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No One Left Alone: Taking the First Steps to Address Cancer Disparities With Kashyap Patel, MD

At the recent International Myeloma Society (IMS) Annual Meeting, Dr. Kashyap Patel, CEO of Carolina Blood and Cancer Care Associates and President of the Community Oncology Alliance, spoke about practical solutions for addressing disparities in multiple myeloma in the United States. In this follow-up interview with Oncology Data Advisor, Dr. Patel digs deep into the multifaceted factors that contribute to cancer disparities and shares his pioneering work that aims to ensure that every patient with cancer receives equitable access to care.  

Oncology Data Advisor: Welcome to Oncology Data Advisor. I'm Keira Smith. Today, I'm here with Dr. Kashyap Patel, who is here to discuss his recent presentation at the International Myeloma Society Annual Meeting. Dr. Patel, thanks so much for joining me today.

Kashyap Patel, MD: Of course, of course.

Oncology Data Advisor: To start off, would you like to tell us a little bit about your work and what you do?

Dr. Patel: As my day job, I work at my own practice that I founded about 20 years back just outside Charlotte, in South Carolina. We have two locations; one is suburban, and one is a rural location where we really see what happens with disparities. I am also President of the Community Oncology Alliance, which is an association of 3,000-plus oncologists from across the country. We represent patients and policy interests to ensure that our work reflects the protection of patients trying to get treatment, and policy that supports keeping practice independent, because many of the policy changes could have inadvertent consequences of patterning the practice's survival. That's my role.

I also work with multiple peers. I work with Medicare/Medicaid as a Care Committee member. I've been on multiple American Society of Clinical Oncology (ASCO) committees. For the last three years, since we saw the publication of the American Association of Cancer Research Report on Disparities, I've been devoting a lot of time on disparity to the point where I've dropped my clinic session by two days a week to focus on how we can take care of all the patients and not just a select few. I've spent over 2,000 hours reading about disparities in the last two and a half years and have read over 300-plus different papers across the world, and I do think that these problems can be fixed at a local level rather than a policy level and the Washington, D.C. level.

Oncology Data Advisor: Absolutely, thank you. I'd love to hear more about your presentation. Just by way of background, what are some of the factors in the US that lead to cancer health disparities?

Dr. Patel: That's excellent. There are about six main factors that lead to disparities. Number one is access to care with finances, so patients who are uninsured or underinsured. Many Americans, probably 19%, do not have secondary insurance, so they don't have 20% out-of-pocket cost, which could be huge. If you look at Medicare beneficiaries who barely make about $2,000 a month or $1,500 a month, if there were to be 20% out-of-pocket costs, they could have to file for bankruptcy or lose their homes. So that's a big one, the financial cost.

Then there are factors regarding the payers, as well. Many payer policies do not allow adequate, otherwise necessary medications, particularly when looking at the Medicare Advantage plans as well as many Medicaid Managed Care Organizations (MCOs). There was an Office of Inspector General (OIG) report that came out earlier this year that showed that 13% of beneficiaries of public insurance, Medicare/Medicaid, do not get appropriate coverage simply because of the payer policy step that prevents them from getting that. That's a payer-related factor.

Third is access to cancer screening. When you look into lung cancer, for example, only 13% of Medicaid beneficiaries get screened for lung cancer. That means 87% do not get screened for lung cancer, even when they have insurance, even when they have clinical indication. Lack of appropriate cancer screening—when you add breast cancer screening, colon cancer screening, a lot of the cancers you've detected early on that can be prevented—that's the third factor.

The fourth factor is personalized medicine, such as access to next-generation sequencing (NGS) testing compared to genomic filing. We are moving from the site of cancer to the biology of cancer, and more than half of the patients with certain tumor types actually have an actionable mutation in the tumor, against which there may be a possible option of targeted therapies. But the rate of cancer testing, depending on where the patient lives, is the fourth factor. That inadequate testing for the molecular genotype leads to, again, the disparities.

Then comes access to clinical trials. Access to clinical trials is a huge issue, and it's not only impacting better care, but there's also the fact that the drugs don't work the same in all population. There's a difference between men and women; there's a difference between African Americans, Caucasians, Hispanics, Asians, Indians. There's a wide variation in what we call pharmacogenomics on different medications. 
Unless we have the appropriate representative population in clinical trials, we may not be able to identify which drug works better in one population. There are actually big differences that are emerging because of lack of understanding about the efficacy for a drug in different ethnicities, so that is the fifth factor.

Unless we have the appropriate representative population in clinical trials, we may not be able to identify which drug works better in one population. There are actually big differences that are emerging because of lack of understanding about the efficacy for a drug in different ethnicities.

The last one is social determinants of health. When you look into food insecurity, housing issues, utility issues, these lead to huge disparities. There's a paper published in the journal Cancer, where they showed that independent of disease type and the type of treatment used, adverse social determinants of health can lead to higher mortality. We could use the same drug for the same disease in the same population, but three or four more adverse factors can lead to higher mortality risks.

When you look into certain areas, for example, in New Orleans, if one is born in the French Quarter, life expectancy is about 55 years. If you're born maybe just 15 to 20 miles northwest of that, life expectancy could be 80 years. The zip code where you're born determines how long you may live, so that's a huge disparity there. These are the factors that lead to disparities.

Oncology Data Advisor: Thank you so much for that overview. It's clearly a lot of issues to overcome, so what are some of the first initial steps that you think can be taken to begin to address these?

Dr. Patel: We started something called the No One Left Alone (NOLA) program last year. We are trying to build the plane as we fly it, I call it. In the first part of our implementation, we looked into existing cancer patients and what we can do. We had three dedicated employees whose only work was to look at the financial issues, find out the foundations, and look at the free drug programs. In the first year, we raised close to $2.3 million in direct and indirect assistance for my patient pool, which is $1.6 million worth of free drugs and under $300,000 worth of oral drugs, assistance, and all of that. We showed that by having three to four full-time employees for the practice of five oncologists, we can virtually cover every patient's financial needs from different foundations as far as treatment is concerned, so that is one that we figured out.

Second one was, I reached out to two large labs and requested that I want to increase the biomarker testing in guideline-concordant fashion, but my patients will not be able to pay the difference if the test is not covered. As a part of the registry that looks into the diversity of genomic profiling in patients of different population, the labs agreed to do it as research so that the cost can be alleviated if the patient does not have appropriate coverage, so that really took care of that. We raised our testing rate to close to 80%-plus, so that is the second step that we addressed.

We have an ongoing study that looks into the lack of cancer screening and social determinants of health, and how we can refer those patients to places where they get some help. Completing the loop of finding the unmet needs, and how we are able to fulfill those needs, is actually going on right now. We are looking into clinical trials and forming a consortium of about seven or eight practices on the East Coast. It's a completely new concept of bringing those teams together and providing resources for phase 3 studies, as well as some real-world analysis studies, to address the lack of access to clinical trials in that patient population.

In payer factors, we are proactively reaching out to the payer and requesting them to review their policies. Unfortunately, a couple of payers have really elevated the need for an additional pre-authorization step as we want to meet the National Comprehensive Cancer Network (NCCN) requirements in caring for our patients. These are some of the things we are doing to address disparities. I already have two papers out about how we addressed the first two parts of disparities. 

Oncology Data Advisor: Great, thank you. It sounds like a lot of really exciting initiatives. On the community level, for community physicians who are treating patients, are there any steps that they can take to try to minimize disparities?

Each unique population may have unique needs, and the best solution is to bring like-minded people together to address disparities locally. It's all going to be local.

Dr. Patel: This is exactly what we are trying to do. We currently have a phase 1 study in populational health. My NOLA project is all about how a community clinic like that of ours—five doctors, four mid-levels—can work with local not-for-profit stakeholders and bring them together under one kind of correlation to try and address disparities. I personally don't think that the government can solve this because it's too large a problem. Each unique population may have unique needs, and the best solution is to bring like-minded people together to address disparities locally. It's all going to be local.

Oncology Data Advisor: Thank you so much. This has been a really great conversation, thank you for sharing it all.

Dr. Patel: You're welcome, thank you.

About Dr. Patel

Kashyap Patel, MD, is the founder and CEO of Carolina Blood and Cancer Care Associates and President of the Community Oncology Alliance. He has a special interest in health care policy, economics, end of life care, revenue cycle management, and cancer disparities. Dr. Patel has published his extensive research in these fields in multiple journals and has spoken at numerous national and international conferences. In addition, he has widespread legislative experience at both the local and national levels, having testified in the South Carolina State Senate and briefed members of the US Congress about precision medicine and other important community oncology issues.

For More Information

Patel K (2022). Addressing disparities in MM: practical solutions across the globe: US perspectives. 19th International Myeloma Society Annual Meeting. Available at: https://events.jspargo.com/IMW22/Public/content.aspx?ID=101241&sortMenu=103002

American Association for Cancer Research (2022). AACR Cancer Disparities Progress Report 2022. Available at: https://cancerprogressreport.aacr.org/disparities/

US Department of Health and Human Services: Office of Inspector General (2022). Some Medicare advantage organization denials of prior authorization requests raise concerns about beneficiary access to medically necessary care. Available at: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf

Epic Health Research Network (2021). Despite insurance coverage, at-risk people not getting life-saving lung cancer screenings. Available at: https://epicresearch.org/articles/despite-insurance-coverage-at-risk-people-not-getting-life-saving-lung-cancer-screenings

Pinheiro LC, Reshetnyak E, Akinyemiju T, et al (2022). Social determinants of health and cancer mortality in the REasons Geographic and Racial Differences in Stroke (REGARDS) cohort study. Cancer, 128(1):122-130. DOI:10.1002/cncr.33894

Robert Wood Johnson Foundation (2013). Metro map: New Orleans, Louisiana – infographic. Available at: https://www.rwjf.org/en/library/infographics/new-orleans-map.html

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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