Tell me more about health inequities as they relate to cancer.

[It is] critically important to talk about this. There [are] disparities that exist for racial and ethnic minorities, underserved populations. I work in a rural area, and I know there [are] even in my own backyard and [throughout] Rochester, Minnesota, lots of health disparities, a disproportionate share of the burden of certain types of cancers. When we look at Alaska Natives or Native Americans, they have an 80% higher incidence rate of kidney cancer. The Hispanic population has more than double the mortality rate from liver cancer. Stomach and prostate cancers and multiple myeloma are disproportionately affecting Black people. And they have more than 2-fold higher death rates from these cancers. Asian populations have a higher incidence of infectious disease or infectious agent-related cancers, and individuals living in the areas in which I work in rural areas have a 17% higher death rate from all cancers combined.



And some of these special groups have a higher percentage of late-stage diagnoses. For example, localized stage disease was diagnosed in 58% of Black women versus 69% of White women with breast cancer and 37% of Black women versus 46% of White women with cervical cancer. And some of these groups have higher rates of overall cancer mortality, with 19% higher mortality rates among Black males than among White males. Black women have a 12% higher overall cancer death rate than their White counterparts despite having an 8% lower incidence rate. So there are a lot of health disparities that need to be addressed in the current system.

Perhaps this is a good transition point to switch our focus to Dr Beer. What concerns need to be addressed for cancer screening to bridge gaps related to health equity?

Thank you for that question. There are a number of concerns that are worthy of discussion. First of all, a history of systemic racism as well as structural barriers stand in the way of access and utilization of screening. For example, residents living in more remote areas generally have less access to health care services. And that’s not only on the patient side but also on the provider side. Bureau of Health Workforce and Health Resources and Services Administration reports, for example, [show] that a 61.5% [shortage] of primary medical health professionals affects the rural areas of our country.

There is mistrust of the health care system deeply rooted in our history of racism and discrimination in this country. Cultural beliefs vary across groups, as does the level of knowledge about cancer screenings. There’s also evidence that even when screening has access, there [are] inequities with access to follow-up care. Follow-up exams may be delayed. Screening guidelines may not be followed equally across various groups in our country…. Compared with non-Hispanic White individuals, racial and ethnic minorities are among those diagnosed with unscreened cancers at later stages, at stages where interventions are likely to be less effective.

Racial disparities also caused treatment delays even following diagnosis. [For instance,] Black women with breast cancer experience delays in surgery beyond 90 days almost twice as frequently as White women. Black men 55 years and younger with prostate cancer experienced treatment delays beyond 6 months almost twice as frequently as White men of the same age. An analysis of 330 million unique patient journeys found that among patients with colorectal cancer who underwent chemotherapy or surgery, Black patients waited an average of 8 days longer than White patients for treatment following initial colorectal cancer diagnosis. So there is much opportunity to improve in this area.

Transcript is AI generated and edited for readability.

Videos

Explore critical issues surrounding health disparities in cancer screening, as discussed by experts, and the urgent need to bridge gaps in access, trust, and follow-up care for underserved populations.

Addressing Health Inequities in Cancer Screening: Challenges and Opportunities

 program…. I’m Betsy O’Donnell from the Dana-Farber Cancer Institute [in Boston, Massachusetts]. I’m the director of the Multi-Cancer Early Detection clinic, and I am joined today by a panel of cancer experts. I would like to ask our esteemed colleagues to go ahead and introduce themselves.

I’m Dr Jon Ebbert from Mayo Clinic [in Rochester, Minnesota,] and medical director for the Nicotine Dependence Center.

I’m Dr Tom Beer, adjunct professor of medicine at the OHSU [Oregon Health & Science University] Knight Cancer Institute, and [I am] vice president and chief medical officer for Multi-Cancer, Early Detection, and Exact Sciences.

Hi, I’m Adam Buchanan. I’m chair of the Department of Genomic Health at Geisinger, and I laid out multicancer early detection research…. Today, we’re going to discuss the emerging landscape surrounding broad-based multiyear cancer screening methods for early detection and diagnosis. We’ll discuss the data in the context of guidelines, the treatment landscape, and its impact on clinical practice. Let’s get started. We’re going to start with Dr Ebbert, a question for you. [What is] the current landscape surrounding the burden of cancer?

Thanks for the question, Adam. Cancer is a major public health concern worldwide, and it’s the second leading cause of death in the United States. And it’s on target to be the leading cause of death by 2030.

And where would you say the greatest challenges lie?

I would say there are a couple of challenges. One is that vulnerable, underserved populations experience higher cancer incidence and mortality rates and that our cancer incidence mortality rates are high. We have approximately 1.9 million new cancers diagnosed each year. About 1 in 2 men or 1 in 3 women will develop cancer in their lifetime, and there are more than 600,000 deaths each year.

Thank you. And then if you could pivot to discussing the current landscape surrounding standard-of-care cancer screening….

Cancer screening is foundational in our fight against cancer. Benefits…obviously [include] the detection of cancer in earlier stages when cancer is more treatable and there are fewer [adverse] effects and reduced morbidity and mortality from treatment. The USPSTF [United States Preventive Services Task Force] recommends screening for only 4 cancers: breast, lung, colon, and cervical. However, approximately two-thirds of incident cancers in cancer deaths are from cancers with no recommended screening options.

So that alludes to some of the current challenges for paradigm and standard-of-care screening. What are some other challenges there?

There [are] barriers and those barriers are on the patient side and on the provider side; there [are] emotional barriers on the side of the patients related to…some of the procedures themselves. In 2019, a survey of patients in the safety net primary care sites said that only 46% were up-to-date on colorectal cancer screening. Also, respondents mentioned that 12% of them felt discomfort or even disgust with some of the procedures, most likely [colonoscopy] prep, which many of my patients find very unpleasant.

And nearly one-third of respondents worry about the procedure itself. There’s a lack of awareness regarding cancer risks or screening benefits. Providers either don’t give this information to patients, or patients hear it but they don’t understand it. And they don’t prioritize it because they don’t understand it, they don’t prioritize the screening. And that same survey mentioned above from 2019, 16% of respondents stated screening was a low priority for them…. A lot of my patients are concerned about costs, co-pays, transportation, and time away from work. Colonoscopy itself takes 2 days away, and you need to find a driver to get you there....

On the flip side, what would you say works well about the current paradigm of standard-of-care screening?

What I would say works well with the standard-of-care screening [is] that we are able to detect cancers, and when we can detect some of the cancers, we do intervene early with them. Sometimes when patients present with symptoms, it’s usually more advanced stages of cancer.… I would say that the current recommended standard for screens has shown clinical benefit.

A panel of esteemed cancer experts explore the challenges and opportunities in cancer screening and identification, shedding light on the evolving landscape and its impact on clinical practice.

Cancer Screening and Management: Overview of the Current Landscape 

Betsy O'Donnell, MD, medical oncologist, Multiple Myeloma Disease Center, director of Lifestyle Medicine, Massachusetts General Hospital, discusses the ideal patients for CAR T-cell therapies in multiple myeloma.

Two CAR T-cell therapies are currently approved by the FDA: idecabtagene vicleucel (ide-cel; Abecma) and ciltacabtagene autoleucel (cilta-cel; Carvykti). These treatments can be obtained by patients through referrals to academic centers, O'Donnell says. When considering the ideal patients for these treatments, the FDA label states that patients should have had 4 or more prior lines of therapy to be eligible, O'Donnell says. Based on these guidelines, clinicians should begin considering a referral when a patient begins their third line of therapy, O’Donnell explains. 

Ideal patients should have been exposed to proteasome inhibitors, immunomodulatory drugs, and CD-38 monoclonal antibodies, and patients should be relatively fit, O’Donnell continues. Moreover, patients should have adequate renal function to be considered for CAR T-cell therapy, since they require the administration of cyclophosphamide chemotherapies, O’Donnell says. Because of the time between the collection of T cells from patients and the re-administration, patients need to be able to handle the bridge period prior to treatment, O’Donnell adds.

There is a commitment when undergoing CAR T-cell therapy, so informing patients and making sure they are prepared is a must, O’Donnell concludes.

Betsy O'Donnell, MD, discusses the ideal patients for CAR T-cell therapies in multiple myeloma.


Dr. O’Donnell on the Ideal Patients for CAR T-Cell Therapies

Betsy O'Donnell, MD, medical oncologist, Multiple Myeloma Disease Center, director of Lifestyle Medicine, Massachusetts General Hospital, discusses the promise of novel targets in multiple myeloma.

Significant progress in targeting B-cell maturation antigen (BCMA) has been made in multiple myeloma, O’Donnell says. Moreover, BCMA-directed therapies, such as CAR T-cell therapies, bispecific T-cell engagers (BiTEs), and antibody-drug conjugates, are FDA approved or under investigation in this setting, O’Donnell says.

However, the field is evaluating novel targets beyond BCMA for patients who become refractory to BCMA-directed treatments, O’Donnell says. For example, talquetamab, which targets GPRC5D, and cevostamab (BFCR4350A), which targets FcRH5, are under investigation, concludes O’Donnell.

Betsy O'Donnell, MD, discusses the promise of novel targets in multiple myeloma.  



Dr. O’Donnell on the Promise of Novel Targets in Multiple Myeloma 

Betsy O'Donnell, MD, medical oncologist in the Multiple Myeloma Disease Center and director of Lifestyle Medicine, at Massachusetts General Hospital, discusses ongoing research efforts in multiple myeloma. 

Once therapies are shown to be safe and effective in the relapsed/refractory setting, they are typically evaluated in earlier lines of treatment, explains O’Donnell.

BCMA-targeted treatment and CAR T-cell therapy are two promising modalities in that regard, O’Donnell explains.

Novel combinations such as ixazomib (Ninlaro), lenalidomide (Revlimid), dexamethasone, and daratumumab (Darzalex) in transplant-ineligible multiple myeloma is also exciting as it could offer a mostly oral regimen for older patients, O’Donnell says. 

Other combinations such as carfilzomib (Kyprolis), lenalidomide, dexamethasone, and isatuximab-irfc (Sarclisa) are also under investigation in this space, concludes O’Donnell. 

Betsy O'Donnell, MD, discusses ongoing research efforts in multiple myeloma.  



Dr. O'Donnell Discusses Ongoing Research Efforts in Multiple Myeloma 

Betsy O'Donnell, MD, medical oncologist in the Multiple Myeloma Disease Center and director of Lifestyle Medicine at the Massachusetts General Hospital, discusses transplant considerations in patients with multiple myeloma.

Historically, if a clinical trial is being run, the definition of a transplant-eligible versus -ineligible patient was based on age, usually, the age of 65 years, says O’Donnell. However, it is known that this is not how it plays out in the real world, and patients up to the age of 75 years can undergo transplant safely and receive benefit from the procedure. As such, a gray zone that exists [with regard to age]. In that area, other factors are often considered, such as ability to perform instrumental activities of daily living and comorbidities; these factors will help determine how fit or unfit a patient is and whether or not they would be able to tolerate high-dose chemotherapy with stem cell therapy versus just doing a longer induction phase, concludes O’Donnell.

Betsy O'Donnell, MD, discusses transplant considerations in patients with multiple myeloma.

Dr. O'Donnell on Transplant Considerations in Multiple Myeloma

Betsy O'Donnell, MD, medical oncologist in the Multiple Myeloma Disease Center and director of Lifestyle Medicine at the Massachusetts General Hospital, discusses the utility of up-front triplet regimens in multiple myeloma.

Most elderly patients with multiple myeloma who are transplant ineligible and younger patients who are transplant eligible are treated with a triplet regimen, says O'Donnell. Physicians will typically draw from the proteasome inhibitor class and immunomodulatory drugs with dexamethasone as the standard. The combination of lenalidomide (Revlimid), bortezomib (Velcade), and dexamethasone is a classic up-front regimen that is used in this space. Data with carfilzomib (Kyprolis) plus lenalidomide and dexamethasone in multiple myeloma are also available.

Now, the standard of care is being challenged with the addition of monoclonal antibodies, such as daratumumab (Darzalex) in the up-front setting, adds O'Donnell. Some recent phase 3 data were presented over the past year that are very exciting. As of this moment, triplets typically serve as the standard induction regimen in this space, concludes O'Donnell.

Betsy O'Donnell, MD, discusses the utility of up-front triplet regimens in multiple myeloma.

Dr. O'Donnell on Up-front Triplets in Multiple Myeloma

Betsy O'Donnell, MD, medical oncologist, Multiple Myeloma Disease Center, director, Lifestyle Medicine, Massachusetts General Hospital, discusses unanswered questions in multiple myeloma.

While numerous strides have been made in the management of patients with multiple myeloma, treatment isn’t unlimited, explains O'Donnell. As such, strategically selecting therapies for patients is critical.

Recently, data with novel agents such as daratumumab (Darzalex) have demonstrated unprecedented overall response rates in the upfront treatment of patients with multiple myeloma. The field is moving toward quadruplet regimens with proteasome inhibitors, immunomodulatory drugs, CD38-targeted monoclonal antibodies, and dexamethasone in the first-line setting, says O'Donnell.

However, the data for quadruplet regimens need to mature before they’re used upfront, says O'Donnell. These data will also shed light on optimal sequencing strategies in multiple myeloma, she concludes.

Betsy O’Donnell, MD, discusses unanswered questions in multiple myeloma.

Betsy O'Donnell, MD

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