Social Determinants of Health Play Key Role in Patients’ Health Journey

Although advances in screening, treatment, and survivability provide hope for patients with cancer, data demonstrating ongoing disparities in health outcomes indicate these benefits are not experienced equally. A recent study showed that over 2 decades, the 5-year survival rate for patients younger than 50 with colorectal cancer improved for White individuals but not for those who are Black, Hispanic, or Asian American. Additionally, Black patients with multiple myeloma have more than double the mortality rate seen among White patients.¹

However, the data show that disparities in cancer care are not solely experienced by populations based on race, as members of the LGBTQ+ community face disadvantages compared with heterosexual patients in terms of screening, diagnosis, and treatment.² In rural areas of the country, the data show that LGBTQ+ individuals have a 17% higher cancer death rate.³ These and other widely documented cancer health disparities are a pervasive challenge threatening health outcomes for patients with cancer and the achievement of health equity in the United States.

Disparities occur most frequently in population groups defined by race/ethnicity/national origin, disability, sexual orientation, gender identity, geographic location, income, education, and age.⁴ As we identify and learn more about cancer and the health disparities facing populations within this field, complex interrelated social determinants of health (SDOH) are increasingly understood to be major drivers of individual and public health. Examining SDOH in the context of cancer treatment within specialty pharmacies is critical to helping address SDOH and cancer health disparities more broadly.

SDOH and Cancer Disparities

To help clarify the growing use of this term in the field, SDOH are defined as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health functioning, and quality of life outcomes and risks.”⁵ Healthy People 2030 was approved by the US Department of Health and Human Services (HHS) in June 2018 and developed based on recommendations made by the HHS Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030. Healthy People 2030 groups SDOH into 5 domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context.

Specialty pharmacies are positioned at the treatment phase of the patient journey, with SDOH in this context including myriad issues that can affect outcomes. For example, patients from underserved communities may present with more advanced forms of cancer due to their living environment; behavioral and psychological risk factors; genetic predisposition; and lack of access to screening, prevention, and quality health care. These patients also may not trust providers due to previously experienced discrimination or bias. Communication barriers, low levels of health literacy, and financial toxicity are also challenges experienced at a higher level among populations predisposed to health disparities.³

Among the underserved and communities of color, the data show that unmet socioeconomic needs negatively impact cancer therapy adherence.⁶ For example, Black and Hispanic patients have been shown to experience financial toxicity twice as often as White patients, which can lead to financial coping behaviors such as skipping doses or rationing medications. Additionally, racial and ethnic minority populations have a documented higher rate of negative adverse effects (AEs) while undergoing cancer treatment.³

Addressing SDOH in Specialty Pharmacies

Achieving health equity requires action from all stakeholders in health care. The National Academy of Medicine recommends 5 actionable ways to address SDOH: awareness, adjustment, assistance, alignment, and
advocacy.⁷ Specialty pharmacies can use this approach to improve, refine, and advance service and support for patients in a way that promotes positive outcomes while addressing SDOH.

Awareness
For specialty pharmacies, approaches that address awareness include ensuring leadership and staff understand SDOH and the resulting disparities, as well as the importance of culturally competent care. Awareness in specialty pharmacies also includes efforts to analyze the organization’s structural components to uproot policies or practices that could unintentionally marginalize or stigmatize patients (or employees). It may also mean taking a critical, ongoing look at programs and services, identifying how patients with cancer are triaged to community and other support resources, identifying potential gaps, and tracking service outcomes relative to SDOH.

Adjustment
Approaches that address adjustment in specialty pharmacies include changes to policies and procedures, as well as the provision of support in clinical and nonclinical settings to better meet social needs that may be influencing patient health.

Assistance
To address assistance in specialty pharmacies, approaches can include allocation of clinical and other support resources to reduce barriers to care, provision of patient navigation services, and promoting adherence to therapy while minimizing AEs and reactions.

Alignment
Specialty pharmacies can take approaches that address alignment through developing and sustaining partnerships with other health care stakeholders, community partners, and local support agencies to address SDOH challenges and health disparities.

Advocacy
A key area for specialty pharmacies is advocacy, which can be accomplished by ensuring a specialty pharmacy’s staff are uniting around the focused goal of voicing and promoting the need for change to conditions that contribute to health inequities within specialty pharmacies and beyond.

Moving Toward a More Equitable Future
Research indicates cancer disparities are a result of determinants within and outside the health system including SDOH, racism, and discrimination.⁶ Although much remains to be done as we move toward achieving cancer health equity, it is important to remember that progress is being made toward that goal.

In the past 2 decades, the disparity in overall cancer mortality between Black and White populations has been reduced by half. Effective interventions addressing SDOH and promoting equity have been proven to reduce disparities while improving care for all patients.³
Specialty pharmacies are positioned at a critical juncture for patients with cancer. By understanding the impact of SDOH in the context of cancer treatment, specialty pharmacies can help improve outcomes and move
toward a more equitable future for all patients with cancer.

References
1. Persistent racial, ethnic disparities found in survival rates for early-onset colon cancer. News release. American Gastroenterological Association. May 24, 2022. Accessed July 14, 2022. https://www.eurekalert.org/news-releases/953191
2. Cedars-Sinai Cancer: Erasing LGBTQ+ healthcare disparities. News release. Cedars-Sinai Cancer. May 19, 2022. Accessed July 14, 2022. https://www.newswise.com/articles/cedars-sinai-cancer-erasing-lgbtq-healthcare-disparities
3. AACR Cancer Disparities Progress Report 2022. American Association for
Cancer Research. Accessed June 15, 2022. http://www.CancerDisparitiesProgress-Report.org/
4. Cancer disparities. National Cancer Institute. Updated March 28, 2022. Accessed July 14, 2022. https://www.cancer.gov/aboutcancer/understanding/disparities
5. Social determinants of health. Healthy People 2030. Accessed July 14, 2022. https://health.gov/healthypeople/priority-areas/social-determinants-health
6. Tong M, Hill L, Artiga S. Racial disparities in cancer outcomes, screening,
and treatment. Kaiser Family Foundation. February 3, 2022. Accessed July 14, 2022. https://www.kff.org/racial-equity-and-health-policy/issue-brief/
racial-disparities-in-cancer-outcomes-screening-and-treatment/
7. Alcaraz KI, Wiedt TL, Daniels EC, Yabroff KR, Guerra CE, Wender RC.
Understanding and addressing social determinants to advance cancer health equity in the United States: a blueprint for practice, research, and policy. CA Cancer J Clin. 2020;70(1):31-46. doi:10.3322/caac.21586