Abstract PO-076: Strategies to improve the reach of interventions to address inequities in cancer care: Results from a six-site initiative

Economic Evaluations of Interventions Addressing Inequalities in Cancer Care: A Systematic Review

Large segments of the US population do not receive quality cancer care due to pervasive and systemic inequities, which can increase morbidity and mortality. Multicomponent, multilevel interventions can address inequities and improve care, but only if they reach communities with suboptimal access. Intervention studies often underenroll individuals from historically excluded groups. The Alliance to Advance Patient-Centered Cancer Care includes 6 grantees across the United States who implemented unique multicomponent, multilevel intervention programs with common goals of reducing disparities, increasing engagement, and improving the quality of care for targeted populations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework informed the evaluation efforts across sites. Each Alliance site identified their intended populations, which included underrepresented minorities (eg, Black and Latinx persons), individuals who prefer a language other than English, and rural residents. We evaluated the demographic characteristics of participants to determine program reach. Between 2018 and 2020, a total of 2,390 of 5,309 potentially eligible participants were enrolled across the 6 sites. The proportion of enrolled individuals with selected characteristics included 38% (n=908) Black adults, 24% (n=574) Latinx adults, 19% (n=454) preferring a language other than English, and 30% (n=717) rural residents. The proportion of those enrolled who were the intended population was commensurate to the proportion with desired characteristics in those identified as potentially eligible. The grantees met or exceeded enrollments from their intended populations who have been underserved by quality cancer care into patient-centered intervention programs. Intentional application of recruitment/engagement strategies is needed to reach individuals from historically underserved communities.

1609 Background: Inequitable access to precision medicine limits its impact. To address disparities, we co-developed a 2-part multi-level intervention with community stakeholders, called the Addressing Latinx CANcer Care Equity Study (NCT04843332). The intervention was designed for low-income and Latinx adults with cancer in rural Monterey County, California. We provided annual training for clinicians about testing guidelines and precision medicine disparities. Trained community health workers educated patients about precision medicine and encouraged them to raise the topic with their oncologist. We tested whether the intervention improved patient knowledge and receipt of precision medicine. Methods: Patients with newly diagnosed or recurrent cancer, age ≥ 18 years, able to consent in English or Spanish, and who self-identified as a racial and ethnic minority OR low-income status OR were insured by public or agricultural company insurance OR uninsured and receiving cancer care at Pacific Cancer Care, a rural community oncology practice in Monterey County, were randomized 1:1 to usual care (control group) or usual care augmented with the multi-level intervention for 12 months (intervention group). The primary outcome was whether the multilevel intervention could increase patient knowledge of precision medicine using a validated 6-question survey from the time of enrollment (baseline) to 6 months post-enrollment between groups. A secondary outcome was the receipt of precision medicine. Patients were followed for 12 months. Results: 110 participants were randomized; 70% (n = 67) reported Spanish as their primary language; 81% (n = 89) identified as Hispanic. The median age was 55 years (55.4 ± 14.3, mean± SD); the majority had annual household incomes (USD) ≤ $34,999 (59.0%, n = 46); the majority obtained a high school diploma/GED or less (67.3%, n = 74). Most had gastrointestinal (35.5%, n = 39) and breast (24.5%, n = 27) cancers and were diagnosed with stage 3 or 4 (64.5%, n = 71) disease. Precision medicine knowledge was low at baseline across both the control and intervention groups (23.5 ± 19.3 versus 23.0 ± 17.7, respectively). Intervention group participants had greater precision medicine knowledge at 6 months (39.2 ± 23.0) than control group participants (24.2 ± 20.0) with a greater increase in knowledge over time than control group participants (p < 0.001).More intervention group participants (n=46, 79.3%) received precision medicine testing than control (n=34, 60.7%). Across both groups, 26 of those tested had an actionable mutation. Of those 26, 66.7% (n=6 of 9) in the control group and 94.1% (n=16 of 17) in the intervention group received targeted therapy (p=0.065). Conclusions: CHW-facilitated interventions may reduce disparities in precision medicine cancer care. Clinical trial information: NCT04843332 .

Background . There are well‐established, persistent inequities in cancer care and cancer outcomes within and between countries. The aim of this article is to explore how implementation theory, specifically the Consolidated Framework for Implementation Research (CFIR), alongside coproduction principles, could be used to maximise the effectiveness of innovations with a vision of reducing inequity in cancer care. Methods. Workshops were conducted with partners from US, Australia, and UK, participating in the University Global Partnership Network (UGPN), which funded the collaboration. From these workshops, three case studies were identified and the framework was applied to identify ways of using CFIR to maximise the effectiveness of innovations. Results. The three case studies focused on human papillomavirus (HPV) testing and vaccination, participation in clinical trials, and use of translation services. We identified opportunities, for each of the case studies, where CFIR could be applied to improve implementation and proposed recommendations to ensure effective implementation of innovations using CFIR domains, including individual constructs (e.g., awareness and cultural competence), inner setting constructs (e.g., technology infrastructure), and outer setting constructs (e.g., how services are monitored, evaluated, and commissioned). Conclusions. Applying CFIR as an implementation framework offers a structured and holistic approach to consider how to maximise the effectiveness of innovations in the context of reducing inequities in cancer care. Working with other countries to apply this framework also provides a uniform approach to understand and reduce inequities across a range of innovations and address the global mission to improve cancer care for all.

1602 Background: Structural racism and social determinants of health (SDOH) have been linked to inequities in cancer care and outcomes. However, little is known about the contribution of such factors to care inequities among patients with endometrial cancer, where Black women experience a nearly two-fold increased risk of death relative to their White counterparts. We examined the role of structural racism and SDOH in explaining racial/ethnic inequities in care for patients with advanced endometrial cancer (aEC). Methods: This retrospective study used the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database, focusing on patients diagnosed with aEC from January 2013 to September 2023 (follow-up through December 2023). Outcomes included time-to-treatment initiation, use of immunotherapy or targeted therapy, biomarker testing, and clinical trial participation. We estimated a series of multivariable Cox proportional hazards models assessing racial/ethnic inequities in outcomes, sequentially adjusting for clinical factors (e.g., age, stage at diagnosis) followed by structural racism (residential segregation) and SDOH factors (e.g., insurance, practice setting, area-level vehicle ownership). Results: The cohort included 5,496 patients (2.2% Asian, 14.8% Black, 5.2% Latinx, 61.4% White, and 16.0% Other/Unknown). Although diagnosed with more aggressive disease (37% vs. 21% serous carcinoma), Black patients were less likely than White patients to initiate treatment during follow-up (hazard ratio [HR]=0.91 [95% CI: 0.83-0.99]), participate in a clinical trial (HR=0.56 [95% CI: 0.38-0.84]), and receive biomarker testing (HR=0.88 [95% CI: 0.81-0.97]). Compared with their White counterparts, Latinx patients were less likely to participate in a clinical trial (HR=0.41 [95% CI: 0.19-0.87]). Black-White (HR=0.80 [95% CI: 0.47-1.38]) and Latinx-White (HR=0.71 [95% CI: 0.31-1.60]) inequities in clinical trial participation were partly explained by structural racism and SDOH factors, while Black-White inequities in treatment and biomarker testing remained largely unchanged following structural and social determinants adjustment. We saw no racial/ethnic differences in use of immunotherapy or targeted therapy. Conclusions: We observed racial/ethnic inequities in treatment initiation, biomarker testing, and clinical trial participation among patients with aEC, with structural racism and SDOH substantially accounting for inequities in trial participation. Thus, findings from this study suggest that efforts aimed at improving diversity in endometrial cancer trials, and overall equity in endometrial cancer outcomes, should prioritize mitigating the structural and social barriers to clinical trial participation.

e18502 Background: While the National Cancer Database (NCDB) is frequently used for observational studies about cancer care including disparities, study populations are often overwhelmingly White. The aim of this study was to assess racioethnic inequities in the NCDB by characterizing the completeness of data in the registry. We hypothesized that Black and Hispanic patients are more likely, compared to White patients, to have missing data about staging, treatment, and survival. Methods: We used the 2004-2016 NCDB files for breast, colon, and lung cancer focusing on non-Hispanic White, Black, and Hispanic patients. The primary outcome was the comparative missingness in data between the three racioethnic groups, measured using multivariable logistic regression models. A stepwise study progression from diagnosis of cancer, histology, clinical staging, treatment documentation, survival, and guideline-concordant care was used. Results: Compared to the U.S. Census data from 2010, Black and especially Hispanic patients were much less likely to be registered in the NCDB compared to Whites. Black and Hispanic patients were also more likely to have missing or non-usable histology data, incomplete or missing clinical staging, and treatment documentation (Table). Survival and follow-up documentation was similar between the three groups. Black and Hispanic patients were less likely to receive surgery for stage I-III disease compared to White patients. Conclusions: Our study suggests that the NCDB may be a limited resource for study of cancer in Black and Hispanic patients, and that inequities in missing data in its own structure may reflect racioethnic inequities in cancer care in the United States. Summary of fraction of missing treatment status, by malignancy, stratified by race/ethnicity in the NCDB. Data are represented as count (percent) unless otherwise noted. The p values are obtained by the Pearson’s chi squared test. Results from a multivariable logistic regression examining the odds of missing treatment status are provided for each malignancy as well. [Table: see text]

Racial disparities in cancer care: can we close the gap?

Purpose: Sub-Saharan Africa has huge disparities and inequities in cancer care. Some low resource countries have no facilities or trained oncologists and other healthcare professionals for cancer care. Patients often must travel long distances to access specialised cancer care such as radiotherapy, chemotherapy and palliative care. Patients with cancer in Lesotho who needed chemotherapy had to be flown to India; those who needed radiotherapy were referred to South Africa. Majority of the cancers diagnosed in the Northern cape province and Lesotho are in late stages and need treatment with chemotherapy and radiotherapy as part of the multimodality therapy. Methods: The Northern Cape Cancer Centre of Excellence and Research (NCCanCER) at Kimberley Hospital in South Africa collaborated with the Senkatana Hospital in Lesotho. Oncologists, specialist oncology nurses and IT personnel were trained at Project ECHO Institute in Albuquerque, NM to use the ECHO model for training, transfer of skills and mentorship. NCCanCER assisted Lesotho to set up a chemotherapy facility at Senkatana Hospital. An initial visit to the Kimberley Hospital Oncology Department for benchmarking was done by oncology staff from Lesotho. NCCanCER oncology staff went to Lesotho to provide on-site training in chemotherapy administration. Weekly virtual ECHO clinics were run from the Hub at Kimberley with spoke sites in Lesotho, Upington, Springbok and Kuruman. At the ECHO clinics, management of patients are discussed using evidence-based management protocols for continued training, transfer of skills, support and mentorship. Results: Doctors, nurses, pharmacists, social workers, clinical psychologists and community healthcare workers have been trained to provide cancer care and palliative care services in the underprivileged and underserved areas of the Northern cape and Lesotho. The first chemotherapy facility was opened in Lesotho in July 2022 and patients in Lesotho are no longer flown to India for chemotherapy. Patients in remote areas of the Northern cape province of South Africa can now receive chemotherapy and palliative care closer to their homes. There is continuous training, transfer of skills, expertise and mentorship of oncology staff. Conclusion: The ECHO model is useful in democratizing knowledge, transfer skills and expertise to improve care to patients in low resource countries. Citation Format: Daniel Osei-Fofie, Kabelo Mputsoe Cekwane, Mobashshar Hassan, Sophie Victoria Masuabi, Pearl Ntsekhe. Using Innovative Technology and Collaborative Efforts to Reduce Disparities and Inequities in Cancer Care and Improve the Lives of Patients in Low-Middle Income Countries in Sub-Saharan Africa: South African and Lesotho Experience of the ECHO Model [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 92.

171 Background: Serious mental illness (SMI), defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, that substantially interferes with or limits one or more major life activities, includes schizophrenia, bipolar disorder, and major depression. Patients with SMI and cancer have poor survival rates attributed to inequities in cancer care. Such patients are often diagnosed at an advanced stage and are more likely to have their cancer care interrupted. This study surveyed the general practices oncologists apply to integrate mental health and cancer care in their clinical practice. The study also surveyed perspectives on personalized collaborative care intervention to improve cancer outcomes in patients with SMI while identifying the barriers to adapting such intervention in clinical settings. Methods: In February and March 2024, US-based hematologists/oncologists convened at live meetings to discuss abstracts presented at the 2023 ASCO Quality Care Symposium. An online premeeting survey was used to collect participants’ demographics. Participants’ approach to mental health care for patients with cancer were captured via an audience response system during the live meetings. Responses were aggregated and analyzed using descriptive statistics. Results: Among 125 participants, 77% were community providers. The majority of participants (60%) reported frequently discussing mental health with their patients with cancer. Respondents support the mental health needs of their patients with cancer by utilizing in-house social workers (52%) or in-house counseling services (31%), or by referring to in-house clinical psychologist (40%) or an external psychiatrist (41%). They identified challenges to integrating mental health care into cancer treatment: lack of dedicated staff (54%), high patient volume (44%), and lack of available psychosocial tools (40%). Additionally, a subset of participants was asked about their perspectives on collaborative care intervention for cancer care of patients with SMI, and while most participants were encouraged, they also reported that mental health services should be coordinated primarily through either a psychiatrist (25%) or a social worker (25%). Interestingly, limited access to psychiatric care (78%) and lack of resources to screen patients for SMI (56%) were the primary barriers to adapting a personalized and collaborative care approach in the real-world setting. Conclusions: Participants were inclined to incorporate personalized mental health assessments into routine clinical care for their patients with cancer, however they face several barriers to implementation. Further research is needed to address those modifiable barriers and assess the impact of a personalized and collaborative care approach on timely diagnosis and mitigating inequities in cancer care to improve cancer outcomes in patients with SMI.

211 Background: Precision medicine improves cancer outcomes but, due to inequitable receipt among racial and ethnic minoritized populations, has worsened disparities. In response, we used community-based participatory research and developed a multi-level intervention comprised of 2 parts. The first part included community health worker (CHW) –led patient education about precision medicine among predominantly low-income and Latinx adults with cancer in a rural community. CHWs delivered culturally tailored education regarding precision medicine and the importance for cancer treatment and outcomes and encouraged patients to discuss such testing with their clinicians to ensure receipt. A second part included clinician training regarding disparities in precision medicine and updates to testing guidelines. This randomized clinical trial, Addressing Latinx CANcer Care Equity (NCT04843332), tested whether the intervention improves patient knowledge about precision medicine. Methods: Patients with newly diagnosed or recurrent cancer, age ≥ 18 years, able to consent in English or Spanish, and who self-identified as a racial and ethnic minority OR low-income status OR were insured by public or agricultural company insurance OR uninsured and receiving cancer care at Pacific Cancer Care, a rural community oncology practice in Monterey County, were randomized 1:1 to usual care (control group) or usual care augmented with the multi-level intervention for 12 months (intervention group). The primary outcome was whether the multilevel intervention could increase patient knowledge of precision medicine using a validated 6 question survey from time of enrollment (baseline) to 6-months post-enrollment between groups. Patients were followed for 12 months to assess primary and secondary outcomes. Results: 110 participants were randomized; 70% (n= 67) reported Spanish as their primary language; 81% (n=89) identified as Hispanic. Median age was 55 years (55.4 ± 14.3, mean ± SD); majority had annual household incomes (USD) ≤ $34,999 (59.0%, n=46); majority obtained a high school diploma/GED or less (67.3%, n=74). Most had gastrointestinal (35.5%, n=39) and breast (24.5%, n=27) cancers and were diagnosed with stage 3 or 4 (64.5%, n=71) disease. Precision medicine knowledge was low at baseline across both the control and intervention groups (23.5 ± 19.3 versus 23.0 ± 17.7, respectively). Intervention group participants had greater precision medicine knowledge at 6-months (39.2 ± 23.0) than control group participants (24.2 ± 20.0) with greater increase in knowledge overtime than control group participants (p<0.001). Conclusions: Multilevel interventions are needed to address disparities in precision medicine cancer care. This intervention is one multilevel solution to improve precision medicine knowledge among low-income and racial ethnic minorities with cancer. Clinical trial information: NCT04843332 .

Strengthening Cancer Nursing Workforce to Overcome Inequities in Cancer Care for People Living in Remote, Border, and Outer Island Areas of Indonesia.

Health systems are rapidly promoting digital cancer care models to improve cancer care of their populations. However, there is growing evidence that digital cancer care can exacerbate inequities in cancer care for communities experiencing social disadvantage, such as Black communities. Despite the increasing recognition that older Black adults face significant challenges in accessing and using health care services due to multiple socioeconomic and systemic factors, there is still limited evidence regarding how older Black adults' access and use digital cancer care. This study aims to better understand the digital cancer care experience of older Black adults, their caregivers, and health care providers to identify strategies that can better support patient-centered digital cancer care. A total of 6 focus group interviews were conducted with older Black adults living with cancer, caregivers, and health care providers (N=55 participants) across 10 Canadian provinces. Focus group interviews were recorded and transcribed. Through a theory-informed thematic analysis approach, experienced qualitative researchers used the Patient Centered Care model and the synergies of oppression conceptual lens to inductively and deductively code interview transcripts in order to develop key themes that captured the digital cancer care experiences of older Black adults. In total, 5 overarching themes describe the experience of older Black adults, caregivers, and health care providers in accessing and using digital cancer care: (1) barriers to access and participation in digital care services, (2) shifting caregivers' dynamics, (3) autonomy of choice and choosing based on the purpose of care, (4) digital accessibility, and (5) effective digital communication. We identify 8 barriers and 6 facilitators to optimal digital cancer for older Black adults. Barriers include limited digital literacy, linguistic barriers in traditional African or Caribbean languages, and patient concerns of shifting power dynamics when supported by their children for digital cancer care; and facilitators include community-based cancer support groups, caregiver support, and key features of digital technologies. These findings revealed a multifaceted range of barriers and facilitators to digital cancer care for older Black adults. This means that a multipronged approach that simultaneously focuses on addressing barriers and leveraging community strengths can improve access and usage of digital cancer care. A redesign of digital cancer care programs, tailored to the needs of most structurally marginalized groups like older Black adults, can enhance the digital care experience for all population groups. Public policies and organizational practices that address issues like availability of internet in remote areas, resources to support linguistic barriers, or culturally sensitive training are important in responding to the complexity of access to digital l cancer care. These findings have implications for other structurally marginalized and underresourced communities that have suboptimal access and usage of digital care.

Objectives People with significant mental health difficulties (SMHD) experience inequities in cancer care. This study aims to deepen understanding of cancer care for individuals with SMHD. Method We conducted semi-structured interviews with seven individuals with SMHD regarding their experiences accessing and engaging with cancer care from August 2021 to February 2022. Data were analyzed using thematic analysis where both inductive and deductive coding was adopted through the lens of the socio-ecological model (SEM) as a theoretical framework. Results The main themes included intrapersonal, interpersonal and organizational barriers and facilitators to care with a specific focus on modifiable factors related to cancer care delivery. Conclusion This study provides further evidence for promoting collaborative mental health and cancer care delivery to prevent inequalities in cancer care for patients with SMHD. Practice implications Adopting an interdisciplinary, team-based approach to cancer care and help with patient navigation across services are potential factors in improving cancer care for individuals with SMHD.

Barriers to identifying and addressing health-related social needs in cancer care: Patient and patient navigator perspectives

PURPOSE The Northern Cape province is the largest province in South Africa. However, it has the least resources for cancer care. Patients have to travel very long distances to access cancer care. Cancers are diagnosed in late stages due to lack of resources including trained health care personnel. There was the need for an innovative model for training health care personnel, mentorship and empowerment to enable provision of cancer care in the rural areas of the province. METHODS In 2017, the Northern Cape Health Department had a collaboration with the Project ECHO Institute, University of New Mexico. An Immersion training in ECHO was provided in Albuquerque under the sponsorship of Bristol Myers Squibb Foundation and the Project ECHO Institute. An ECHO Hub was established at the tertiary cancer center with spoke sites in two district hospitals. The first cancer ECHO in Africa was launched at Kimberley Hospital in July 2018 to provide training and mentorship in Lung cancer and Mesothelioma care. In 2020, during the COVID-19 pandemic, the ECHO clinics were used on a more regular basis for patients' management. RESULTS Doctors, nurses and community healthcare workers have been trained using the ECHO model to provide cancer care in all the district hospitals. The ECHO clinics have now been expanded to cover other cancers. Palliative care ECHO has also been launched to improve provision of palliative care services. There has been retention of staff in the rural areas to provide cancer care due to mentorship and empowerment using the ECHO model. CONCLUSION ECHO is an effective innovative model to democratize knowledge and help reduce disparities and inequities in cancer care and for cancer control in low-middle income countries. In the era of the COVID-19 pandemic, ECHO clinics can assist with effective patient care.