A Solution to Cancer Disparities Improves Care for All

For decades, researchers have documented disparities in the US cancer burden, especially in racial and ethnic groups. Black women have lower rates of breast cancer than White women, for example, but they are more likely to die of the disease.

In response, numerous studies have sought to understand and find remedies for the complex causes. But few studies have assessed any interventions for their actual effect on narrowing the differences in outcomes, as a recent review pointed out.

One study stands out. A few years ago, a pair of US cancer centers agreed to see if making a few changes in their care system could help close the racial gap for their patients. 

In the 5-year study, the changes eliminated the treatment disparities between Black and White patients with early-stage lung and breast cancer. As hoped, more Black patients completed their treatment — and so did more White patients.

The evidence from this study, called ACCURE (Accountability for Cancer Care through Undoing Racism and Equity), was a milestone of hope amid longstanding differences in who lives and who dies that has less to do with disease biology and more to do with the circumstances of people’s lives. 

The causes of disparities may be complex, with roots in seemingly intractable issues of historical, socioeconomic, and geographic factors. But the study shows some differences can be addressed by straightforward solutions at the point of patient care. And the data also show the same changes can improve care for everyone.

“When you build a system where care is transparent, you don’t have to know the reason that somebody’s not getting care along the way,” said Samuel Cykert, MD, who helped lead the study. “If I’m building a system that helps everyone, and no matter what the reason is they’re not progressing, if a signal comes up, then a caring individual can deal with that patient and that clinical situation and fix it.”

Data Tell the Story

ACCURE enrolled 302 patients diagnosed with early-stage lung and breast cancer at two cancer centers, Cone Health in Greensboro, North Carolina, and Hillman Cancer Center in Pittsburgh, Pennsylvania, between April 2013 and March 2015. 

The successful intervention combined a real-time electronic health record alert system for missed care milestones, specially trained patient navigators for individualized assistance in overcoming barriers to care, and clinical team feedback on treatment completion rates according to race.

The primary outcome was completing treatment. For breast cancer, that included surgery, radiation and chemotherapy. For lung cancer, it was either surgery or stereotactic body radiotherapy, as well as chemotherapy if warranted.

None of these components were new inventions to address racial disparities in cancer care, Cykert and his co-authors noted in their paper, but the trial combined them in a way that worked for their patients.

The research team set up two statistical control groups — a retrospective control of nearly 9000 patients diagnosed up to 5 years earlier and a concurrent control of almost 3000 patients diagnosed about the same time and not enrolled in the intervention. 

Black patients in the intervention group achieved a treatment completion rate of 88.4%, compared with 89.5% for White patients, a statistical tie. The overall treatment rates also improved compared with that for the retrospective control individuals (79.8% Black individuals; 87.3% White individuals) and for Black patients compared with that for the concurrent control individuals (83.1% Black individuals; 90.1% White individuals).

More dramatic results surfaced in a larger analysis focused on patients with early-stage lung cancer. The analysis combined data from ACCURE and another study Cykert helped design to look at the effect of ACCURE-like interventions on black patients with lung cancer at three other cancer centers in North and South Carolina. In the combined results, treatment rates in the intervention group surged to 96%, a jump from 76% in the retrospective group overall and from 69% in Black patients. It also boosted treatment rates for all, compared with the retrospective baseline.

The ACCURE system changes seemed to spill over to benefit all similar cancer patients in the Cone Health system, according to a follow-up analysis led by Matthew Manning, MD, a radiation oncologist at Cone Health who was involved in the original ACCURE study. Cykert is a co-author.

Manning reported higher 5-year survival rates for both Black and White breast cancer patients and White lung cancer patients. In a statistical knock out of the racial gap, the 5-year survival narrowed in breast cancer from 91% for White individuals and 89% in Black individuals to 94% for both groups. The 5-year survival also increased for lung cancer: From 43% to 56% in White patients and from 37% to 54% in Black patients. 

“The really important thing is taking a systematic approach,” said Cykert, a general internist and health services researcher at the University of North Carolina School of Medicine, Chapel Hill, North Carolina. “It’s relatively cheap. It’s easy to do. And it helps everybody.”

Community-based Partnership

ACCURE arose from a collaborative group organized to address disparities in Greensboro, North Carolina and beyond, which included Cykert. They began by interviewing Black and White breast and lung cancer survivors who had undergone treatment in that last year. An in-depth analysis exposed “pressure points” in the care system that either encouraged or discouraged them from continuing their care.

The group came up with the idea of ACCURE and its guiding concepts — transparency, accountability and communication. They secured funding from the National Cancer Institute to test how well the system changes worked to reduce the Black-White racial disparity in treatment completion among patients with early-stage lung and breast cancer. 

Cykert and his colleagues figured out how to translate the three guiding concepts into the clinic. Through the trial, the community group met monthly with the research partners to discuss study design, express concerns and weigh in on decisions.

Lung cancer is the leading cause of cancer death for both men and women in the United States, and breast cancer is second only to lung cancer in women. Nationally, the Black-White difference in lung cancer survival has narrowed, but hasn’t budged much in breast cancer, where Black women continue to have nearly a 40% higher mortality rate.

Components of Better Care

The researchers used electronic health records to develop a real time registry and alert system when care wasn’t progressing the way it should. They programmed milestones of care into the records, such as surgery scheduled within 60 days for lung cancer or the timing of chemotherapy or radiation therapy or testing in breast cancer. This was the hardest part, according to Cykert.

The cancer centers used different electronic health record software, and patients had separate electronic health records for different services, such as in-patient, out-patient, radiology, and cancer center. It took almost a year to harmonize some health records and build an umbrella system that could utilize all the data.

A second piece of the conceptual framework was accountability. “On a quarterly basis, we gave feedback to clinical teams as to how they were doing and included race specific data,” Cykert said. ACCURE also established “physician champions” at each institution.

At first, clinicians responded to the data feedback, correcting any clinical inertia and taking action to move the patient through treatment. “But as the years of the study progressed, we saw less of that [waiting for feedback], because people were aware that this sort of thing happens” and monitored patient milestones proactively to keep treatment on track, Cykert said.

The third part of the package was communication. “We trained navigators, not only about common barriers to care, but about specific barriers that affect disadvantaged groups, and those navigators proactively stayed involved with the patient,” he said. “They didn’t wait till there was a problem before they would jump in.”

System Changes Improve Care for All

ACCURE holds broader lessons for cancer disparities in all communities, said Erica Warner, MPH, ScD, a cancer epidemiologist at the Massachusetts General Hospital in Boston.

She and her co-authors highlighted the ACCURE study as a promising solution in a recent meta-analysis that found Black women have a higher risk of dying from breast cancer across all tumor subtypes, showing the higher rates are at least partly independent of tumor biology.

Warner likened efforts like ACCURE to those involved in building a culture of safety in medical care arenas.

“It is a great example of a system-level intervention that used data to help people identify where there were disparities and then also provided the resources to address them,” she said.

Cone Health has integrated ACCURE lessons and strategies into its usual cancer care, Manning told Medscape Medical News. They rely on a database built into the electronic medical record and patient navigators to ensure patients complete the planned therapy. 

Beyond oncology, Cone Health has applied the concepts of transparency and accountability to tackle racial disparity in other diseases, with an incentivized twist. Quality improvement endpoints for hypertension, diabetes, and psychiatric conditions according to race are tracked, reported, and tied to hospital leader compensation.

“At the root of the work, ACCURE takes a new perspective on healthcare delivery which is more patient centered,” Manning said. “People from all walks of life face barriers in healthcare, which may range from transportation, financial, medical literacy, childcare, etc. While these burdens are heavier for people of color, they exist to some extent for all. Historically, health systems would make services available and hold patients fully responsible to overcome barriers to complete care. When ACCURE shifts the responsibility and accountability of treatment completion from the patient to the healthcare system and creates supporting roles and a safety net, it not only closes racial gaps but improves the delivery for all.”

From Evidence to Implementation

It takes time to apply and adapt even the most promising evidence-based solutions so that patients in other communities can reap the benefits, but one component appears to be on the verge of mainstream care for cancer and perhaps other chronic diseases: Patient navigation.

“The idea of oncology patient navigation has gained a lot of traction” since the ACCURE results, said Vikas Mehta, MD, MPH, associate professor and vice chair of Otolaryngology/Head and Neck Surgery at Montefiore Medical Center in the Bronx, New York. Montefiore was one of the 21 institutions in a 2-year patient navigation study that just ended.

“The ACCURE trial is my favorite study, because it actually eliminated disparities,” said Mandi Pratt-Chapman, PhD, associate professor of medicine at the George Washington University Cancer Center in Washington, DC. Pratt-Chapman and her colleagues highlighted the trial in one of the lessons on a free online training for oncology patient navigators they developed with funding from the US Centers for Disease Control.

Better Cancer Care at Risk

The results reflect how health care for all can be improved by catching patients before they fall behind in care. But the right-wing crusade to end racial equity efforts may put evidence-based quality improvements — and patient lives — at risk.

The federal directive to eradicate diversity, equity and inclusion (DEI) services reaches beyond government agencies, schools and universities, and corporations. It affects cancer care and research. Recently, Fred Hutchinson Cancer Center, Seattle, Washington, announced the end of its DEI initiatives because of “the federal administration decision to make the termination of DEI programs a condition of federal funding.”

“The political landscape adds complicating layers for those of us who are trying to study and reduce racial disparity,” Manning said. “But there are themes in the ACCURE study that point out a better way to deliver healthcare for all. Healthcare outcomes can be measured as a Bell curve with most patients in the middle, and outliers at both ends. If researchers study a subpopulation that achieves poorer results, identifies reasons, and creates universal solutions from that work applied to the whole population, the ACCURE study would suggest that all subgroups of the population may benefit.”