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Addressing Challenges in Cancer Care With Dr. Neeraj Agarwal

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May 26, 2022

Dr. Neeraj Agarwal, of the
University of Utah Huntsman Cancer Institute, tells host Dr. John
Sweetenham, of the UT Southwestern Harold C. Simmons Comprehensive
Cancer Center, about the first study to examine the quality of
diagnosis and treatment of breast cancer in sex and gender minority
patients and other key studies on disparities associated with
access to clinical trials and rising drug
costs.
 


Transcript

Dr. John
Sweetenham:
Hello, I’m
John Sweetenham, the associate director for Clinical Affairs at UT
Southwestern Harold C. Simmons Comprehensive Cancer Center and host
of the
ASCO Daily
News
podcast. 

I’m delighted to welcome my friend
and colleague Dr. Neeraj Agarwal, the director of the Genitourinary
Cancers Program and a professor of medicine at the University of
Utah’s Huntsman Cancer Institute. Dr. Agarwal also serves as
editor-in-chief of the
ASCO
Daily News.
 

Today, he’ll be sharing his insights
on compelling studies that will be featured at the 2022 ASCO Annual
Meeting, addressing access to clinical trials, disparities
associated with high deductible health plans, rising drug costs,
and more.
 

Our full disclosures are available in
the show notes and disclosures of all guests on the podcast can be
found on our transcripts at
asco.org/podcasts.
 

Neeraj, it’s great to have you back
on the podcast.
 

Dr. Neeraj
Agarwal:
Thanks,
John.
 

Dr. John
Sweetenham:
Neeraj,
let’s begin with
Abstract
6503
. This study looks at the
impacts of high deductible health plans on delays in metastatic
cancer diagnosis. What do you think about this study and why should
it be on our radar?
 

Dr. Neeraj
Agarwal:
Well, John, in
high deductible health plans, patients are liable for the cost of
all cancer-related care, with the exception of screening tests,
until their annual deductible is met. Due to increased
out-of-pocket costs, patients may postpone seeing a physician for
concerning symptoms or diagnostic testing, leading to delayed
diagnosis.
 

So, in this study,
Mr. Nicholas Trad
and J.
Frank Wharam
assessed the impact
of high deductible health plans on the timing of metastatic cancer
detection.
 

The authors leveraged a nationally
representative cohort of more than 340,000 privately insured
members whose employers mandated a switch from a low deductible of
less than $500 plan to a high deductible plan of more than
$1,000.
 

So, the group consisted of more than
1 million individuals in a contemporary time frame, whose employers
offered only low deductible plans. Participants were matched based
on multiple baseline characteristics, time to metastatic cancer
diagnosis, and the before and after switching to high deductible
health plans was investigated using a weighted Cox
proportional-hazards model.
 

After matching, there were no
systematic differences between the 2 groups with regards to
baseline characteristics, and there were no differences in time to
metastatic cancer diagnosis prior to the switch to high deductible
health plans.
 

However, after the employer-mandated
switch to the high deductible health plans, these participants had
lower odds of metastatic cancer diagnosis, which was significant,
statistically speaking, and indicates delayed detection of
metastatic cancer diagnosis relative to the control
group.
 

Dr. John
Sweetenham:
This is
certainly concerning data, Neeraj. What’s your key takeaway from
this study?
 

Dr. Neeraj
Agarwal:
So, the key
takeaway from the study is that compared with conventional health
plans, high deductible health plans are associated with delayed
detection of metastatic cancer, implying that patients postpone
seeking care for concerning symptoms or even defer diagnostic
testing when they’re exposed to high-cost
sharing.
 

Dr. John
Sweetenham:
Thanks,
Neeraj. So, let’s continue with this theme of the financial burden
of cancer care for our patients. Of course, we’re all aware of the
rising costs of targeted oral therapies, and this was addressed
in
Abstract
6504
, where the study looks
at the rising costs of targeted oral treatments among Medicare
beneficiaries. And the study reported a substantial increase in the
total cost and out-of-pocket costs of these medicines. Can you tell
us more about this abstract?
 

Dr. Neeraj
Agarwal:
Yes! So, due to
the rapidly rising cost of targeted oral anticancer medicines, Drs.
Meng Li and
Ya-Chen T.
Shih
examined recent trends and
the financial burden of these oral medicines among patients with
cancer with Medicare Part D insurance. So, eligible patients in the
SEER-Medicare database had to be 65 years and older and had to have
one primary cancer diagnosis.
 

The investigators estimated the
trends in the share of patients who used targeted oral anticancer
medicines, the percentage of users reaching catastrophic coverage,
and the total and patient out-of-pocket spending on these medicines
in the catastrophic phase in a year.
 

So, from 2011 to 2016, the uptake of
these oral anti-cancer medicines increased from approximately 4% to
9%. The percentage of those who reached catastrophic coverage
increased from 55% to 60%.
 

Among those who reached the
catastrophic phase, the mean total annual gross spending on oral
anti-cancer medicine increased 4-fold from approximately $16,000 to
$64,000. And the mean out-of-pocket spending for the patients rose
from approximately $600 to $2600.
 

Dr. John
Sweetenham:
Yes, this is
more evidence that the financial toxicity generated from an
increase in spending and out-of-pocket costs is going to have
serious impacts on our patients. Would you agree with that,
Neeraj?
 

Dr. Neeraj
Agarwal:
Yes, John. The
key takeaway from this study is that the financial burden of these
oral anti-cancer medicines continues to increase. In the relatively
short period of time, we see here, 5 years from 2011 to 2016, there
was a 4-fold increase in the total cost and out-of-pocket cost of
these medicines. And in my view, these findings warrant immediate
actions to rein in drug prices and cap out-of-pocket spending for
our patients.
 

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Dr. John
Sweetenham:
Absolutely.
It’s very difficult to know where this will end unless we see some
kind of slowdown in these rising costs. I’m going to change gears
just a little bit now to address the access to clinical trials,
which is the subject of
Abstract
6505
. 

This study looks at the
implementation of the Affordable Care Act Medicaid expansion, which
was associated with an almost threefold increase in the proportion
of patients using Medicaid in cancer clinical trials by early 2020.
What are your thoughts on this study?
 

Dr. Neeraj
Agarwal:
As you said,
the Affordable Care Act Medicaid expansion resulted in increased
use of this platform across the nation. However, its impact on
access to clinical trials has not been
examined.
 

So, in this study, Dr. Joseph Unger
and Dr. Dawn Hershman examined the number and proportion of
patients insured by Medicaid at enrollment over time using data
from the SWOG Cancer Research Network.
 

In addition, they also examined all
patients, 18 to 64 years old, enrolled in treatment trials between
1992 to 2020 using Medicaid versus private
insurance.
 

So, the implementation of the
Affordable Care Act Medicaid expansion was associated with a nearly
threefold increase from 7% to 21% in the proportion of patients
using Medicaid in cancer clinical trials by early
2020.
 

The increase per year of Medicaid
uses for patients in these treatment trials from states that
implemented the Affordable Care Act Medicaid expansion was 27%
compared to 7% for patients from other states who did not implement
this platform of Affordable Care Act Medicaid
expansion.
 

So, the key takeaway from the study
is that better access to clinical trials for more vulnerable
patients is critical to improving confidence in how generalizable
these trial findings are. In addition, these results suggest that
the recently enacted Cancer Treatment Act may continue to improve
access to clinical trials for those with Medicaid insurance or
those who are vulnerable patients.
 

Dr. John
Sweetenham:
Yes, I think
this is a really important study which adds to the growing
literature on the benefits of the Affordable Care Act and Medicaid
expansion on cancer care in general, in this case, specifically
related to clinical trials. So, so important, I
think.
 

On that theme of equity, I think the
next 2 abstracts we’re going to discuss address specific aspects of
equity, which I think are both interesting and really important.
So,
Abstract
6510
has interesting research
which conveys an urgent need to ensure equitable patient-reported
access and implementation and to address the greater reported
symptom burden among minority patients. Why do you think this study
is important?
 

Dr. Neeraj
Agarwal:
The routine
collection of patient-reported outcomes for patients with cancer is
an evidence-based practice and a critical component of high-quality
cancer care, but the real-world adherence and reporting patterns
are poorly understood.
 

In this study, Dr. Samuel Takvorian
and Dr. Ravi Parikh examined differences in adherence to the
collection of patient-reported outcomes and reported symptoms by
race and ethnicity.
 

This was a retrospective
cross-sectional study using de-identified electronic health record
data from an National Cancer Institute (NCI)-designated
Comprehensive Cancer Center. The participants included adults seen
in follow-up at 1 of the 2 medical oncology practices—one was in
academics and one was in the community—from June 2019 to February
2020. Using ordinary least-squares regression, the authors modeled
patient adherence as a function of race or ethnicity, and this was
adjusted for age, sex, insurance, median area income, ECOG,
performance status, and many other patient-related
characteristics.
 

The results show that adjusted mean
PRO adherence and reported symptoms varied by race and ethnicity,
with Black and Hispanic patients being less likely to complete PRO
questionnaires, but reporting significantly higher symptom burden
compared to the White patients.
 

Dr. John
Sweetenham:
Right. So,
it seems that more work is needed to ensure equitable access and
adherence to PRO questionnaires so we can better address the
symptom burden of our minority
patients.
 

Dr. Neeraj
Agarwal:
Correct, John.
In this large cohort reflecting real-world PRO collection patterns,
Black and Hispanic patients were less likely than White patients to
complete these PRO questionnaires, but more likely to report more
severe symptoms. And I think there is an urgent need to ensure
equitable PRO access and implementation and to address the greater
reported symptom burden among minority
patients.
 

Dr. John
Sweetenham:
Let’s
continue the theme of health equity and cancer care equity into the
use of telemedicine. Of course, we saw a massive expansion of
telemedicine for patients with cancer during the COVID-19
pandemic.
 

But studies are emerging now to show
that there have been substantial disparities among the Black,
uninsured, non-urban, and less affluent patients who are less
likely to use telemedicine services.
 

Abstract
6511
reminds us that
telemedicine may expand access to specialty care, but the
proliferation of these services may widen cancer care disparities
if vulnerable populations don’t have equitable access. Can you tell
us more about this abstract?
 

Dr. Neeraj
Agarwal:
These are
indeed very interesting findings, John. The COVID-19 pandemic was
associated with declines in in-person clinical visits, with a
concurrent increase in the use of
telemedicine.
 

In this study, Dr.
Gregory S. Calip
assessed demographic and socioeconomic
factors associated with telemedicine use among patients initiating
treatment for 21 common cancers at community oncology
clinics.
 

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This was a retrospective study and
made use of the nationwide Flatiron electronic health record
derived de-identified database of patients with cancer. The authors
focused on differences in telemedicine use across race and
ethnicity, insurance coverage, rural versus urban areas, and
socioeconomic status.
 

They used logistic regression models
for this analysis, which was adjusted for clinical characteristics
to examine differences in telemedicine use among these different
cohorts.
 

Results indicate Black patients were
significantly less likely to use telemedicine services compared to
White patients. Telemedicine use was also significantly lower among
patients without documented insurance than well-insured patients.
It was also lower in patients from rural and suburban areas versus
patients who were living in urban areas. Lastly, telemedicine use
was significantly lower in patients in the least affluent areas
than those in the most affluent areas.
 

So, during the COVID-19 pandemic,
nearly one-fifth of patients initiating cancer treatment using
telemedicine services—among these patients, we see substantial
disparities. So, Black, uninsured, non-urban, and less affluent
patients were less likely to use telemedicine
services.
 

So, the take home message from this
study is that while telemedicine may expand access to care, the
proliferation of these services may actually widen cancer care
disparities if vulnerable populations do not have equitable access
to these services.
 

Dr. John
Sweetenham:
Thanks,
Neeraj. So, the final study that we’ll discuss today also looks at
another aspect of disparities, and that’s
Abstract
6517
. It’s a case-controlled
study of health care disparities in sex and gender minority
patients with breast cancer. What are the key takeaways from this
study?
 

Dr. Neeraj
Agarwal:
Disparities and
the quality of diagnosis and treatment of breast cancer in sex and
gender minority populations are largely undefined. Only 24% of
studies funded by the National Cancer Institute capture data on
sexual orientation and only 10% capture data on gender
identity.
 

In this case-control study, Drs. Eric
Eckhert and
Allison W.
Kurian
matched sex and gender
minority patients with breast cancer to cisgender heterosexual
controls in the Stanford University health care database.
Ninety-two sex and gender minority patients were identified who
were then matched by year of diagnosis, age, stage of cancer,
presence of estrogen receptor (ER), and HER-2/neu receptor status
to cisgender heterosexual controls within this
database.
 

Additional data on demographics,
diagnosis, treatment, and relapse were then manually abstracted
from the electronic health care records. The sex and gender
minority cohort were comprised of 80% lesbians, 13% bisexuals, and
6% transgender men.
 

One of the most pertinent findings
was a significant, almost twice as much delay in time to diagnosis
from the onset of symptoms in these minority patients versus
control. Although there was no difference in the receipt of surgery
or surgical radiation or new adjuvant therapy, sex, and gender
minority patients were significantly less likely to undergo chest
reconstruction surgery, and if they were estrogen
receptor-positive, they were significantly less likely to complete
at least 5 years of ER directed
therapy.
 

Please also note that sex and gender
minority patients used more alternative medicine, had a higher rate
of documented refusal of recommended oncology treatments, and they
experienced a higher recurrence rate.
 

So, the key takeaway from this study
is that—this is the first study, I really want to congratulate the
investigators who examined the quality of diagnosis and treatment
of breast cancer in sex and gender minority patients. Several novel
potential health care disparities are identified in these patients,
which should be further evaluated in population-based studies to
inform further interventions.
 

Dr. John
Sweetenham:
Neeraj, it’s
always a pleasure to talk with you and have an opportunity to spend
some time with you. Thanks very much for sharing your insights on
these compelling studies today. Our listeners will find the links
to these abstracts in the transcripts of this
episode.
 

Dr. Neeraj
Agarwal:
Thanks,
John.
 

Dr. John
Sweetenham:
And thanks
to our listeners for your time today. If you’re enjoying the
content on the
ASCO Daily
News
podcast, please take a
moment to rate, review and subscribe wherever you get your
podcasts.
 

Consulting or Advisory Role: EMA
Wellness
 

Consulting or Advisory Role: Pfizer,
Medivation/Astellas, Bristol-Myers Squibb, AstraZeneca, Nektar,
Lilly, Bayer, Pharmacyclics, Foundation Medicine, Astellas Pharma,
Lilly, Exelixis, AstraZeneca, Merck, Novartis, lily, Eisai, Seattle
Genetics, EMD Serono, Janssen Oncology, AVEO, Calithera
Biosciences, MEI Pharma, Genentech, Astellas Pharma, Foundation
Medicine, and Gilead Sciences  
 

Research Funding (Institution):
Bayer, Bristol-Myers Squibb, Takeda, Pfizer, Exelixis, Amgen,
AstraZeneca, Calithera Biosciences, Celldex, Eisai, Genentech,
Immunomedics, Janssen, Merck, Lilly, Nektar, ORIC Pharmaceuticals,
ORIC Pharmaceuticals, CRISPR therapeutics, and
Arvinas 
 

The purpose of this podcast is to
educate and to inform. This is not a substitute for professional
medical care and is not intended for use in the diagnosis or
treatment of individual conditions.
 

Guests on this podcast express their
own opinions, experience, and conclusions. Guest statements on the
podcast do not express the opinions of ASCO. The mention of any
product, service, organization, activity, or therapy should not be
construed as an ASCO endorsement.
 

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