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Nurse Navigation and Financial Toxicity Programs to Reduce Socioeconomic Disparities in ALL With Greg Knight, MD

In this interview from the 2023 American Society of Hematology (ASH) Annual Meeting, Oncology Data Advisor speaks with Greg Knight, MD, Clinical Assistant Professor of Medicine at Levine Cancer Institute, about his presentation on the impacts of nurse navigation and other supportive care services for reducing socioeconomic disparities in acute lymphoblastic leukemia (ALL) treatment. Additionally, Dr. Knight describes Levine Cancer Institute's Financial Toxicity Tumor Board, the first program of its kind, and shares advice for how other centers can implement similar interventions for mitigating socioeconomic disparities experienced by their patients.  

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today, we're here at the ASH Annual Meeting, and I'm joined by Dr. Greg Knight. Thanks so much for coming on the show today.

Greg Knight, MD: Thanks for having me.

Oncology Data Advisor: Today, we're talking about your presentation on enhanced support services, including nurse navigation, to mitigate socioeconomic disparities in the treatment of patients with acute lymphoblastic leukemia. I'm excited to hear about this presentation. To start off, would you like to first introduce yourself and share a little bit about what your research focuses on?

Dr. Knight: Sure, I'm Greg Knight. I'm at the Atrium Health Levine Cancer Institute in Charlotte, North Carolina. Clinically, I'm a Leukemia and Bone Marrow Transplant Physician. From a research perspective, I'm most interested in looking at disparities in care, especially focusing on things like financial toxicity and the financial implications of care, but also looking at socioeconomic disadvantage and things like the area deprivation index. We're trying to look at neighborhood-level factors and being able to really tailor strategies to help those patients.

Oncology Data Advisor: For some background about your presentation here, what are some of the barriers that impact delivery and care and lead to outcomes disparities in ALL?

Dr. Knight: ALL is an interesting disease in that we think of it in almost a bi-phenotypic way where it's two different diseases. There are our young children and adolescent young adults and then our older adults, and then you see a little bit in the middle, but we see it mainly in those two. Having said that, both have huge issues with getting care, especially in the fact that ALL is not a disease that you can treat out of the hospital. It requires intensive chemotherapy. A lot of the time, it requires long hospitalizations.

Most of the time, you're not able to work, which is a huge issue in our adolescent/young adult folks, and there can be severe toxicity with the treatments. Obviously, you are much more immunocompromised, not just from your cancer but also from the treatments we're giving you. It is a real challenge, and it basically has to become your life. There are a lot of folks that when they have to get these types of treatments, it completely disrupts everything. Then the question is, can we deliver the therapy that we need to get them cured?

Oncology Data Advisor: That's a great overview of all of these barriers. For this study, what was your goal for it, and how did you go about designing it?

Dr. Knight: This is a study that was designed to look at where we are. In terms of our institution at Levine Cancer in Charlotte, we have a lot of ancillary services, and we designed a lot of things to try to combat a lot of these issues, but we weren't sure if they were working and what we need to focus on next. So, what we did was a retrospective look at all of the patients treated at our institution from 2016 onward to see how they did. Then we wanted to actually identify, are there certain areas or other potential barriers that we need to be thinking about that we aren't?

Specifically, what we're looking at are socioeconomic disadvantage and the area deprivation index. If you're not aware of what that is, it's basically a way we can look at neighborhood-level data and then be able to say, "Here are all the different things in your neighborhood that could such determinants of health that can affect your care." We wanted to know if we were seeing differences amongst the different neighborhoods and the different socioeconomic areas of our catch area. Now, having said that, we've presented data on this in lymphoma. We've looked a little bit at a couple of other disease states, but we've never looked at something like ALL, which is so intensive in terms of treatment.

Oncology Data Advisor: That's great. What results did the study show?

Dr. Knight: It was great in that we found that we did not see significant disparities in care amongst our population, which is actually similar to the results that we presented at ASH a couple years ago and then published for lymphoma, looking at racial-ethnic disparities. This was more looking at socioeconomics in terms of geography. Having said that, we were very happy to discover that we were not seeing significant disparities, but what we know is that there are disparities; that's the bigger issue. In fact, we have another paper that we're presenting here this weekend, looking from a national standpoint using Surveillance, Epidemiology, and End Results (SEER) data in all these different areas. We know there are huge disparities in care in ALL, so the fact that we didn't find them at our institution makes us have to go, "Okay, why did that happen, and what are we doing that maybe we can apply it in other places?"

Oncology Data Advisor: Do you have theories as to why you didn't see them in this study?

Dr. Knight: One of the things that we discussed was our nurse navigation. We have a very strong nurse navigation program that—because we are a relatively new center in the grand scheme of things—we were able to design it in the way that we wanted. One of the things that was designed was very strong nurse navigation, not just at the primary center, but it also includes our ancillary rural locations. They have a nurse navigator, which is not necessarily the standard of care for a lot of community practices. What we saw in this study was that patients coming from higher disadvantage or having factors that would lead you to be concerned about them actually had higher levels of navigation than those that didn't, which is how the system should work. Our nurse navigators should be going after and helping the folks that need the most help.

The second thing that we think probably contributed to it that we do have a very strong financial toxicity system. Financial toxicity is the idea that we need to think about toxicity of treatment not just in terms of knowledge about vomiting but also the financial piece. We've been very interested in that and have done a lot in terms of interventions. One of the things we did was we created the first-ever Financial Toxicity Tumor Board, which is a comprehensive tumor board involving not only clinicians, nurses, and navigators, but we also have social workers, administrative people, financial counselors, insurance authorizers, you have all these people in one room. This has been a program that has really seemed to have a huge impact. I think that developing those systems and really trying to focus on this probably shows us that we're having a great impact on our patients.

Oncology Data Advisor: Absolutely. That's a huge testament to the power of nurse navigation, and it's also fascinating about the Financial Toxicity Tumor Board. I'm sure that it plays a huge role. Do you have any suggestions for how more centers can implement both nurse navigation and financial toxicity programs to help mitigate these risk factors?

Dr. Knight: I think that a lot of times these programs are very effective. For the Financial Toxicity Tumor Board, we've actually shown that it's cost-effective for the institution. That actually is probably the biggest barrier for most institutions—if it's not a drug trial and they can't show a significant amount of financial improvement with this, then it's hard for them to put the money out there. While piloting these types of programs, I've had a lot of folks reach out from around the country asking about some of the things we do, not just in ALL but in other cancer types in terms of looking at financial issues, doing stronger navigation, and being financially-focused.

One of the things we've always tried to do when we design these studies is to say, "Look, I understand that most of the time, administrators don't think about these things or sometimes care about these things," but if we can show them the benefit of these programs and really pilot them in a way that shows that they're helping patients, they're improving people's lives. Then at the same time, we're not seeing readmissions, and patients are getting their medications and are able to not have to come in with complications. I think that those are the types of ways that we've been designing it to also prove it at an administrative level and prove that these things can actually happen.

Oncology Data Advisor: That's amazing that your center is really paving the way in that area, and it's also incredible that you've seen such great results already. Finally, do you have any next steps or additional research planned in this area?

Dr. Knight: We do. I think that one of the biggest things for us is that we don't want to rest on our laurels. We feel great that we didn't see disparities, but we know that there are disparities, especially nationally. The second piece is that we can only look at the people that were touched by our center. We know that a lot of the disparities happen before they come to us—say, an elderly patient who's never referred or someone who doesn't have the ability to travel to a big center.

The biggest thing for us, and one of the things that we're focusing on in some of the projects we have now, is looking at impacting these issues at a community level and then also really trying to start to work with community sites and rural sites in areas of greater disadvantage in terms of being able to increase that access piece. If we're doing well, that's great, but like I said, it's the only the people that we're touching, and we need to make sure that we're able to spread this more. Then the last piece is publishing this stuff. I think that a lot of times, with the work that we do, we don't publish it. Nurse navigation is almost never published, right? It's important to publish these things so that you can prove how well they're doing, and that helps as we build it nationally.

Oncology Data Advisor: Right, it's a way to quantify it and show that it works. Well, this is amazing to hear about. Thank you so much for stopping by today. I look forward to hearing more about this work in the future as well.

Dr. Knight: All right, thanks so much.

About Dr. Knight

Greg Knight, MD, is a Clinical Assistant Professor in Hematology and Oncology at Atrium Health and Levine Cancer Institute at Wake Forest University School of Medicine in Charlotte, North Carolina. He specializes in the treatment of leukemia and bone marrow failure syndromes, with a research focus on socioeconomic disparities and the financial impact of cancer treatment. He co-founded and serves as Chair of Levine Cancer Institute's Financial Toxicity Tumor Board, the first-ever tumor board specifically focused on financial toxicity.

For More Information

Knight TG, Boselli D, Verbyla A, et al (2023). Enhanced support services including nurse navigation mitigate socioeconomic disparities in the treatment of patients with acute lymphoblastic leukemia. Presented at: 2023 American Society of Hematology Annual Meeting. Available at: https://ash.confex.com/ash/2023/webprogram/Paper182371.html

Atrium Health (2022). This board's mission: fighting the financial burden of cancer. Available at: https://atriumhealth.org/dailydose/2021/06/10/this-boards-mission-fighting-the-financial-burden-of-cancer

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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