intervention, the 5-year survival rate for African-American patients with breast cancer was 89 percent, compared to 91 percent for White patients. After the system-level changes were initiated, 5-year survival rates for both groups rose to 94 percent. Among those treated for early-stage lung cancer, survival rates increased from 37 percent to 54 percent for African-American patients, and from 43 percent to 56 percent for White patients.


"Historically, African-American and White patients had different survival rates after treatment, but that difference disappeared [in the trial]," said Manning. "We are now able to say that this intervention eliminated disparities in overall survival."


African-American individuals face the highest cancer death rate and shortest cancer survival rate of any racial/ethnic group in the U.S. According to the American Cancer Society, African-American populations also encounter "greater obstacles to cancer prevention, detection, treatment, and survival." By identifying and addressing the specific obstacles facing their patient populations-like limited access to transportation or difficulty taking time off work without penalty-and intentionally examining how obstacles varied by race, the ACCURE team was able to curb the negative impact of these barriers, Manning noted.


"The bottom line is, unless we ask what happens when an appointment or milestone is missed, we just don't know what's going on, and the patient may never come back to us," he stated. "If we do ask, we often have systems in place that can address those barriers. We can provide transportation or provide a letter for the patient for work. We can overcome many barriers, both internal and external to our health care institutions, but only if we know what they are."


Manning previously led a pilot study that found providing a free rideshare program to transport patients to radiation therapy sessions reduced no-show rates among vulnerable populations.


An emphasis on structural, institutional change rather than individual change to combat disparities was key to the ACCURE trial's success, said Samuel Cykert, MD, Professor of Medicine at the University of North Carolina School of Medicine and principal investigator for the trial.


"The onus for change is on the system, not the individual patient. People can't help it if they miss a treatment day because they have a child to take care of, for example. The intervention also flags delays in care within the health system itself that occur even when patients don't miss appointments," he said.


"The clinic can provide safety nets by instituting a method to flag these obstacles and delays, and by having steps in place to help the patient return to and complete treatment. That made all the difference with this trial," Cykert noted.


Investigators took direction from the foundational work of the Greensboro Health Disparities Collaborative-a longstanding, community-initiated partnership between medical, academic, and community representatives-when designing the intervention, said Christina Yongue, MPH, MCHES, Assistant Professor of Public Health Education at the University of North Carolina at Greensboro and project manager for the ACCURE trial.


"The main concepts driving ACCURE-transparency, accountability, and enhanced communication-came out of this collaborative and workshops on racial equity that were required for providers and staff," said Yongue. "These pillars were essential to building trust with our research participants, especially with African-American patients who are historically marginalized in health care. The clinical results would not have been possible without this trust."


Moving forward, the ACCURE team is considering other applications for the intervention, such as addressing disparities in pregnancy/maternal care. "We've shown it's possible to eliminate disparities in cancer treatment completion and that this change has the potential to close cancer survival gaps downstream," Manning stated. "But we think the application can be much broader."


Kurt Samson is a contributing writer.