2023 Cancer Trends Highlight Opportunities to Close Gaps in Care in Community Practice

Joseph Mikhael, MD

Specificity remains a top priority as investigators anticipate the trends that will dominate oncology practice in 2023. Innovation in molecular analysis, genomic testing, and screening have aided in the development of novel therapeutics; however, in the community setting, oncologists are facing barriers to fruits of the bench side labor. Therefore, in the coming year a renewed focus on dismantling the barriers and closing gaps in care will aid in the mission to drive down the rate of cancer mortality and incidence across disease states.^1,2

The 2023 cancer statistics report published by the American Cancer Society cited a 33% cancer death rate decline since 1991, with a 1.5% decline between 2019 and 2020. Declines in rate of mortality have been noted in tumor types such as leukemia, melanoma, and renal cancer even as the incidence of cancer in these areas has seen an increase.2

Approximately 2 million new cancers are expected in 2023, with prostate, lung, and colorectal cancer (CRC) as the leading diagnoses in men (combined 48%), and breast, lung, and CRC accounting for 52% of diagnoses in women.2 Prostate (29%) and breast (31%) have the highest anticipated incidence rate among men and women, respectively.²

Gains in survival have been on the rise with the 5-year survival rate for patients with a diagnosis made between 2012 and 2018 reaching 68% compared with 49% for patients who received a diagnosis in the 1970s. A component of these increases is better stratification of patients to therapies targeting driver mutations.

Starts and Stops in Early Detection

The National Opinion Research Center, or NORC, at the University of Chicago in Illinois cites that only 14% of cancers detected through a preventive screening test.3 Using a proprietary algorithm to detect the percent of cancers detected by screening (PCDS), the organization noted that among all cancers, 14.1% of breast, cervical, CRC, and lung cancer diagnoses are made through screening, with 11% of prostate cancers also being diagnosed this way. By cancer type, 61.3%, 51.5%, 45.4%, and 77%, of breast, cervical, CRC, and prostate cancers are detected by screening with mammography, Papanicolaou tests, recommended testing such as colonoscopies, and prostate-specific antigen (PSA) tests being the most notable, respectively.³

In lung cancer, early detection is minimal in this area, with only 3% of diagnoses made through preventative screening.³

Findings from a recent report from the Annals of Internal Medicine has shown that guidelines for cancer screening may not offer a clear identif ication of associated harms related to screening tests. Investigators of the report analyzed guideless from 33 sources including the National Comprehensive Cancer Network guidelines, to identify whether adequate information about screening is offered beyond that benefits of an assay outweigh the harm of a diagnosis. Some of the key harms identified in the report highlighted no standardization of interventions and a lack of available data on repeat assays, overdiagnosis, and possible exposure to unnecessary radiation.³

Experts have concluded in published literature that cancers which are curable in early stages, such as anal, bladder, breast, CRC, renal, lung, melanoma, among others, would benefit from early detection. However, due to the variability of screening across cancer types a consensus on a one-size-identifies-most assay remains elusive and not widely recommended.⁴

For now, advances in individual tumor types should undergo evidence-based review by expert panels for the purpose of a cost-benefit analysis. In CRC, for example, the findings from the recently reported at-home test for disease detection in the phase 3 CRC-PREVENT trial (NCT04739722), may provide opportunities to improve outcomes for a broader panel of patients.⁵ In this study, specifically, the investigators evaluated the efficacy of the RNA biomarker test among 8289 participants from diverse racial, ethnic, and socioeconomic backgrounds. In a comparison with results from a colonoscopy conducted within 120s of the at-home test, the test had a 94% sensitivity for CRC detection, a 45% sensitivity for advanced adenomas, and an 88% specificity for no f indings on a colonoscopy.

Prior to integration, guideline reviewers should be open about what harms and benefits being considered prior to the publication and should be as specific as possible. These justifications will not just better equip clinicians in practice but allow for patients and caregivers to weigh the value behind the recommendation prior to making a decision, especially if it calls for an invasive procedure.⁶

Overcoming Across Barriers

Access to and the availability of these tools at the community level remains a hurdle for the future of this practice as well. For instance, in a report at the 64th American Society of Hematology Annual Meeting and Exposition, less than half (40%) of patients with heavily pretreated relapsed or refractory multiple myeloma designated to undergo chimeric antigen receptor (CAR) T-cell therapy received the treatment within 1 year. The study of patients able to access idecabtagene vicleucel (Abecma; ide-cel) at 2 institutions showed that 1.34% of patients received the therapy at 3 months, with 31.9% of patients dying before they were able to receive the CAR T therapy. Further, 12% of patients were removed from waiting and over one-quarter of patients (27%) were still waiting at 1 year.⁷

Limited production was cited as the main cause of delays in the analysis; however, it is reflective of larger systemic issues. As uptake in academic and institutional settings increases, challenges facing the practitioner in the general setting may include administrative barriers, technological access, delays in reporting, and educational gaps.⁷

In a closer look at hematologic malignancies, Joseph Mikhael, MD, noted that early access and detection are paramount issues for patients with multiple myeloma in ethnic and minority groups. “We can sadly talk all day about disparity, but [to] summarize the top 5 things that come to mind are: No. 1, the time to diagnosis, No. 2, time to therapy, No. 3, access to specialized centers, No. 4, the 4 T—access to triplets, transplants, trials, and CAR-T, and No. 5, physician bias,” said Mikhael, who is a professor in the Applied Cancer Research and Drug Discovery Division at the Translational Genomics Research Institute in Phoenix, Arizona. Mikhael is also the chief medical officer of the International Myeloma Foundation, which is actively trying to reduce the gap in time to diagnosis through awareness campaigns at the both the community and physician level. “[This is a] bi-modal approach, not just doing the deep engagement with both the medical and nonmedical communities, [but also] working with the National Medical Association and Black Nurses Association. We’re going deep into the primary care community to raise awareness [to address questions such as:] How do I know if my patient may have myeloma? How do I distinguish diabetes from myeloma? What testing should I do?”

Sikander Ailawadhi, MD

Sikander Ailawadhi, MD, a professor of medicine in the Division of Hematology/ Oncology at Mayo Clinic in Jacksonville, Florida, noted in the discussion that addressing disparities in multiple myeloma is a multifactorial problem. “We can make the diagnosis, [but] how do we get the right treatment? How do we change the physician bias that the patient may not have money to afford that drug? How do we get the appropriate resources to the patient to overcome their social determinants, their poor social determinants, so that they are able to come in for that injection of bortezomib [Velcade]?” Access is not just based on availability of the agents, but on the surrounding social determinants of health that may affect a patient’s ability to get to the clinic for treatment that requires an in-office visit. “These are challenges of we are facing [and] what a patient facing,” he said.

Patient advocacy and education, an area of focus for cancer care identified by the American Association for Cancer Research, is another avenue Ailawadhi cited for clinicians to develop a knowledge base. “A smaller but significant piece [of the puzzle] is when patients receive a diagnosis, even those who come from larger cancer or academic centers, is that we must teach our patients, the fellows, the residents, the community,” he said. “Frequently, patients don’t have an understanding about their diagnosis. We all love to say, we want the patients empowered. We want the patients to be their own advocate. But if the patient doesn’t know what to ask, they’re not going to be able to do so.”

Bridget A. Oppong, MD

In breast cancer, disparities between outcomes for White women and Black women is an area where improvements have been pacing a relatively slower rate. “We hear a lot about these disparities, and we need to appreciate that the situation is still the same,” Bridget A. Oppong, MD, said in an interview with OncologyLive^®. Oppong is deputy director of the Center for Cancer Health Equity at the Ohio State University Comprehensive Cancer Center (OSUCCC)–James and an associate professor in the Division of Surgical Oncology at The Ohio State University College of Medicine. “Although the overall population is doing better with breast cancer, there is still a 40% mortality difference [between White and Black women]. We have a lot of work to do to ensure that we can provide care in an equitable fashion so that this disparity can be reduced…. Addressing these disparities begins with knowledge and awareness.”

Oppong noted that cultural barriers and stereotypes are barriers facing minority women in screening and that even if early detection is achieved, access remains a concern. “We need to think about things such as Medicaid expansion, where we can increase the number of [individuals] who may be underinsured to get that screening. Additionally, we need to ensure that we continue funding things such as breast and cervical cancer programs to encourage screening.”

Education about delays in treatment is another area that Ailawadhi noted will be of importance. “Although I cannot change a patient’s insurance or the access to a drug, [one thing] I can do is make sure a physician is aware that if they don’t treat the patient [in a] timely [fashion], the patient is going to have more morbidity,” he said. This also comes with advocating for a patient to have consults or access to academic centers whenever possible. “Patients need to stay and get treated where they are. They have their infrastructure, their social support system, their caregiver, their circle of care. But if they get a consult [at an institution], they’re going to be more empowered. They’re going to get more knowledgeable. They need to know about [available] drugs.”

Bridging the Gap to Novel Therapeutics

Genomic analysis has come into the spotlight as targeted therapies have become more readily available for patients. In a retrospective analysis of solid and liquid biopsy samples submitted for broad-panel genomic analysis to Foundation Medicine, the predominant ancestry of patients was European (75.6%), reflecting underserved racial and ethnic groups in the testing pool. The analysis, which collected data from 2013 to 2022, noted that in the first 12 months of the study 11,827 samples were submitted for nextgeneration testing (NGS) compared with 96,360 submitted in the last year. In the 9-year period, the number of African ancestries increased by nearly 0.5 percentage points annually, ending at 12.4% of persons who underwent genomic testing by 2022.¹⁰

Awareness and accessibility of clinical trials has been a slow pathway to establish between community and institutional research. With recent studies citing enrollment rates of approximately 4% for patients treated in community sites, a physician-reported analysis of barriers to enrollment have highlighted the complexity of facilitating patient enrollment from multiple levels.^8,9

Oppong said that she actively works to normalize research and scientific investigation for her patients and the among the Black community.

“The only way to answer questions [about genetic differences in breast cancer] is through research. The only way to know if Black women’s cancers are genetically somehow different from those of White women is through research. We have work to do in increasing enrollment when it comes to minorities, especially African Americans.”