Lionel A. Kankeu Fonkoua, MD, medical oncologist, Department of Medical Oncology, Mayo Clinic, discusses the importance of addressing barriers to clinical trial access that patients with cancer may face and increasing patient access to routine, primary care.

Disparities in cancer care are multifaceted, as these issues involve several different parameters, Fonkoua begins. For example, social determinants of health, such as health literacy, health behaviors, social support, social needs, and access to health care, often contribute to cancer care disparities, Fonkoua emphasizes. Social determinants of health should always be considered when investigating reasons for barriers in access in cancer care, he says.

Moreover, most patients with cancer who are treated in academic centers have access to more specialized care than those treated in the community, as academic centers house most clinical trials, Fonkoua expands. This unequal access to care is important to consider because patients in minority populations often lack access to academic centers, which may be located far from where they live, Fonkoua notes. These patients may instead livein communities without a clinical trial infrastructure, Fonkoua says.

Overall, these patients do not have access to basic routine care, Fonkou continues, adding that these patients may also not have timely, appropriate cancer screenings. These disparities can also lead to delayed diagnosis in underserved patients, who then can potentially miss opportunities to receive the best treatments, which can include enrolling in clinical trials, he explains. Because of these notable disparities, the oncology community must begin to bridge the divide between routine, primary care, and clinical research, he emphasizes. When patients eventually have adequate access to routine primary care, their opportunities to receive timely cancer diagnoses will increase, Fonkoua notes. Patients with cancer who do not receive proper screening or diagnoses cannot be linked with appropriate care or enroll in potentially beneficial clinical trials, Fonkou concludes.

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Lionel A. Kankeu Fonkoua, MD, discusses the importance of addressing barriers to clinical trial access that patients with cancer may face and increasing patient access to routine, primary care. 


Dr Fonkoua on Addressing Barriers to Cancer Clinical Trial Access

Lionel A. Kankeu Fonkoua, MD, medical oncologist, Department of Medical Oncology, Mayo Clinic, discusses prevalent liver cancer clinical trial enrollment disparities.

Clinical trials intend to develop new treatments without harming patients along the way, making for strict eligibility criteria to minimize the risk for patients who participate in these trials, Fonkoua begins. Unfortunately, these criteria can create bias by representing only the healthiest patients or those who come from certain racial or ethnic backgrounds, he emphasizes. One such example is that Black patients tend to be disproportionately excluded from trials based on standard exclusion criteria. For instance, Black patients tend to have lower creatinine clearance levels than White patients, and established trial enrollment criteria regarding creatinine clearance levels should be adjusted accordingly, Fonkoua explains.

Other factors, including low albumin levels and infectious diseases, are significantly more likely to be found in patients of racial and ethnic minorities. These patients are more likely to be malnourished and have comorbid infectious diseases, he expands. Those factors inequitably exclude patients from clinical trials, Fonkoua says.

In liver cancer clinical trial eligibility criteria, Child-Pugh score has traditionally been used assess liver function, he continues. However, most clinical trials exclude patients who have a Child-Pugh score of B or C, only including the healthiest patients with a Child-Pugh score of A, Fonkoua emphasizes. Most real-world patients with liver cancer do not have a Child-Pugh score of A, and are thus ineligible for many clinical trials, he says. Therefore, the data that these trials generate are not representative of the entire liver cancer population. Instead, oncologists must rely on real-world evidence in addition to objective, high-level clinical trial data, Fonkoua says. Overall, these are some of the eligibility criteria that can limit the participation of patients from underrepresented minority groups and the extrapolation of data from clinical trials to the real world, he concludes.

Lionel A. Kankeu Fonkoua, MD, discusses prevalent liver cancer clinical trial enrollment disparities.


Dr Fonkoua on Clinical Trial Enrollment Disparities in Liver Cancer

Lionel A. Kankeu Fonkoua, MD, medical oncologist, Department of Medical Oncology, Mayo Clinic, discusses how the platinum chemotherapy shortage in the United States may exacerbate disparities in cancer care and the importance of conducting research to investigate the potential implications of this shortage on patients in underserved communities.

the National Comprehensive Cancer Center (NCCN) reported

 that 93% of 27 United States NCCN member institutions were experiencing carboplatin shortages, and 70% of these institutions were experiencing cisplatin shortages. Carboplatin and cisplatin are used in the treatment of an estimated 500,000 newly diagnosed patients with cancer each year, and the NCCN Drugs & Biologics Compendium indicates these 2 agents for the management of multiple tumor types, including breast, lung, gynecologic, and prostate cancers.

This platinum chemotherapy shortage appears to be most prevalent in community oncology settings, however, data are needed to confirm these anecdotal, real-world experiences and indicate the reasons for this disparity between community and academic centers, Fonkoua says. Since academic centers tend to have larger supplies of cisplatin and carboplatin than community centers, many community sites were among the first cancer centers in the United States to run out of these agents, Fonkoua explains, citing conversations he has had with colleagues and patients.

As a consequence of this shortage, several patients from underserved and/or rural communities who were previously treated at community centers have needed to travel longer distances or relocate to be closer to their nearest academic centers, according to Fonkoua. Some patients have even needed to switch oncologists to continue their platinum chemotherapy treatment without interruptions, he adds. Data regarding this issue may be collected and reported in the coming months or years. The information collected could reveal that this shortage has increased existing disparities and negatively affected patients, particularly those in minority populations who already disproportionately experience inequities in access to cancer care, Fonkoua concludes.

Lionel A. Kankeu Fonkoua, MD, discusses how the platinum chemotherapy shortage in the United States may exacerbate disparities in cancer care and the importance of conducting research to investigate the potential implications of this shortage on patients in underserved communities.

Dr Fonkoua on the Effects of the Platinum Chemotherapy Shortage on Disparities in Cancer Care

Lionel A. Kankeu Fonkoua, MD, medical oncologist, Department of Medical Oncology, Mayo Clinic, discusses challenges arising from the ongoing shortage of platinum chemotherapy in the United States and suggests potential alternatives to cisplatin that may benefit patients with cancer during this shortage. 

In June 2023, the National Comprehensive Cancer Center (NCCN) released results from the NCCN Best Practices Committee Carboplatin & Cisplatin Shortage Survey, which was conducted between May 23 and May 31, 2023, and included answers from 27 NCCN member institutions. This survey found that 93% and 70% of participating institutions reported shortages of carboplatin and cisplatin, respectively. Although all the surveyed centers noted that they could still treat patients in need of cisplatin with no delays or claim denials, only 64% were able to continue administering carboplatin to all patients currently receiving that drug. Additionally, 16% of the surveyed centers faced treatment delays from the need to re-obtain prior authorization for treatment plan modifications in response to these shortages. 

Throughout the ongoing platinum chemotherapy shortage, which affects patients with several different cancer types for which platinum-based regimens are standard treatments, centers across the United States have been attempting creative solutions using different platinum agents, Fonkoua says. For instance, many cancer centers experiencing a lack of cisplatin have considered using other platinum agents in greater supply, such as oxaliplatin and carboplatin, Fonkoua explains. Although the efficacy of carboplatin and oxaliplatin has not been tested across tumor types, they may be feasible alternatives to cisplatin for certain patients, Fonkoua emphasizes. 

Although several institutions still have access to oxaliplatin and cisplatin, the national supply of these agents may decrease, following the pattern of cisplatin availability, Fonkoua notes. If the supply of these agents does not increase, cancer centers may completely run out of these therapies and have limited treatment alternatives for patients who rely on platinum-based regimens, Fonkoua concludes.

Lionel A. Kankeu Fonkoua, MD, discusses challenges arising from the ongoing shortage of platinum chemotherapy in the United States and suggests potential alternatives to cisplatin that may benefit patients with cancer during this shortage. 

Dr Fonkoua on Alternatives to Platinum Chemotherapy in Cancer Care

Lionel Kankeu Fonkoua, MD, medical oncologist, clinical fellow in hematology and oncology, Mayo Clinic, discusses key considerations when selecting a treatment regimen for patients with hepatocellular carcinoma (HCC).

Both the phase 3 IMbrave150 (NCT03434379) and HIMILAYA trials (NCT03298451) have introduced reliable and effective first-line treatment options in the disease space, Fonkoua begins.

Data from IMbrave150 showed that atezolizumab (Tecentriq) plus bevacizumab (Avastin) improved overall survival (OS) compared with sorafenib (Nexavar), Fonkoua explains. The combination performed better despite the inclusion of several high-risk patient groups, including those with portal vein thrombosis, Fonkoua notes.

In contrast, patients with portal vein thrombosis were excluded from the HIMILAYA trial, Fonkoua continues. A single dose of tremelimumab followed by a monthly dose of durvalumab (Imfinzi) improved OS in patients with unresectable HCC, Fonkoua adds. Based on these results, atezolizumab plus bevacizumab remains a preferred first-line option for patients without contraindications, Fonkoua concludes. 

Lionel Kankeu Fonkoua, MD, discusses key considerations when selecting a treatment regimen for patients with hepatocellular carcinoma.

Lionel Kankeu Fonkoua, MD

Articles

Dr Fonkoua on Addressing Barriers to Cancer Clinical Trial Access

Dr Fonkoua on Clinical Trial Enrollment Disparities in Liver Cancer

Dr Fonkoua on the Effects of the Platinum Chemotherapy Shortage on Disparities in Cancer Care

Dr Fonkoua on Alternatives to Platinum Chemotherapy in Cancer Care

Dr. Fonkoua on Determining First-Line Treatment Strategies in HCC