Memorial Sloan-Kettering Cancer Center is more than just a renowned leader in cancer treatment and research, it has also made a commitment to advance health equity. Three doctors from MSK give us insight into how they are working to eliminate health disparities among people of color.
Transcript
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Dr. Carol Brown: How can we change our health system, the way it's set up, in order to overcome these barriers? Because the individual barriers, we as physicians know how to do those right, but it's the system barriers that I think are the most challenging.
MILLICENT: Hi, you're listening to Vital Voices, a podcast from Corning Incorporated, where we explore innovative ways companies can be a force for good. I'm Millicent Ruffin.
SISSY: And I'm Sissy Siero. In this episode, we continue our discussions around health equity. In our last episode, we talked about a new plan for a mobile clinic that’ll bring much needed dental care to the upstate New York community.
MILLICENT: For this episode, we’ll cover another exciting Corning initiative - this time in collaboration with Memorial Sloan Kettering. We’ll hear from a grant recipient about his research, which will further what we know about health disparities in colorectal cancer.
Before we get to that though, we'll hear from two providers at Memorial Sloan Kettering Cancer Center about working with marginalized communities, the importance of changing policies as well as funding research on health disparities.
SISSY: First up, we’ll hear from a physician who is at the intersection of cancer and cardiology…two of the leading causes of death in the U.S.
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Dr. Michelle Johnson: Cardiology is still the number one killer in the United States and cancer is number two. So from where I sit, I have the mixed blessing of seeing both being a cardiologist in a cancer institute.
SISSY: This is Dr. Michelle Johnson -- She's a clinical cardiologist specializing in cardio-oncology -- She's also the vice-chair for health equity in the Department of Medicine at Memorial Sloan Kettering.
Dr. Michelle Johnson: A lot of my work surrounds impacting the health of marginalized peoples. So I am involved in efforts to target cardiovascular issues in people of color, primarily, black and Hispanic patients.
SISSY: As a woman of color herself, Dr. Johnson relates to her patients and does this work to address the health disparities she sees in her community.
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Dr. Michelle Johnson: What we see is that new therapies reach our population slower than they do white population. And some of that tracks by economics, but economics does not account for it all.
SISSY: Her experience as a Caribbean immigrant has also helped her connect with patients.
Dr. Michelle Johnson: I am an immigrant to the US and as are some of the patients that I treat. It's very difficult for people to feel comfortable if they don't see anybody who looks like them on the other side of the stethoscope. You know, trying to pause in the midst of a busy clinical day to remember that you have to meet each patient where they're at.
SISSY: Dr. Johnson approaches her patients with compassion and a holistic understanding of the social and economic pressures that her patients face.
Dr. Michelle Johnson: What goes on in the room with the patient plays out what goes on in society at large. And so it's not reasonable to expect that some of those tensions are not going to enter into the clinician-patient experience.
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I can tell you about a patient of mine, an African-American woman, she’s in her forties. And then she got diagnosed with congestive heart failure. And over the course of working up this, she had a cardiomyopathy where you have a reduced pump function of the heart. And went on to need a defibrillator, which is lifesaving therapy for people who have reduced pump function, who are at risk of having life-threatening arrhythmias or life-threatening conduction problems.
SISSY: Defibrillators are devices that restore a normal heartbeat by sending an electric pulse or shock to the heart. There are a few types of defibrillators and they can be surgically implanted or wearable on the body.
Dr. Michelle Johnson: And she declined the defibrillator for the longest time, and I couldn't understand why. It's not a major procedure, at least not in our minds, we're not cracking open the chest and it’s lifesaving. And I, and finally, after about a third meeting about this, she said, you know, she was concerned about how this was going to impact her job as a home health aid and that she didn't want her employer to know. She was afraid she'd lose her job because she would be seen as having a heart problem.
SISSY: Her concern was that the defibrillator would be external.
Dr. Michelle Johnson: She could be taking meds but her employer is no wiser. But this now she sees as being something that would stick out of her chest and taking time off for the procedure. So we were able to talk her through that and we showed her a device and she could see that it was you know and that you wouldn't really see it.
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And that to me was just such a clear example of how, what's going on when we talk about social determinants of health and when we talk about what's going on in people's external milieu impacting their medical decision making, a way in which as a provider, you just might not know. Ultimately she got a defib is the good news. You don't know what's going on in people's lives and you have to ask.
SISSY: Yeah, I think that that’s a really common thing that happens. Like, you have to, you have to even know what questions to ask. So her consciousness about that just seems like it’s gonna really help people.
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MILLICENT: It does. It does. And, and Dr. Johnson referred to social determinants of health. And traditionally, in the United States, when we want to improve our health or address a problem, we turn to doctors or we turn to the healthcare system. But research has confirmed that our health and our well-being is impacted by so many social factors. And healthcare is actually just one small contributor to that.
Our health outcomes are impacted, yes, by the healthcare we receive, and certainly by genetics, but also by all these other social and environmental factors. And that’s what Dr. Johnson is referring to when she talks about the social determinants of health. She’s talking about these conditions that people are born into, that they grow up in, that they live in, and that they grow old in.
And these are the conditions that affect the quality of our lives. So our economic stability, do we have secure employment? Does our income cover our expenses and cover our basic needs? Do we live in a neighborhood where we have safe, affordable housing and access to transportation? Do we have parks and green spaces? Do we have access to education and is it quality education? Do we have access to healthy food? Like, all of these things are things that impact our health and our wellbeing.
SISSY: Hm. This sounds like medical schools need to really, really dig in and, and start teaching doctors different ways to be and, and questions to ask and see the person in front of them.
MILLICENT: That, that and. Right? I think that our medical professionals, you know, obviously have to think beyond the symptoms that they see in front of them.
SISSY: Mm-hmm.
MILLICENT: But I think also our school systems, our policy makers, we all have to be approaching things differently to ensure a more equitable quality of life for all Americans. There are so many factors that impact the quality of our lives that it's impossible to solve it with just a medical appointment.
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SISSY: Right. You know, because of her empathy, that’s what helped Dr. Johnson be more aware in some way, right? Because she was identifying with the community and she saw what was going on.
Because people don’t know what to ask. You know, if they don’t know what to ask, they can’t get what they need.
MILLICENT: Right. Being able to see the whole life of the person.
SISSY: What a great way to put it. Right. You know, and speaking of that, so as an immigrant to the US - Dr. Johnson had a much different expectation for the healthcare system here.
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Dr. Michelle Johnson: I grew up in the Caribbean, so I'm coming from an under-resourced healthcare system,
And in large part envisioned that as resource rich as we are here in the US, would have more equitable distribution of its resources.
And in medical school you start to see clinically where that's just not the case. You see where your black and brown patients have more comorbid conditions, tend to present later, having more challenges with following, the prescriptions that their physicians give.
And you see that as you, as you get more sophisticated in your understanding of what's going on, you understand that it's social determinants of health, it's systemic racism. It's all these things that are making it more difficult for marginalized communities to engage in their care in the way in which we would like.
And my hope is that as there are increasing pressures to collect data on social determinants of health, that we can meet people where they are.
SISSY: Through our discussion, it was clear that collecting this type of data would benefit society as a whole… but we were curious about what this meant for Dr. Johnson personally.
Dr. Michelle Johnson: It is important to me because I'm a woman of color and because I continue to see people who look like me have worse outcomes due to no fault of their own.
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And this is not a fault of an individual patient or an individual provider. You know, we are talking about things that are built into the system. The system was created this way generations ago.
SISSY: For our next guest, we wanted a big picture perspective on health equity. So we talked to another Memorial Sloan Kettering physician who works closely with Dr. Michele Johnson.
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Dr. Carol Brown: When I give talks, I often show a photograph of Dr. Martin Luther King, and he made a statement that of all the forms of injustice that he was fighting against injustice in healthcare as one of shocking. And unfortunately, that's from 60 years ago, and it's still true.
SISSY: This is Dr. Carol Brown, she fights against injustice in healthcare. She’s a gynecologic oncologist at Memorial Sloan Kettering Cancer Center. We caught her while she was at her office in New York City.
MILLICENT: And it’s important to note too that Dr. Brown is the Senior Vice President and first ever Chief Health Equity Officer at Memorial Sloan Kettering Cancer Center. Sloan Kettering’s Office of Health Equity was established in 2020. And the office works to address disparities that exist due to racial, ethnic, cultural, and socioeconomic barriers.
Dr. Carol Brown: What it really means is that I'm responsible for initiatives and programs which are designed and have the goal of making sure that every patient has the best possible chance to have a great outcome from their cancer.
We wanna make sure that all the people affected by cancer, no matter what challenges they're facing - whether it's their geography or the language they speak, their physical ability - so that everyone has basically the same shot at getting cured.
There are some factors that affect people who are affected by cancer that you can't change. But there are many more that we can change. For example, if somebody lives at a certain distance from the hospital or grew up in a rural area, but we can change if they don't have transportation to get to the hospital. We can't change that someone speaks a different language, nor would we want to, but we can change the services that we provide and we can change our perspective in terms of dealing with people in a culturally respectful and helpful way.
MILLICENT: There's a lot of opportunity for change. But according to Dr. Carol Brown, there is still a long way to go.
Dr. Carol Brown: The main issue in the United States is that healthcare in the United States is not a right. It's seen and accepted as a privilege. I think institutions like Memorial Sloan Kettering are really working hard and leading the way. Not just in terms of what we're doing at our cancer centers, but also working to change policies and working to make sure that there is funding to support initiatives and programs that are directed towards cancer health equity. And also very importantly, working to preserve and increase funding for research to understand the causes of cancer health disparities and find ways to reduce and eliminate those cancer health disparities.
How can we change our health system, the way it's set up, in order to overcome these barriers? Because the individual barriers, we as physicians know how to do those - right? But it's the system barriers that I think are the most challenging.
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MILLICENT: But there have been some advances...
Dr. Carol Brown: Medicaid was not required to cover the cost of participating in a clinical trial until very recently, which disproportionately meant that poor people in the United States would be less likely to enroll in a cancer clinic or any clinical trial, but specifically a cancer clinical trial. In the last year, federal legislation has been passed to remedy that so that now people covered by Medicaid have equitable access to cancer clinical trials.
MILLICENT: Also on the federal level – Dr. Carol Brown is one of three members of President Biden’s cancer panel.
Dr. Carol Brown: And the job of the President's cancer panel is to advise the president of the United States on the National Cancer Program.
And what it usually does is takes a particular topic in cancer, a topical challenge or issue and works over a period of several months holding town halls and doing research, and then produces a report where the panel makes recommendations about a particular topic in cancer. So, for example, in recent years, they've produced reports about the importance of cancer screenings and access to cancer screening.
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MILLICENT: For the Biden administration - there’s a big push to advance research to end cancer as we know it.
Dr. Carol Brown: NCI and the president just launched and announced a national cancer plan, which has identified eight areas of key focus to try to get to the goal of really reducing deaths from cancer significantly by 2025. So the other exciting thing is that, every aspect of the federal government, every agency is working on cancer. All of these agencies working together and meeting together to work on the cancer plan and make sure that we reduce deaths and improve people's lives with cancer. So it's a very exciting time.
SISSY: One of the best ways to fight cancer is through knowledge and data gathered from clinical trials. But when a clinical trial primarily has samples from predominantly white populations, its usefulness for diverse populations falls flat. Dr. Michelle Johnson again -
Dr. Michelle Johnson: Most recent FDA review of clinical trials showed that Black percentage of patients per clinical trial is somewhere between two and three percent.
It's 2-3% for Asians, and this is just not representative of our population, and we know that everybody doesn't respond the same.
We're trying to generate biomedical knowledge that's applicable to everybody and it's impossible to say that it's applicable to everybody if we don't have representative samples.
SISSY: According to Dr. Johnson, not having diverse representation in clinical trials impacts the trust and legitimacy of medical research and institutions.
Dr. Michelle Johnson: You know, we're just not gonna be credible to the population at large if what we're looking to do is to get buy-in on results of a population that does not represent people we're looking to prescribe.
Research says that, you know, many non-whites have never been asked to participate in clinical trials. If you don't ask, they aren't gonna participate.
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It is also important that when companies are embarking on designing clinical trials, that they have diversity, inclusion, as one of their goals. It can't be an add-on at the end because you'll build in biases into your research question, your processes will not be equitable, and so you're gonna end up with problems at the end.
MILLICENT: I really, really love this point on diverse representation in clinical trials because that is very important in addressing cancer disparities. That's the only way we're going to be able to generalize treatment advances and really get to solutions that work across a diversity of people.
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And so as we look at the data, we know that Black men have the highest overall cancer mortality rate. We know that Black women have a 40% higher breast cancer death rate than white women despite having a lower incidence rate. We know that something more has to be done.
And when we looked around to see, okay, what can we, as Corning's Office of Racial Equality and Social Unity, actually do? Well, the one thing we can do is partner with one of the leading national cancer institutes in the country. So that's when we reached out to Memorial Sloan Kettering Cancer Center with the proposal to partner on a two year health equity research grant.
Dr. Michelle Johnson: We were very excited when Corning reached out to us. We know that research questions about issues that have disproportionate impact on communities of color do not get as much funding.
SISSY: As a member of the selection committee, Dr. Michelle Johnson knew exactly the types of grant proposals they were looking for.
Dr. Michelle Johnson: So this is our first year with the grant and the request for proposals asked for applicants to be from groups that are historically underrepresented in medicine and to support either preclinical or translational or clinical health equity research.
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We purposefully made it broad so it can be for issues that disproportionately impact cancer outcomes in underserved communities.
MILLICENT: The first Corning Memorial Sloan Kettering Health Equity Research Grant has been awarded to Dr. Francisco Sanchez-Vega. He's an incredible scientist focused in the field of computational oncology.
His research involves disparities in outcomes seen with colorectal cancer in people of African descent. And he's investigating both genomic and socioeconomic factors that lead to negative outcomes.
Dr. Sanchez Vega: I spend most of my time in front of a computer analyzing the data. I'm interested in looking at associations between genomic features and clinical outcomes.
SISSY: His ultimate goal is to advance personalized oncology through genomics - the study of a person’s genes. This approach to medicine is considered precision medicine.
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Dr. Sanchez Vega: So let's consider a patient who arrives at Memorial Sloan Kettering and they have been diagnosed with cancer. Let's consider, for example, some patient with colorectal cancer. So nowadays we will typically take a biopsy of the tumor and also some blood from the patient, and we will perform genomic sequencing of the DNA of the tumor.
SISSY: What this means is that Dr. Sanchez-Vega and his team are able to identify changes in the DNA that are specific to the tumor. This information can reveal whether the patient's tumor can be targeted with specific drugs or it can give prognostic information about how the patient’s cancer will evolve throughout treatment.
Dr. Sanchez Vega: You know, a few years ago there was this model where, in certain cancer types, they would just get systemic chemotherapy or chemo radiation or some type of treatment that wasn't really tailored to each patient. Now, as we are starting to accommodate more and more data, more and more scientific evidence, we are starting to be able to choose the best treatment for each patient based on the genomic profile of the tumors.
MILLICENT: While collecting data for his research, Dr. Sanchez-Vega noticed a trend…
Dr. Sanchez Vega: We found that that race seemed to be playing an important role; when you compare the survival for self-reported Black patients versus self-reported white patients, we were seeing that the Black patients were doing significantly worse.
MILLICENT: This got Dr. Sanchez-Vega’s team really curious - they looked more in-depth at the genomic profiles and at statistics from the American Cancer Association.
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Dr. Sanchez Vega: It turns out that this is a well-known fact that, both incidents and mortality is higher among African-American patients in the US than white patients or patients with European ancestry.
And I don't think that the causes are still well understood at this point. It seems pretty clear that there is a socioeconomic component to it, that there are differences in risk factors and access to healthcare that probably explain a lot of these disparities. But as far as I know the role of genomics has not been entirely clarified at this point. And this is what we are trying to, to understand in our research. We want to know if there are also genomic differences in the tumors that can explain the differences in outcomes.
MILLICENT: Beyond genomics, Dr. Sanchez-Vega takes a holistic approach. He’s planning on incorporating data from medical images and from electronic records…
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Dr. Sanchez Vega: I'm also very, very interested in the idea of starting to look at some of the socioeconomic factors that maybe play in a role in, in these outcomes.
For example, we can try to understand what's the distribution of different insurance types that the patients had. We can get for each patient, whether they had commercial insurance, whether they were receiving Medicare, Medicaid, whether they were self paying patients.
The ultimate goal for us is to be able to integrate all these different sources of information to get a more accurate profile of the tumor, and see how we can use that information to improve patient care.
SISSY: We were curious about specific ways this data would have an impact....
Dr. Sanchez Vega: One of the abstracts that we presented last year, we were reporting that we were seeing a higher fraction of right-sided tumors among the African-American patients, right-sided colorectal tumors.
And, you know, if that is true and, and that that observation will probably need to be validated in larger cohorts. But if that is true, that that suggests that, that those patients may benefit from having full colonoscopies when they are being screened.
So we believe that that, that some of the insights that we are starting to get may really have a, a clinical impact in the future and may, may be helpful for, for managing patients.
SISSY: With so many promising research observations by Dr. Sanchez-Vega and his team, the Corning / MSK Health Equity Grant came at just the right time.
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Dr. Sanchez Vega: I feel really honored and, and very grateful. We have all this data that, that we have not been able to analyze so far because we can really benefit from recruiting more people and growing our team. And for that, the fellowship gives us a, a really amazing opportunity to look at all these questions in detail and, you know, to look at it from every possible angle.
I'm optimistic because I think that people are starting to realize the importance of this topic and funding is starting to also help us tackle these questions.
SISSY: This is amazing to me. And it seems like a no brainer in a way. It's so surprising to me that it's just now, although it's probably been going on more, but to hear the way he's talking about it, it sounds like something new and exciting and thank goodness there's a focus on it. And how unfortunate that this has been largely under researched.
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MILLICENT: Under researched until now.
SISSY: Right, right.
MILLICENT: And, and that is what excites me about this work and about my job in general. But this is exactly what we hope to accomplish with this partnership and with this grant. And this is the type of research that we wanted to fund. And so we're getting at the heart of the issue.
We're understanding both the genomics of what's happening in Black bodies, and we're also looking at socioeconomic factors that impact access to treatment and willingness to stick with treatments.
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So I'm really excited about the work that Dr. Sanchez Vega and his team are tackling. And I'm really excited that I get to work in an office where our focus gets to be helping people live better lives. We get to understand social determinants of health and figure out ways to help people have better outcomes.
MILLICENT: Join us for our next episode where we'll go even deeper on the topic of colorectal cancer health disparities.
Dr. Charles Rogers: it's a preventable, beatable and treatable cancer with screening. So it's one of the few cancers where, like, you literally can save your life.
SISSY: Thanks for listening. You can find and listen to episodes of Vital Voices wherever you get your podcasts. For more information about the Office of Racial Equality and Social Unity and how its programs are impacting the community, click on the links in the show notes.