Programs addressing unmet social needs improve cancer care
Women who face economic vulnerability as well as gynecological cancer would benefit from interventions focused on unmet social needs, improving their care and reducing disparities, according to a prospective survey-based study in Cancer.
Researchers polled 135 women, many of whom were immigrants and living with low incomes, at the public safety-net Olive View-UCLA Medical Center gynecologic oncology clinic near Los Angeles between August 2018 and February 2019.
“When we started this project, I kept reading paper after paper that described inequities in cancer care based on the social determinants of health,” author Abdulrahman K. Sinno, MD, of the Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, told Healio.
“You have decades of data showing that Black patients do worse regardless of where they get treated, for example, or poor patients do worse. Patients who are less educated do worse with cancer care. That was very frustrating,” continued Sinno, who was a member of the staff at Olive View when the study was conducted.
Sinno realized that he was unable to change patients’ social determinants of health, defined as the conditions in which they are born, grow, live, work and age. But he could look at alternative mediators of poor outcomes — specifically, unmet social needs.
Social needs occur when patients lack a basic resource, such as housing, transportation, child care, food, health insurance or even companionship or the ability to read and comprehend medical information.
These needs interfere with care and lead to poor outcomes, Sinno and his colleagues hypothesized. But by addressing these needs, the researchers believed, cancer care outcomes would improve.
The patients in the study had a median age of 54 years (range 23-86 years). Most were Hispanic (60.7%) with Spanish as their preferred language (53.2%). Also, most patients (84.4%) had very low household income. The most common diagnoses were ovarian (37%), cervical (26.7%) and uterine (22.2%) cancer.
“The majority of these patients are immigrants. First-generation immigrants. Non-English speakers. Under- or uninsured,” said Sinno. “The majority have income below 138% of the federal poverty level. And they’re really the most vulnerable patients within our population.”
According to the survey, 65.2% (n = 88) had at least one unmet social need of the 12 that the researchers investigated, and 33.3% (n = 45) had two or more unmet needs.
The most frequently reported need was help with reading hospital materials at 30.4% (n = 41). A lack of someone to talk to, social isolation, housing instability, financial toxicity, food insecurity and transportation difficulties also ranked among the most prevalent needs.
Care suffers when these needs are not met, Sinno said, so Olive View’s gynecologic oncology clinic launched programs and brought personnel on board to remove obstacles and reduce disparities in care.
The clinic’s cancer care navigator, for example, helps patients read hospital materials. This member of the staff also connects patients who are unaware that they qualify for public insurance with Medi-Cal so they do not have to forego needed care.
“They just had no idea services existed or how to access them. And while the process to enroll is not significantly complicated, for patients who don’t even know where to start, or those with poor literacy, or who are misinformed about their rights, these services may as well have not existed,” Sinno said.
When patients skip appointments because they lack transportation, the navigator can customize care plans to stack appointments and minimize travel. Also, patients can get support in applying for transportation assistance programs via their insurance or through the American Cancer Society and other organizations.
“All of this multimillion-dollar research doesn’t mean a thing if the patient can’t make it to the hospital,” said Sinno. “If the patient can come to her visit, then there are no delays in care, and that patient is going to have better outcomes.”
This one position has had a significant and positive impact on the patient population.
“We did a cost-effectiveness study and showed how this single cancer care navigator was able to completely flip outcomes for a whole cohort of cervical cancer care patients. One human being was able to impact entire cervical cancer outcomes for a community,” Sinno said.
Who you hire for these roles makes a big difference, too.
Olive View’s cancer care navigator grew up in the San Fernando Valley. “She knows this population, and she is very committed to it. She is a good human being,” Sinno said.
While these patients confront cancer, they also wrestle with mental health challenges, as 37.8% screened positive for psychological distress during the study.
“There’s a ton of data that shows that patients that have psychological distress have a lower overall survival rate than patients who don’t have that stress regardless of anything else as an independent risk factor,” said Sinno.
That is why Olive View embedded a social worker who specializes in mental health as well as a psychiatry resident and attending physician into its oncology clinic, to remove barriers to mental health care for patients who screen positive for distress.
According to Sinno, patients are screened via the Distress Thermometer and the Emotion Thermometers Tool from the National Comprehensive Cancer Network. Patients simply indicate on these visual tools their level of distress.
The psychiatrist then immediately offers counseling or medication to patients who are identified with psychological distress. The team also traces this distress back to unmet needs such as social isolation and provides a solution such as peer-to-peer support.
“We ask a patient who, for example, has finished ovarian cancer treatment and is in remission if she’d be willing to mentor another patient who is actively going through it,” said Sinno.
Diet plays a significant role in outcomes, but many patients face food insecurity. Olive View then connects patients with nonprofits such as Meals on Wheels America and Project Angel Food to make sure they get the nutrition they need.
Meanwhile, a registered dietician conducts nutritional assessments of each patient and teaches them what to eat during their treatment.
One patient reported vomiting after chemotherapy, prompting Sinno to reduce the treatment’s doses, but the dietician discovered that the patient was rewarding herself after each round of therapy with her favorite spicy meal, causing the nausea. By correcting her diet, outcomes began to improve.
The clinic additionally connects patients with county-sponsored services, such as Housing for Health, which offers safe and supportive housing to patients with complex behavioral and medical needs who are experiencing homelessness.
“How are we going to give someone chemotherapy, and have them be immunosuppressant, and then they go sleep in a tent under a bridge?” Sinno asked. “We connect them with services that already exist without spending money.”
Sinno extols how cost-effective these programs can be, whether they rely on internal staff or on partnerships with outside organizations. Now, the hospital system is creating an entire cancer care navigation model based on the results that Sinno’s clinic produced.
These programs’ successes aren’t just measurable in dollars saved either.
“They not only improve someone’s quality of life. They improve their quantity of life, too,” Sinno said, adding that cancer treatment is not just about drugs and technologies.
“It has to be 360-degree care,” he said.
These results can be reproduced, according to Sinno, who worked with colleagues to develop tools that other clinics can use to implement their own programs using both internal and external resources.
“All hospitals need to institute this,” he said. “Universal social needs and distress screening has to become the norm for all cancer patients.”
Next, the researchers say they will demonstrate how identified social need intervention algorithms can be effectively utilized to improve health outcomes and quality of life while reducing health care disparities.