Income- and race-related disparities concerning supportive therapies for hormone receptor–positive breast cancer require further study to ensure equitable care and access for all patients, according to Melanie Wain Kier, MD, MBA.
Findings from a retrospective chart review presented during the 2022 American Society of Clinical Oncology (ASCO) Annual Meeting highlighted how income and race impacted the rate at which patients with hormone receptor–positive breast cancer used supportive therapies proven to help mitigate toxicities from aromatase inhibitor, according to Melanie Wain Kier, MD, MBA.1
Patients in the upper-income demographic, or those with family income more than $156,600 per year, had higher rates of supportive therapy utilization (odds ratio [OR], 1.46; P = .031), yet was not associated with a lower 1-year rate of treatment discontinuation. Moreover, Black vs White women had similar rates of aromatase inhibitor–related toxicities but experienced a significantly lower incidence of supportive therapy usage (28% vs 46%).
“I hope our colleagues take away from this conversation more self-awareness and bring it back to themselves,” Kier, a hematology-oncology fellow at Icahn School of Medicine at Mount Sinai in New York, said in an interview to CancerNetwork®. “Be a little more self-aware when you’re interacting with patients. Think [about if you’re] behaving the same with everyone. Is there a reason why higher-income patients receive supportive therapies [more?] Try to bridge the gap with lower- or middle-income patients who are not utilizing those same supportive therapies. Try to make sure that we’re closing those gaps within our own care with our patients.”
In the interview, Kier discussed the rationale and results of her work while suggesting where future efforts and research may go in providing equal access to supportive therapies for hormone receptor–positive breast cancer.
Kier: The title of our abstract that we presented at ASCO was Socioeconomic disparities in supportive therapy use and tolerance of aromatase inhibitors in patients with early-stage, hormone-positive breast cancer. This was an expansion on work that we had done previously that was presented at the 2021 San Antonio Breast Cancer Conference.2 There, we had looked at the impact of supportive therapies on tolerance of aromatase inhibitors in patients with early-stage hormone receptor–positive breast cancer. We found that patients who received 1 or more supportive therapies had increased rates of aromatase inhibitor adherence for 1 year compared with those who did not receive any supportive treatment.
I am interested in health equity and health care delivery and access, so I was interested in building off that. We looked at a lot of demographic factors, but we hadn’t looked at socioeconomic factors that might be affecting our population. While retrospective data are not going to be as good as doing it prospectively, like doing surveys or things of that regard. We wanted to look at whether we were able to evaluate [data] based off zip codes, insurance, and primary language [to see] if there was any impact on the rate of discontinuation of aromatase inhibitors based on the use of supportive therapies. That was the background, the impetus, that brought along this study that we did.
We used the Pew Research Center to help us categorize median family income with zip codes, which is what we pulled from the electronic medical records based on the national census data. We also looked at their insurance coverage and [primary] language, as well as demographics such as race, ethnicity, and others. What we found was that upper income was associated with a higher use of supportive therapies statistically but was not associated with a lower 1-year rate of discontinuation. We didn’t find a difference for lower income [individuals]. We found that insurance—for which Medicare was the most common insurance coverage—[did] not impact use of supportive therapies or rate of discontinuation. Neither did primary language which we categorized as English or other. And in evaluating race, we did find that Black patients had the least use of supportive therapies, yet this group also had the lowest 1-year discontinuation rate. We are not entirely sure why that is, but we’re very interested in exploring [this] to make sure that all patients are being encouraged or at least offered the same supportive therapies and to better understand why this might be.
That is a big question that I wish I had the answer for. One part [of the problem] is identifying disparities and that they exist; it is nice to be able to get data that demonstrate it. A question we’re starting to explore is how to strategize different approaches that we can try to look back at retrospectively to see if they make a difference. I know that we’re brainstorming them ourselves and hopefully there’ll be more of that to come in the future.
From a clinician’s perspective, knowing what sorts of therapies are available [is a start]. Making sure that oncologists or providers, whether they’re allied professionals or the physicians themselves, are very familiar with all of the supportive therapies that do exist is important. There is a long list of [therapies] to help women with adverse effects of aromatase inhibitors to help women with, and having that be geographically available, whether it’s in urban or suburban areas is essential. [Health professionals must] train themselves on the knowledge and feel comfort in prescribing or at least advising patients on all of these great supportive therapies that are proven to help patients tolerate therapies longer. And then a lot of it is about the doctor-patient relationship, and in doctors making sure that they’re having the same conversations with all patients and that they are ensuring that all patients are getting the same care.
Future efforts can be relevant by designing different strategies that we can do prospectively to implement in our clinics and see if they have an impact. We can have a lot of assumptions on what may or may not make a difference and it can help you to narrow this gap. But implementing different strategies from a quality improvement perspective and then evaluating whether those strategies worked and then expanding on whatever is needed is what will be the most helpful. We can look back and say that these [disparities] exist, but designing and implementing strategies to make those changes and assessing them in real time [will be most impactful.]