Examining Interventions to Increase Participation of Hispanic/Latinx Populations to Clinical Trials for Cancers

Rodolfo Gutierrez, MD

The Hispanic and Latinx community have experienced disparities in cancer incidence, care, and survival due to potential biological differences and clear socioeconomic barriers that are hindering access to care, according to Rodolfo Gutierrez, MD. However, efforts being made at an institutional level have helped to overcome some of the challenges faced.

After finding that transportation and financial issues represented 2 of the biggest barriers to clinical trial participation within the local Hispanic community, 1 study performed by investigators at the Wake Forest School of Medicine offered patients transportation assistance (31%), meal vouchers (21%), and parking validation (40%) to create more accessible clinical trials. Within 1 year, participation of these patients on clinical trials increased from 20% to 34%.1

In his own experience at Cedars-Sinai Medical Center, Gutierrez has found that the utilization of promotoras, or lay navigators who are part of the Hispanic community, to be of particular importance in addressing gaps in care. Promotoras are trained by the institution on cancer screening and education so that they can disseminate information throughout the community and help to build trust with the healthcare system.

“A lot of the focus is definitely on the socioeconomic factors that affect health, but there are going to be some biological differences in cancer types based on ethnic background,” Gutierrez explained. “Many tumor genomic studies that are done with biobanking, are unfortunately very skewed toward non-Hispanic White patients. We have to put a focus on that. Some trials and studies are looking specifically at genetic mutations that may affect Latinx women [with regard to] breast cancer.”

In an interview with OncLive^®, Gutierrez, a hematology and oncology specialist with Providence Saint John's Health Center, Cedars-Sinai Medical Center, and The Angeles Clinic, discussed racial disparities in cancer care and interventions to encourage increased participation of the Hispanic and Latinx community on clinical trials.

OncLive^®: What are some of the disparities with regard to cancer care and survival in Hispanic and Latinx populations?

Gutierrez: The Latinx community in the United States is rapidly growing and changing. Certain cancers within the community are more prevalent [or] have worse outcomes…[such as] breast cancer, for example. For a variety of reasons, we are seeing patients being diagnosed with [cervical cancer at] more advanced stages, having worse survival, and higher incidence. Some of this has to do with education, background, and risk of certain infections for [the disease] like the human papillomavirus [HPV], but some of it is just access to care. Cervical cancer is a great example of this. A big reason why a disparity [exists] between Latina and Hispanic women and White non-Hispanic women [has to do with] access to screening. Now that we have a vaccine available for HPV, [it means that] access and utilization of these vaccines are a big part of why we have this discrepancy.

What are some of the discrepancies you have noticed within your own practice?

I'm a medical oncologist here in Los Angeles, CA. I practice at the Angeles Clinic and Research Institute. We conduct many phase 1 trials that are mostly focused on [evaluating] novel immunotherapeutics. My experience at our clinic unfortunately [shows] a lack of participation from the Latinx community in [these] trials. This is 1 of the big issues that I like to [try to] tackle and discuss because if we don't have diverse participation in clinical trials, our results and outcomes are going to be very difficult to be generalizable to the entire population.

Unfortunately, many obstacles [hinder the participation of] individuals in the Latinx community on clinical trials. Some of it, again, [has to do with] accessibility, a lack of insurance, [or not] living within proximity of a university or a cancer center that has clinical trials [available].

Studies have looked at the biases of providers, researchers, clinical research coordinators who unfortunately identified patients of lower socioeconomic status, [such as members of] the Latinx community, as having more difficulties and obstacles to participating on clinical trials; [this] unfortunately [includes being] dismissed or not even being considered for trials that they [might] qualify for. Even before having the opportunity to participate, some of these groups of people are unfortunately put aside. It's a real shame because they can work to enrich or enhance the results of our studies.

How can providers work to close this gap?

At our center, we're trying to find ways to minimize this. I actually came across an abstract looking at ways to improve participation of the Latinx community on clinical trials. [This effort is evaluating] Hispanic clinical trial navigators; essentially, these culturally trained and bilingual individuals [have been enlisted] to assist the population at the university center to engage and participate on clinical trials. They identified some obstacles in recruitment—a lot of it was just access, time, and the money that goes [into] participating on the trials—and [began offering] transportation vouchers, meal vouchers, and parking validation. [These factors] seem simple enough but can be very limiting to patients [in terms of] participation.

They compared the 1 year where they implemented [the use of] these navigators with the subsequent year and they saw an increase in participation of the Latinx community on clinical trials. [Participation] went from 20% to 34%, which is a significant jump [because of a] fairly simple [intervention]. Every cancer institute or every institute that has clinical trials needs to take a deep look into some of the easy changes that can be made to increase participation.

Have any other trials examined barriers to clinical trial participation?

A very interesting study recently looked at the Latinx community in Texas, specifically [in relation to] hematologic malignancies, namely acute lymphoblastic leukemia [ALL], which is more prevalent in the Latinx community. Patients tend to be younger and, unfortunately, don't tend to do as well. This cancer registry study looked at the outcomes of patients within Texas who had hematologic malignancies, namely ALL, and examined the demographics and issues that may have impacted overall outcomes.

One thing I found very interesting was that patients who lived close to the Mexico/Texas border, around El Paso, for example, had worse OS than the rest of the population in Texas. If you really think about that, it's probably because they don't have access to these cancer centers where clinical trials are available or higher-resource medical centers. The mere fact that where someone lives can have an effect on their cancer outcome [is important to be aware of].

What efforts are being made at your institution to overcome some of these challenges?

I'm very fortunate to be working with Cedars-Sinai Medical Center where we're really committed to closing these gaps—not only in the Latinx community, but [in the] Korean American and LGBTQA communities, as well. We've established a variety of different task forces to come up with solutions to these different problems. I, myself, am part of the Hispanic task force, [which is] really aimed [toward] decreasing differences in OS, incidence, and clinical trial participation.

One thing that is really great and has been very helpful to patients is the utilization of promotoras; these are lay people who are very trusted and engaged with the community they live in. We've developed programs where we train them and educate them on the basics of cancer screenings and education, and they serve as point people in their church and their community. [They] provide guidance [to people] on how to [proceed] with screening procedures and [help connect them to] the medical system. That has been 1 really useful [approach] that we have started to use.

I have participated in these training sessions with the promotoras and they had many questions that I was happy to answer. If we can educate them, this [knowledge] will be disseminated into the community in a trustworthy way. There is a lot of distrust in the medical system as a whole in certain groups—definitely in the African American and Latinx communities. Having these point people, mostly women, to serve as a starting off point has been helpful.

Where should future research efforts focus to ensure equal care is achieved?

[Future efforts] really [need to look] at mutations outside of BRCA that are perhaps more prevalent in the Latinx community. Also, a lot of work is being done to identify how gastric cancer, for example, is biologically different in the Hispanic and Latinx community.

There is also some work being done at the University of California Davis Cancer Center to elucidate some of the genetic differences in the tumor biology in these different subgroups. [The cancer space as a whole is] focusing more on precision medicine; by understanding [disease] biology better, our treatment options will grow. Hopefully, as a result, outcomes will also improve.

Reference

1. Strom C, Weaver KE, Ruiz J, et al. Abstract A20: Hispanic patient navigation: an intervention to increase clinical trial participation. Cancer Epidemiol Biomarkers Prev. 2018;27(suppl 7):A20. doi:10.1158/1538-7755.DISP17-A20