RE: How the Coronavirus Disease-2019 May Improve Care: Rethinking Cervical Cancer Prevention

In a recent article in the Journal, Feldman and Haas wrote a timely piece on the potential to enhance cancer prevention and cancer care delivery in the coronavirus disease 2019 (COVID-19) era (1). Using cervical cancer prevention as a use case, the commentary described clinical care provided via virtual platforms and in nontraditional settings, such as the patient’s home, as areas needing creative approaches to ensure care is provided safely and efficiently. As we consider factors that are relevant to delivering effective cancer prevention and cancer care post-COVID-19, we suggest that addressing social determinants of health, an often-forgotten dimension of lived experience, should be prioritized as a strategy to enhance the equity of care provision (2). Social determinants of health, including food and housing insecurity, have been shown to impact outcomes of patients with cancer through a number of mechanisms including delays and incomplete care (3).

Successful approaches exist for addressing social determinants of health as a part of cancer care and prevention (3). As an example, through the Translating Research into Practice study, we are working with oncology practices to implement a best-practice model of patient navigation among racially and ethnically diverse and low-income patients newly diagnosed with breast cancer, which includes screening patients for social needs and connecting them with services to promote timely breast cancer care (4). Since the program began in 2018, we have observed that social needs in our breast cancer patients are profound and common: 43% of our patients have at least one social need at the time of diagnosis (Table 1). Patients’ needs for assistance finding food (26%) and paying for utilities (23%) and difficulties with unemployment (24%) were the most frequently identified. Securing housing, paying for treatment, and obtaining legal assistance were also identified as common concerns. Addressing foundational social needs is essential to providing equitable care so that all patients can receive care, in virtual or traditional settings.

Table 1.

Demographics and social needs among breast cancer patients (n = 161) in the Translating Research into Practice (TRIP) Study

Characteristic	Total eligible TRIP patients No. (%)
Age, y
<40	15 (9.3)
40-54	46 (28.6)
55-64	49 (30.4)
65 and older	51 (31.7)
Race/Ethnicity
Hispanic	41 (25.5)
Non-Hispanic White	17 (10.6)
Non-Hispanic Black	86 (53.3)
Non-Hispanic Asian	17 (10.6)
Preferred language
English speaking	85 (52.8)
Non-English speaking	76 (47.2)
Insurancea
Private/Commercial	40 (24.8)
Medicare (including private/Medicare advantage)	29 (18.0)
Medicaid (including dual Medicare/Medicaid) or uninsured	91 (56.5)
No. of social needs
No needs reported	52 (32.3)
1	16 (9.9)
2	19 (11.8)
3 or more	35 (21.7)
Missingb	39 (24.3)

^aInsurance status type could not be determined for 1 patient.

^bMissing responses includes patients who have not received social needs screening.

Reframing cancer prevention and care delivery to address social determinants of health has policy implications, including implications for care payment models (5). In the ways that the Centers for Medicare and Medicaid has broadened reimbursement for telemedicine and other virtual care, it is necessary to consider payment models and strategies to better fund navigators as critical resources to address social determinants of health that will increasingly become barriers and facilitators to receiving care in the COVID-19 era (5). As we implement the Translating Research into Practice navigation model, we have observed that 24% of patients in our eligible population have not received social needs screening, despite integration of the model within oncology programs. Performing screening is time-intensive and requires appropriate staffing and training. Allocating appropriate resources for implementing workflows for social care is a critical part of navigation to identify and address social needs (6). Therefore, in addition to considerations raised by Feldman and Haas, we also suggest cancer care guidelines be expanded to include formal recommendations for addressing social determinants of health, including appropriate staffing and funding for models of patient navigation to address social needs, as strategies to prioritize equity in the transformation of cancer care and prevention (5).

Funding

The Translating Research into Practice study is a multisite patient navigation intervention study funded by NIH/NCATS U01TR002070.

Notes

Role of the funder: The funder had no role in the design of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; and the decision to submit the manuscript for publication.

Disclosures: Karen M. Freund: Policy Task Force Chair – National Navigation Roundtable (no honorarium, travel to meetings support by the American Cancer Society); consultant and travel to a national meeting, support by the National Minority Quality Forum. Tracy A. Battaglia: Chair, National Navigation Roundtable (no honorarium, travel to meetings support by the American Cancer Society); executive committee member, Boston Breast Cancer Equity Coalition (volunteer, no honorarium). The other authors have no competing interests to declare.

Author contributions: CRC conceptualized and drafted the manuscript. JSH, SCL, KMF and TAB led the study and provided critical revision to the manuscript. KBW led the study coalition that hosts the study and provided critical revision to the manuscript. CM, AW, AL, VX, and NC provided critical revision to the manuscript. CLT performed data analysis and provided critical revision to the manuscript.

Data Availability

The data underlying this article cannot be shared publicly due to concerns to protect the privacy of individuals that participated in the study.