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When researchers looked at the load of psychological stressors that contribute to biological functioning in a cohort in South Carolina, they found something somewhat surprising: Race didn’t play a role when social factors were taken into consideration.
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November 2021The study of what’s known as allostatic load—the day-to-day living pressures that can affect cellular stress and contribute to disease—found that this burden was, instead, significantly linked to social isolation and income, said Chanita Hughes Halbert, PhD, who is leading the work and is the associate director for cancer equity at the University of Southern California Norris Comprehensive Cancer Center in Los Angeles.
The finding is an example of the expanding research base on the social factors that contribute to racial disparities in medical outcomes, an area of particular importance in head and neck cancer, in which some of the greatest disparities exist among all cancer outcomes.
The priorities in clinical work and public health, when it comes to social health determinants, should be to make these determinants standardized and measurable, to develop workflows that refer patients to needed services, and to measure patient acceptance of these services and the outcomes that result, she said.
Researchers in the South Carolina projects are examining the effects of stress reactions and allostatic load on immune responses to a prostate cancer vaccine among survivors who are at a high risk of recurrence; identifying new biomarkers in prostate tissue samples and characterizing them based on allostatic load as well as social and psychological factors; and integrating genomic and sociobiological data to guide development of prostate cancer treatment, Dr. Halbert said.
I think that when we measure our outcomes we should also consider not just the quality of
care we provide, but how well do we do across a variety of different disadvantaged groups. —John Cramer, MD
The disparities in head and neck cancer outcomes between socioeconomic groups are stark, said John Cramer, MD, assistant professor of otolaryngology–head and neck surgery at Wayne State University. A study in 2018 found that the one-year survival rate was about 10% lower for the quintile that was the most deprived compared to the least deprived, and five-year survival was 25% lower (Int J Cancer. 2019;144:1262-1274).
Treatment delay plays a big role in disparities. Patients, of course, can contribute to this delay by way of lack of screening, poor health literacy, cultural beliefs that run counter to prompt treatment, and insurance concerns, Dr. Cramer said. Delays associated with providers—including delays in seeing otolaryngologists and diagnostic errors—contribute as well. “We can try to build systems to ensure that those who have symptoms that are potentially concerning are seen as expeditiously as possible, hopefully within a week or less,” he said.”
Research on Treatment Delays
It has been known for a long time that treatment delays are common and lead to worse outcomes for patients with head and neck cancer. It’s only relatively recently, however, that research has drilled down into the causes of treatment delays and developed strategies to improve the delivery of timely head and neck cancer care, said Evan Graboyes, MD, MPH, associate professor in the departments of otolaryngology–head and neck surgery and public health at the Medical University of South Carolina in Charleston. Work by Dr. Graboyes’s team suggests that inadequate patient education, post-treatment complications, care fragmentation, and travel for socioeconomically disadvantaged patients are also key causes of treatment delay (JCO Oncol Pract. 2021;17:e1512-e1523).
Researchers at Stanford University used the A3 problem-solving approach to create strategies for tackling these delays. This is a step-by-step approach in which the problem is identified, the current situation is described, goals and targets for the desired condition are developed, a root cause analysis is performed, countermeasures are considered and planned for, results are gathered, and follow-up and review are performed (J Otolaryngol Head Neck Surg. 2018;159:158-165). Researchers identified important delay drivers in starting postoperative radiation therapy, including failure to perform dental extractions in a timely manner, delayed radiation oncology consults, and inadequate patient engagement.
This work to understand the reasons for treatment delays has resulted in new strategies to improve the delivery of timely care for patients with head and neck cancer, he said. Researchers in the Stanford University study showed that after measures to fix these steps were put into place, delays in starting adjuvant therapy dropped from 38% to 27%. At the Medical University of South Carolina, a program was put into place to improve patient education, provide travel support, restructure care delivery processes, improve care coordination, and enhance referral tracking. Following these changes, they found that the rates of delay decreased from 45% to 14%.
Thomas R. Collins is a freelance medical writer based in Florida.