There's much evidence to back up that the COVID-19 pandemic exacerbated existing health disparities for vulnerable and marginalized groups. But characterizing the extent of these harms is based in large part on low-quality data sources, including anecdotes, single-institution experiences, and analyses that use indirect socioeconomic data from the U.S. Census in terms of where a patient lives.
That's the argument from a team of New York City researchers from Memorial Sloan Kettering Cancer Center and Columbia University Medical Center. They recently published an article in JAMA Oncology on the topic (2022; doi:10.1001/jamaoncol.2022.4543). Earlier in 2022, they published a study that investigated the association of various demographic factors, as well as social determinants of health data, with cancer treatment delays among patients from multiple sites who had also tested positive for COVID-19 (JAMA Netw Open doi:10.1001/jamanetworkopen.2022.24296).
"Specifically, we were interested to see whether there were any systemic factors in play that impacted delay or cancellation of cancer treatments among a cohort of patients who all had COVID-19," noted Samyukta Mullangi, MD, MBA, a medical oncology fellow at Memorial Sloan Kettering Cancer Center.
The team used ASCO's COVID-19 in Oncology Registry, a large registry built to better understand how having both cancer and COVID-19 interacted and influenced treatment patterns. "The ASCO COVID registry truly was novel in that it collated the experience of scores of community oncology practices," Mullangi said. That's compared with other COVID registries that focused on experiences at academic institutions.
They were also able to incorporate other social determinants of health variables, such as census-tract levels of race, ethnicity, education, income, and health insurance levels, into the analysis by using the American Community Survey, Mullangi explained.
But there are limitations to using the ACS, she noted. "The American Community Survey is often what's used in research looking into social determinants of health because it is the most comprehensive source of such information. Sometimes this is very interesting and useful," she said. "Other times, as we argued in this study, it can be too far removed from the individual patient's experience and during the pandemic a bit delayed to boot."
The point of writing the article was to call out the need for real-time and patient-level data to allow the medical community to act more quickly on findings and operationalize solutions, Mullangi said.
Study Details
For the original analysis, the research team looked at data from 3,028 patients in the ASCO registry. That data was collected prospectively between April 2020 and July 2021 at 60 academic and community medical practices across the United States. Everyone in the registry had a cancer diagnosis, scheduled treatment, and contracted COVID-19.
Treatment delay was considered more than 14 days between the original date treatment was scheduled and the initiation or discontinuation of therapy. The data was split into patients receiving medical, radiation, or surgical oncologic care. The first group was the largest and, therefore, its conclusions may be considered the most robust, Mullangi said. Key findings included the following:
* Almost half of all patients experienced a delay or discontinuation of chemotherapy.
* Factors associated with chemotherapy delay (per a multivariable logistic regression) included Black race relative to White race, Hispanic ethnicity versus non-Hispanic ethnicity, multimorbidity relative to one or fewer comorbidities, metastatic disease relative to local or regional disease, having COVID-19 complications relative to no complications, diagnosis earlier in the pandemic relative to later in the pandemic, and certain variations by malignancy.
* A higher proportion of local area residents reporting Hispanic ethnicity was associated with a lower likelihood of delay among patients receiving medical oncologic care.
* In the radiation cohort, a higher local area median household income was associated with lower likelihood of delay.
Better Data Needed
There's a lot of data that suggests the pandemic worst hit already marginalized communities. But to do better moving forward, Mullangi believes better data is needed.
"At first glance, given the preponderance of data even before the pandemic about the impact that social determinants of health can have on medical outcomes, I would have expected a stronger association between these variables and cancer outcomes," she said. "But the fact is that many of these variables were collected before the pandemic and, therefore, have an element of delay (e.g., the American Community Survey would not have reflected change in employment during the pandemic) and are also incomplete (e.g., the American Community Survey did not collect information on things like household density)."
Two important features include more real-time data and more patient-level data, she noted, as well as better utilizing technology for solutions. "For example, consumers are used to getting real-time updates on their shipments, bank deposits, and a host of other transactions. Patients expect similar back-and-forth with their health systems, and are increasingly more familiar with electronic patient portals or mobile health apps," Mullangi said. "Establishing a technology-assisted system that would allow physicians and health systems to get real-time, patient-reported data can allow for flexibility, accuracy, and responsiveness."
Mullangi believes the bottom line of this topic is this: "The COVID pandemic's exigencies, as well as the current moment in time with the state of technological maturity, both yield to a possible solution-utilizing technology to enable health systems to be the locus of data collection."
Next Steps
So what are the next steps to actually get this done? It's solving both the technical aspects of how to build systems to do this and the logistical and operational aspects of how to implement it. The latter is arguably hard, Mullangi said. The software and technological advances to electronic health records is already happening.
"We anticipate that physician buy-in will be tempered by the expectation of adding more work into a busy clinical schedule, or the fear of yet another metric," she stated. "Further, health systems that collect social determinants of health data on a more routine basis should also put in place resources and workflows for how to respond to the data. For example, if a patient describes food insecurity, this needs to be addressed. Administrators need to be thoughtful in designing a solution that supports clinical care, research, and quality improvement, and align a shared vision across stakeholders."
Sarah DiGiulio is a contributing writer.