Reintroducing SDOH: Conversation with ASCO Past President Dr. Lori Pierce

Social Determinants of Health in Cancer Care

This episode sets the stage for the second season of the Social Determinants of Health (SDOH) in Cancer Care series. As the first African American president of ASCO, Dr. Pierce continues to build her legacy on her presidential theme, “Equity. Every Patient. Every Day. Everywhere.” We will discuss the landscape of SDOH in cancer care. Dr. Pierce will share what sparked her interest in SDOH and why she considers a focus on patient social needs a critical aspect of cancer care. In addition, to highlighting ASCO’s efforts and continued charge to make progress to address cancer health inequities.

TRANSCRIPT

The guest on this podcast episode has no disclosures to declare.

Dr. Reggie Tucker-Seeley: Hello and welcome to the second season of the ASCO Social Determinants of Health series. I am Dr. Reggie Tucker-Seeley, Vice President of Health Equity at ZERO - The End of Prostate Cancer, and Chair Elect at ASCO's Health Equity and Outcomes Committee. With me today is Dr. Lori Pierce, Professor with tenure in Radiation Oncology, and Vice Provost for Academic and Faculty Affairs at the University of Michigan, and Director of the Michigan Radiation Oncology Quality Consortium. Dr. Pierce served as President of ASCO in 2020 through 2021, and is the current Chair of the Board of the Association for Clinical Oncology.

Welcome, Dr. Pierce. Thank you for joining us today.

Dr. Lori Pierce: I am absolutely delighted to join you today. So thank you for having me. And I am particularly thrilled to be talking about social determinants of health and to be the first of the 2.0 episodes of Social Determinants of Health. As you know, we had an initial series, and it really focused on some of the basics of the social determinants of health and really understanding the impact of these determinants on cancer care. And when we did the first Social Determinants of Health series, we really focused on trainees and early career oncologists because, of course, these are going to be our future leaders. So we had an advisory group made up of trainees and early oncologists, and they suggested various topics, and those topics then led to the series. So it is a thrill for me to be on the first episode of Social Determinants of Health 2.0.

Dr. Reggie Tucker-Seeley: Great. And I participated in that first round. So those first episodes were really meant to lay the foundation to introduce social determinants of health to the oncology community. And in this next set of episodes, what we're attempting to do is to answer the question of how to address social determinants in the cancer care delivery system to advance cancer health equity. While we've been talking about social determinants of health and public health, which is where I was trained for quite some time now, these discussions are relatively new in healthcare delivery and cancer care delivery and research. So in this next set of episodes, what we're hoping to do is to answer the question that I often get asked, that we all often get asked in the social determinants of health space by cancer care providers, by cancer care researchers and community organizations, is: What can we do? How do we actually address social determinants in the cancer care delivery system?

So in this episode, we will discuss where the current conversation is in cancer care delivery related to the social determinants of health and hopefully help to move from talking about this issue to action within the cancer care delivery system. And Dr. Pierce will share her thoughts on how far we have come and how far we have to go when it comes to addressing the social determinants of health and cancer health inequities.

So there's been an increase in the discussion about social determinants of health and patient social needs. However, I've realized in my own work related to health disparities and social determinants of health that not everyone comes to the table knowing what these terms mean. And one of our first podcast episodes was about defining terms. And our Social Determinants of Health Task Force introduced our definitions for these terms in our ASCO Daily News post that I co-authored with Dr. Surendranath Shastri of MD. Anderson. But Dr. Pierce, can you tell our listeners why these initial first steps of aligning on definitions is so important and how you define these terms for your practice and for your research?

Dr. Lori Pierce: So I prefer to use a comprehensive community-based definition of social determinants of health. I know, as you said, there are different ways that we can define it, but I have generally used the World Health Organization's definition. It's a very comprehensive definition. Social determinants of health are really those non-medical factors that influence health outcomes. And they talk about these conditions in which people are born, grow, work, live, and age, so along the full continuum. And they talk about the wider set of forces and systems that really shape the conditions of our life from beginning to end. And quite honestly, these forces end up being related to power and money. You see that these forces include economic policies that will disadvantage one group compared to another and systems that have been in place for a long, long time, again that disadvantage one group relative to another. There are development agendas, there are social norms, social policies, and they are just political systems that are ingrained in our lives. And they then allow these social determinants of health which then influence health inequities. And the unfair and avoidable difference is that you see, no matter what country you're in, that health and illness follow a social gradient, with those who have the lower socioeconomic position in all cases doing worse. And obviously, we are in cancer, and we see that's reflected with respect to increased mortality rates for those who are in a lower socioeconomic status.

So that's the good news with using the social determinants of health definition as defined by the World Health Organization. But the downside is it's broad. And so, in order for it to be really useful, we have to decide how we are going to define it within our own practices, and then we have to define metrics. As you said, we can talk about social determinants of health forever, but the point is, what are we going to do? What changes are we going to make? And so you have to translate that into metrics where you can assess that there is change, change with regard to screening, change with regard to intervention. And we also have to take into account the intersectionality of so many of these factors. And we think about factors such as obesity, violence, poverty, stress, and communities. So many of these factors that are connected. And a good example is, let's say you have a patient where we have advocated weight loss to improve the patient's outcome both for their overall health and also to decrease the risk of certain cancers. And so you have this program, and you advise this person to exercise, and they're being very diligent, but you're not really seeing a change in outcome. Well, it's probably because they live in an environment where crime is such an issue, where they can't go outside and actively exercise. So again, we have to be aware of the intersectionality of so many of these factors that will hold us back from really moving the needle for social determinants of health.

Dr. Reggie Tucker-Seeley: That's such a great example. We come to the table not just, or we come to the healthcare delivery system, not just with that single issue that sort of brought us to care. We bring our whole selves to the care encounter. So it's important that those are recognized as we navigate that system. I think it's so important to have our leaders recognize the importance of social determinants of health. And during your tenure as ASCO President, you championed cancer health equity and elevated the focus on social determinants of health. So where do you hope to see ASCO go in addressing social determinants of health and health inequities? That is, how can we build on what you started during your term as ASCO president?

Dr. Lori Pierce: Well, first of all, I want to say that I strongly feel that we've come such a long way. So much of the groundwork was already in place at ASCO before my presidency. I mean, everything ASCO has done since ASCO existed has been to focus on the improvement of the care of patients. And a part of that, of course, is being able to weed out those inequities and make it an equitable system. So when I then became President, the stars were aligned. And ASCO, with the work they were doing, they had the infrastructure in place, and they could not have been more encouraging, more supportive of the work that we wanted to do. So one of the programs, as I mentioned earlier, the Social Determinants of Health, the initial set of podcasts, as you mentioned, really looked at some of the basics of social determinants of health. And we had things such as taking a Social Determinants of Health History, which you were a key part of that podcast. And it really focused on we as physicians have been taught to take a history, but if we don't ask the right questions, we won't be able to elicit the barriers that patients are facing, which are largely the social determinants of health. And we focused on the cost of cancer care. We focused on modifiable risk factors such as tobacco cessation. We talked about access. We talked about a lot of the basic tenets of social determinants of health.

During my presidency, we also focused on an initiative where we want to increase the accrual of minorities onto clinical trials so that everyone has equal access to trials. And we know this has been something that has been worked on by so many amazing researchers such as yourself through the years. And so we harnessed a lot of the ideas from many of our colleagues to really promote and put together an outline and a guide that institutions can use to improve their enrollment of minorities on trials. And we also worked on a program to help to bring in more minority medical students into Oncology to make them aware of all the amazing programs and careers that they can have in Oncology.

And then, Dr. Everett Vokes was president from 2021 to 2022, and his focus was advancing equitable cancer care through innovation. And he really extended my theme for equity of care and really focused on bringing down barriers across scientific disciplines, using innovation at the intersection of medicine, technology, and scientific discovery. And that was an important initiative worldwide. And then, Dr. Eric Winer, who’s our current president, his theme is ‘Partnering with Patients: The Cornerstone of Cancer Care and Research’. Of course, we do so much, but we have to take the lead from our patients. We have to listen to them. We must understand their barriers, and we must partner with them. And that will be his focus for this year. So there is a lot that ASCO has done and will continue to do to really hone in on how we can eliminate social determinants of health.

Dr. Reggie Tucker-Seeley: Well, it's so great to see this sustained discussion around health disparities generally and social determinants of health specifically. And although we've come a long way in talking about social determinants of health and healthcare delivery, there remain many, many barriers to implementing efforts to actually address the social determinants of health in the cancer care delivery system. So in your own practice and research, what have you heard during your tenure as ASCO President? And can you tell our listeners about some of the facilitators and barriers to addressing the social determinants of health and patients' social needs in the cancer care delivery system? And if you have any best practices around how we can remove or limit those barriers, I'm sure our listeners would be eager to hear those as well.

Dr. Lori Pierce: So I firmly believe that advocacy is key. Everyone can advocate at a local level, at a regional level, at a national level, or even at an international level. We work with patients every day, we hear their stories, and we can advocate for patients. In many cases, they're not able to advocate for themselves. One key example of how advocacy is so important was the Clinical Treatment Act, which was passed. And that was a policy where prior to this law being passed, unlike patients who had Medicare coverage, unlike those who had private insurance, those who had Medicaid did not have their routine care costs covered for if they were participating in a clinical trial. So things like seeing your doctor, getting routine blood studies, getting routine X- rays, getting anti-medics, those kinds of things that are needed when you're on a clinical trial, Medicaid patients did not have that covered. But if they were not on a clinical trial, it was paid for.

So then, going on a clinical trial was a disincentive for patients who had Medicaid coverage. And this was a group of patients that we absolutely want to be able to offer a clinical trial to, as we do with everyone else. And so when that was changed, when that law was passed, we now have the resources for Medicaid patients to be able to have those routine care costs covered. And how did it get passed? It was passed because of advocacy. Everyone can advocate. So awareness, acknowledgement, appreciation, understanding of what our patients are going through. Be aware. And we all need to improve our listening skills, again taking Social Determinants of Health History and listening to what our patients are saying.

In the Perception of Health Equity survey that ASCO conducted during my year as President, we learned that most providers were aware of health disparities but didn't feel prepared to address them. And we also learned that respondents wanted resources to empower them to address disparities, such as scripts for communicating with patients and additional training. So we learned a lot through that survey to help us as ASCO to make materials available to our patients. And we started to deliver on resources through the ASCO-ACCC research statement on diversifying clinical trials. That was the initiative that I mentioned. We partnered with ACCC, the Association of Community Cancer Centers, to ensure that there is a document that institutions can follow to assess where their barriers are for allowing patients to go in trials. And I'll say that's a very detailed assessment because every practice is different. The barrier in one practice may not be the barrier in another practice, but we want to be able to self-assess where the barriers are so that we can eliminate them. And a perfect example is, let's say you are a practice where you have 100 African-American patients who walk in your door in one month, but only three of them go in a clinical trial. Well, this assessment says: What happened to the other 97? Where were the steps that we lost these patients? And so it's very important to do a self-assessment.

And we also focused on the ‘Just ASK’ training program, which really focused on implicit bias. We all have biases. We have to know our biases, and we have to eliminate those biases. And this is a very powerful tool to really self-reflect on our own biases. So these tools are now available on the ASCO website. And I would encourage everyone to take advantage of them, utilize them fully.

Dr. Tucker-Seeley: Well, thank you so much, Dr. Pierce, for illuminating those examples. I think one point that you made regarding the Perception of Health Equity Survey was this notion of why screen if you can't navigate and connect the patient to a resource. And then the importance of understanding the individual context around the particular practice in order to implement social needs screening and addressing patient social needs.

But in doing that and in addressing patient social needs, oftentimes, the physician is viewed as the captain of the healthcare delivery team. But for social determinants of health and addressing patient social needs, we might need a different captain to lead this approach. So how might we prepare teams or systems for identifying the best leader of this effort? How can physicians be champions of cancer care equity, and then what is one resource or action that a listener can do today?

Dr. Lori Pierce: So, with regard to having cancer teams and captains, I think we need to have co-captains. We need to have an inclusive team of physicians, nurses, nurse practitioners, PAs, pharmacists, clinical pharmacists, social workers, et cetera, because each of us brings an expertise to the group. And there may be ease and also availability for the patient to interact with members of the team who may not always be the physician. So, I think in order to optimize communication, we need to have multiple captains. We need to be co-captains. We all need to work together. People excel in different ways.

We need to make sure the infrastructure is in place to do what we need to do to have these teams and to be successful. And so, we have to make sure that we've got the resources, we have the infrastructure. So, we have to engage leadership in these conversations so that we know we have the support we need. We can't do this without leadership support. And everyone, I think, really needs to be held accountable. Everyone can be an advocate for their patients. As I mentioned before, we can be involved at the state level, local level, or even the national level.

And ASCO has programs to help connect our members and to help bring them in so they can be engaged in an advocacy effort. There's a day that ASCO and ASCO members go to the Capitol Hill to advocate, and I can tell you, having done that multiple times, it is a very powerful experience because, again, we bring the stories – we're not making this up. We bring the stories of the patients that we see. And our lawmakers don't have that perspective, and we give them that perspective, and then they really get it in terms of how important the things are that we're advocating for. Meetings are held with the representatives on the Hill, and I would encourage our ASCO members to be active in that program.

And then again, the ASCO-ACCC Site Self-assessment Tool for Clinical Trial Participation. All patients who want to participate in clinical trials should have the opportunity to do so. And I would highly encourage our members to take that self-assessment tool and see where our institutions, where our practices, where the barriers are, and also to take the Implicit Bias Training. And you can visit asco.org/equity to access both of those tools.

I can't emphasize enough that no act is too small. There is something that everyone can do to move the needle and to decrease the inequities, and make this a more equitable system. Advocate for your patients. Listen to your patients. They are always our North Star. They're always the ones to guide us.

Dr. Reggie Tucker-Seeley: Dr. Pierce, thank you so much for those closing comments. I do want to highlight those last couple of points that you raised, that is, the importance of having the infrastructure in place within your system because that ensures sustainability of being able to address these social needs so that the program isn't just a pilot program. The importance of advocacy – I served as a Health Policy Fellow for a year, so I was on the receiving end of those stories, and those stories are indeed important to policymakers. And they definitely inform how those policies get developed and implemented. And then lastly, understanding your context for implementing patient social needs and understanding the infrastructure around that implementation.

So again, thank you so much, Dr. Pierce, for your leadership on health equity and social determinants of health here at ASCO. And thank you to our audience for joining us for this first episode of ASCO's Social Determinants of Health, our second season.

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