Clinical Perspective #1 from Dr. Editha Krueger: There is a Stark Contrast Between Resource-Rich and Resource-Poor Oncology Practices

Drawing upon two decades of clinical practice within a suburban region of the Midwest, followed by my current practice in an urban setting in a border state, I have observed striking differences in patient demographics and resource availability in our country. In the Midwest suburban context, unemployment rates were low, the Medicaid population constituted approximately 5% of patients, and the uninsured population rate was even lower. Regional cancer centers were well resourced. Each patient engaged with a financial advisor, social worker, and a cancer navigator on the initial consultation and on a regular basis thereafter. Financial concerns were addressed promptly, with uninsured patients receiving assistance in applying for state Medicaid programs or support from local foundations. Housing needs during treatment were infrequent but if identified, were managed swiftly through shelter placements or temporary housing provided by the health system. As a physician in this setting, the primary focus was on delivering optimal treatment to patients, with minimal concern on how clinical outcomes would be affected by SDOH, such as housing, resource availability, food insecurity, or insurance coverage, because these factors either did not exist or were managed effectively.

Conversely, my experience in an urban environment within a border state has highlighted significant disparities in patient care and associated challenges. Many patients in this context are uninsured, underinsured, unhoused, or undocumented. The cancer center, lacking a substantial insured population, operates with limited resources. There is only one social worker available on an as-needed basis, while clinic nurses also assume the role of care navigators, managing this complex responsibility alongside their standard duties. Unlike my previous practice, where Medicaid was perceived as “bare bones,” there is considerable relief among providers when a patient qualifies for or possesses state Medicaid coverage, as this ensures treatment is funded, albeit at very low reimbursement rates. In the absence of state program coverage, funding must be sourced from charitable organizations. The completion of applications for hospital charity programs has become a common practice, often placing the burden on clinic nurses. However, even when charity programs cover treatments, patients frequently struggle to afford over-the-counter medications for managing treatment side effects and lack basic necessities such as food. Many patients experience homelessness or reside in shelters. A substantial portion of the patient population does not speak English, complicating communication regarding treatment plans and potential adverse effects. Even with the assistance of translators, the complexity of the discussions raises concerns about whether the complete message is adequately conveyed.

In this urban practice setting, health care practitioners must consider not only the clinical aspects of treatment tolerance, such as comorbid conditions, but also broader SDOH factors. Treatment decisions are heavily influenced by patients’ stability in housing, access to sufficient food, transportation availability, resources for purchasing medications, and support systems at home for managing their health during illness. These SDOH considerations play a crucial role in shaping treatment recommendations and the overall approach to patient care.

I have come to the conclusion that a multifaceted approach will be needed to address the disparities in oncologic care, necessitating comprehensive changes across several domains, including economic conditions, public policy frameworks, and the dismantling of structural biases that contribute to health inequities. These initiatives, however, will take a considerable amount of time and effort. We have patients with cancer now who are at risk of inferior outcomes. Practical and real-world solutions must be applied soon. At a minimum, enhancing the patient care model requires the integration of an adequate number of social workers, or potentially even trained laypersons, who can engage with each patient at their initial visit and ideally throughout the course of their treatment. This engagement should involve a comprehensive screening for SDOH to identify factors such as financial, housing stability, food security, transportation access, and social support networks. Following this initial assessment, these professionals would play a vital role in assisting patients in navigating the health care system, connecting them with resources and support services that address identified barriers throughout the course of their treatment. Such proactive measures would facilitate timely interventions thereby improving health outcomes.

Clinical Perspective #2 from Dr. Monique Gary: Challenges and Opportunities for Providing Comprehensive Care to Patients Impacted by SDOH

Oncology practice in both rural and urban settings has revealed stark differences in the assessment, resources, treatment, and outcomes among patients with mBC. These differences are largely attributable to structural and SDOH. Many patients residing in resource-constrained communities lack transportation, stable housing, employment, and experience food insecurity. Health literacy and the presence of a caregiver are additional SDOH factors that are critical to treatment adherence and side effect management, which are in turn crucial for effective mBC care. Financial toxicity arising from the cost of medical care not only worsens other SDOH factors but can also influence treatment selection. When cost and other non-medical factors carry more weight in treatment decision-making than clinical factors, outcome disparities are exacerbated. Addressing these inequities is a moral imperative.

Resource constraints are real; community cancer programs may lack the full staffing needed to adequately assess and address complex and multifactorial patient needs. While many programs do discuss these issues and concerns, oncology teams may feel inadequate to take action to address SDOH. As a result, teams may experience feelings of hopelessness about securing the resources necessary to support patients as they navigate the complexities of care beyond the clinic. Fortunately, successful strategies for identifying and leveraging existing resources have been identified. For example, an effective approach to increased navigational and health literacy support has been demonstrated by oncology program partnerships with local and national advocacy organizations. Many advocacy groups now offer navigator training to support patient care and clinical trial enrollment, representing a key opportunity for collaborative support with greater sustainability. In my institution, we have found that a dedicated financial navigator has been immensely helpful in addressing financial toxicity among our patients with cancer. By identifying and securing charity care, reviewing insurance and managed care enrollment strategies, and pursuing grant opportunities, financial navigators can help minimize the undue burden cancer can place on patients and their families.

Programs serving under-resourced communities would, of course, benefit from tangible investments such as additional staffing and direct fiscal support. However worthy, these are long-term goals beyond the control of individual clinics. In the interim, cancer teams must do what they have always done: be resourceful, patient centered, and willing to explore innovative solutions that can lead to institutional and policy change. Once effective strategies have been identified, drafting and disseminating consensus guidelines for securing existing resources will alleviate the need for individual programs to reinvent the wheel. Our institutional experience is that the efforts of the cancer program to address SDOH at such a critical juncture in the health of a patient can serve as a blueprint for the transformational, comprehensive care every patient deserves.