Social Determinants of Health in Cancer Care

This episode sets the stage for the second season of the Social Determinants of Health (SDOH) in Cancer Care series. As the first African American president of ASCO, Dr. Pierce continues to build her legacy on her presidential theme, "Equity. Every Patient. Every Day. Everywhere." We will discuss the landscape of SDOH in cancer care. Dr. Pierce will share what sparked her interest in SDOH and why she considers a focus on patient social needs a critical aspect of cancer care. In addition, to highlighting ASCO's efforts and continued charge to make progress to address cancer health inequities. TRANSCRIPT The guest on this podcast episode has no disclosures to declare.  Dr. Reggie Tucker-Seeley: Hello and welcome to the second season of the ASCO Social Determinants of Health series. I am Dr. Reggie Tucker-Seeley, Vice President of Health Equity at ZERO - The End of Prostate Cancer, and Chair Elect at ASCO's Health Equity and Outcomes Committee. With me today is Dr. Lori Pierce, Professor with tenure in Radiation Oncology, and Vice Provost for Academic and Faculty Affairs at the University of Michigan, and Director of the Michigan Radiation Oncology Quality Consortium. Dr. Pierce served as President of ASCO in 2020 through 2021, and is the current Chair of the Board of the Association for Clinical Oncology. Welcome, Dr. Pierce. Thank you for joining us today.  Dr. Lori Pierce: I am absolutely delighted to join you today. So thank you for having me. And I am particularly thrilled to be talking about social determinants of health and to be the first of the 2.0 episodes of Social Determinants of Health. As you know, we had an initial series, and it really focused on some of the basics of the social determinants of health and really understanding the impact of these determinants on cancer care. And when we did the first Social Determinants of Health series, we really focused on trainees and early career oncologists because, of course, these are going to be our future leaders. So we had an advisory group made up of trainees and early oncologists, and they suggested various topics, and those topics then led to the series. So it is a thrill for me to be on the first episode of Social Determinants of Health 2.0.  Dr. Reggie Tucker-Seeley: Great. And I participated in that first round. So those first episodes were really meant to lay the foundation to introduce social determinants of health to the oncology community. And in this next set of episodes, what we're attempting to do is to answer the question of how to address social determinants in the cancer care delivery system to advance cancer health equity. While we've been talking about social determinants of health and public health, which is where I was trained for quite some time now, these discussions are relatively new in healthcare delivery and cancer care delivery and research. So in this next set of episodes, what we're hoping to do is to answer the question that I often get asked, that we all often get asked in the social determinants of health space by cancer care providers, by cancer care researchers and community organizations, is: What can we do? How do we actually address social determinants in the cancer care delivery system?  So in this episode, we will discuss where the current conversation is in cancer care delivery related to the social determinants of health and hopefully help to move from talking about this issue to action within the cancer care delivery system. And Dr. Pierce will share her thoughts on how far we have come and how far we have to go when it comes to addressing the social determinants of health and cancer health inequities.  So there's been an increase in the discussion about social determinants of health and patient social needs. However, I've realized in my own work related to health disparities and social determinants of health that not everyone comes to the table knowing what these terms mean. And one of our first podcast episodes was about defining terms. And our Social Determinants of Health Task Force introduced our definitions for these terms in our ASCO Daily News post that I co-authored with Dr. Surendranath Shastri of MD. Anderson. But Dr. Pierce, can you tell our listeners why these initial first steps of aligning on definitions is so important and how you define these terms for your practice and for your research? Dr. Lori Pierce: So I prefer to use a comprehensive community-based definition of social determinants of health. I know, as you said, there are different ways that we can define it, but I have generally used the World Health Organization's definition. It's a very comprehensive definition. Social determinants of health are really those non-medical factors that influence health outcomes. And they talk about these conditions in which people are born, grow, work, live, and age, so along the full continuum. And they talk about the wider set of forces and systems that really shape the conditions of our life from beginning to end. And quite honestly, these forces end up being related to power and money. You see that these forces include economic policies that will disadvantage one group compared to another and systems that have been in place for a long, long time, again that disadvantage one group relative to another. There are development agendas, there are social norms, social policies, and they are just political systems that are ingrained in our lives. And they then allow these social determinants of health which then influence health inequities. And the unfair and avoidable difference is that you see, no matter what country you're in, that health and illness follow a social gradient, with those who have the lower socioeconomic position in all cases doing worse. And obviously, we are in cancer, and we see that's reflected with respect to increased mortality rates for those who are in a lower socioeconomic status.  So that's the good news with using the social determinants of health definition as defined by the World Health Organization. But the downside is it's broad. And so, in order for it to be really useful, we have to decide how we are going to define it within our own practices, and then we have to define metrics. As you said, we can talk about social determinants of health forever, but the point is, what are we going to do? What changes are we going to make? And so you have to translate that into metrics where you can assess that there is change, change with regard to screening, change with regard to intervention. And we also have to take into account the intersectionality of so many of these factors. And we think about factors such as obesity, violence, poverty, stress, and communities. So many of these factors that are connected. And a good example is, let's say you have a patient where we have advocated weight loss to improve the patient's outcome both for their overall health and also to decrease the risk of certain cancers. And so you have this program, and you advise this person to exercise, and they're being very diligent, but you're not really seeing a change in outcome. Well, it's probably because they live in an environment where crime is such an issue, where they can't go outside and actively exercise. So again, we have to be aware of the intersectionality of so many of these factors that will hold us back from really moving the needle for social determinants of health.  Dr. Reggie Tucker-Seeley: That's such a great example. We come to the table not just, or we come to the healthcare delivery system, not just with that single issue that sort of brought us to care. We bring our whole selves to the care encounter. So it's important that those are recognized as we navigate that system. I think it's so important to have our leaders recognize the importance of social determinants of health. And during your tenure as ASCO President, you championed cancer health equity and elevated the focus on social determinants of health. So where do you hope to see ASCO go in addressing social determinants of health and health inequities? That is, how can we build on what you started during your term as ASCO president?  Dr. Lori Pierce: Well, first of all, I want to say that I strongly feel that we've come such a long way. So much of the groundwork was already in place at ASCO before my presidency. I mean, everything ASCO has done since ASCO existed has been to focus on the improvement of the care of patients. And a part of that, of course, is being able to weed out those inequities and make it an equitable system. So when I then became President, the stars were aligned. And ASCO, with the work they were doing, they had the infrastructure in place, and they could not have been more encouraging, more supportive of the work that we wanted to do. So one of the programs, as I mentioned earlier, the Social Determinants of Health, the initial set of podcasts, as you mentioned, really looked at some of the basics of social determinants of health. And we had things such as taking a Social Determinants of Health History, which you were a key part of that podcast. And it really focused on we as physicians have been taught to take a history, but if we don't ask the right questions, we won't be able to elicit the barriers that patients are facing, which are largely the social determinants of health. And we focused on the cost of cancer care. We focused on modifiable risk factors such as tobacco cessation. We talked about access. We talked about a lot of the basic tenets of social determinants of health.  During my presidency, we also focused on an initiative where we want to increase the accrual of minorities onto clinical trials so that everyone has equal access to trials. And we know this has been something that has been worked on by so many amazing researchers such as yourself through the years. And so we harnessed a lot of the ideas from many of our colleagues to really promote and put together an outline and a guide that

This episode was originally released September 29, 2021 In this Social Determinants of Health (SDOH) episode, Dr. Jacquelyne Gaddy (UNC-Chapel Hill) speaks with Dr. Marvella Ford (Medical University of South) and Dr. Jennifer Ligibel (Dana-Farber Cancer Institute) on obesity and energy balance as modifiable risk factors and how clinicians can respectfully engage with their patients on this topic. View COI. TRANSCRIPT LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care and is not intended for use in the diagnosis or treatments of individual conditions. Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere. I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learned new ways of thinking about these issues and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high quality equitable cancer care. Thank you. JACQUELYNE GADDY: Welcome to the ASCO Social Determinants of Health Series. I am Dr. Jacquelyne Gaddy, and I'm a current third year fellow in the Division of Oncology at UNC Chapel Hill. With me today is Dr. Marvella Ford, endowed chair of cancer disparities from the Medical University of South Carolina and South Carolina State University, and I also have the pleasure of having Dr. Jennifer Ligibel, director of the Zakim Center for Integrative Therapies and Healthy Living at Dana-Farber Cancer Institute. In this episode, we will be discussing obesity and energy balance as modifiable risk factors, and how clinicians can respectfully engage with their patients on these topics. Dr. Ligibel, we've had some time talking together. And I want to start by actually just getting an introduction of how we can actually relate cancer and the outcomes of cancer with this topic today of obesity. JENNIFER LIGIBEL: Sure. This is definitely a topic that we've learned a lot about, especially within the last few decades. We recognize that obesity is an epidemic, not just in the United States, but everywhere. In the US, many adult populations across various states have a prevalence of 40% or more of the adult population having obesity. And this rate is rising around the world. And we've known for a long time that obesity increases the risk of a lot of diseases, heart disease, diabetes. The connection between obesity and cancer is something that we have recognized more recently. And in fact, in 2016, the International Agency for Research in Cancer reviewed all of the data looking at the relationship between excess adiposity, whether it was measured through BMI, through body composition and the risk of developing cancer, and found that there were 13 different cancers for which there was a clear and consistent relationship between higher levels of obesity and higher levels of cancer. We also know that there's a relationship between a number of factors that contribute to excess adiposity, things like inactivity and poor dietary quality and excess cancer risk. We also know that individuals with obesity face increased challenges after cancer diagnosis. There are higher incidences of things like surgical complications, neuropathy, and other side effects of cancer therapies. And for many diseases, individuals with obesity at the time of cancer diagnosis have an increased risk of cancer recurrence and mortality as compared to leaner individuals. So we know that there is a strong relationship between obesity and the risk of developing cancer and the risk of dying from cancer, as well as suffering increased toxicity from cancer treatment. JACQUELYNE GADDY: Thank you for that, Dr. Ligibel. That gives us a really introduction into this important topic. And Dr. Ford, if we can dive a little bit deeper, I know this past summer for our ASCO conference, I had the pleasure of listening to you as you presented. And I wanted to specifically ask you to address what you discussed in regards to inflammation and its relation to cancer and obesity. MARVELLA FORD: Yes, absolutely. So as Dr. Ligibel just noted, there is an association between being overweight and likelihood of being diagnosed with cancer, and also, the cancer treatment outcomes. What we have seen is that there's an underlying association between bile inflammation. The same bile inflammation that is linked to heart disease is also linked to cancer. And the good news is that there's something that we can do about it. So when we talk about the modifiable behavioral health risks, this is one of them. What we're seeing is that physical activity can actually reduce levels of bile inflammation in the body, which is great news. And Dr. Ligibel and others around the country are leading the way in developing physical activity interventions for people who are diagnosed with cancer so that we can intervene early on to develop strategies to improve their cancer treatment outcomes. You know, that leads us to the broader question of physical activity for the general population. How can we increase physical activity for everyone to reduce cancer risk? And I think there are some very attainable goals that we can set and there are some strategies that are achievable that we can accomplish in that arena. JACQUELYNE GADDY: As we think about the social determinants of health and why we got started with this, and Dr. Pierce did an amazing job of putting that at the forefront of ASCO's goals this past year during her presidency, before we dive even deeper, Dr. Ford, I want you to address specifically, you had a wonderful figure. And I can kind of see it in my mind right now in regards to the race maps when addressing obesity, and again, tying that back into its relation to cancer. MARVELLA FORD: So when we talk about obesity, what we don't want to do is get into a blaming-the-victim kind of approach where, oh, these people are just so overweight, that is exactly what we do not want to do. It's really important to look at the social determinants of health and the contributors to overweight and obesity. Because people are working with what they have available to them. And so the map that you're talking about really highlights the social determinants of health in relation to obesity. And so what we saw-- I showed a series of maps-- is that obesity in the US, it's associated with race but it appears to be driven by socioeconomic position. So areas that have lower levels of income, education, you know, upward mobility is what we used to call it, have higher rates of obesity. And a lot of that is due to what's in those communities. And so if you drive around those communities, whether they're rural or urban, you see a lot of fast food places. You see a lot of food deserts. Food deserts are not just a purview of inner cities, urban areas, rural areas where you would think, well, that's ironic because food is grown in the rural areas. But rural areas can also be food deserts. And so in my work at the Hollings Cancer Center, we're focusing a lot on the I-95 corridor of South Carolina, which ranges from North Carolina at the top, to Georgia at the lower end. And I know that's been an area of interest to many in our state. And what we have seen is that it's one of the poorest and most medically underserved areas of our state. And if you just do a visual exam, if you drive on the I-95 corridor and just get off on some of the side roads, you see just a dearth of healthy foods, grocery stores. There are convenience stores. There are gas stations. I call it gas station food, convenience foods, where you can eat to fill up. But it's not really healthy food and it's not life-affirming, life-promoting, life-enhancing food. And so this is what people have available to them. We have seen this with the impact of COVID-19 on the school systems. What we're seeing is that the schools, even if they're closed due to COVID, they still have to remain engaged in food distribution. Because for a lot of the children, the meals that they had at school may have been the only meals that they had that day. And so kudos to the school systems around the country for continuing to distribute healthy food to the children even when school is not physically in session, even when they're in a hybrid model or a virtual model. And on the weekends, they're sending kids home with backpacks full of healthy foods. I just spoke with a principal on Friday. One student tested positive at a local high school, and so she had to inform the other students who were in contact with that student that they had to get sent home. And one young lady was crying and said, but I want to stay in school. And there are a lot of reasons, and one of them is food security, being able to eat healthy foods and having access to healthy foods. Healthy foods can help to reduce inflammation in the body. But we also know that there are stressors that are associated with the social determinants of health that also raise levels of bile inflammation, stress, stressors. What are the stressors associated with the social determinants of health? The same stressors that we're experiencing in this pandemic. The pandemic is really highlighting the stressors that many people in the US have lived with on a daily ba

This episode was originally released October 28, 2021 In this Social Determinants of Health (SDOH) episode, Dr. Deepak Vadehra (Roswell Park) moderates a discussion with Dr. Carmen Guerra (Abramson) and Dr. Daniel Carrizosa (Levine) on how access to care impacts SDOH and the available interventions and resources that can mitigate these issues for patients. View COI & Cancer.Net Podcast. TRANSCRIPT LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 President of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care and is not intended for use in the diagnosis or treatments of individual conditions. Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative and some even uncomfortable, but ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere. I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high-quality, equitable cancer care. Thank you. DEEPAK VADEHRA: Welcome to the 10th episode of the ASCO Social Determinants of Health Series. I am Dr. Deepak Vadhera, and I'm a GI medical oncologist at the Roswell Park Comprehensive Cancer Center. I am joined today by Dr. Carmen Guerra, who is Associate Director of Diversity and Outreach at the Abramson Cancer Center at the University of Pennsylvania, and by Dr. Daniel Carrizosa, Medical Director of the Disparities and Diversity Program at Levine Cancer Institute in Charlotte, North Carolina. In this episode, we will be discussing access to care and how it impacts the social determinants of health and the available interventions and resources that clinicians can utilize to mitigate these access issues for their patients. So thank you very much to both Dr. Guerra and Dr. Carrizosa for being here. When I, sort of, think about access to care, I intimately equate it with equity. I think that, at its core, access to care is an equity issue and that not every solution is appropriate for every patient. But I think that the important thing is that, as we move forward in our discussion and sort of as we think about things globally, that we all recognize the importance of allowing appropriate access to care and making sure it is equitable for all our patients. So with that in mind, Dr. Guerra, one of the things that I think about in access to care are barriers, and one of the biggest areas, I think, is that we need to improve, with terms of access to care, is the access to clinical trials and the coverage of clinical trials. So I know that's something you're passionate about and so would love to hear some of your thoughts on that and other barriers you see, in terms of access to care. CARMEN GUERRA: Thank you, Deepak. First of all, it's a pleasure to be here. Thank you for the invitation. And yes, I'm very passionate about the equitable access to cancer treatment trials, and it's a space that I've been working on. We know there are inequities in accessing trials, because we know that the proportion of Black individuals that participate in trials is very small. In the 28 new oncology drugs approved by the FDA between 2018 and '19, If you look at all the participants, only 4% were Black. And we saw this, as well, in our own Abramson Cancer Center. In 2014, we just presented data at the ASCO National meeting, where we saw that even though in our catchment area, the proportion of Black patients with cancer was about 16.5% in our catchment area, the patients who were coming to the Abramson Cancer Center who were Black was only 11.1%. So I call that a community-to-clinic gap. And then we looked at who was participating on trials, and that was about 12.2% of the population was Black. And so we began, in that year, 2014, on a whole series of strategies to understand, better understand and address the barriers. And one of the barriers that we focused on was transportation. Nationally, we know that Black individuals are less likely to have a car, own a vehicle. About 20% of Black households do not have access to a vehicle. So one of the things we developed was a transportation program. We also worked on building partnerships with faith-based groups that serve the Black communities, as well as nonfaith-based groups, to increase our ability to go out to the community and educate the community about cancer, cancer prevention, and clinical trials. And then in addition, we also did some internal things. We worked with our PIs to show them-- our investigators-- to show them where the burden of cancer in the Black communities was. What were the cancers, and what were the trials we needed to design for them? And then we also asked them to include a minority participation paragraph in all protocols they submitted. And so in 2018, we were able to reassess the data. And what we found was a two-fold increase in the individuals who are coming to the Abramson Cancer Center because now, they had access through transportation and information. And then we also saw a two-fold increase in the individuals who participate in on clinical trials. And for us, that really showed us that we could do this, that we could provide the equitable access to cancer clinical trials. And so that just has continued to embolden us to continue to work on this, because I think you do have to sustain your efforts. Otherwise, we might see the same statistics that we saw back in 2014. DEEPAK VADEHRA: No, I couldn't agree with you more. And those are great interventions and great ideas that the Abramson Cancer Center was able to roll out. Dr. Carrizosa, what do you see as some of the barriers to our patients being able to access the care that they deserve as cancer patients? DANIEL CARRIZOSA: Yes, I think it's very interesting, because I think there's a lot of questions you can ask, in general, that help you think about these barriers to care. And Dr. Guerra was just talking about, almost, the what. You know, what do we do for patients so that we can get things done and help them? So other things are, simply, the question of who is it that you're looking at? What different type of person it is-- is this a elderly person that we need to think of different options, like different trials, different therapies? Do we also have to look at how they can access information? Is telemedicine something that's very easy for them? Or are they not able to use a smartphone? You also have to think about people with differences, such as transgender patients, who sometimes have significant, unique interactions with the medical community and unique needs, and we need to think about them. Also, at our annual Think Academy, which is a large conference we do that looks at inequities, we had Susan Magasi, from the University of Illinois Chicago, come and speak. And she really opened my eyes, because she talked about disabled people. And I had never thought about how a disabled person gets a mammogram. So that's a who and a how. On top of that, we also think about where. So we've talked a little bit about the transportation issue, and we have transportation issues in cities, rural, how they get telemedicine or broadband, where they might actually have a medical center close to them. They could be in parts of the country where people have to drive hours to be able to get good cancer care. And then the why. What is it that we're trying to do for them? And importantly, how can we educate people about cancer and about what these barriers are and how we can try it overcome them. DEEPAK VADEHRA: I think those are all very important points that you make, and things that we are all very important to think about as we move forward in both designing trials and working on improving our access for our patients. I think one of the things that providers and practitioners, who may not be in urban centers or are community providers and not, quote, unquote, academic providers, like we are-- what resources, what practical things can they do to help, sort of, break down the barriers and break down the walls that prevent patients from getting the proper access to appropriate clinical trials and supportive care, such as that? So Dr. Guerra, have you-- what are some practical tools out there that providers can use to help lessen the burden of access to care issues? CARMEN GUERRA: It's an important question, and thank you, so much. One of my volunteer hats is that I am the Board Scientific Officer for the American Cancer Society. And they have programs precisely to help individuals with access issues, such as transportation, such as lodging. One of their programs is the American Cancer Society Road to Recovery Program. And this is a program that provides transportation to patients with cancer to their appointments. It was a program initially launched back in the 1960s, but it was adopted nationwide by the American Cancer Society in 1983. And it's available to anyone with a diagnosis of cancer. They have provided, in the past, before the pandemic, in a year, about 35,000 patients were served with almost half a million rides, and it's available, again, for free, if you go on their website, cancer.org. And there's a phone number, which I'll be happy to share with your listeners. It's 800-227-2345. And that's a general American Cancer Society number for

This episode was originally released July 21, 2021 In this episode of the Social Determinants of Health (SDOH) series, Dr. Shekinah Elmore (University of North Carolina at Chapel Hill) and Dr. Ramy Sedhom (Johns Hopkins University) provide research highlights in Social Determinants of Health topics from the recent 2021 ASCO Annual Meeting, provide context to the research, and discuss clinical implications. View episode slides and COI. TRANSCRIPT LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care, and is not intended for use in the diagnosis or treatments of individual conditions. Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite Guests with a wide range of views and perspectives. Some of these conversations may be provocative, and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere. I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table-- voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high-quality, equity for cancer care. Thank you. SHEKINAH ELMORE: Hi, and welcome to the seventh episode of the ASCO Social Determinants of Health Series. I'm Dr. Shekinah Elmore, and I'm an assistant professor of radiation oncology and urology at UNC Chapel Hill. With me is Dr. Ramy Sedhom, a medical oncology fellow at Johns Hopkins. We're happy to be joining you, wherever you are in the world. RAMY SEDHOM: Yes, absolutely. This series is part of an initiative proposed by ASCO president Dr. Lori Pierce, focused on increasing oncologists' understanding of the social determinants of health, its impact on patients, and modifiable risk factors for cancer, inspired by Dr. Pierce's presidential theme of equity, every patient, every day, everywhere. In this episode, we will review highlights in social determinants of health topics from the recent ASCO annual meeting, provide context to the research, and discuss clinical implications. SHEKINAH ELMORE: In the social determinants, some of us might need a refresher, and that's OK, too. So the social determinants, as most of us know, are really those things at the interpersonal, community, social, structural higher levels that pattern health outcomes and access. So it's education, it's health care, its neighborhood and built environment, social and community context, and economic stability in one model from Healthy People 2030. But what we'll be talking about in many ways is at the individual level-- so the individual social risk factors that are lower than the social determinants of health. And then we'll also be talking a lot about race and racism. And so in terms of racism, the best definition that I have found is by Dr. Ruth Wilson Gilmore. She's a noted geographer. And that definition is that racism is the state-sanctioned or otherwise extralegal production and exploitation of group-differentiated vulnerability to premature death. And one of the benefits of the podcast format is that you can rewind, fix yourself on this slide, and read the definition a few times, like I did when I first came upon it, to just see how straightforward, but how all-encompassing, it is. And so racism is really a structural determinant of health. It sits above even some of these social determinants that we talk about. It patterns health inequities directly. It also has these interactions with all of the social determinants of health. And I think that that will become clear with the abstracts that we're talking about. RAMY SEDHOM: Really, really powerful definitions. And with regards to care access, almost 40 years ago, Penchansky and Thomas published their five As of access framework. And the five As, as you can see here, represents affordability. So thinking about what is the cost to patients. And there's been a lot of work coming out over recent years showing that these costs are increasing for patients directly with time. Accessibility-- what is the distance to location or a particular service for patients throughout the country. Availability-- what is the access to specialists and specialty resources, accommodation, flexible scheduling, and acceptability. And the reason why we bring up this framework is it's a context to discuss the first of the abstracts that we will discuss coming from Dr. Guerra and colleagues at the Penn Abramson Cancer Center. While published 40 years ago, these issues remain pertinent today. And we know that clinical trials do not operate in a vacuum, but instead mirror a lot of the problems within our current health care infrastructure. And that's what makes this work most impressive to me. I do encourage all to listen to the oral presentation from the ASCO annual meeting, abstract number 100, titled "Accrual of Black Participants to Cancer Clinical Trials Following a Five-Year Prospective Initiative of Community Outreach and Engagement." So what was the problem they were tackling? The team identified a major gap for full inclusion of minoritized patients in their cancer clinical trials network. And their goal, as highlighted by this abstract, was to increase the accrual of Black participants in cancer clinical trials. Importantly, they took a multilevel approach. But before thinking about any intervention, they went out into the local communities. They spoke to the patients, to the community leaders, pastors, community advocacy groups, and outreach groups to really listen to what the problems were. And by engaging with those most important stakeholders, did they really think about what were the most important interventions? And what did these interventions look like? Well the team at the Penn Abramson Cancer Center focused on educational efforts in Black communities dispelling many myths about cancer clinical trials. They also increased touch points and access points for patients to access care. Most importantly, these came through breast cancer and colon cancer screening for both insured and uninsured patients. One thing that really stuck out to me, very pragmatic and thoughtful in its design, was to make sure that culturally-tailored marketing strategies were also available for patients to see. They worked with pharma to make sure that Black patients were also shown on pamphlets discussing cancer clinical trials. And when thinking about access to care, we know that transportation is oftentimes a barrier, especially for our most vulnerable patients. So they had made sure to have contracts and connections with Lyft and other ride-sharing agencies to make sure that people can make it to the cancer center. And from the health care infrastructure side, they established new requirements for minority accrual plans, and made sure to use community health workers and one-on-one patient navigation. And what was the ultimate impact of their work? Over a five-year effort, they reached more than 10,000 individuals through various venues. And when looking at their primary outcome, they more than doubled the number of Black patients who were accrued on cancer treatment trials. And they saw up to a four-fold increase in the accrual of Black patients in non-intervention treatment trials. However, what is most important is they established a new level of trust with patients in communities that they were not before reaching. And they were able to remodel their organizational care delivery infrastructure to address this major gap in care delivery. So what was the hallmark of the strategy and how can we pragmatically implement it in our own institutions? First, they focused on understanding local needs. Importantly, they established bidirectional relationships, and they made sure to acquire data to show the business case for why this is a return on investment for patients, their local city, and their health care infrastructure. I want to applaud Dr. Guerra and her team for making sure that this was a long-term investment in the Philadelphia area. What first started as a research grant later grew to involve the entire cancer service line, all the way with the director of the cancer center, and making sure to involve their entire organization. And what is the lesson learned? Well, Black participants are significantly underrepresented in clinical trials. But it is not because they are resistant to participating. Instead, this is likely due to structural, clinical, and organizational barriers. In our local communities, the underrepresented minoritized groups may look different. Perhaps they may be racial minorities. They may be rural dwellers, adolescents, or perhaps elderly patients, sexual and gender minorities, and so on and so forth. So I'd like to open this up to Dr. Elmore, and see if you have any other comments or thoughts from hearing about this. SHEKINAH ELMORE: This is such tremendous work. And I agree. I think that it's a testament to so many things. I think that responsive development of interventions is so critical, and that truly, Black patients and Black people want to be included in the things that are meaningful to changing health outcomes. And there's so much here, and I really hope to see more efforts like this in both trial enrollment and for standard of care enrollment. RAMY SEDHOM: Absolutely, and hats off for ASCO advocacy for really pushing forward the CLINICAL TREATMENT Act, which made sure

This episode was originally released August 23, 2021 In this Social Determinants of Health (SDOH) episode, Dr. Narjust Duma (DFCI) moderates a talk with Dr. Danielle McCarthy (University of Wisconsin-Madison) and Dr. Erica Warner (Harvard Medical School & MGH) on tobacco cessation as a modifiable risk factor and how clinicians can respectfully engage with their patients on this topic. View COI. TRANSCRIPT LORI PIERCE: Hello. I'm Dr. Lori Pierce, the 2020-2021 president of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care and is not intended for use in the diagnosis or treatments of individual conditions. Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals. Every patient, every day, everywhere. I dedicated this vision to my term as ASCO president, and these conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what resources they have, receives high-quality equitable cancer care. Thank you. NARJUST DUMA: Welcome to the eighth episode of ASCO Social Determinants of Health Series. I'm Dr. Narjust Duma, and I'm the associate director of the Cancer Care Equity Program at the Dana-Farber Cancer Institute. With me is Dr. Danielle McCarthy, associate director for research and the Center for Tobacco Research and Intervention at the University of Wisconsin-Madison. I also have the pleasure of having Dr. Erica Warner assistant professor of medicine from Harvard Medical School and assistant investigator for Massachusetts General Hospital. In this episode, we will discuss tobacco cessation as a modifiable risk factor and how clinicians can respectfully engage with their patients on this topic. I would like to thank Dr. McCarthy and Dr. Warner for being here today. ERICA WARNER: Thank you. DANIELLE MCCARTHY: My pleasure. NARJUST DUMA: Moving forward, we address Dr. McCarthy and Dr. Warner by their first name. We're colleagues and friends, and this is a friendly conversation about a very important subject. So we're going to start with a few questions, and they're going to give us their great insightful comments. First, we want to speak about the stigma with tobacco use. There's a lot of stigma associated with tobacco use and subsequently with lung cancer. This affects all patients, but it can be worse in some communities versus others. Dr. Warner, can you speak to us about this stigma with tobacco? ERICA WARNER: Yes, certainly. I think stigma is a really important issue. And I'm doing some work around this right now with cancer patients. I think that anti-smoking campaigns have been amazingly effective really at spreading the message that smoking is associated with a long list of negative health outcomes. I think the most well-known being the link with lung cancer risk. And over time, as smoking rates have declined in the United States-- focus is mainly on the United States, but I think some of these comments are relevant for other places. As smoking rates have declined, you've seen that the populations that continue to have the highest rates of smoking are largely lower socioeconomic populations in the US now. And so I think this combination of the sense that messaging has told us that smoking is, quote, unquote, "bad," that marginalized populations tend to have higher smoking rates currently, coupled with this idea that smoking is just a poor choice, a bad decision that any given individual is making, leads to smoking and ultimately people who smoke being stigmatized in our society today. And I think there's a lot that we can do to try and combat this, but really focusing on this idea that smoking is a poor personal choice that someone is making. We know that there has been lots of advertising that has been targeted at specific communities to try and get them to smoke and even now that we're not allowed to have smoking advertisements on TV and on billboards in the way that they used to be, there are still many ways in which these communities are being targeted, as well as recognizing that smoking is an addiction. So there are plenty of people who smoke, who recognize that it can have bad consequences for their health. They don't wish to continue to smoke but are struggling for smoking cessation. And so I think that really all of us, and as we'll talk later about providers, need to approach smoking and individuals who smoke with more empathy. NARJUST DUMA: And connected to that question, we have seen marketing that is targeted to certain populations. So while living in the Midwest, I have a very close contact with Native Americans. And the amount of mail these populations receive about smoking, like you turn 16, and you get an advertisement in the mail about here's your first Marlboro package for free. And this can be for the two of you, how is this targeted marketing that also affected women in the 1970s and '60s in which is smoking was associated with weight loss, like if you want to stay thin or slim, you need to smoke. So how this has affected tobacco in the past and currently now with this targeted marketing to populations. DANIELLE MCCARTHY: Yeah. I can certainly speak to that in Wisconsin. We see, it's not just marketing at point of sale. There is direct marketing, as you mentioned. There are also just a greater concentration of tobacco retail outlets in certain communities. So there's just more access. And the Wisconsin African-American Tobacco Prevention Network has done a lot of really great work reaching out to retail sites, convenience stores, corner markets, to try to encourage them to verify a customer's age before they sell tobacco and also gotten them to agree to no menthol Sundays. Like they've had some days where they just won't sell menthol cigarettes because menthol has been so aggressively marketed to African-American communities. And they've gotten these retailers to agree to this and to buy into this, that this is a social justice issue. It's not just a matter of commerce. It's a matter of equity. And it's really exciting to see that even people who make a little profit on selling tobacco are willing to modify their conduct to address these issues, at least in a small way. And so if we see a menthol ban enacted on a broader scale, that could have a big positive impact. NARJUST DUMA: Thank you for your comment, Dr. McCarthy. We have seen some changes at the corporate and institutional level, such as made by CVS to stop to sell tobacco. And this is very linked to your comment. What has been the role of health care institutions in promoting tobacco cessation? I know we have talked about also being reactive to be more proactive, but what has changed and what can change still? DANIELLE MCCARTHY: Right. A lot has changed. We now assess smoking status along with height, weight, and blood pressure. It's now considered a vital sign because it's the leading preventable cause of death. So knowing your patient's tobacco use status and addressing it is really important. Knowing it and doing nothing with that information is not very helpful. And so the next step is really important. And we know that from population studies that only about half of patients who walk out of a doctor's office walk out and say, yeah, the doctor talked to me about my smoking and offered me something. And so we want to get that up to 100%. And we think that health systems can implement changes to make that happen. And we've shown that if you integrate some prompts and reminders into the electronic health record, that that can greatly increase the rates at which treatment is offered and that about 12% or so of people who come in off the street for another reason to your clinic will agree to set a quit date within the next 30 days and accept treatment. So that's pretty impressive, right? So even though the majority of people say they want to quit smoking, that doesn't mean that they want to do it today. But if you ask them today, more than 1 in 10 will probably say, yes, I will agree to treatment. Sign me up. I'm willing to quit within 30 days. So you really can intervene. Health systems can support that by creating workflows that are efficient and effective and connect the patients who smoke with cost low-barrier treatments. For example, State Tobacco Quit Lines that don't charge for their services and now offer pharmacotherapy and free phone coaching or counseling. So that's something that we've been working on here in Wisconsin. And multiple health systems have now adopted electronic referral to the State Quitline as one of their standard options that they provide for patients who smoke. The other thing is that 52 cancer centers in the country are now part of an NCI-funded initiative called the Cancer Center Cessation Initiative to more proactively address smoking in cancer settings. And so if you're working in a cancer center, odds are that they're participating in this program and that they're developing some sort of initiative to try to improve the rates of addressing tobacco use among people who present with cancer. NARJUST DUMA: And the follow-up question, which is a little bit out of script, is have we seen differences in smoking cessation counseling across racial/ethnic groups and across gender? And you can spend a little bit more on this, Dr

This episode was originally released May 27, 2021 Dr. Demetria Smith-Graziani (University of Texas) moderates a discussion with Ericka Hart, an activist and sexuality educator, and Dr. Kemi Doll (University of Washington) on the historical and structural reasons for patients' mistrust of the healthcare system due to systemic racism in medicine, with insights from both the clinician and patient perspective. TRANSCRIPT LORI PIERCE: I'm Dr. Lori Pierce, the President of the American Society of Clinical Oncology. Thank you for tuning in for this discussion on social determinants of health and their impact on cancer care. The purpose of this video is to educate and inform. It is not a substitute for medical care, and is not intended for use in the diagnosis or treatments of individual conditions. Guests on this video express their own opinions, experiences, and conclusions. These discussions should not be construed an ASCO position or endorsement. For this series on the social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative, and some even uncomfortable, but ASCO is committed to advancing equitable cancer care for all individual – Every Patient. Every Day. Everywhere. I have dedicated this vision to my term as ASCO president. These conversations bring many voices to the table, voices that we need to hear to move forward and find solutions. We hope you learn new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what they look, receives high quality, equitable cancer care. Thank you.   DEMETRIA SMITH-GRAZIANI: Welcome to the fifth episode of ASCO Social Determinants of Health Series. I'm Dr. Demetria Smith-Graziani, and I'm a clinical fellow at M.D. Anderson Cancer Center. I'm joined today by Ericka Hart, an activist and sexuality educator, and Dr. Kemi Doll, a health equity researcher and gynecologic oncologist from the University of Washington. This series is part of an initiative proposed by ASCO President Dr. Lori Pierce focused on increasing oncologists' understanding of social determinants of health, its impact on patients, and modifiable risk factors for cancer. Inspired by Dr. Pierce's presidential theme of equity every day, every patient everywhere, in this episode, we'll discuss the historical and structural reasons for patients mistrust of the health care system due to systemic racism in medicine within the clinician and patient perspective. So it's important to know that race is a social construct that continues to affect the health of marginalized populations. We have laws and practices that date back to chattel slavery, and clinicians really need to understand each patient's identity within the appropriate historical context in order to provide optimal care and engage in meaningful research to improve outcomes. The health care system has not proven itself to be trustworthy in the past. It's still not trustworthy today. And there's a long history of institutional discrimination against racial and ethnic minorities, sexual and gender minorities, people with disabilities, and other marginalized groups that continues today and affects the patient-provider relationship. We'll focus today on anti-Black systemic racism within health care, and this will provide a foundation that we hope will encourage further discussion about other forms of discrimination within health care. Thank you both so much for joining me today. We'll start with the first question, and that's that conversations about trust and health care among the Black community are usually centered around the Tuskegee study of untreated syphilis in the Negro male. But there are many other instances of clinicians and researchers engaging in unethical medical neglect and experimentation on African-Americans. So what other historical and current events should clinicians know about and what resources should they be using to stay informed? And we can start with Dr. Doll. KEMI DOLL: SURE. So I think history is vital because without understanding our history, it's very hard for us to make sense of what's happening around us. And I think that the US study of untreated syphilis is-- in many ways, a medical education obscured the contemporary racism and the contemporary exploitation and mistreatment of Black people in the health care system. And so my first-- in terms of what else do people need to know-- is that they need to know that horrors as terrible as the syphilis experiment continue today all the time. I don't think you have to look far to find these incidences. I will point out Dr. Susan Moore, a Black woman doctor, who died just a few months back being mistreated in a hospital system in the region where she practices and could not get care to the point where she was able to verbalize, I'm going to die. Because I am being mistreated, I'm not going to make it, and she didn't. So I want to gently remind us that to have to pull back to the syphilis experiment is demonstrating a willful not seeing, a willful choice not to see what's happening to us every single day. The other thing that I would say for clinicians or researchers that want to stay abreast is that everything impacts health care. So the current trial of Derek Chauvin right now for the murder of George Floyd is an example of racism and how we value Black life. And so we need to understand as clinicians that when you walk into a room-- and now thinking about the oncology world that I'm in, the cancer world that I'm in-- and you are for example, trying to have a discussion with somebody about the risks and benefits of a certain treatment and survival and their life and maybe even trying to have a conversation that maybe it's time to stop treatment because I don't think you're going to make it and that patient is Black, you need to understand that that's happening in the context of us understanding that our lives do not matter to the same extent that other people's do just walking around on a daily basis. DEMETRIA SMITH-GRAZIANI: Great point. Great point. Ericka, anything to add? ERICKA HART: Yeah, for sure. Thank you for saying that, Kemi. That's brilliant and I do think it's important to be thinking about how this is continuing to show up contemporarily as folks will hearken back to the past as if we are now in a new day, and we are 100% not. But I do think what's important to talk about is whose stories get told. The focus now is on the Derek Chauvin trial due to the murder of George Floyd, but there wasn't this much attention, I would say, around Breonna Taylor's case and the fact that it wasn't actually addressed. And even again, another marginalized community is Black trans people. When Black trans women die, what then is the national conversation? It doesn't exist. And I think that has a lot to do with the bodies that we are saying are worthy to be considered. And so what we talk about when I get so frustrated about the Tuskegee experiment being repeated over and over again is the erasure of Black femmes. So J. Marion Sims is a pseudo medical provider who operated on countless Black femme people without anesthesia and then was named the father of gynecology. And then we come into the 1920s with Margaret Sanger and the experimentation of birth control experiments and the sterilization that continues to happen to this day. And what was happening is that Margaret Sanger used Black folks to say W. E. B. Du Bois was on-- I always say, "DeBwa"-- Du Bois is their name. They're from Massachusetts, so I'm going to give them spice. W. E. B. DuBois really worked alongside of Margaret Sanger's eugenics project to essentially eradicate disabled folks and Black people and also went all the way to Puerto Rico to essentially attack and harm Black Puerto Ricans to create this birth control for white people. And then coming to the 1950s, we have Henrietta Lacks and the experiment on her body when she went to John Hopkins for actual care and the lack of informed consent. So I get frustrated when the focus is always on the Tuskegee experiment just as much as I get frustrated when we talk about police brutality being focused on Black cisgender man. There are so many folks who get impacted by the state, and often times we don't even hear their names because the media has construed who we see as important. And beyond the media, whiteness says whose identities are most important. And it's important that when folks are studying medicine that you understand that you are also indoctrinated in this idea that certain people's identities are more valuable than others. And oftentimes, I'm told that there isn't much conversation around racial and social justice, gender justice at all in medical spaces. And I would say my resource is Medical Apartheid by Harriet A. Washington. It is necessary reading for anyone who wants to do anything in the world that relates to people's bodies beyond the medical spaces. I think it's important that you understand how folks bodies have been regarded in this country. Another book I just got is called Medicalizing Blackness-- hold on, let me give you the author-- by Rana A. Hogarth. This is the book. Also, highly recommend-- it's just you have to do your research and really be applying this. Again, like Kemi said, it is not a function of the past. It is happening currently. We can look to maternal mortality to really get the continuation of medical experimentation. I'm not a linguist, but even the word experiment has a lot to do with using someone to prove something. So even inside of that, there is so much that we don't know that's not even really covered in these books. There's so much that has been buried. So yeah, that's what I would say. DEMETRIA SMITH-GRAZIANI: Great [INAUDIBLE]. ERICKA HART: Thank you. KEMI DOLL: May I have one more book Deirdre Cooper Owens, Medical Bondage, which focuses on th

This episode was originally released June 9, 2021 In this Social Determinants of Health (SDOH) episode, Dr. Randy Vince (University of Michigan) moderates a talk with Dr. Robert Winn (VCU Massey Cancer Center) and technology innovator and cancer survivor, Sylvie Leotin (Equify Health) on solutions for rebuilding patient-provider trust and communications, with insights from the clinician and patient perspective. TRANSCRIPT LORI PIERCE: Hi. I'm Dr. Lori Pierce, president of the American Society of Clinical Oncology. Thank you for tuning in to this discussion on social determinants of health and their impact on cancer care. The purpose of this podcast is to educate and inform. It is not a substitute for medical care, and it is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experiences, and conclusions. These discussions should not be construed as an ASCO position or endorsement. For this series on social determinants of health, we invite guests with a wide range of views and perspectives. Some of these conversations may be provocative, and some even uncomfortable. But ASCO is committed to advancing equitable cancer care for all individuals, every patient, every day, everywhere. I have dedicated this vision to my term as ASCO president. These conversations bring many voices to the table, voices that we need to hear in order to move forward and find solutions. We hope you learned new ways of thinking about these issues, and we invite you to join us in working toward a world in which every person with cancer, no matter where they live or what they look like, receives high-quality, equitable cancer care. Thank you. [MUSIC PLAYING]  RANDY VINCE, JR.: Hello, and welcome to the sixth episode of the ASCO Social Determinants of Health series. I'm Dr. Randy Vince, Jr., a fellow of urologic oncology at the University of Michigan. Today, I'm joined by Dr. Robert Winn, the director of the Virginia Commonwealth University Massey Cancer Center, and Dr. Sylvie Leotin, who is a technology innovator, cancer survivor, and a recent recipient of a $750,000 Health Equity Innovation Award. This series is part of a new initiative proposed by ASCO president Dr. Lori Pierce, focused on increasing oncologists' understanding of social determinants of health, its impact on patients, and modifiable risk factors for cancer, inspired by Dr. Pierce's presidential theme of equity, every patient, every day, everywhere. During the fifth episode of this series hosted by Dr. Smith-Graziani, there was a deep dive into the impact of structural racism on medicine, both historically and contemporarily. As a country, we find ourselves at a point of inflection. Many citizens and health care providers are starting to grapple with the fact that both interpersonal and structural racism impacts various aspects of our daily lives. As health care providers, it is imperative that we understand this history and how this affects our patient-provider interactions. To build on episode five, we will discuss the importance of patient-provider relationships and eliminating cancer disparities. So the first question goes to you, Dr. Winn. I know you have made community engagement an essential pillar at the Massey Cancer Center with the goal of reducing and ultimately eliminating cancer disparities. This initiative is a critical step. But many times when we discuss social determinants of health, we talk about factors outside of the health system. But I'm wondering if you can comment on how patient-provider communication influences cancer disparities. ROBERT WINN: No, absolutely, and thank you for that. And I think that the work that's happening at the ASCO right now is just outstanding. I wanted to actually also go back to making sure that we don't conflate individual needs with social determinants of health, because there sometimes is muddying of individual needs with social determinants. And I want to make sure that as we talk about it, and through the lens of social determinants, that we understand that that's built on structure. And part of that structure is the doctor-patient communication, but also the medical community's communication to communities, which is frequently very one direction. And even when we talk about being patient centered, frequently we don't have the patient at the center of our discussions. It becomes almost this very colonial-like— but benevolent colonialism, right? It starts from a good place. But it becomes this very benevolent, colonial flavor to it where we're talking for people, we're talking at people, but we're not talking with folks, nor with communities. And so I think that to keep my answers short, we are going to have to, as a health profession, have a little bit of grace and a little bit, just a touch more of humility to understand that where we have— although well meaning, and certainly we're armed with knowledge, but they are too in communities. And I'll end with saying that while we also talk about our patient-centered approaches and communities as being illiterate— health delivery system illiterate or scientifically illiterate, they'll remind you that we are, too, illiterate. And so trying to talk at people in this unidirectional way will give us some results, but not the best results. And I think there's many more, much more productive results to come if we have a little bit more humility of making sure that we are not just engaging but involving community. RANDY VINCE, JR.: So the next question I'll pose to you, Dr. Leotin. First, I'll say this. You have an impressive background that spans multiple disciplines. And so I have a two-part question for you. First, with your expertise as an innovator and your personal experience as a cancer survivor, I wonder if you can share your thoughts about what can be done broadly to improve cross-cultural patient-provider interactions. And the second part of the question is, you were recently awarded a large grant to collaborate with Emory School of Medicine. Can you share some information about your project and the innovative solutions you're developing to help reduce cancer disparities? SYLVIE LEOTIN: Thank you for your question, Dr. Vince. First, I would like to stress, [INAUDIBLE] the patient first, that cross-cultural patient-provider communication is worse than many health providers imagine. And this directly affects disparities. There was a recent study, as an example from Genentech, that showed that 50% of Black, Latinx, and LGBT patients have delayed or discontinued their care because they didn't feel understood by their providers. So second, to answer your question, I agree with Dr. Winn, and I applaud your leadership in transforming community engagement. As you said, I think that it's also part of the solution. I think that another part of the solution is really improving patient-provider relationship inside the hospital. And I see that a lot of providers are not looking at this when, as a patient, I can tell you that it is really an essential component of reducing disparities. And I'm going to try to unpack that. So we talk about trust, we talk about mistrust, and we talk about patients needing to trust the health care system. But we have to realize that trust is a two-sided process. And it's not incumbent upon the patient to trust the health care system if the health care system keeps perpetuating mistrust. So my position is really that providers need to step up. As Dr. Vince was so eloquently saying, they need to step up to inspire trust. And more than inspire trust, they have to stop fueling and perpetuating mistrust in their day-to-day interactions with patients. So I think that the providers are not equipped today to build trust and have good relationships with cross-cultural or racially discordant patients. I don't see this taught in medical school, and I don't see it in continuing education today. So people will tell me that now we are starting to see anti-bias trainings and why this is a positive thing. I do not think that these trainings are sufficient to really have an impact on the patient experience of Black and Brown patients. I think that we need something that is a lot more practical, a lot more pragmatic, experiential, and, as Dr. Winn was saying, patient centered to really transform cross-cultural patient-provider relationships, which leads me to my grant. So I'm happy to share that I recently won a $750,000 Health Equity Innovation Grant from Genentech in collaboration with Emory School of Medicine. And the grant is going to fund some research with Black patients and oncology providers at Emory Winship Cancer center, but also at the Grady Hospital in Atlanta. And we are also going to pilot an innovative training, which I designed, which is going to help improve cross-cultural patient-provider communication. This training is coming from my background as a multicultural cancer patient, but I also have 20 years of experience in innovation and in human-centered design. And before I got cancer, I developed a model that is really the underpinning innovation about this training that will really give providers an experiential understanding of what it's like to be a Black patient in the health care system. So I'm not going to take the whole time. RANDY VINCE, JR.: No, that's amazing. That's amazing. Thank you. And I'm looking forward to seeing the research that comes out of this and really provide some useful techniques for providers to implement in their daily interactions with patients. So I'm definitely going to be looking out for that, Dr. Leotin. For my next question, I'm going to pose it first to you, Dr. Winn. And then, Dr. Leotin, you can weigh in on this as well. So we know that the history of structural and interpersonal racism can influence these patient-provider interactions. And so I wonder if you can provide thoughts on how, specifically, providers can establish a trusting rel

This episode was originally released January 21, 2021 In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Dr. Jacquelyne Gaddy (University of North Carolina Chapel Hill) moderates a discussion with Dr. Reginald Tucker-Seeley (University of Southern California) and Dr. Katie Reeder-Hayes (University of North Carolina Chapel Hill) on how to take a social history, with a focus on cultural humility and addressing implicit bias. Read more about this topic in Dr. Gaddy's recent ASCO Connection article. TRANSCRIPT   PRESENTER: The purpose of this podcast is to educate and inform. This is not a substitute for 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. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  JACQUELYNE GADDY: Welcome to episode three of the ASCO Social Determinants of Health Series. My name is Dr. Jacquelyne Gaddy, and I'm a fellow in the Division of Hematology and Oncology at the University of North Carolina at Chapel Hill. Today, I am joined by Dr. Reginald Tucker-Seeley, Assistant Professor of Gerontology at the University of Southern California, and Dr. Katherine Reeder-Hayes, Associate Professor of Oncology and a Health Services Researcher at UNC Chapel Hill.  This series is a part of a new initiative proposed by ASCO president, Dr. Lori Pierce, focused on increasing oncologist's understanding of social determinants of health, its impact on patients and modifiable risk factors for cancer inspired by Dr. Pierce's presidential theme of equity, every day, every patient, everywhere. In this episode, we will look at how to take a social history with a focus on cultural humility and addressing implicit bias. Dr. Reeder-Hayes, I think I will start by asking, why do you think the social history and the taking of it is so meaningful and impactful?  KATHERINE REEDER-HAYES: So to me, as a provider, it has always felt that the social history really is serving a dual purpose. One of those purposes is simply the development of rapport and relationship, learning about your patient as a person, learning about maybe points that the two of you have in common or that you may be able to connect about, just as we would in social conversation with any other human being. But the other purpose is to identify social factors that may impact the journey that your patient is starting out on, assuming that you're meeting a new patient. We know that social determinants of health have a huge impact on a patient's ability to stick with their treatment plan, their ability to navigate their way through the health care system, and have direct impacts actually on their physical health. So those are all reasons why the social history really may be as important as any other part of a new patient history and physical exam.  JACQUELYNE GADDY: I want to Pose this next question to both you, Dr. Reeder-Hayes, and Dr. Tucker-Seeley. What are key questions that you guys believe should be asked of your patient when completing the social history? Or Dr. Tucker-Seeley, just for you, like, what are just meaningful things that you should be able to walk away knowing about your patient? REGINALD TUCKER-SEELEY: Well, I think it's important to understand that, as Dr. Reeder-Hayes mentioned, the things that impact how a patient navigates health care and their ability to adhere to treatment, those things may be happening outside of the doctor's office. So getting an understanding of your patient's life outside of that 10 to 20 minutes that you see them is really important. So for example, I'm working with some colleagues-- and I'll be talking about this throughout the conversation today-- with some colleagues at the Los Angeles Department of Health Care Services, and we've decided to focus on three key areas. One is housing insecurity, food insecurity, and transportation needs. And so those are three key factors that have been shown to impact how folks are navigating health care, and also, to impact their ability to adhere to treatment. KATHERINE REEDER-HAYES: So I would add to that the kinds of approaches that Dr. Tucker-Seeley is talking about and the kinds that are pretty natural to folks who work in a public health situation are not the same-- [AUDIO OUT] we were taught in medical school, right? So we were taught to ask about risk factors. It's really an epidemiology-based understanding of what the social history is for. What have you been doing? Have you been smoking? Have you been drinking a lot of alcohol, doing illicit drugs, sitting around being sedentary instead of exercising, and how did that lead to the health state that you're in now? That's how we were taught as physicians to obtain a social history. Now, some of these things are still relevant. I'm not saying that they're not relevant. But you can imagine, if this is the first interaction you have with your provider, first of all, it might be kind of off-putting to be intimate about your health habits as the very first encounter with the person, especially when it's the only focus. So you need to move to a more complex model. As Dr. Tucker-Seeley was saying, that focuses on actionable items. When was the last time we were taught in medical school to ask about how our patient got to the appointment and how reliable their transportation is, and it's highly actionable. And it's also an approach to the social history that's really multilateral. The physician probably can't make the best come on time to pick up the patient for his appointment. There might be a social worker who can get the patient a Lyft coupon or help the patient find public transit or get a volunteer to give them a ride. There are lots of things that a social worker on the team might be able to make that actionable information. And then, finally, I think the models that we need to move to for social history need to be much more patient-led and patient-centered, so open-ended questions. Tell me something about yourself outside the hospital. What's been your biggest challenge since you got this diagnosis? Let the patient tell us which parts of their social Story. Are most important or most challenging rather than assuming that we have a checklist that's going to hit the right pieces of information if we just go down the checklist. REGINALD TUCKER-SEELEY: I think Dr. Reeder-Hayes is highlighting that the difference in training from those of us who come from a more public health background-- I trained in public health, specifically, social epidemiology and health and social policy, and we've been talking about the social determinants for a very long time. And so I think making sure that, in addition to having physicians at the table, having social work at the table, having someone from social epidemiology or medical sociology at the table to help the team come up with the best set of questions that are most relevant for that particular practice environment. KATHERINE REEDER-HAYES: Absolutely. And the last thing I would say is that we are in the era of the electronic health record. Not everything about it is great for patients. But one thing we can do is we can build social history over time.  So if the chart tells you the patient's smoking history you can go deeper in a small amount of time. You can say, hey, Mr. Jones, I saw it mentioned in your chart that at some point, you were a smoker. Have there been some times you tried to quit smoking? That shows respect for the patient, respect for time, and the fact that they maybe already answered this question many times, and it also allows you to get to a point in the social history that's more actionable than just repeating the same questions over and over again. JACQUELYNE GADDY: Dr. Tucker-Seeley, you mentioned something earlier that I wanted to ask, and I know, Dr. Reeder-Hayes, you'll be able to add to this also. Who do you believe is the best person on the care team to ask these questions? Who should be initiating this conversation?  REGINALD TUCKER-SEELEY: That's a very good question. And I think we often see this in the financial hardship and cancer space where patients want to talk about cost, but physicians may not necessarily want to talk about cost because you aren't aware of what everything is going to cost, so trying to think about what is the best framework or model for thinking through this process. In the project that I mentioned earlier, we developed this framework and it's called Screen, Navigate, Connect, Address, Evaluate.  And so it takes you through the entire process. So not just thinking about am I checking something off of a list that I'm required to do, but also thinking about, how do I help the patient navigate through the process? How do I then connect the patient to the social service that will eventually address that social need? And then investigating whether or not that need was actually addressed, and then an evaluation component that then determines, did addressing this particular need actually impact outcomes or help facilitate the navigation of health care? It can be a challenge to figure out who on the team should be asking these questions. And I think with this particular framework, you can decide who's going to be responsible for screening. Who's going to be responsible for navigation? Who's going to be responsible for connecting? And thinking within the scopes of practice of the members of the care team, who's best suited for those particular roles?  KATHERINE REEDER-HAYES: That is a great thought. And I think it connects to what I would call the need for professional humility as physicians to realize that-- we have been taught that we have to do it all, but we're not necessarily very good at doing it all. When we walk into the room with the patient, we're faced with a lot of different competing priorities, includin

This episode was originally released February 24, 2021 In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Dr. Hala Borno (University of California San Francisco) moderates a discussion with Dr. Fumiko Chino (Memorial Sloan Kettering Cancer Center) on understanding the cost of care and ways care providers can help patients and caregivers mitigate financial toxicity. TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for 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. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.  [MUSIC PLAYING]  Welcome to the fourth episode of the ASCO Social Determinants of Health Series. I'm Dr. Hala Borno. I'm an Assistant Professor of Medicine at the University of California, San Francisco, and a genitourinary urinary medical oncologist. I have the pleasure today of being joined by Dr. Fumiko Chino, who's a radiation oncologist for Memorial Sloan Kettering.  This series is part of a new initiative proposed by ASCO President Dr. Lori Pierce, focused on increasing oncologists understanding of social determinants of health, its impact on patients, and modifiable risk factors for cancer. Inspired by Dr. Pierce's presidential theme of equality every day, every patient, everywhere.  In this episode, we will look at issues of financial toxicity and related barriers to cancer care. Again, thank you Dr. Chino for joining us today. First, I thought I would ask what do you consider to be financial toxicity and how can it be a barrier to access to care.  FUMIKO CHINO: Thank you so much for having me. I am very passionate about this topic. I have dedicated my life to it. And it's actually the reason why I am in medicine. I think financial toxicity is a very-- it's a hot topic nowadays, especially with the rising cost of cancer care and then I think highlighted by the COVID pandemic.  But financial toxicity is really a patient-facing problem, meaning it's how patients deal with the cost of their cancer care and how that affects the quality of their care, their access to care, and ultimately can affect their survivorship from cancer. Personally, interested in it because of my own experiences with financial toxicity. And it's really the reason why I ended up in medical school at all.  I think realistically, it's like the old adage where you haven't-- unless you ask about a problem, you're not going to identify it. And from my own experiences, I know that there are patients that you will see in your clinic that are having problems with financial toxicity, but they won't necessarily talk to you about it until they're given permission. And so I think this topic is increasingly important. And it's something that I'm really happy that we're spending some time with today.  HALA BORNO: Dr. Chino, thank you again. You really have been quite open about your personal experience, a very powerful experience to highlight this critical problem. Do you mind sharing a little bit about that story. And how does that impact the way that you interact with patients in your own practice and also inform your research?  FUMIKO CHINO: I think that my story, my husband's story, and ultimately our struggle through the health care system really highlights a lot of what this whole issue is about the social determinants of health. And I think the lens I bring to it is someone who's been on both sides of the stethoscope so to speak.  So my husband was diagnosed with cancer at a very young age, when he was in his 20s. And unfortunately, we dealt with some very poor quality health insurance, which did not have a lot of coverage for cancer. And we had a lot of out-of-pocket expenses for care.  Ultimately, I had to quit my job to help take care of my husband. And when he died from cancer, when he was less than 30, it left me with an incredible burden of debt related to his cancer treatment.  I think the flip side of the access problems, in terms of insurance, is that I have a very privileged background. Unlike a lot of patients with cancer and families with cancer, I am from a pretty wealthy family. So I was able to rely on the support of my family to help me get me back on my feet. And even, again, when we are suffering these great costs, we had people who could loan us money.  And I think that privilege that we had really helped us stay at least minimally afloat with our struggles with financial toxicity, instead of completely going under. And I think that really highlights some of the disparities that for patients that don't have wealth in their family, or people that they can rely on to loan them money, or flexibility within their jobs, financial toxicity of cancer treatment really hits them so much harder.  HALA BORNO: Yeah, that's certainly a really powerful experience. And I do in a moment want to hear how that informs the research questions you ask, but I do want to first highlight that you brought up two really important points.  So the first point is this notion of coverage, where access to insurance doesn't necessarily mean access to affordable insurance. And that this issue of cost sharing and out-of-pocket costs that patients bear can be quite burdensome and compromise their circumstance. And I think your story certainly highlights that. The other piece that your story highlights is this notion of wealth versus household income and how different individuals enter their cancer journey from a different circumstance. And that circumstance of wealth versus household income can have huge ramifications on their experience of financial toxicity. So I think that that's a really critical point to make. Could you share a little bit about how that experience now has become really the cornerstone of the research questions you're asking in your academic career? And then have you carved out certain solutions to identifying these among patients that you're seeing?  FUMIKO CHINO: I think that the experience that we had in terms of navigating the health care system, and the obstacles, and the rat race that cancer care treatment is for everyone, especially coming from a background of having-- a high educational and a family in medicine, and just how difficult it was for us really highlights for some patients how it can be insurmountable. And these problems of access, or even getting the right diagnosis.  So my husband was given, I think, three false diagnoses before he was actually told he had cancer. And then from cancer, he was originally told he had non Hodgkin's lymphoma. And he ultimately ended up having a high-grade neuroendocrine carcinoma.  So realistically, those barriers to even getting the right diagnosis are even worse for patients that may have a lower education standard or may have built-in racism within the system, which is holding them back from being able to trust their health care team and being able to get the proper diagnosis and the proper treatment for their care.  I think our experience has really focused me on trying to think about highlighting the populations that really could benefit the most from an intervention, and then piloting specific interventions that may actually help people receive the high quality, high value cancer care that everyone really deserves. I think within the United States, we are-- we like to think of ourselves as being leaders. And I think that to call ourselves leaders, we need to lead.  We cannot live in a society where a quarter, a third of our patients are really suffering huge burdens related to the cost of their cancer care. In highlighting a little bit about what you said before about wealth, we already know that, for example, Black families have one tenth of the wealth that white families have in the United States. There was a really compelling Brookings evaluation of that.  So if you think about just the out-of-pocket burden for cancer care eroding wealth, what we're talking about with financial toxicity is something that can really be durable within families. So not just eroding the financial security of a patient, but also potentially compromising the educational success of their children or causing housing instability within the family. That affects the entire family unit.  So thinking about these issues are really what has galvanized me to consider what are the next steps to actually getting people the care that they need in a facilitated way. And I think-- again, not to bring up COVID again, but that's really highlighted the gaps in the US health care system and the patients that are disproportionately affected by burden.  So if you think about someone who has now potentially lost health insurance, or does not have the job flexibility, or paid sick leave to deal with a cancer diagnosis, we're talking about an entire group of patients that are now going to have even worse cancer outcomes.  And we know that, for example, patients that do have-- the working poor, actually, those with essentially borderline private insurance, that they really do suffer the most in terms of financial toxicity in terms of their out-of-pocket costs, and their coverage gaps in terms of-- what their insurance insufficiently covers in terms of their cancer treatment are the highest.  And that's really, in terms of the people to really think about how do we help them, how do we get them the care that they need, that's really what I'm most interested in pursuing. HALA BORNO: Really important points that you brought up. I think we can't ignore our context, the COVID context. And certainly, this current pandemic has shone the spotlight on the relationship between disease and our financial circumstance and in a variety of ways.  And so I think it emboldens us to understand and to evoke change in our clinics, in our hea

This episode was originally released October 26, 2020 In ASCO eLearning's first Social Determinants of Health (SDOH) series episode, Dr. Ramy Sedhom, MD moderates a discussion with ASCO President, Lori Pierce, MD, FASTRO, FASCO; Abenaa Brewster, MD, MHS; and Katie Reeder-Hayes, MD, MBA, MS on why understanding SDOH's impact on patients is critical to providing equitable care. We hope you enjoy this episode. TRANSCRIPT ANNOUNCER: The purpose of this podcast is to educate and inform. This is not a substitute for 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. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. RAMY SEDHOM: Hello, and welcome to ASCO's newest podcast focused on the social determinants of health. My name is Ramy Sedhom, and I'm a medical oncology fellow at Johns Hopkins. Today, I am joined by ASCO president Dr. Lori Pierce, professor of radiation oncology at the University of Michigan. We are also joined by Dr. Katherine Reeder-Hayes, associate professor of oncology and health services researcher from UNC Chapel Hill, also chair of the ASCO Health Equity Committee. And finally, we are also joined by Dr. Abenaa Brewster, chair of the ASCO Prevention Committee, medical oncologist, and professor of epidemiology at MD Anderson. All our distinguished health researchers focused on disparities work. We are excited to launch this theme in light of the theme as highlighted by Dr. Pierce, equity, every patient, every day, everywhere. Dr. Pierce, why are the social determinants of health relevant? How do they relate to our work at ASCO and to the theme of equity? LORI PIERCE: Thanks, Dr. Sedhom. Yes, the ASCO theme this year is based on equity, and treating patients with equitable care is at the very heart of what ASCO does. It's what ASCO stands for. But we know there are factors, including social determinants of health, that can significantly affect the quality of health care that our patients receive, so we're hoping that this series of talks will increase awareness to many of those factors so providers can understand even better what some of the barriers are that our patients are experiencing. So we feel that understanding what they are, that's an important first step in terms of determining meaningful actions that we can take. RAMY SEDHOM: Thank you, Dr. Pierce. Dr. Reeder-Hayes, any additional comments? KATHERINE REEDER-HAYES: So I would just add that the reason I think oncologists inherently do care about the social determinants of health is that we care who gets cancer, and we care about the survival of that cancer. That's what we do as physicians. And as we follow cancer outcomes and cancer registries over time, what we realized is that there are a lot of biological things about cancers that determine their outcomes, but there are also many things that determine that outcome of a person's cancer that aren't biologic, and we have put those things together in a large group and use labels like the social determinants of health to understand what those non-biological factors are. But as physicians, as people who want to cure cancer, I think that it's just as important for us to have a good understanding of those non-biologic factors and how they're going to influence our patient's chance of the best outcome from their disease as it is for us to have a good grasp on the biologic determinants that are going to influence our patient's outcome. RAMY SEDHOM: Thank you. And I think this is a really good time to emphasize that the series is at the intersection of work through the Health Equity Committee and the Prevention Committee as being put forth by ASCO, and the ASCO Education Committee as well. And Dr. Reeder-Hayes, how would you importantly define the social determinants of health? KATHERINE REEDER-HAYES: So that's a pretty broad range of definitions, because there are a lot of people in health care who have talked about this concept of non-biologic determinants of how patients do for a long time, both in cancer care, and in other fields, like primary care, diabetes, and hypertension research. And so there are several organizations that have put forth definitions. The first one that I would point people to as the World Health Organization. So these patterns occur globally, not just in the United States. And the WHO describes the social determinants of health as the circumstances in which people are born, grow up, live, work, and age, and the systems that are put in place to deal with illness. So there's this idea that the circumstances that people find themselves in, as well as the structure of the health care system are part of this conversation about social determinants of health. The Robert Wood Johnson Foundation has done a lot of work to help put these concepts into more understandable and everyday language. And so the definition they use is that health begins where we live, learn, work, and play. So the social determinants of health include factors that operate on a few different levels. So there's the level of societal conditions, social conditions, economic conditions, physical conditions of where and how people live, and where and how people work, and then there are also psychosocial levels, like the patient-level psychosocial factors. And Centers for Disease Control also focus a lot of their work on social determinants at this idea of psychosocial factors at the patient level. So even though the concept is simple, it's actually also very broad. And when people talk about social determinants of health, they can be talking about things that are operating at several different levels, from the structure of the health care system, on down to the structure of the apartment complex where your patient lives. And so you have to think broadly, I think, when you're thinking about analyses for research or how to talk to your patients about social determinants of health. But the American Cancer Society has recently also put out a paper that tried to help people put these social determinants into appropriate buckets, particularly the ones that really seem to impact cancer care. And so the three categories or domains that they've suggested are structural inequities, so things that happen in a larger society and in the structure of the health care system that impact our patients and how they access care. Secondly, institutional environments. What do the places where we treat cancer look like? What are their structures? And how does that impact our patients outcomes? And then, finally, living environments. Where do our patients go back to when they go away from the health care setting? So those are some of the ways that we can think about the finding and talking about the social determinants of health. RAMY SEDHOM: Thank you for sharing that. That's a lot to think about and to consider. Dr. Brewster can you comment on the impact of those social determinants of health in disparate groups beyond race and ethnicity? ABENAA BREWSTER: So I agree that we're really used to thinking about social determinants of health as explaining some of the race-ethnic disparities that we see in cancer incidence and outcome. But we know that there are other groups that also experience differences in outcomes based on these determinants. For example, characteristics of sex, gender identity, sexual orientation, geography, immigration status, these are all characteristics that are impacted by social determinants of health. An example that I like to give for the race-ethnic disparity is the 40% increase in mortality that African-American women experience who are diagnosed with breast cancer compared to white women, and that, for a large part, is due to socioeconomic poverty and insurance differences. And in fact, then those characteristics then explain decreased screening, later stage of diagnoses, and then leads to disparate delays and receipt of treatment. There was a really nice paper published in JCO by Jamal and others which showed that insurance alone accounted for about 37% of that 40% increase in mortality that Black women experience who are diagnosed with cancer. And so you can see the great opportunities that are there to make care more equal if you're able to improve access. And so examples of other groups, for example, we have registry data showing that urban populations, although they have higher cancer incidence, the rural populations actually have a higher incidence of the cancers that are related to tobacco use or HPV. And we also know that rural populations also have higher mortality than urban populations when it comes to cancer, and that's largely driven by poverty, under insurance, socioeconomic status, isolation. And so that's another group that is impacted by those social determinants of health as outlined by Dr. Reeder-Hayes. And then, lastly, the LGBT community. Although there haven't been a lot of large studies looking at the impact of cancer incidence and outcomes in that community, there have been lots of survey studies that have shown that these determinants of health tend to cluster within those communities. Once again, social isolation, negative patient-provider relationships, under insurance, poverty, and so that's another group where this becomes very meaningful. And I think kind of what cuts across all of these groups are really characteristics that have been linked to historical discrimination. And so that's something that we see very clearly. And then, we also see it reflected in our oncology population, right? Only about 2% of oncologists are African-American. And so these social determinants of health not only impact our patients, but they impact what our workforce looks like, and then, that, in turn, leads to differences in terms of the patient-provider relationships. RAMY SEDHOM: Absolutely. And this

This episode was originally released December 9, 2020 In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Narjust Duma, MD, moderates a discussion with ASCO CEO, Clifford A. Hudis, MD, FACP, FASCO and Sybil R. Green, JD, RPh, MHA, Director of Strategic Initiatives in ASCO's Policy and Advocacy Department, on what ASCO is doing as a professional society to address equity as part of its mission.  TRANSCRIPT PRESENTER: The purpose of this podcast is to educate and inform. This is not a substitute for 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. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. NARJUST DUMA: Welcome, everybody, to the second episode of ASCO's Social Determinants of Health series. My name is Dr. Narjust Duma. I am an assistant professor at the University of Wisconsin and also a thoracic oncologist. Today I'm joined by ASCO's CEO, Dr. Cliff Hudis, and Sybil Green, Director of Strategic Initiatives in the policy and advocacy department for ASCO. This series is a new initiative proposed by ASCO president, Dr. Lori Pierce. It focuses on increasing oncologists' awareness about the social determinants of health through the cancer care and how impacts our patients' outcome, including modifiable risk factors. This series is inspired by Dr. Pierce's presidential team of equity, every day, every patient, everywhere. In this episode, we look at what ASCO is doing as a professional society to improve health equity and cancer care. Welcome, Dr. Hudis. Welcome, Mrs. Green. First I would like to us what is ASCO doing as an organization in the matter of health equity and cancer care? CLIFF HUDIS: So I guess I'll start here. Thank you very much for spending some time with us on this. If you look at ASCO's mission, it is conquering cancer through research, education, and the promotion of the highest quality and equitable cancer care. So the idea of equity and our responsibility to address disparities is really in our organizational DNA. I have to point out something that many people may not realize. But when ASCO was founded in 1964, one of the seven founders was a black woman, Jane C. Wright. Dr. Wright died in February of 2013. But her father was among the first African-American graduates of the Harvard Medical School. His father was also a physician. And he was educated at what became Meharry. So I remind everybody of this as often as I can, to make the point that not only do we have an opportunity to advance equity and to deal with disparities in health care, but it's my perspective as a leader of ASCO that we have a special obligation and responsibility to do all of that. So we can talk more about it. But I'll just introduce maybe the answer by saying there are really two broad themes at work for us at ASCO. One is externally facing. And one is internally facing. The externally-facing work includes a range of projects and output that we can talk about a little more, but for example our position papers describing disparities and then identifying potential steps to take to address and solve them. But it also includes support for targeted research that is meant to narrow those gaps. It includes our educational efforts, both for our members and for legislators, advocacy for policy, and so on. And then on the internal side-- and here I'll ask Sybil to talk a little bit-- I think we've recently recognized our opportunity, and again responsibility, to think about the workplace itself and to think about our staff and to think about the activities and actions we can take and the roles we can model to create a better world. So I know I've been high level in my initial answer here. But the two domains again are external and internal. And then we can talk about some of the specific projects as we go on. NARJUST DUMA: Mrs. Green, I think it's very important to share about these internal aspects of ASCO because many of us are now aware as members, we see the surface. But ASCO is a large organization with many staff and members. So it would be great that you can share that with us. SYBIL GREEN: Absolutely. And thank you for allowing us to share that. I think Dr. Hudis pointed out some of what we've done since ASCO's establishments and really charging everyone on staff to really live out that obligation of equity, diversity, and inclusion. And so through our programs, our staff have to do their work, make sure that we are creating equitable opportunities for patients and physicians, but it starts at home. And so we have to make sure that internally, we are offering those same opportunities for our staff to engage because what we know is that when staff are engaged, and they have the opportunity to bring their true selves to work every day, they bring their personalities. They bring their lived experiences. And that all plays out in the work that we're doing on behalf of members, in their patients, but also for staff. I think if I were sum up where our program is going, similar to what Dr. Hudis has done, the three components are really enabling staff success. We ought to be able to do that for our staff internally. Every day we ought to provide opportunities for them to succeed. And then making sure that our partnerships-- those that we work with, whether it's in our publications, our meetings-- making sure that our partners goals and ideals align with ASCO's values and ideals. And all of this, of course, is in support of the greater ASCO enterprise, which is our members and the patients and of course, ASCO staff. NARJUST DUMA: And I think that it's really important-- I had the pleasure of interacting with several staff members with diverse backgrounds. And I think as we develop the mentorship program and other things, their input is diverse. It means we also are able to cover the trainees needs because every trainee's needs are different. And because I cannot give a talk or do a podcast without mentioning my grandma, [INAUDIBLE], I have to say that it's important to clean your house first before you go and try to clean other people's houses. I do promise it's beautiful in a Spanish. But I think it's important that everybody knows that internally ASCO is doing a lot of work. And I think it's important to talk about the grants in health equity. And I'm mentioning this because I haven't been doing health equity since I was a med student. And sometimes you find yourself not having enough grant opportunities. Now there is an increase. But when you compare it to other areas of oncology, you may be more competitive because there are less grants. And I think it would be great to hear from the both of you about the new health equity grants, the breast cancer disparity grant, and beyond. CLIFF HUDIS: Well I would just point out something to build on your comment, first of all. Since we were founded in 1964 til now-- so just over 55 years-- we've made unbelievable advances, I think, in oncology in general. Indeed the reason I as an old man chose to go into an oncology in the 1970s was that the vision ahead was that this was going to be an exciting field. And it has not disappointed. However there's a dark that I think we should acknowledge. The advances have not been fairly or evenly distributed. And indeed in some cases when we make massive improvements in outcomes in terms of what's possible with state-of-the-art care, we increase disparities because not every group catches up. And I say all that because it's important to understand that this is not about abstraction. These grants that address that gap are as or more important than the basic science grants that actually advance the biology and understanding in the first place. One without the other is incomplete. So I can't agree more that this is important. And actually from an investment or return on investment point of view, in some ways, these grants are an even better deal because we can rest many of these gaps in care delivery and in knowledge pretty quickly and narrow the gap. And we've seen it. I'm going to give you some examples in a moment. Whereas funding basic science, honestly, is a much higher risk proposition, if you think about it. So I don't mean to set up a false competition here. But I want to point out that there's a big reward. So here's an example. The plenary session abstract at ASCO two years ago now-- abstract number one, if you recall, was no moral less than an analysis of the impact of Medicaid expansion. And what did it show? It showed that with Medicaid expansion, those states that implemented it quickly narrowed the gap in time to initiation of therapy for curable colon cancer. It's a simple take-home point. I care passionately about this personally because these are differences in outcome that have been labeled as associated with race for many years or other specific ethnic facts. But really what they're about is nothing except unfair, uneven access to care in the first place on the basis of race. And it's something that we can address. So we are building out programs to address this through a number of granting mechanisms. For 2020 alone, there are going to be two Young investigator awards that are earmarked for underrepresented populations. And there's a career development award and another YIA, Young Investigator Award, in health disparities specifically. But this is just, I think, part of the issue. The other issue for us-- and actually a commitment going back for years-- is to do something about the workforce itself. And I don't have to tell you, but of course, there is a huge disparity playing out when we look at makeup of medical students in America. And it gets accentuated to the extreme when we look at black men. They are the most disproportionately underrepresented group right now. So how are we going to address th

In this episode, guest host, Dr. Christopher Cross, Director of Global Health Equity Strategies at ASCO moderates a discussion with the Dr. Ophira Ginsburg Co-Author of the Lancet Commission on women, power, and cancer and Dr. Julie Gralow, an advisor to the Commission.  Dr. Ginsburg and Dr. Gralow share their insight into social determinants of health in cancer and prevention among women and global efforts underway to advance health equity. TRANSCRIPT The guest on this podcast episode has no disclosures to declare. Dr. Christopher Cross: Welcome to ASCO's Social Determinants of Health in Cancer Care Podcast. I'm Dr. Christopher Cross, Director of Global Health Equity Strategies at ASCO. I'm joined by Dr. Ophira Ginsburg, Senior Advisor for Clinical Research Center for Global Health at the National Cancer Institute, and Dr. Julie Gralow, Chief Medical Officer, and Executive Vice President of ASCO. In this episode, we will discuss social determinants of health, focusing on women, cancer, and prevention. Thank you both for being a part of our podcast, we're excited to have you on. Dr. Ophira Ginsburg: Thanks so much. My pleasure. Dr. Julie Gralow: Thanks, Chris. Dr. Christopher Cross: So, we'd like to start the conversation with asking our guests, how do you define social determinants of health and cancer care? Dr. Ophira Ginsburg: Well, social determinants of health, according to the World Health Organization, I'm sure as you know, is really looking at a person's background that leads them to health inequities or health inequality. So, it has to do with the conditions under which people are born, how they develop, grow, live, work, age, and all the sort of forces and systems that shape their daily living conditions. With respect to the interaction of women and cancer with respect to the social determinants of health, as we put forward in our commission report, really, gender has an influence on all of these factors. And not just gender, but the other intersectional aspects of a person's identity that can serve to compound and influence in a negative way their opportunities to understand what their risks of cancer are, to avoid those risks, to seek and obtain respectful, prompt, timely quality cancer health services. And this also influences the way in which women interact with the health systems for cancer as care providers, whether it's clinicians, et cetera, or also, is the unpaid caregivers, as we sometimes call them, informal workforce. There's nothing informal about it. Dr. Julie Gralow: And I would agree with the Ophira's definition. I think of it as the environment in which people are born, live, learn, and work, and how it impacts health. And so, that can include economic stability, education access and quality, healthcare access and quality, the neighborhood and the environment in which the person lives. And then the social community context, the family, the relationships, all of those can combine to impact health. Dr. Christopher Cross: Thank you for those responses. What does social determinants of health for women mean at a global level, Dr. Ginsburg? Dr. Ophira Ginsburg: Global is local. So, we see social determinants of health, and by the way, also commercial determinants of health, which would be wrong not to include in this discussion as greatly impacting the aspects of opportunities to seek and prevent cancer, et cetera, everything we just discussed; this happens also on a global level. So, as we show in our commission report where a woman lives does greatly influence cancer incidents, mortality, survival, and also, very importantly, who that woman is in her community. Whether she's living in a circumstance situation or there are identity factors that render her structurally marginalized will impact also on her lived experience of cancer. And we have nine stories that highlight and offer some human aspect to what people are going through, whether they're care providers or women living with the experience of cancer on a personal level, the different countries and context in our report. Dr. Julie Gralow: With respect to social determinants of health and women, particularly at a global level, I think women interact with cancer in so many ways. I mean, the easy way to think about it is women with a diagnosis of cancer, but we've also got women working to reduce their risk of cancer and detecting it early. We've also got women in the workforce, health professionals, researchers, we've got women as policymakers, and in the home environment, we have women as caregivers. And they are much more frequently the decision makers for everybody in the family with respect to healthcare related issues. So, women interact with cancer in so many different ways, and those social determinants of health mean that women are more commonly subject to discrimination. It can be discrimination due to their gender, but also, their age, their race, their ethnicity, their socioeconomic status. And as Dr. Ginsburg has pointed out that this can marginalize them. And these factors can restrict a woman's rights and her opportunities to reduce her risk of getting cancer. And it can be a barrier to early diagnosis to achieving quality cancer care. And we've got this whole (which is really predominantly portrayed in there) unpaid caregiver workforce that is almost all female around the world. And this can hinder a woman's professional development as well. Dr. Christopher Cross: When you were talking, Dr. Gralow, it made me think of hearing about the story of the former First Lady Rosalynn Carter. Her father passed away when she was around 13 or 14 from cancer, and she said she had to become the caregiver as like the oldest sibling. And talking about that in wake of her passing, in her advocacy for mental health and caregiving, I think is right along this conversation that people may not be experts as you two are, but they have lived experiences where they've had to step into these roles. And so, thank you for bringing to light the global context. Like you were saying, Dr. Ginsburg, local is global, and I think this is something that everybody can relate to. Now, let's get into the work that you both are doing. Can you tell our audience about Women, power, and cancer: A Lancet Commission and your role and any of the key findings you may want to highlight? Dr. Ophira Ginsburg: Yeah, I'm happy to take that one on. To start with, I was very fortunate to have a conversation with the editor-in-chief of the Lancet, Dr. Richard Horton, several years ago now, three years ago actually. And we at that time, were making kind of note of where we were at some three years after the publication of a three-part series called Health, Equity, and Women's Cancer that was published in the Lancet that was specifically oriented around breast and cervical cancer, and the difficulties and challenges women have in obtaining equitable access to care. And to some extent, we commented on what we don't know about, for example, the children that are left behind when a woman dies of one of these cancers. And we emphasized the importance of more research in that area. This led to my pitching proposal for a commission, and this was approved, and we published an initial commentary (Richard and myself) in July of 2020 that led to the commission that we now have as a major report in the Lancet that was published on September 27th, and excited to speak about that. I might just emphasize a couple of key data points in the report that I think the listeners would be interested to know. Well, for the first time, we were able to show the number of women's lives that could be saved if just four risk factors were addressed. So, we found that 1.3 million women's lives would be saved if tobacco, alcohol, obesity, and infections could be controlled. Now, why is this important for women? Well, it's important for men as well, and I know people often ask, "Why did you focus on women?" We can get to that if people are interested. But to emphasize the importance of the preventability and lack thereof, we know what is contributing to a large proportion of cancer in women, but what many people don't know is what the numbers actually show with respect to premature mortality and how that relates to maternal orphans, that I just mentioned that hadn't been really addressed before. So, when you look at the number of men and women with cancer, it's roughly equal. It's almost 50/50. Now, men are more likely to die of cancer than women. About 44% of all cancer deaths occur in women, so it's not that much less. But when you look at the number of women experiencing cancer under the age of 50, in 2020 alone, of the 3 million adults diagnosed with cancer, two in three were women. That was a data point hiding in plain sight, we produced that. That was published in advance of this report in the Lancet Oncology with a few of us on the commission. And then in the commission report, we really dug into the preventability of premature deaths, and we found that 1.5 million women could be spared, a death under the age of 70 due to cancer if everyone had access to primary prevention and early detection strategies that we know work and we know exist. And another 800,000 women's lives could be saved premature deaths below the age of 70 if every woman everywhere diagnosed with cancer had access to optimal care. In 2020 alone, 1 million children lost their mothers due to cancer, just that year. And when we looked at the prevalence, so the number of kids who were without their mothers who were still children in 2020, it's seven and a half million. This was work done by our colleagues at IARC, Dr. Valerie McCormack group, and many of us were on that report as well. So, these are big numbers and I think that's what's gotten people talking about this. Dr. Julie Gralow: I was fortunate to be invited by Dr. Ginsburg early in the formation of this commission to serve as an advisor on the commission. I

In this episode, guest host, Dr. Surendra Shastri is joined by Dr. Timothy Rebbeck to discuss social determinants of health at the global level and the impact on cancer care, prevention, and control. Dr. Surendra Shastri is a Professor, Department of Health Disparities Research at MD Anderson Cancer Center. Dr. Timothy Rebbeck is the Vincent L. Gregory Professor of Cancer Prevention at the Harvard T.H. Chan School of Public Health and Professor of Medical Oncology at Dana-Farber Cancer Institute. Professor Rebbeck also serves as the director for the Zhu Family Center for Global Cancer Prevention Harvard TH Chan School of Public Health and the Center for Cancer Equity and Engagement at Dana Farber Harvard Cancer Center.  TRANSCRIPT  The guest on this podcast episode has no disclosures to declare. Dr. Surendranath Shastri: Hello everyone. Welcome to ASCO's Social Determinants of Health in Cancer Care podcast. My name is Surendranath Shastri and I serve as Professor in the Department of Health Disparities Research, the Division of Cancer Prevention and Population Sciences at the MD Anderson Cancer Center. Joining us today is the very renowned Dr. Timothy Rebbeck, who serves as a Professor at the Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health. In this episode, we will discuss social determinants of health with a global perspective and what impact those have on cancer care in general with a little specific attention to cancer prevention and control.  Thank you, Professor Rebbeck, for agreeing to be a part of our podcast.  Dr. Timothy Rebbeck: Happy to join you today.  Dr. Surendranath Shastri: Thank you very much. We are really blessed to have you on this podcast. So let's get the podcast rolling. We would like to begin the conversation with a simple question: How do you define social determinants of health in cancer care, particularly those in prevention? Dr. Timothy Rebbeck: So I think the definitions that we need to be thinking about are really very specific to the questions we're trying to address. So there are many ways one could define social determinants. They are generally, in the United States at least, consequences of the legacy of historical, political, economic, and social influences, particularly for minority populations; those of the legacy of slavery and other related discrimination and segregation activities that have happened over many, many years and centuries, really. So that's not really an answer to how we define it, but I think that way we define it in terms of the research question or the clinical or public health question, and that using those variables that we define, we should be able to identify different groups who have specific needs or for whom we need to create interventions or prioritize activities to eliminate disparities.  Dr. Surendranath Shastri: So speaking about social determinants of health in cancer care, particularly in the US, looking at the global perspective, I'm sure you'll agree that the social determinants might not be the same for people living in the US as compared to, say, people living in countries in South America or people living in Asia. So let me ask you a direct question pertaining to your work because you have been working globally and you have a lot of multicentric studies: Have you seen real life differences in social determinants of health based on geography and country in some of your multicentric studies? For example, you have this very large score study where you're looking at population groups of different backgrounds. So something like that?  Dr. Timothy Rebbeck: Yes, absolutely. I would say that the categories or domains of social determinants are not fundamentally different in different parts of the world. They all involve things like access to care, insurance and payment, education and knowledge, things like that. Those are common to anywhere in the world. But the manifestation of those social determinants is really quite different in different parts of the world. So we can assume that a lot of the same factors are acting, but they are magnified in places that are low resource because the health systems and the governmental payer and care systems are quite different. The specific activities or limitations, barriers, vary by country or system. And so I think that we can think about the same problems as being universal worldwide, but the manifestation and specific things that we need to address in a particular region or country will vary quite a bit.  Dr. Surendranath Shastri: Understood. So you would also agree that even within the same country, you will find huge disparities between populations and between people of different social classes if I'm permitted to say that? Dr. Timothy Rebbeck: Yeah, absolutely. And so, not unlike what we see in the United States, there are people that can afford access to the very best health care in the entire world. In Africa, for example, where I do a lot of my work, the very wealthiest people can get on an airplane and fly to France or England and get their care there. And the poorest in the United States or in Africa or South America have significant barriers to obtaining the best care. And in fact, in places like Africa low resource countries, the care is, maybe for the lowest socioeconomic groups, the lowest income groups in those countries, the barriers are really substantial and probably lead to the incredibly late diagnoses, high mortality rates that you see in a lot of low and middle income countries.  Dr. Surendranath Shastri: Absolutely. I completely agree with you because even in my personal experience, there are a couple of countries in sub-Saharan Africa which have maybe just one or two pathologists and just general pathologists - they're not even cancer pathologists.  So, it's tough for them to access good quality health care.  So I have read some of your work, and you speak about neighborhood, social and natural environment. Could you explain that a little bit?  Dr. Timothy Rebbeck: Yeah, I think that when we think about environmental as an exposure, there are a lot of different classes of what environment could mean. And again, it depends a lot on the question, the goal that we have in defining these different characteristics and what we want to do to ameliorate disparities. So most environment that we tend to think about is individual level exposures. So radon exposures or cigarette smoking or sunlight, whatever those may be, we think about individual level exposures. And those are, of course, incredibly important.   But I think that there are other levels of exposure that we might want to explore. One of those is the neighborhood and contextual environments that are all around us. So where we live has an impact on our health, and particularly in the context of disparities, the neighborhood in which you live may determine your access to care. It may determine your access to healthy food. It may determine exposure to pollution, all kinds of levels that we may or may not be able to measure in a person, but we can measure in a neighborhood or an area context. Thinking about those gives us an additional layer of information about the kinds of risks people face as a group or as a neighborhood. And very importantly, they allow us to think about policy solutions. So if we can identify types of areas, say very polluted areas or areas that have very poor access to health care, those areas can be identified as having a particular need, and that need might be able to be addressed by policy or funding or things like that. And again, I would say that's true in the United States, but it also is true in Africa or India or South America or any place where neighborhood exposures and neighborhood level factors vary, which they do everywhere. So we can learn from that, and particularly we can learn to make policy decisions. Dr. Surendranath Shastri: Absolutely. We have large slums in many parts of Africa, as well as Asia. In India and South Asia particularly, you have large slums. You have large slums in Indonesia. So all those neighborhoods in the US—of course, you just mentioned, and the red line districts were historically denied all possible care and facilities - those districts also will be having all these problems. One example that immediately comes to my mind in the US is the smoking rates are very high among the African American Black people. Neighborhoods where you have a majority of African American Black people living, the second hand smoke exposure rates are going to be really very high. Is that what you meant by saying neighborhood social? Dr. Timothy Rebbeck: Yes. So that's part of it. I mean, I think that individual level smoking exposures may affect the individual and may affect people in their household, but there are larger level factors that are acting. So, for example, tobacco companies target neighborhoods based on who lives there. It's not uncommon for a tobacco company to have offers for cigarettes, coupons, and vouchers that will be used in neighborhood stores in low resource neighborhoods. They will target their advertising.  For example, we know that African Americans tend to smoke menthol cigarettes more than other kinds of cigarettes, and that's really been a consequence of advertising and targeted marketing by tobacco companies to specific groups of people in specific neighborhoods. So there's all sorts of different levels at which neighborhoods are disadvantaged because of the socioeconomic position they're in, of historic segregation, redlinings, other social determinants, and also the targeting by companies or businesses around specific neighborhoods as well. So there's a lot of levels at which these impacts are occurring. Dr. Surendranath Shastri: Excellent examples, and I've personally seen all of those, so I know exactly what you're talking about.  So another interesting area where you're working which could be a game changer, which may

In this episode guest host, Dr. Reggie Tucker-Seeley, moderates a discussion with two leaders from two remarkable organizations with the mission to provide food to those that are facing long-term illnesses like cancer.  In this episode,  the importance of the community and organizations addressing food insecurity and providing needed interventions are highlighted by Alissa Wassung, Executive Director at Food is Medicine Coalition and Alyssa Baldino, Associate Director of Nutrition Services and Therapeutics at Project Angel Food. TRANSCRIPT  The guest on this podcast episode has no disclosures to declare.  Dr. Reggie Tucker-Seeley: Welcome back to ASCO's Social Determinants of Health and Cancer Care podcast. I am Dr. Reggie Tucker-Seeley. We are continuing our conversation on "Community and Organizations Focused on organizations addressing Patient Needs in the Cancer Community." I'm joined by Alissa Wassung, Executive Director of Food Is Medicine Coalition, and Alyssa Baldino, Associate Director of Nutrition Services and Therapeutics at Project Angel Food. In this episode, we will discuss a patient and household need that often gets overlooked following a cancer diagnosis, and that is food insecurity. We are fortunate to be joined by two people from amazing organizations with a mission to provide food to those that are facing long-term illnesses. First, we have Food Is Medicine Coalition, which is a national organization that provides evidence-informed medical, food, and nutrition interventions to critically and chronically ill people while working to advance public policy surrounding food and nutrition. And second, we have Project Angel Food, located in Los Angeles, California, and is a part of the Food Is Medicine Coalition, which prepares and delivers healthy meals, comfort, and hope to people impacted by serious illness.  So, given that both of our guests today are named Alyssa, we're going to say Alyssa B and Alissa W to distinguish between our two guests. So, thank you both for being part of our Social Determinant of Health conversation focused on communities and organizations. Alissa Wassung: Thank you so much for having us. We're so excited to be here. Dr. Reggie Tucker-Seeley: Great. Let's dive right in. And this first question is one that we ask all of our guests, and that is: What does Social Determinants of Health in cancer care mean to you? We'll start with you, Alissa W. Alissa Wassung: I would have to say that it means making sure that everyone who is coping with cancer has everything that they need to survive and thrive through the process. From our perspective as caregivers in the community for over 40 years, a lot of this knowledge and wisdom comes from our roots in the HIV epidemic and seeing how the toll of illness can take on a person and also their caregiving structure, that it affects the whole family. So really, having that holistic, person-centered view of what wellness and health means through a diagnosis like cancer, making sure that we are showing up for the food piece and paying attention to the rest of it as well. Alyssa B? Alyssa Baldino: I've been a dietitian for nearly 15 years, and someone's ability to manage their chronic illness is so heavily influenced by their environment and the resources available. So, education is obviously a good building tool to help someone work within their resources, but it only goes so far. So, the more holistic you look at, especially cancer clients, the better you can help someone, the more you understand all the outside factors that affect their lives. Dr. Reggie Tucker-Seeley: Thank you for providing those perspectives. Social Determinants of Health feels like such a broad term. It's often described as where we live, learn, work, and play, and that's everything. So, would you consider food insecurity as a social determinant of health? Alissa Wassung: Absolutely. The ability to nourish oneself as you are supporting your own body through treatment and recovery is foundational to what we understand about health. I think what's different for our organizations is that food insecurity can be reduced to hunger. And certainly, our programs, medically tailored meal and medically tailored grocery programs that also provide the services of a registered dietitian that helps people with the education piece and some of the more clinical pieces like what's called medical nutrition therapy, are so much more than just addressing the hunger piece. So, food insecurity is absolutely a social determinant of health. So, in a spectrum, I would say food insecurity can be really addressed in the prevention phase and what we are doing is more on the treatment side of that food insecurity spectrum. Alyssa Baldino: Education as registered dietitians is so powerful and can be a great tool for clients. But as a medically tailored meal provider, it's also empowering to be able to provide the food we are educating clients to nourish themselves with. So, in addition to the education piece through medical nutrition therapy, we're also able to provide the food as a resource to help address the treatment and the food insecurity.  Dr. Reggie Tucker-Seeley: So, it sounds like both of your organizations go well beyond just the notion of checking the box of "Are you hungry, are you food insecure, yes, or no?" I'd love to hear more about your organization. So, Alissa W, can you tell us a bit more about Food Is Medicine? Alissa Wassung: The Food Is Medicine Coalition's history is really the history of our partner agencies, and so many of them got their start, as I briefly mentioned before, at the height of the AIDS pandemic back in the 1980s. And this was a time when HIV was not as understood as it is today. It was tremendously stigmatizing, and it was scary for some. Our communities across the country stepped into that space and brought hope and dignity to that situation in a time when there wasn't a lot of service available for folks. This was volunteers going into people's homes and bringing them food, as they recognized the effects of HIV, which included wasting, and tried to help people be as healthy as they could be when there was no treatment available.  The biggest realization during this time was that folks in this situation needed more than just access to food. They were too sick to shop or cook for themselves. And so, people were delivering groceries and they got left on the counter and just stayed there. And so, the recognition that people needed more than a meal, they needed meals tailored for their illness and delivered to their home so that they could live as long as they could with the illness that they had. Registered dietitians were actually foundational to this process because their services and understanding how to combat wasting or side effects of medication when it came on the scene was foundational to people actually eating. Appetite tends to be one of the first things to go when someone is sick, and that is certainly true in cancer care. And so fast forward to a time when most of our agencies expanded their missions, now serving people living with multiple illnesses in communities across the country. What's very different about our clients is that they actually tend to be living with multiple illnesses at once. So, a client where I used to work at God's Love We Deliver, which is our non-sectarian, nonprofit peer agency in New York City, about 40% plus or so of folks were living with four or more illnesses at once. So very much trying to address the complexity of that situation with access to compassionate nutrition care.  We do all of this in the community with the help of thousands of volunteers a year and the support of our communities through philanthropy. Because despite the awesome intervention and its life-saving results, there still is no dedicated federal funding for what we do.  Dr. Reggie Tucker-Seeley: I'd love to hear from Alyssa B. Alyssa Baldino: We were founded 35 years ago by Marianne Williamson. That name might sound familiar. As Alissa W. was saying, we started out of the HIV/AIDS epidemic. We started out to provide food for people who didn't have food. They needed a lot of calories, and as medications got better for HIV/AIDS, about 20 years ago, we shifted to medically tailored meals and started providing meals to, actually cancer patients was one of our first groups that we started providing medically tailored meals to. And then kidney disease is something we address, diabetes, heart disease. And usually how patients find us is through their doctor and also, I like to think we're pretty well known in Los Angeles. We have a lot of celebrity support that gets our name out there. Harry and Meghan made deliveries for us. Like Alissa was saying, volunteers, so we have the spectrum of volunteers. Patients are generally referred to us from medical providers and a lot of the cancer centers. Dr. Reggie Tucker-Seeley: Well, in two words, you mentioned Harry and Meghan. If you just have to say their first names, then you know that they're famous. So that's amazing.  I'd like to talk about how both of your organizations partner with healthcare delivery systems and healthcare organizations. Can you talk a little bit about how you partner and whether or not you're housed within healthcare systems or you're outside of healthcare systems? We'll start with Alissa W.  Alissa Wassung: Oh, my goodness, what an incredible question. That would only take us about five hours to discuss, so we'll try to keep it brief. So FIMC is an organizing entity. We organize service providers, so we don't provide service specifically, but we know a lot about how best to provide service. So, we gather together, as you heard earlier in the podcast, to advance equitable access to medically tailored meals and medically tailored groceries through policy change, research, and evaluation, and best practices. The way that that translates into our partnership with healthcare really is t

In this Part 2 episode guest host, Dr. Reggie Tucker-Seeley, discusses the importance of the community and organizations meant to address the social needs of patients as they navigate their cancer journey and the financial burden on the household following a cancer diagnosis. Dr. Tucker-Seeley is joined by Carla Tardif, Chief Executive Officer at Family Reach and Eucharia Borden: Vice President, Programs and Health Equity at Family Reach, whose mission is to remove the financial barriers standing between cancer patients and their treatment.  TRANSCRIPT The guest on this podcast episode has no disclosures to declare. Dr. Reggie Tucker-Seeley: Hello and welcome to ASCO's Social Determinants of Health and Cancer Care podcast. I am Dr. Reggie Tucker-Seeley, Vice President of Health Equity at Zero Prostate Cancer and Chair of ASCO's Health Equity and Outcomes Committee. I'm joined today by Carla Tardif, chief executive officer at Family Reach, and Eucharia Borden, vice president of programs and health equity at Family Reach.  In this episode, we will discuss the importance of the community and organizations meant to address the social needs of patients as they navigate their cancer journey. There are many needs that cancer patients face and one of the biggest is the financial burden on the household following a cancer diagnosis.  We are lucky to have two change makers from the organization Family Reach with us here today. Family Reach is an organization in Boston, Massachusetts that dedicates their work to removing financial barriers with financial education, financial planning, resource navigation, and emergency funds to patients and caregivers.  Dr. Reggie Tucker-Seeley: So there is a discussion in healthcare services research now about whether the service to meet some of those patient social needs should be within the healthcare organization or the system, or whether community organizations should address those. And so, as a patient-focused organization, how does your organization partner with healthcare practices and systems? Carla Tardif: Yeah, so that's a great question. There is not one answer. We all have to be involved in this conversation. We all have to be able to step in with financial resources, having the conversation to normalize the conversation around finances and health. One of my north stars is to make financial health a standard of care because it affects your care so much. So, yes, patients need to hear about it in the healthcare system. We partner with over 1000 cancer care centers in this country, working with over 4000 oncology social workers in those hospitals. We give them our financial education program. They have access to an online portal to talk to my team of licensed social workers and resource navigators. That is a really critical intersection with the patient.  And we partner with nonprofits, as Eucharia shared, throughout the country who are working with patients because many patients do not feel comfortable talking about their finances in the healthcare system. How is this going to affect my care? Will I get a generic drug? Will I be invited to a trial? So they say nothing. If a parent has a child with cancer and a social worker sees that they cannot provide for their children, they could actually lose their children. The children could be removed from the home. This is the fear in talking about your finances in the healthcare system.  So the advocacy organizations outside the healthcare system play a critical role in trust, as Eucharia said as well. Many of them are under-resourced. Many of them don't have the financial interventions that we have. So that partnership is critical. Then we have our website. So many people are just googling, looking up on the internet to take matters into their own hands - "How can I get financial support? How do I figure this out? Where do I get help?" So the answer really is every one of us needs to be educated and armed with the resources and the financial assistance to support patients when they have the courage to ask for help and to raise their hand that they're in trouble. Dr. Reggie Tucker-Seeley: Are there infrastructure needs that policymakers could address here? Because it sounds like there are just so many holes in our social safety net that people are falling through. But how can policymakers help us address this issue? Eucharia Borden: That's a loaded question, but it's a good question and it's a question that we do need to be asking. Carla is a part of the Cancer Moonshot and this is certainly something that's being discussed at that level on a number of fronts. But also as we think about the fact that people are living in different states and different counties in different jurisdictions within those counties, one of the things that is so important but so often overlooked is the power of advocacy. I think we jump to policy immediately, but I always like to think about advocacy with a big 'A' and a little 'a' because they're different but both relevant.  So if we think about advocacy with that big A, those are those big policy initiatives, things that are moving legislation forward and that kind of thing. But there's also advocacy with a little a. But it doesn't mean that it's less important, it just means that it doesn't rise to that level, perhaps of like a big policy or legislative initiative that moves forward. But what about the advocacy that can happen in communities? Because sometimes that's the thing that we really need to be doing, even as we think about something like Medicaid expansion, not something that every state did, and so even as you try to address that, well, that's going to be state dependent.  As we enter into these spaces where we think about policy, we need to think about the varying levels of that policy work that occurs. But also this is another place where we don't need to cut out patients and their families. They are some of our best advocates for change because they bring that human element to whatever conversation they're a part of, just like we're doing here, to humanize a term like financial toxicity. So there are so many grassroots ways that people can be involved and I think they should be involved. Carla Tardif: We saw after COVID there were a lot of relief programs. SNAP benefits were expanded and housing relief and mortgage forbearance. So these are things that we had been talking about pre-COVID. It was a heavy lift and I was told we were out of our lane and I was out of my lane. I mean, I'm just sitting here shaking the trees saying, "This is what we're seeing. We've got to do something about it." "We can't." COVID hit "You can! We've seen it! There it is!" So that gives me some hope. So the data we are collecting, all of these programs, all of these intersections, we are really unearthing data to tell this story.  When they just cut the SNAP benefits back, we were inundated with cancer patients who are food insecure because they've lost that. COVID is over but cancer is not. And all of the things people were afraid of was COVID - fear of getting sick, isolation, job loss, housing insecurity, food insecurity, that's cancer. Those programs need to continue for the cancer community. It will affect survival rates. So policy is important. Dr. Reggie Tucker-Seeley: One of the themes that's been woven through this conversation is the shame that families may be feeling as they are attempting to manage the financial burden of having cancer and the financial toxicity that comes with that. Do you find that patients are open about discussing their social needs and are they more likely to discuss their needs with their physician or do they prefer to have this discussion with a social worker or other members of the care team or administrative staff? Eucharia Borden: No, not all patients are open about discussing their social needs. Not even just their financial needs but even their more broad social needs. However, when they are, they tend to discuss their needs with the members of their team that they feel most comfortable with. So these are people that they've started to feel like they can trust or people that they begin to understand sort of what their roles are and they think well maybe this is the person I should talk to because they've started to build relationship with them. But the reality is that different kinds of needs are discussed with different team members. It's just kind of how that works.  Some patients are very much unaware of who is actually a part of their treatment team. Because, as you think about someone bringing up a need, well, maybe they didn't know that they had an oncology social worker on their team because they didn't have a need that the other team member they were talking to thought rose to the level that they needed to talk to an oncology social worker. In fact, I often had the experience as a licensed clinical oncology social worker for people not even knowing that I'm part of the team. And when they did find out that I was part of the team they had no idea what I actually did.  Because if we go back to that conversation about systems, social workers are a part of many systems and unfortunately we are a part of systems where we're there when there are just problems. People think we're there just to take children. We're there to do those unpleasant things that are sometimes necessities. But I remember a patient coming to my office one day, quite unhappy about being sent to my office. Knocked on my door and came in, literally with her arms folded, sat down, and said, "My surgeon sent me to you, but I don't need a social worker. So I don't know what I'm here for. But why don't you tell me what you can do for me?" And I said, "Well, why don't we talk about why your surgeon sent you to me?" That's where I had to start that conversation because that's what she came in with. "I'd heard this term social worker. I don't know what it means here, but I know outside of here, I don't l

In Part 1 of this episode guest host, Dr. Reggie Tucker-Seeley, discusses the importance of the community and organizations meant to address the social needs of patients as they navigate their cancer journey and the financial burden on the household following a cancer diagnosis. Dr. Tucker-Seeley is joined by Carla Tardif, Chief Executive Officer at Family Reach and Eucharia Borden: Vice President, Programs and Health Equity at Family Reach, whose mission is to remove the financial barriers standing between cancer patients and their treatment.  TRANSCRIPT The guest on this podcast episode has no disclosures to declare. Dr. Reggie Tucker-Seeley: Hello and welcome to ASCO's Social Determinants of Health and Cancer Care podcast. I am Dr. Reggie Tucker-Seeley, Vice President of Health Equity at Zero Prostate Cancer and Chair of ASCO's Health Equity and Outcomes Committee. I'm joined today by Carla Tardif, chief executive officer at Family Reach, and Eucharia Borden, vice president of programs and health equity at Family Reach.  In this episode, we will discuss the importance of the community and organizations meant to address the social needs of patients as they navigate their cancer journey. There are many needs that cancer patients face and one of the biggest is the financial burden on the household following a cancer diagnosis.  We are lucky to have two change makers from the organization Family Reach with us here today. Family Reach is an organization in Boston, Massachusetts that dedicates their work to removing financial barriers with financial education, financial planning, resource navigation, and emergency funds to patients and caregivers.  Thank you both for being a part of our Social Determinants of Health podcast series in this episode focused on community and organization. Carla Tardif: Thank you for having us. Dr. Reggie Tucker-Seeley: Let's start the conversation with the question that we like to ask all of our guests. What does social determinants of health and cancer care mean to the both of you? Carla Tardif: It's a great question and there are so many buzzwords now around this topic, so I really appreciate the opportunity to even define some of them, like social determinants of health, like financial toxicity, like health-related social risks and how are they different and what do they mean. We talk about social determinants of health being more about societal impact on people according to where they are born, live, work, play, and pray. And we talk about financial toxicity as the financial impact that a cancer diagnosis has on a family. Financial toxicity is a word that we say often and that really is about cancer affecting your finances and your finances affecting your cancer. And what does it mean when work is stopped, income is cut, out of pocket expenses, the cost of care, and how does that affect your ability to access care and adhere to treatment which will affect your survival rate? And then I'll pass it to you Eucharia, because I love her definition of social determinants of health. Eucharia Borden: Thank you so much for having me here today. I think one of the first things that we need to put out there is that our professional language is full of jargon, and patients often don't understand things like social determinants of health, financial toxicity, what do these things mean to them? Which is why at Family Reach, we talk about meeting their basic needs, meeting their needs in areas like food, transportation, housing, and utilities, because that is also something that's important when you're approaching patients and working with patients who really do have financial toxicity - to make sure that you're on the same page with them about what their needs are and therefore what kinds of problems you're helping them to solve. Dr. Reggie Tucker-Seeley: My first question is for you, Carla. Can you take us to the beginning? How did Family Reach get started and what led you to work with this organization? Carla Tardif: Family Reach was started by two families out of New Jersey who both lost their child to cancer, pediatric cancers. And they saw firsthand spending so much time in the hospitals overhearing conversations that families did not have heat, they were being evicted, they were hungry, they couldn't pay to get out of the garage after they'd been there for weeks. So the families both saw this side of cancer and when their children passed, they got together and said, we need to do something about this. And they started Family Reach.  And how they started was they raised money. They did a golf tournament, and they took those funds back to the hospital social workers and said, this money is not for the hospital. This money is for the families that you interface with that we know are hungry, are in homes without heat, and cannot put gas in the car to get to and from treatment. That's how it started. They functioned like this as a volunteer organization, a pure labor of love for 12 years. And they had three hospital partners that they worked with in New York; New York Presbyterian, Memorial Sloan Kettering, and then Dana-Farber.  I lost a dear friend to brain cancer not long out of college. My friend Pat Kelly played in the NFL. He was diagnosed with brain cancer. He would bring Jets players through the pediatric floors to meet the kids, as so many athletes do. And Pat would call me to say the same thing. "Carla, I just saw a husband and wife fighting at the vending machine. They're so hungry, they have enough change for one snack, and they cannot agree on the snack. Do something." He called me once because there was a single mother crying on the curb. Her two-year-old had brain cancer and she had no money to go pick her four-year-old up at preschool. And she was just scared and lost and done. So he kept calling me to tell me to do something.  A few weeks before he passed away, I went to say goodbye to him. I was holding his hand with a few of our college buddies in the room. He squeezed my hand, and said, "Look me in the eye and promise me you are going to fix this." So clearly, having no idea what this was, I promised him that I would fix this. So I spent the next two years really searching, what is this? And I found Family Reach. And I approached them and said, told them my story, and said, "Can I help you? You have a model I can scale." Work with the hospitals. They identify the families, pay bills directly, literally get in there and have a tangible impact on that day. So I spent two years meeting with families, meeting with social workers, doing grocery shopping, sitting in hospital rooms, really trying to understand this side of cancer that people don't talk about, where there is a lot of shame and a lot of fear, but clearly affects their ability to survive and affects the whole family. That was 16 years ago. Dr. Reggie Tucker-Seeley: 16 years ago. Speaking for the cancer community, we are so grateful that you have kept your commitment to your friend at the bedside.  Eucharia, you are the Vice President of Programs in Health Equity, and several organizations have created senior roles to lead health equity efforts, really to address some of those examples that Carla was mentioning. We know that cancer doesn't discriminate necessarily by socioeconomic circumstances, but the issues that Carla mentioned are disproportionately impacting certain groups. So what does health equity mean to you at Family Reach and what are your responsibilities in this area? Eucharia Borden: There are so many organizations that have created roles focused on health equity, some of them more specifically than others. Some of them are kind of rolled up into diversity equity and inclusion positions. Some are more specifically focused on health equity, and they're not the same I have to say. One of the things that I love at Family Reach is that so many people talk about doing the work, and we're actually doing the work. That's what's different about our health equity initiatives.  In fact, through our cancer equity initiative, we're actually meeting patients where they are. And as a social worker, meeting people where they are is something that's like Social Work 101. It's one of the first things they teach us. And then through the early days of the pandemic, this phrase of 'meeting people where they are' was suddenly mainstream, which is kind of surreal for me and other social workers because we're like, "Wait a minute, that's what we've always done!" And unfortunately, because it has become this mainstream term to meet people where they are, it's not actually happening all the time.  And so as I think about what health equity means for Family Reach, it means not just having actions that are performative, but to actually say, you'd like us to tell you about what our cancer equity initiative means. Let me give you the examples of how we're meeting Black and Hispanic patients in particular. Our cancer equity initiative, for example, is focused in two areas. One of those is through our community partners. And these community partnerships are partnerships that we form with organizations that are serving 90% Black or Hispanic patients with cancer.  And trust is the other thing that I have to bring into this conversation. It's really important to establish trust with the people that you're serving. Let's face it, like, you started us off with this question, Reggie, cancer doesn't discriminate, but many of the centers where people get their care, well, they do. And so even when it comes to seeking help. People are often not doing that for a variety of reasons, but one of those reasons is because, unfortunately, their system's involvement, even before coming into healthcare, has taught them that systems are not set up for me, they're not set up to help me, they're not here to meet my needs.  And so what we've done is partnered in communities where people already have trust with organizations that are meeting some of the

In this episode, guest host Dr. Maysa Abu-Khalaf, Director of Breast Medical Oncology at Sidney Kimmel Cancer Center – Jefferson Health examines the role providers play in collecting social determinants of health data from cancer patients to assist with receiving the care they need. Dr. Abu-Khalaf is joined by Dr. Luis Raez, Co-Director of Memorial Cancer Institute of Florida Atlantic University and Whitney Renau, Patient Care Coordinator of Hematology and Oncology from North Florida and South Georgia Veteran Health Services. TRANSCRIPT The guests on this podcast episode have no disclosures to declare.a Dr. Maysa Abu-Khalaf: Social Determinants of Health in Cancer Care podcast. I'm Dr. Maysa Abu-Khalaf, Director of Breast Medical Oncology and Interim Chief of Cancer Services at the Sidney Kimmel Cancer Center at Jefferson Health. I'm joined today by Dr. Luis Raez, Co-director of the Memorial Cancer Institute at Florida Atlantic University and Florida Cancer Center of Excellence, and Whitney Renault, patient care coordinator of hematology and oncology for North Florida and South Georgia Veteran Health Services. Thank you both for being a part of the conversation on data gathering.  Dr. Luis Raez: It's a pleasure to be here. Whitney Renau: Thank you for having me.  Dr. Maysa Abu-Khalaf: In this episode, we will discuss the challenges and barriers to collecting and documenting social determinants of health information for patients after a diagnosis of cancer. Our guests will share their experience in collecting social determinants of health information from patients and share who in their clinical team has been tasked to assist in obtaining this information. Last episode, we discussed data gathering from a patient's perspective, but we'd love to know why you both believe it's important to address social determinants of health and social needs when providing care for your cancer patients.  Dr. Raez, would you like to just give us your thoughts on the importance of social determinants of health?  Dr. Luis Raez: Yes. Thank you. I am a medical oncologist. I'm a director of the cancer center here at Memorial and South Florida. It's a public healthcare system. I practice lung cancer. And as much as the social determinants of health topic is a topic that many medical oncologists believe is not ours, that is in the realm of the social worker or somebody else, there's no way to avoid that. Because when you are providing the best target therapy of the world or the best immunotherapy of the world, and the patient has insurance, and you see that the outcomes are not the outcomes that you see in the clinical trials, you see that there is something else other than the biology that has an influence. That is why I consider the social determinants of health very important. In our own cancer center, we have several publications about target therapy, immunotherapy in black patients or Hispanic patients that clearly show inferior outcomes, despite the fact that they are getting the same drugs, the same doctors, the same care that we provide. That's why we're considering our healthcare system, as I said, Memorial Healthcare system, that very important topic that we have been trying to address for the last years. Dr. Maysa Abu-Khalaf: Thank you so much. Whitney, would you like to add to this? Whitney Renau: Absolutely. Exactly. It indirectly affects all the outcomes or overall disease survival. If they can't get to the treatments, if they don't eat well during the treatments, if they don't have support during the treatments, it's going to negatively impact all of the outcomes. We do a great job in being able to pay for the drugs and have great regimens, but if we can't get them to the drugs and the regimens and keep them coming, they're going to have overall poor disease survival rates.  Dr. Maysa Abu-Khalaf: Absolutely. Thank you for that. Well, let's touch on the physician and clinician perspectives. Dr. Raez, there has been a lot of interest in evaluating the impact of SDOH and patient social needs on cancer care delivery. Can you tell our listeners how you ask your patients about SDOH and their social needs and does it happen during the clinic visit or at a later time point? Dr. Luis Raez: The point of collecting the data of SDOH is the first step because even though you don't have an idea what is the impact of this, that is why in our healthcare system, we are 2000 doctors, we have created a dashboard of SDOH, social determinants of health, that basically we collect 13 of them from social connections, tobacco use, depression, transportation, physical activity, etc.. So this is a dashboard that is embedded in the EMR. So when the physician opens the EMR, if he has, on the left side, the vital signs, the dashboard of SDOH is on the right side with the medications, allergies, everything. So in that way, the physician cannot really ignore it because it's part of his dashboard.  So we figured out this working with Epic Systems, Epic is one of the most popular EMRs in the United States and this has the capability to do that. So, we were working at the level of the healthcare system, not only for cancer but for everything else. Now that we have these 13 SDOHs, what we do is we are trying to flag a green or red, depending on what deficiency the patient has. You know, if the patient has food insecurity, there is a red. If the patient has transportation it is a green. So the physician can easily see if there is any red in the SDOH dashboard that can bring awareness about if there is something wrong that needs to be addressed. And as we said before, I cannot expect that the patient will have a great outcome if I'm looking at a bunch of reds in the SDOH dashboard, despite the fact that I have the best chemos in the world on the left side. Dr. Maysa Abu-Khalaf: And are you as a physician collecting this information during the clinic visit? Or is there someone in your office that does that before they go into the clinic space to see you? Dr. Luis Raez: The dashboard, we already have the template of the dashboard, and then it's being populated by the social workers. When you get a new patient, you come as a new patient in the cancer center, you interview the social workers, the nutritionist, the multidisciplinary team, and then we start to populate the dashboard. But as you understand, also collecting data one time is not enough. The necessities can change. The patient may have transportation one year, next year, no. So, once that dashboard is created and kept by the social workers, the medical assistants in each visit briefly ask the patient if something has changed. The same when they change age, any of your medication has changed, and the medical assistant has to fix it if you have a new drug or not, the medical assistant keeps track of the dashboard whether it is updated or outdated. Dr. Maysa Abu-Khalaf: Okay, wonderful. So it's continuity of care. It's not something that you just would do one-time point. Every time they come in, the MA makes sure that it's updated, and you as a physician, during the clinic visit, will address any of the social needs that are identified or flagged to you. Dr. Luis Raez: Yeah, or if I cannot address them because some of them are out of my expertise, for example, the patient may be the patient lost insurance. Now it's January 2, and the patient lost insurance. But at least if I see that red flag, I refer the patient to the social worker immediately because now we need to fix insurance. The patient just lost insurance or something like that. You cannot pretend to ask the doctors to fix these things by themselves because the doctors are really very reticent, very negative about doing more clicks. That's why when you present this to the doctors, the first reaction is everybody goes to the back like, "Oh, my God, they're giving me more work."  But it doesn't have to be like that. That's why we work as a team. We want you, at least at the minimum, that the doctor has to do, is notify the social worker, send a- it's a couple of clicks in the EMR. So we know that this needs to be addressed. We are not asking the doctors to fix things because otherwise, the doctors get against this because they think it's more work for me in the less time, and I don't get paid anything extra, and it's not my problem. It's not like that. It's the same thing when you see that the blood pressure is high, and you notify the nurse to give a pill. Now the SDOH has red flags, and I will notify the social worker to please fix this or the nutritionist or somebody else in the cancer center that can address this.  Dr. Maysa Abu-Khalaf: And I think that's very important because this comes up a lot. How much work is it? Can you really fit it in during a clinic visit? And the way that you've outlined this, it's a team of clinicians and staff that need to address this collectively and longitudinally. It's not a one-time point where you address it and you move on.  Whitney, can you tell us, since your work has been with veterans, are there templates or guidelines that you found useful when asking patients about SDOH and social risks?  Whitney Renau: Great question. Thank you. And that sounds like, again, one of the reasons my job exists is to help physicians, such as yourself, be able to keep determining along the continuum of care what's going on with the vet and if they are having changes. We use the NCCN distress thermometer and problem list, and the nurses actually in our infusion are seeing every single patient and assessing them upfront, and then if they score higher than a four they're being sent to the social worker to be able to assess for needs support. And then we actually are creating a consult to kind of flush out of that assessment into also mental health providers. Depending on what, as Dr. Reyes was saying, where the needs are, we might have consults to both social worker and the mental health team.  I also do stem

 In this episode, guest host Dr. Leslie Hinyard explores the importance of collecting social determinants of health data from patients to assess needs and the best practices to collect this data in an oncology setting. We enlist expert insights from Wenora Johnson, a cancer survivor and patient advocate, and Krista Nelson, an Oncology Social Worker at Providence Health and Services and past President of the Association of Community Cancer Centers. TRANSCRIPT The guest on this podcast episode has no disclosures to declare.  Dr. Leslie Hinyard: Hello, everyone, and welcome to ASCO's Social Determinants of Health and Cancer Care Podcast. I'm Dr. Leslie Hinyard, Chair of the Department of Health and Clinical Outcomes Research and Executive Director of the Advanced Health Data Institute at the St. Louis University School of Medicine. I'm here with Krista Nelson, past President of the Association of Community Cancer Centers and an Oncology Social Worker at Providence Health and Services. And also, Wenora Johnson, a cancer survivor, and patient advocate. Thank you both so much for joining us in this conversation on data gathering, the patient's perspective.   And we're going to dive right in. Social Determinants of Health, or SDOH, as we like to refer to it, represent nonmedical factors that affect health, that is, the characteristics of where we live, work, and play that influence our health. These social determinants are only recently being explicitly considered in medical context. Currently, there's no consensus on what questions should be asked of patients, who should be asking questions about SDOH, and how the information will be used to improve patient care.  In this episode, we will be discussing the importance of collecting SDOH data from patients in order to assess needs. We hope to discuss best practices to collect SDOH data in an oncology setting from both the patient and provider perspectives.  Now, I'd like to start with you, Krista. Social Determinants of Health have been a topic at the forefront of public health conversations, especially with COVID-19. Can you tell our listeners how you define this term? Krista Nelson: Yes. Thank you so much for checking in and for this opportunity to talk about Social Determinants of Health. As an oncology social worker, we've known that Social Determinants of Health impact patients' outcomes, and we see it every day. And the National Academies of Science, Engineering, and Medicine came out in 2019, right before the COVID-19 pandemic, they came out with a report talking about the importance of integrating social needs care into the delivery of health care to improve the nation's health. So, when I think about Social Determinants of Health, just like you had just said, it's the environment or the conditions in which people are born, grow, work, worship, live, and age. And it's how all those forces and systems shape the conditions of their daily life. So, when I think of cancer patients and Social Determinants of Health, I think of socioeconomic status, education, job security, food stability, housing, social inclusion, and all the environmental factors that really construct a patient's environment.  Dr. Leslie Hinyard: Thank you so much. Wenora, as a cancer survivor and a patient advocate, how do you define social needs and why is it important for patients to self-report these social needs?  Wenora Johnson: That is a great question. And then I actually look at it in four different ways. I think first and foremost about my psychological needs. And those needs are just basic for human survival, like food, water, clothing, housing, and then finally just overall health and quality of life. That second one is going to be my safety needs. Protection from violence and theft, emotional stability, and well-being. And then what we're all feeling a pinch of lately is financial security. And then my third one is love and belonging needs, having close bonds with our family, friends, physical and emotional intimacy, interacting with social groups, all of this provides us with the feelings of love and connection we need not only just to survive, but to thrive off of. And then finally, fulfillment of our full potential. This can be in just caring for others, improving things like our artistic abilities like cooking, music, athletics, and then experiencing new things in life, traveling, things like that, that just do a lot for our physical psyche. So, there's so much when it comes to social determinants that can affect us as patients. And self-reporting these needs are just essential and can be at the same time difficult for patients to do.  Dr. Leslie Hinyard: Now, speaking of difficult things that patients can do, Krista, in your work, what are the most commonly reported needs or social risks that you encounter reported by patients?  Krista Nelson: Well, I really loved what Wenora just said, and I think that really articulates exactly what I'm hearing day-to-day in the work as an oncology social worker. Right away, I think the biggest struggle or the reason we get notified of a patient having needs is around financial toxicity. So, we know that finances and medical bankruptcy is caused, number one, by a cancer diagnosis. But if you think about your socioeconomic status, it really impacts everything that we do. It's our ability to be able to get to treatment. It's an ability to get healthy food, it's an ability to be able to take time off of work and actually get to the treatment. It might mean, "Gosh, do I have someone who can watch my children? And can I pay for screening, can I pay for childcare to go to screening? Am I going to prioritize that? And most of all, do I have access to insurance and good health care?" So, I'm hearing a lot about that.  The other thing I think I hear a lot about is social isolation. And when Wenora spoke about it, about your community, what I heard her saying is her community and having that sense of love. And when I think about social isolation, sometimes a trigger for me is when someone is coming in for a giant cancer surgery and needs a ride to the treatment. Now, you may think, what does that tell me as a social worker? But what that tells me is that this person may not have a giant community of people around them to help them if they have no one who can bring them in for this big surgery. A lot of times when I'm working with physicians and we're meeting with patients, there is so much isolation out there that I remind doctors, this might have been the only time that this patient was physically touched in the last year when you do your exam.  Other things that come up are housing insecurity. We're seeing a lot of that in the community where I live. And then also just access to healthcare and the ability to navigate it. A referral of a patient that I was seeing because the physician noticed that they had a lot of weight loss, and they were in breast cancer survivorship and there was some question of maybe dementia or access to food. And so, of course, I was eager to check in with this patient who lives in kind of a rural part of our state. And she was 80 years old. And when I went to talk with her, I was kind of wondering about depression. Is she not motivated to eat? What's happening here? And as I talked with her and I asked her about her appetite and I asked about finances, she shared with me that it was her teeth and that her teeth were broken, and she was having a hard time chewing. And I asked her specifically, was she interested in dental care? And she said, "No, not really at this place in my life." But I was able to find some supplements through messaging our dietitian. But what also came out is that she said, "Well, I don't have a computer or a smartphone to be able to order this."  So even though here we are in 2023, I do think there is a large population of people who don't have access to the resources that we think as practitioners or providers that maybe are more accessible. So, it's really important to meet with each patient where they're at and figure out the best plan for them.  Dr. Leslie Hinyard: Thank you, Krista. This next question is actually for both of you. In addressing these needs from a patient, who should they be having these conversations with? Now, should patients rely on their healthcare team or their providers to address their social needs? And do you believe patients are comfortable having conversations about social needs with their providers? And I'm going to go ahead and ask Wenora to speak first and then Krista, I'd love to hear your response as well.   Wenora Johnson: This is really such a great conversation because what I'm getting out of this is really that communication and teamwork are essential for providing just plain old good quality healthcare. And it can be difficult for patients to have these conversations with their healthcare team without feeling stigmatized or made to feel less than because they can't adequately take care of themselves. I think of the example of my brother who suffered from mental health issues and he also had a late stage cancer, but a lot of times just felt powerless and unable to speak up because of his mental health diagnosis. His fear of being treated differently was real, and at times, this experience caused him to just shut down when it came to his own care.  And so as a big sister, this is where I had the opportunity to step in and be that virtual, more or less, caregiver for him and speaking up and being that voice for him. If nothing else, this is where it takes a village, an entire team to recognize maybe what symptoms or to help the patient when the patient can't speak up. It means taking a little bit more notice of how your patients look, as Krista mentioned. Do they look well-fed and clothed? How are they getting to their appointments? Do they even have any close family or friends that they can talk to during their appointments? This is just all so important just for o