AMCP Podcast Series - Listen Up: Susan Wojcicki - Breaking Biases in Breast Cancer

Fred Goldstein  00:01 

Hello and welcome to the AMCP Podcast Series - Listen Up as we take a deep dive into the challenges, trends and opportunities in managed care pharmacy, follow the show's social hashtag #AMCPListenUP, and to learn more about AMCP Visit amcp.org. I'm your host Fred Goldstein. On this episode we will be presenting a continuing education program on innovations in women's health with a focus on breast cancer. All medications mentioned in this episode are for educational purposes only. This activity is supported by an independent medical education grant from Novartis Pharmaceuticals Corporation, and Merck Sharp and Dohme. AMCP is accredited by the Accreditation Council for pharmacy education as a provider of continuing pharmacy education. Instructions for claiming credit are located in the show notes. Please refer to the handout in the show notes for detailed instructions on how to claim CPE credit. At the completion of this activity, participants should be able to understand the impact of health disparities and their significance in cancer treatment outcomes of women and women who belong to marginalized communities. It is now my pleasure to introduce our faculty for today's program. Dr. Susan Wojcicki. She is the clinical pharmacy lead at Humana Pharmacy solutions. Welcome Dr. Wojcicki. 

Susan Wojcicki  01:21 

Thank you glad to be here. 

Fred Goldstein  01:23 

It's a pleasure to get you on. So why don't we start Dr. Wojcicki. Let's start by defining what we mean by health disparities in breast cancer management. 

Susan Wojcicki  01:32 

Thank you before diving into the complexities that exists within breast cancer population, zoom out and acknowledge where we are today and where we want to go. The ultimate goal is to achieve health equity, which can be defined as every person's right to attain their full health potential by minimizing health disparities. Health Disparities refer to the differences in health care outcomes, and access to health care services among different patient populations. In breast cancer, these disparities can affect everything from early detection rates to treatment outcomes, and ultimately survival. The universal application of breast cancer prevention, risk reduction and detection strategies for all persons at risk for breast cancer. In addition to ensuring the same persons are empowered and have necessary health care support during their breast cancer journey is crucial to eliminating health disparities. Health care institutions are prioritizing health equity efforts by ensuring equal access to education, screening and treatment services, regardless of race, ethnicity, socioeconomic status, in order to promote achieving equitable outcomes in breast cancer care. 

Fred Goldstein  02:43 

So Susan, what do we currently know about health disparities found within the breast cancer population? 

Susan Wojcicki  02:49 

This is a really good question, since the first step toward improving breast cancer outcomes is to understand what disparities in breast cancer exist. So let me start by sharing some examples of what we know. disparities are known to be related to socioeconomic status. Poverty is associated with poor breast cancer outcomes among all women, regardless of race. And when we're reviewing health care literacy data, survivors of breast cancer with low health care literacy report lower health related quality of life compared to those survivors with high health care literacy. It's also been reported and accepted in the clinical community that racial disparities in breast cancer exist when evaluating early detection through routine and timely screenings. Minority Women are more likely to have longer intervals between screening mammograms, which contributes to higher rates of late stage diagnosis within Black and Hispanic populations. Additionally, Black women have a 42% higher likelihood to die from breast cancer than non Hispanic white women, despite roughly equal incidence rates. Black women also have a two fold higher risk for aggressive triple negative breast tumors, which traditional endocrine therapy which is standard of care would be ineffective. They are also less likely to be diagnosed with Stage 1 breast cancer but twice as likely to die of early breast cancer. So in addition to addressing these racial disparities, there's also a need for holistic proper representation for underserved populations suffering from breast cancer. Many of my early stats are related to women. However, cis females are not the only persons diagnosed with breast cancer. Males diagnosed with breast cancer are more likely to present at a later disease stage compared to females. And younger age at the time of breast cancer diagnosis has been reported in transgender people. A younger age of diagnosis is commonly associated with more aggressive disease. 

Fred Goldstein  04:54 

So given these data, how do these disparities specifically impact managed care organizations? 

Susan Wojcicki  05:01 

Addressing disparities in health and health care is important from an equity standpoint, and will elevate us as a nation and over the world through prioritizing better health outcomes. Specific to breast cancer health disparities lead to high costs due to later stage diagnoses, or more intensive treatments are needed. And although our management for breast cancer and associated technologies is improving for all stages of diagnosis and treatment, if health disparities are contributing to the failure of disease prevention, we're missing an opportunity to conserve healthcare dollars and minimize pain and suffering. Additionally, the generation of clinical trial data and real world evidence in a diverse manner is essential to our success. This includes diversity in study enrollment, strengthening trial designs to better detect possible mixtures and patient response and expand subgroup reporting to allow assessment of those differences in formulary evidence review process. For instance, for new drugs to market plans rely on the results from clinical trials to evaluate the safety and efficacy of new medicines. And to determine the appropriateness of the drug replacement on the plans formulary. It is very challenging for plans to design formularies that are representative of their unique beneficiary populations, diverse characteristics if medications are only tested in a narrow cohort of patients. It has been well established at this point that drugs have many different effects on different populations due to a variety of factors, including environmental or genetic reasons. However, minority populations make up a disparate proportion of individuals enrolled in clinical trials. In order for us to use formulary as a tool to advance healthcare, it'll be critical to have data on a diverse patient population. 

Fred Goldstein  06:53 

So Susan, what are some of the social determinants of health that Humana is focusing on in a broader sense that also impact persons who experience breast cancer? 

Susan Wojcicki  07:05 

Great question. So let's talk about what social determinants of health are. These are the conditions in which people are born grow live, work and age. It relates to economic stability, environment, education, food, community safety, and social contexts. These all interplay together in a very complex manner to determine health outcomes. So then taking that to the next step, what is modifiable and non modifiable risk factors related to breast cancer here? So looking at non modifiable risk, knowing your family history and your genetic base risk is very important. therapies such as PARP inhibitors are within the arsenal for treating things such as germline BRCA mutation in both the metastatic and early stage breast cancers. And the only way that you know that you have this non modifiable risk of BRCA mutation is by genetic counseling and screening. So social determinants of health and access to these types of screening is paramount to getting the treatment that you need and understanding your risk. But then looking at modifiable risk factors, this could be a variety of things, and health equity and prevention of breast cancer requires that all individuals have access to resources and education for adopting these healthy lifestyles. This includes regular physical activity, balanced nutrition, and avoidance of known risk factors such as smoking and excessive alcohol consumption. So when we look at what Humana is doing here, to encourage these modifiable risk factors, we have several initiatives in play. So looking at food insecurity, we want to make sure that we're addressing food related social needs. This can include nutritional literacy and food security initiatives. We are working on a Bold Goal to have an impact on food insecurity, and food literacy, and impact this modifiable risk factor in breast cancer and more broadly. We also have programs that promote smoking cessation. We know smoking contributes to the incidence and prevalence of cancer. And this is not absent in breast cancer. Again, this is a modifiable risk factor. Promoting a healthy, well balanced lifestyle can reduce your risk for breast cancer. 

Fred Goldstein  09:54 

We often hear the data are critical to understanding where inequities exist and for measuring progress and addressing them what role can your company or institutions such as PBM, or health systems play in developing this needed data? 

Susan Wojcicki  10:06 

First, healthcare effectiveness data and information sets can be used to observe trends and promote quality care. We are monitoring and finding ways to decrease those members that are eligible but noncompliant for routine breast cancer screenings. Last year, 74% of our eligible members were compliant for breast cancer screenings. This is a quality measure that will drive better outcomes for our members because mammograms and clinical breast exams save lives. Also, real world data in collaboration with external partners to create innovative screening tools and techniques to identify the social determinants of health needs of those that you serve, will be necessary. Going beyond electronic and written communications and starting conversations can allow proper identification. I'm pleased to share that in 2023, over 1.8 million Humana members across Medicare Advantage, Medicaid and commercial plans were screened for these social needs. And lastly, we need to think about having financial flexibility as organizations we'll need to invest in resources to meet individual needs, including investing in technology, community resources, and designing payment arrangements that incentivize and reward providers for addressing health inequities. 

Fred Goldstein  11:28 

So given that, for those listeners that are affiliated with managed care organizations, and PBMs, how can they tackle improving health disparities in those with breast cancer? 

Susan Wojcicki  11:38 

To supplement the development of healthcare effectiveness, data and generation of real world data for identifying social determinants of health needs for the population of those you serve, we need to lobby for proper representation within clinical trials, we need to encourage those responsible for clinical trial design, screening and recruitment to eliminate bias. Another facet is health literacy. It is understood that health literacy and those with breast cancer impacts health related quality of life, and therefore tackling and mitigating differences in health literacy, as well as promoting self-efficacy and access to resources, which will all improve overall health outcomes and impact the timeliness of diagnosis and the initiation of treatment. Here in my organization, we're promoting health care literacy by using clear and understandable language and written materials, and making sure members are receiving communications and language that they're most comfortable with, and it's their preferred language. Furthermore, ensuring gender is not a barrier to access by evaluating point of sale gender edits on formulary products, since breast cancer is not only diagnosed in women would be paramount. Health Equity and detection involves ensuring that all individuals have access to timely and affordable screening services regardless of their socioeconomic status or geographical location. This may require implementing outreach programs in underserved communities, offering free or subsidized screening services and addressing barriers such as the lack of transportation or language barriers. And finally, how we tackle improving health disparities needs to be a collaborative effort between policymakers, healthcare institutions, community organizations, and individuals to create a more equitable health care system for all efforts are being made on this front for broader inclusion of patient demographic and social determinants of health data in standardized datasets and electronic health records. By bridging the gap for providers to ensure they have sufficient information on a patient's social background at the point of prescribing, Humana participates in the Gravity Project, which is working to identify and harmonize social risk factor data for interoperable electronic health information exchange. I would encourage listeners to find broad healthcare collaborations such as this, that their organization can partner and create a more equitable health care system for all. 

Fred Goldstein  14:15 

Well, I'd like to thank you Doctor Wojcicki for sharing your expertise on this important topic of health disparities and breast cancer treatment. 

Susan Wojcicki  14:22 

I appreciate being here it's been a true delight Fred. 

Fred Goldstein  14:26 

To learn more about this topic, check out an on demand webcast featuring Dr. Susan Wojcicki and Dr. Danielle Roman available on AMCPlearn.org. To claim credit for today's podcast, you can go to amcplearn.org/code and enter the code. K is in Kilo, A is an Alpha T as in Tango. V is in Victor. A is an Alpha X is an X-ray, that's KATVAX. From there, you will need to go back and complete the evaluation to claim your CE. Full instructions are available in the show notes. And thank you for joining us today. If you liked the show, you can find all our episodes at amcp.org/podcast, on our show page at HealthcareNOWradio.com or on your favorite listening platform by searching Healthcare NOW Radio. You can follow our show's social hashtag at #AMCPListenUP. And don't forget to share, like and follow AMCPorg on LinkedIn, Twitter, Instagram and Facebook. I'm Fred Goldstein for AMCP. Until next time,