Inequalities: Disparities and Discrimination in Cancer Care
Nicolò Battisti, Co-Chair of the Inequalities Network, opened the session by observing there are many potential sources of inequalities and are among the major reasons for variations in cancer care and outcomes. This is no longer acceptable and beating inequalities should be a priority for policymakers. However, any advocacy should involve concrete action, and to those ends he introduced the Resolution to be voted on at the end.
Hendrik Van Poppel, Co-Chair of the Network, said they have identified a number of immediate priorities in tackling inequalities, the most remarkable being the East-West divide in Europe, but also those relating age, ethnicity, gender, sex, education, socioeconomic status and disabilities. Age and the East-West divide were the subjects of a special Community 365 Roundtable Meeting on Inequalities on 14 October 2020, which led to the launch of an action report: It Can Be Done – Beating Inequalities in Cancer Care.[3]
Row 1 - Kateřina Konečná MEP (European Parliament’s Special Committee for Beating Cancer); Nicolò Battisti (European Cancer Organisation’s Inequalities Network); Robert Greene (European Cancer Organisation’s Patient Advisory Committee). Row 2 - Hendrik Van Poppel (European Cancer Organisation’s Inequalities Network); Richard Sullivan (Journal of Cancer Policy; Institute of Cancer Policy, King’s College London); Katie Reeder-Hayes (American Society of Clinical Oncology). Row 3 - Lori J. Pierce (American Society of Clinical Oncology); Masum Hossain (Pfizer).
Every Patient, Every Day, Everywhere
Lori J. Pierce, President of ASCO, highlighted that every country has disparities in cancer outcomes. Examples in the USA include black males having the highest incidence and death rates from cancer, and black females having a 40% higher rate of breast cancer deaths than white women.
These inequalities are highly dependent on the social determinants of health and shaped by the distribution of money, power and resource. These can be addressed through initiatives such as reducing smoking rates and improving access, and via the prevention, early detection and treatment of cancer, and improved survivorship.
The scope needs to be broader than biological factors and include community-omics, as well as examining the intersectionality of interdependent factors. All factors need addressing together, otherwise there may be no change at all.
Pierce’s theme for her ASCO presidency is every patient, every day, everywhere, and now is the time to focus on equity of care. It is easy to say but complicated to achieve, however. The forces holding back equity need to be addressed. Biases need examining and bold action is required. ASCO has done this since the start through outreach programmes, care initiatives in older adults and grants focused on health disparities, among others.
The Delaware Cancer Treatment Program showed that when black and white colorectal cancer patients had equal access to care, their survival rates were almost the same, and care was cheaper because everyone was treated appropriately and in a timely fashion. ASCO is looking at how to apply these lessons more broadly, and is launching new initiatives to include minorities and offer practical solutions, as well as an oncologist training programme in social determinants and asking patients about them.
It is important to break down silos to fuel discussion and to embed equity. To those ends, ASCO has changed its mission statement to: Conquering cancer through research, education, and promotion of the highest quality and equitable patient care.
Inequalities Will Only Increase
Richard Sullivan, Editor-in-Chief of the Journal of Cancer Policy, and Director of the Institute of Cancer Policy at the King’s College London, said inequalities drive many policy changes and lead to fundamental declines in patient outcomes.
There will be appalling increases in inequality in the coming years that will not meet the values of social justice, and the impact will be felt directly on cancer outcomes. Looking around the world, it is clear some countries have seen huge increases in the gross domestic product, but development has been extremely unequal. Crucially, there is no model for transitioning cancer services, and many patients have to make huge journeys to obtain care.
The Time is Now
Robert Greene, Member of the European Cancer Organisation’s Patient Advisory Committee, said the time to combat disparities and discrimination across all areas is now. It is not enough to understand them but to look at how individuals live their lives in terms of social support, work and comorbidities.
Yet how well are they represented in discussions? The only way to achieve change is to not only talk about people dealing with disparities but also talk with them. Collaboration is key for the development and execution of plans, and the European Code of Cancer Practice is the perfect tool for that.[5]
Focusing on Preventable Inequalities
Kateřina Konečná MEP, Member of the European Parliament’s Special Committee on Beating Cancer, said the common features of the cancer strategies in Europe are early detection, affordable and effective treatments and working with patients.
Cancer risk factors are often discussed but there must be more focus on these to prevent cancer. Interventions to reduce exposure to cigarettes, alcohol and other carcinogens are needed to slow the growth of new cases.
Coordinated action is needed and behavioural modification interventions should be available to all healthcare disciplines, not just oncologists. Konečná said addiction is a clear sign of inequality in a society. As complete abstinence is almost impossible, however, the focus should be on risk reduction.
Another major issue is the lack of an EU-wide HTA. The devolution of HTAs to member states is a source of disparities between countries that causes huge delays in access to cancer care.
The Power of the Cancer Dashboard
Masum Hossain, Presidentof International Developed Markets at Pfizer, highlighted the growing inequality between Central and Eastern Europe and the rest of Europe, which could be made worse by the COVID-19 pandemic.
Pfizer has collaborated with a range of stakeholders over the development and implementation of national cancer control plans (NCCPs). While there has been some progress, notably in Poland, Ukraine and Croatia, more than half of Eastern European countries still do not have an NCCP.
Building on the importance of collating evidence for change and organising data to gain insights and make better quality decisions, Pfizer is helping develop country cancer control dashboards. These are designed to enable policy and decision-makers identify gaps and areas for improvement, and provide a benchmark to monitor policy development.
The dashboards are developed in collaboration with a range of experts, and this highlights the importance of multi-stakeholder engagement. Pfizer has held meetings across the region, but translating that into actionable solutions to improve cancer outcomes is crucial.
This was underlined by the Community 365 Roundtable Meeting on Inequalities and its subsequent action report,[3] which emphasised how partnership is fundamental to understanding inequalities and develop policy action to narrow the divide.
The Universal Impact on Inequality on Outcomes
In the following discussion, Katie Reeder-Hayes, Chair of the Health Equity Committee of ASCO, said the exact mechanisms by which social disadvantage is connected to cancer outcomes vary between countries and regions but the link itself is universal. And the way that link is broken can be common to different settings, and be shared.
The levers affecting this include being aware of biases, and examining how providers who serve the most disadvantaged patients are themselves served by the healthcare system and society, which affect care delivery everywhere.
Sullivan added that welfare and employment policies need updating to stop the so-called ‘brain drain’, where nurses and other oncology professionals migrate to Western Europe due to a poor remuneration and a lack of career progression in their home countries.
The Time for a Pan-European Health Policy is Now
Konečná said a common health policy at a European level could be achieved if patient and cancer organisations create enough impetus. Before COVID-19, there was a lack of interest in health but this focus should be used to push the agenda.
She believes the biggest barrier is the national governments, but the European Parliament supports these efforts. The time to make the change is now.
