Trial remedies racial disparities in treatment for early-stage lung and breast cancer patients
Results from a study published in the Journal of the National Medical Association show that a pragmatic system-based intervention within cancer treatment centers can nearly eliminate existing disparities in treatment and outcomes for black patients with early-stage lung and breast cancer. The treatment completion rates before this intervention were 87.3 percent for white patients versus 79.8 percent for black patients. With the intervention in place, treatment completion climbed to 89.5 percent for white patients and 88.4 percent for black patients.
"These results show promise for all cancer treatment centers," said Samuel Cykert, MD, professor of medicine at the UNC School of Medicine and co-principal investigator of the trial.
This trial is similar to another led by Cykert that reduced treatment disparities for patients with early-stage lung cancer, while this study focuses more on breast cancer patients. The results of the previous work were published in the journal Cancer Medicine in February.
Leading up to these trials, Cykert and his colleagues conducted studies in 2005 and 2009 to find out why race disparities in cancer treatment exist. They found multiple reasons that contribute to the overall reduction in treatment.
"We found what seems to be implicit bias with some clinicians that made them less willing to take the same risks with patients that were different from them," Cykert said. "A black and a white patient of the same age could require the same surgery, have the same comorbidities, have the same income and insurance, yet white patients were more likely to receive the surgery and get their cancer treated."
Cykert says they additionally found that black cancer patients who did not have a regular source of care, as a result of poor clinical communication, did not end up pursuing adequate diagnosis or treatment. This finding highlights the need for systems that fully follow the trajectory of patient care. Rather than blaming the patient for incomplete care, recognition of these barriers allows for the cancer team to be accountable for re-engagement and full communication to promote completion of standard treatments.
"With that knowledge, we wanted to build a system that pointed out these lapses in care or communication in real time to help us keep track of patients who would otherwise drop off the grid," said Cykert.
The intervention consisted of multiple parts: a real-time warning system derived from electronic health records, race-specific feedback to clinical teams on treatment completion rates, optional health equity training sessions for staff, and a nurse navigator specially trained in racial equity to engage with patients throughout treatment.
The real-time warning system notified nurse navigators when a patient missed an appointment or treatment milestone. The navigator then reached out to the patient to reengage and bring them back into care. The nurse navigators were encouraged to become familiar with patients and build trust in case of a missed appointment, miscommunication between doctor and patient, or other circumstance that created a potential barrier to care.
Cykert, who is a member of the UNC Lineberger Comprehensive Cancer Center, says he and colleagues came up with the intervention model in partnership with the Greensboro Health Disparities Collaborative, an academic-community partnership experienced in community-based participatory research. Their goals were to create elements of real-time transparency, race-specific accountability, and enhanced patient-centered communication.
"I think it is revolutionary that we have devised an intervention to address the way that the health care system creates disparities," said Kari Thatcher, co-chair of Greensboro Health Disparities Collaborative. "We have made systemic changes that close the disparity gap and have improved health care for all races involved."Terence "TC" Muhammad, fellow co-chair of the Collaborative, said, "This is a result of real collaboration amongst researchers, health care providers and community members that helped shape an action plan to make real change."
One of the participating institutions, Cone Health Cancer Center in Greensboro, NC, is now working towards permanently implementing this intervention into its cancer care for all patients.
"This treatment model can be applied to most any chronic disease," said Matthew Manning, MD, interim chief of oncology for Cone Health, who helped support the ACCURE trial. "It builds a more culturally competent care delivery system that would benefit all chronic diseases."
The study team recruited 302 patients aged 18-85 from Cone Health and University of Pittsburgh Medical Center's Hillman Cancer Center in this prospective trial sponsored by the National Cancer Institute. Cykert was a co- principal investigator along with Geni Eng, DrPH, in UNC Gillings School of Global Public Health, a national expert in community participatory research.
Researchers are in the process of submitting a grant proposal with the National Cancer Institute to implement this intervention to cover whole cancer center populations rather than study patients alone.
More information: Samuel Cykert et al. A Multi-faceted Intervention Aimed at Black-White Disparities in the Treatment of Early Stage Cancers: The ACCURE Pragmatic Quality Improvement trial, Journal of the National Medical Association (2019). DOI: 10.1016/j.jnma.2019.03.001