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Oct 16, 2020

In today’s episode, we discuss the science presented during the 2020 ASCO Quality Care Symposium with the chair of the meeting, Dr. Dawn Hershman, leader of the Breast Cancer Program at the Herbert Irving Comprehensive Cancer Center at Columbia University. Dr. Hershman shares insights on key abstracts that addressed COVID-19, technology innovations, health care disparities, financial toxicity, and more.


ASCO Daily News: Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. Joining me today is Dr. Dawn Hershman, Director of the Breast Cancer Program at Columbia University's Herbert Irving Comprehensive Cancer Center. Dr. Hershman we'll share highlights from the 2020 ASCO Quality Care Symposium.

Serving as Chair of the Symposium, Dr. Hershman helped shape the vision of the meeting, which explored technology innovations, health care disparities, financial toxicity, COVID-19, and more. Dr. Hershman is a co-author of a variety of the abstracts featured at the symposium, including several studies that we'll discuss today on clinical trial accrual and the impact of the pandemic on cancer care delivery. Full disclosures relating to all ASCO Daily News Podcasts are available on our episode pages. Dr. Hershman, it's great to have you on the podcast today.

Dr. Dawn Hershman: Thank you, it's great to be here.

ASCO Daily News: Dr. Hershman, the symposium featured a range of studies on COVID-19 and its impact on cancer care delivery. Some of these addressed telehealth. Many practices and institutions quickly adopted telehealth when the pandemic struck. But despite its benefits, telehealth has also exposed potential disparities in care.

Dr. Dawn Hershman: Absolutely. It's hard not to have a conference these days that doesn't have at least some components focused on COVID-19 because it's had such a major impact on all of our lives on every level. We had already decided to have several sessions focused on how we deliver care, including sessions focused on telehealth.

The first one was an abstract that was presented by Dr. Cardinale Smith looking at disparities in the use of telehealth during the COVID-19 pandemic (Abstract 87). And while we have learned so much about telehealth, in general, and how institutions had rapidly transformed the care that they give to providing telehealth services, we saw many abstracts focusing on that rapid adoption.

What she did, and her colleagues at Mount Sinai, was look at the differences in the adoption of telehealth overall and by ethnic and racial minority groups. And her data really pointed to the fact that the proportion of minorities that were participating in telehealth activities was much less than the non-minority counterparts proportionally. I think that this brings up that with every silver lining, like telehealth was for so many people, it has the potential to introduce new health care disparities.

And I think we recognize that not all patients have access to the internet, not all patients have access to smartphones. Some electronic medical record systems require complex interaction with the electronic medical record for these video consults. And issues related to language and health care literacy can all impact a patient's likelihood of having consultations like this, or having access to consultations like this.

One of the things they were able to do was to get a grant from the government to provide smartphones to patients, which did help, but it doesn't solve all of the problems. And I think when we think about this in retrospect, we need--and think about how to provide telehealth services, we need to account for all of these things and learn from the lessons that this has been pushed upon us, so that we can figure out what things work and what things don't work remotely.

ASCO Daily News: Well, COVID-19 caused huge delays in care. At the height of the pandemic, surgeries were postponed, chemotherapy and radiation therapy were delayed. Dr. Tejus Satish's study, entitled "The COVID-19 Pandemic's Impact on Breast Cancer Care Delivery at an Academic Center in New York City," addresses this issue (Abstract 88). And I believe you are a co-author on this study. Can you tell us more about this?

Dr. Dawn Hershman: Absolutely. The second abstract that I think brought up a lot of important issues and data that was really lacking was looking at the impact of the COVID-19 on health care delivery amongst non-infected patients, as similar to the abstract on telehealth, was looking at routine care.

This abstract looked at issues related to delays in care as a result of services being shut down or transformed during the height of the pandemic, looking at breast cancer specifically, where there was a large number of patients that had surgeries postponed, had treatments delayed, weren't coming in for infusions. Patients had radiation therapy delayed, changes in the order of their care, and that they had treatment prior to surgery.

So there were a substantial number of delays. I think it was reported, over 35% of patients had some type of delay or change in their care during this time. It really wasn't that different for patients that had newly diagnosed cancer versus ongoing treatment. One of the things they found, however, was that delays were longer in patients with Medicaid insurance as opposed to commercial insurance (Abstract 88).

And there appeared to be longer delays in some minority populations, although it's not clear that persisted after accounting for confounding with insurance. And there were delays related to age and some other tumor-related factors. It's not clear that any of these delays actually altered patients' outcomes, but much of the research to date has focused on patients with infections. So this was very interesting, in that it focused on just the routine care of patients that we give.

ASCO Daily News: Let's focus on financial toxicity. The costs of cancer care continue to rise. And we know that financial toxicity can potentially compromise patients' overall health and well-being. So what are the abstracts that stood out for you on cancer-related financial hardship?

Dr. Dawn Hershman: Yes. It's an area of huge importance to the cancer community because, as we've seen over time, increased recognition of the cost of cancer care has a huge impact on patients. And this has been increasingly recognized over time.

The financial toxicity was highlighted in both research sections, where two really important research findings were presented. One was looking at the cumulative incidence of financial hardship in metastatic colorectal cancer patients (Abstract 137). And this was a study that was presented by Veena Shankaran. It was a prospective study done through the NCI NCTN and Core System SWOG in particular. And they evaluated patients with colorectal cancer and linked their records to their credit reports.

So they were able to show, over the first 12 months of a patient's treatment, that over 70% of patients experienced some form of financial hardship, which I think is eye-opening. A lot of the studies that have been done to date have been cross-sectional studies, observational studies. This is really the first prospective study to look at what happens to patients over time, looking at not only patients' self-report of financial hardship, but also issues related to their credit.

I think that was really eye-opening, I think, for a lot of people that saw this as being sort of a rare event. And it also was eye-opening because, I think, a lot of people thought that it couldn't be done. It's hard to do prospective studies and ask people about their finances. It's not something that everybody always feels comfortable about, but patients were eager to participate. And she showed that once patients were approached regularly about this trial, the accrual to this trial really picked up rapidly. And so this answers a really important question.

And along with it, Dr. Robin Yabroff from the American Cancer Society then presented her study looking at the association of cancer history and medical financial hardship with mortality, showing that patients that have a history of cancer or cancer survivors that experience financial hardship have a much, much higher mortality rate than those that don't, more than a two-fold increase (Abstract 86). And so this has major implications in terms of thinking about the importance of this issue as it affects the care that patients get that could compromise their overall health and well-being.

So these two abstracts really fell in nicely with a session that was designed ahead of time looking at approaches to reducing cancer-related financial hardship. And in this session, several investigators presented work that they're doing prospectively now to understand ways to mitigate financial hardship or understand interventions that might bring it to patients' and providers' attention earlier in their course.

So Lauren Hamel looked at an app she called the Disco App as a pilot study of an electronic patient intervention that really focuses on trying to reduce the financial burden of cancer by improving cost communications (Abstract 1). Anne Kirchhoff presented interventions that are focused on mitigating financial hardship in the adolescent and young adult patient population, looking at various apps and other web-based programs to try to mitigate that in that patient population. And then that session also, Dr. Shankaran presented her ongoing study looking at financial navigation, which is being investigated.

So it's one thing to know that it exists. It exists really in a profound way. It has huge impact in terms of worsening mortality. But encouragingly, there's a lot of research that's being done looking at interventions to mitigate it.

ASCO Daily News: That's great. Let's focus on clinical trials for a moment. The symposium addressed barriers to patient accrual in clinical trials in a few different ways. Can you tell us about these studies?

Dr. Dawn Hershman: Yes. So one was a presentation by Dr. Joseph Unger that did a meta-analysis looking at issues related to clinical trial enrollment (Abstract 92). And basically, the title of his abstract was, "When Offered to Participate, a Systematic Review and Meta-Analysis of Patient Agreement to Participate in Clinical Trials." And what they found through looking at the entire literature was that when offered a trial and eligible for a trial, over 50% of patients agreed to participate in that study. A major barrier to participation is not being offered a trial.

And despite the well-known disparity in enrollment to clinical trials, when you look at patients that have been offered, there's actually no disparity in enrollment, suggesting that there are either not enough trials being offered to patients or open in the centers where patients are treated, or there are limitations to enrollment, such as not having all patients meet inclusion criteria. And that we may be able to improve the diversity of patients on clinical trials by reducing some of those upfront systematic barriers and institutional barriers to participation. And it falls, maybe, less on the patient level factors as was commonly believed.

So I think that analysis got a lot of attention. There was also a study that was presented looking at AYA patient populations and clinical trial enrollment, and in that particular patient population, finding larger disparities in the AYA population, which is a patient population that is often underrepresented in clinical trials, where we should really focus a lot of our energy and effort (Abstract 91).

Interestingly, there were two studies focused on the financial impact of clinical trial accrual. And one of them was presented by Dr. Kerin Adelson from Yale Medical Center, where she looked at the association between clinical trial participation, pharmaceutical costs, and saving performance in the oncology care model (Abstract 2).

And basically, what they found was that in looking at the overall cost of care, a huge amount of the cost is correlated to the drug costs. And that when patients are enrolled in clinical trials and their drugs are provided, the overall cost of their care goes down. So the thought was that you could enhance institutional finances by putting more patients on clinical trials and reduce, potentially, the out-of-pocket costs to patients that don't have to pay the extra cost associated with those drugs.

ASCO Daily News: Dr. Hershman, is there anything you'd like to add before we wrap up the podcast today?

Dr. Dawn Hershman: I think that there were some really interesting talks looking at novel ways to enhance communication. There was a session that focused on telehealth. And while we talk about telehealth a lot in terms of providing follow-up appointments to patients, some of the talks really focused on using this technology to help disseminate information to providers and to providers that may be in rural locations.

Jens Rueter from the Jacks Lab talked about a very innovative program that they've set up throughout Maine, and there are a lot of rural practices in Maine that looked at disseminating personalized medicine through virtual molecular tumor boards. And they showed that they could engage all of these smaller practices in centralized molecular tumor boards, where there may not be a critical mass at any one location. But using web access or Zoom technology to have experts weigh in on cases, that this improved genomic confidence amongst providers. And it also improved decision making that was based on genomic alterations that may prove to improve outcomes down the line.

So very, very interesting presentation, as well as presentations focusing on using telehealth to expand the reach of palliative care because, as we know, there are few and far between palliative care providers. And so sometimes we can use this advanced technology to get specialists out to communities that may not have such expertise, following on that same theme. So I think those were two areas that were highlighted in terms of innovative new ways to practice medicine.

ASCO Daily News: Well, thank you, Dr. Hershman for sharing these great highlights from the ASCO Quality Care Symposium.

Dr. Dawn Hershman: You're very welcome. Hopefully, we'll all be able to be in person next year for another spectacular conference.

ASCO Daily News: Absolutely. I hope so. And thank you to our listeners for joining us on the ASCO Daily News Podcast. If you're enjoying what you're hearing on the podcast, please take a moment to rate, review, and subscribe.


Dr. Hershman has served in an advisory role for AIM Specialty Health within the past two years. 

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.