In this interview for National Minority Health Month, Oncology Data Advisor speaks with Dr. Ian Bouligny, a third-year Hematology/Oncology Fellow at Virginia Commonwealth University (VCU) Massey Cancer Center. Dr. Bouligny shares updates on his research regarding health care barriers faced by patients of minority populations with acute myeloid leukemia (AML) and suggests questions that clinicians can ask their patients to ensure proper treatment support and accessibility.
Oncology Data Advisor: Welcome to Oncology Data Advisor, I'm Keira Smith. Today, for this interview in honor of National Minority Health Month, I'm joined by Dr. Ian Bouligny, who is a Hematology/Oncology Fellow at VCU Massey Cancer Center.
Dr. Bouligny, thank you so much for joining me today. To start off, would you like to introduce yourself and say a little bit about what you do?
Ian Bouligny, MD: Absolutely, no problem at all. My name is Dr. Ian Bouligny, and I am one of the third-year Hematology and Oncology Fellows at VCU Massey Cancer Center. I am sub-specializing in acute leukemia, and this year I will be headed to the University of Texas MD Anderson Cancer Center, in just a couple of months.
Oncology Data Advisor: In light of National Minority Health Month, I know your team has recently compiled an AML analysis with an updated sample size and new data. What are some of the data points related to health care disparities that you've collected in this analysis?
Dr. Bouligny: So, we had two analyses that we just recently completed and updated. In the Project ERIS database, we analyzed 600 patients with AML who were treated at VCU Massey Cancer Center. Our aim was to investigate the impact of health care disparities in the treatment of AML. We wanted to see if there were any differences in outcomes between minorities and non-minorities with respect to the new European LeukemiaNet (ELN) 2022 criteria, so we did a couple of studies.
First, we took a group of patients who identified as minorities by self-report, who were predominantly Black patients, and we compared them with those who identified as non-minorities, who were predominantly White patients. Using the new ELN 2022 criteria, we split those 600 patients into three groups, which are the favorable, intermediate, and adverse genetic risk categories in ELN 2022.
The first thing we looked at was favorable risk. In the favorable risk category, we found that everyone tends to do relatively well, and there was no difference in overall survival between both groups, minorities and non-minorities. Similarly, when we looked at the adverse risk category, we found that everyone tends to do relatively poorly, with a median overall survival of about 8.5 to 9.4 months. We did, however, notice that Black patients with adverse risk disease tended to live for slightly longer compared with White patients, although the difference was not statistically significant.
In summary so far, in the favorable-risk group, everyone tends to do relatively well. They were at a median overall survival of more than two years. And in the adverse-risk group, everyone tends to do relatively poorly, and there are no overall survival data that were supported by self-reported race between the two groups.
So, the intermediate risk group is where things really started to get interesting. We noticed that White patients with ELN 2022 intermediate-risk disease were associated with an overall survival of 1.8 years. However, Black patients with intermediate-risk disease, the same risk group, had an overall survival of 9.3 months. Overall, this finding was striking. It appeared that the survival differences that we observed between minorities and non-minorities by self-report were largely driven by the intermediate-risk category. So, why is that? We looked at why that disparity might exist, and there are a few thoughts.
One of the first things we looked at was the intensity of chemotherapy, whether one group may be more likely to get higher-intensity chemotherapy versus lower-intensity chemotherapies. We did show that there were no significant differences between the level of intensity that minorities and non-minorities received, which is a good thing.
Then we looked at whether there may be an imbalance between the intermediate-risk patients who proceeded to transplant and if this might explain the survival disparity that we were seeing—if a higher proportion of patients proceeded to transplant one cohort versus another. We did notice that there were more non-minorities who commonly proceeded to stem cell transplant compared with the minorities, but this narrowly missed statistical significance. It was very close, and fairly striking, although not statistically significant overall.
That finding made us look into things a little bit deeper, and we ended up doing an entire second analysis just looking at insurance coverage in AML. That built upon some of the data that we presented at the American Society of Hematology (ASH) just a few months ago. We recently updated that, and we found that AML patients with Medicaid or who were without insurance were significantly more likely to be younger minorities. In fact, when we looked at patients who received intensive chemotherapy, the median overall survival significantly favored those with private insurance or Medicare compared with no insurance or Medicaid.
This suggested that insurance coverage may be a primary driver in health care disparities in minorities in AML. There are certainly other social, economic, and structural factors that are very likely to contribute, but this may explain some of the survival differences we're seeing that appear to be the most prominent in the intermediate-risk category. So, those are a couple of studies that we just recently updated this month, and we are currently preparing for publication now, so I figured you might find that interesting.
Oncology Data Advisor: Awesome, thank you. That's a lot of useful data that can be used to tackle this issue. Do you have any advice for how your data can be used to address health care accessibility?
Dr. Bouligny: Yes, I think that is an excellent question. You kind of hit the nail on the head with the direction that we're trying to go in the future as an institution here at VCU Massey Cancer Center, where health care disparities are one of our big focuses, making sure that everyone gets equal access to care.It's a very complex question. To be honest, more research is needed to identify what other factors are likely contributing to health care disparities so that we can appropriately address those issues, so that we know the solutions we come up with are the best solutions.
There are a lot of ways to improve access to care, both at the local and at the national levels. Determining what changes would be the most impactful is honestly something that remains to be seen, because there are a lot of issues. I don't think we can really boil it down to just one issue. Insurance coverage would be a big one, as we're saying. Finding ways to improve access to care, that's a big issue. But other issues such as social, economic, and structural factors need to be identified through research, so that we can identify them and address them. I think you hit the nail on the head with that question. Ultimately, more research is needed to be able to find those issues and identify them so we can appropriately adjust them.
Oncology Data Advisor: Definitely, thank you. Do you have any other advice for practicing clinicians who are trying to promote accessibility for their patients? How can they help here?
Dr. Bouligny: Yes, I do. One of the things that we encounter the most, at least with the acute leukemias, is being sure that people have access to things that you wouldn't necessarily think about when you're practicing day-to-day. For example, you can ask your patients whether or not they have reliable transportation and if they have a caregiver who can help them out—who is able to give them some sort of access to care if they're independently able to come to the clinic themselves, to be able to give their medications to themselves—do they have that support?
Not everybody has that support. Different people have different needs, and different communities have different needs. It's important to take a step back from clinical practice sometimes and remind yourself of that and recognize that. And it's not just within minorities versus non-minorities. Age disparities exist as well, and community disparities exist. There are differences depending on where you live, even with being in a rural versus being in an urban area. We have shown survival differences as far as location goes.
So, it's important to take a step back and remember not just where you're practicing and who you're seeing, but what support the patients have access to and how can you help them get that support so they can get the best treatment that they possibly can.
Oncology Data Advisor: Awesome, that's great advice, thank you. And I'm looking forward to seeing your future publications in this area as well.
About Dr. Bouligny
Ian Bouligny, MD, is a third-year Hematology/Oncology Fellow at VCU Massey Cancer Center in Richmond, Virginia. His research focuses on health care disparities and molecular outcomes in acute leukemias, and he has presented his work at several national conferences.
Dr. Bouligny wishes to recognize the leukemia clinical research team at VCU in this work, including Graeme Murray, Michael Doyel, Tilak Patel, Josh Boron, Valerie Tran, Juhi Gor, Yiwei Hang, Yanal Alnimer, Thuy Ho, Kyle Zacholski, Chad Venn, Nolan Wages, Steven Grant, and Keri Maher. We thank the patients and their caregivers for their contribution to the efforts of Project ERIS.
For More Information
Bouligny IM, Murray G, Doyel M, et al (2023). Venetoclax with decitabine or azacitadine in the first-line treatment of acute myeloid leukemia. E J Haematol. [Epub ahead of print]. DOI:10.1002/jha2.663
Maher KR & Bouligny IM (2021). Minority health disparities in acute myeloid leukemia: a metropolitan, single-center retrospective analysis. Blood, 138(1): 1987. DOI:10.1182/blood-2021-153642
Bouligny IM, Murray G, Tran V, et al (2022). Healthcare disparities among African Americans are pervasive in the treatment of AML. Blood, 140 (suppl_1): 5281–5282. DOI:10.1182/blood-2022-171063
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.
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