Leading Causes: Interrogating the “Why” Behind Health Inequity in Cancer Care

How do social and environmental determinants of health impact outcomes in cancer care? When promoting health equity, how should clinical leaders think about the factors that are beyond the walls of the clinic and the hospital?

In this video discussion, New Century Health Associate CMO Dr. Monica Soni and Radiation Oncologist Dr. Onyinye Balogun answer these questions and more as they peel back the onion on the forces driving health inequities in cancer.




Moni Soni, MD

As Associate Chief Medical Officer, Dr. Monica Soni works to ensure high-quality, cost-effective care for patients and the best possible experience for providers. She is a board-certified, practicing internal medicine physician with over a decade of experience in both inpatient and outpatient safety net care. Immediately prior to joining New Century Health, Dr. Soni served as the director of specialty care for the Los Angeles County Department of Health Services, the second-largest municipal health system in the United States. She is also an assistant clinical professor within the UCLA Department of Medicine.


Onyinye Balogun, MD

Dr. Onyinye Balogun is an Assistant Professor of Radiation Oncology at Weill Cornell Medicine specializing in the treatment of breast and gynecologic malignancies. She is a graduate of Harvard College and Yale University School of Medicine. Dr. Balogun initiated her residency training at the University of Chicago and completed her final year at New York University. Her research aims to address domestic and global disparities in women's health. She serves as a Cancer and Ethnicity Scholar at the New York Genome Center where she oversees the Polyethnic 1000 project, an initiative to diversify populations recruited to genomic studies and uncover the genome's contribution to cancer disparities. 

Through the Polyethnic 1000 project, she is also investigating genomic causes of high-grade endometrial cancers among Black women in the Diaspora. She also has an interest in triple-negative breast cancer and has conducted and published research in novel therapeutics for this disease. Her global health activities focus on improving the delivery of radiation therapy in low and middle-income countries through medical education and capacity building. 



Discussion Transcript:

Dr. Monica Soni: Hi, everyone. Thank you for joining us. Monica Soni here, Associate Chief Medical Officer of New Century Health. And I am so pleased to have a guest with me, Dr. Onyinye Balogun, who is both a friend and a colleague, and really a specialist in the field that we're going to be discussing today. So welcome. Welcome today.

Dr. Onyinye Balogun: Thank you so much for having me, Monica, I appreciate it.

Dr. Monica Soni: So Onyi, let me just share a little bit about your background and then please fill in some of the gaps. So you are a Radiation Oncologist practicing in New York. We actually went to college together at Harvard, and then you trained at Yale. But you had been working deeply in global disparities, women's health, really thinking about how do we do personalized medicine for a diverse group of women. Can you share a little bit about your research? I think that will be helpful to ground us in the conversation we're going to have.

Dr. Onyinye Balogun: Yes. Thank you. So, I have focused on global disparities in women's health for I'd say, over a decade. Lately, the issue that has caught my interest has been uterine cancer. So this is the most common gynecologic malignancy. And what we find is that over the past decade at least, the rates have been rising amongst both Black and white women. But particularly amongst Black women, we're seeing a rapid rise in uterine cancers, particularly the more aggressive subtypes. And we are also seeing continued and worsening disparities in terms of outcomes. So, a Black woman who develops uterine cancer is more likely to die than her Caucasian counterpart. So, given these dynamics, we need to understand why. I think you and I probably sat in a lot of classes and heard professors say, "Well, Black women are more likely to die of this, Black men are more likely to die of this. Hispanic individuals are more likely to die of this."

And there was always this discomfort, this curiosity about why. Frequently we never got the why. It was just stated as, those are the facts. And I think myself and a number of individuals are out here to interrogate the why. So recently, as part of my faculty position at Weill Cornell Medicine, I joined an initiative called the Polyethnic-1000, which looks at genomic studies. Basically, right now, the genomic data that we have, over 75% of that comes from people of European ancestry. And we know that we have a population in this world that's just rich and full of many different sorts of individuals. So we're really doing ourselves a disservice by not tapping into that diversity. And so that's the goal of the Polyethnic-1000 project is to enrich genomic projects with people of diverse backgrounds, including Black, Asian, American, Indian, et cetera. So we're starting with New York because of course it's a melting pot, and we can access all those populations.

And my specific project within this portfolio of seven projects is focused on uterine cancer and looking at, why are Black women more likely to develop more aggressive subtypes? And perhaps it's a genomic reason, but I think there are also other elements at play.

Dr. Monica Soni: I'm so fascinated in this, and I can't wait for the output of it. Can we just unpack even this idea of like, what is it to be a Black woman? And what's the sort of genomic or genetic underpinning of it? I'm not going to call you out. But you and I would both be identified as Black women, and our genetic makeup could be extremely difficult. So my background, I identify as a Black woman in America. My father's side of the family is all from subcontinent India. And my mother's side of the family is from the Caribbean, from Jamaica. And so again, like actually, do you and I have more in common or do we have more different from that perspective?

Dr. Onyinye Balogun: You're hitting the exact points that are important to bring up, because when we say Black, when we say White, what does that mean? And more and more over the past few years, we've realized that race is a social construct. It's arbitrary. It does not necessarily reflect the genomic similarities or differences that people may have. You'll find in a number of studies, including our own that we've done at the Genome Center, when you ask people to self-identify a number of people will put down White, and then you'll find, there's 30% genes that are associated with people of African ancestry. So we like to talk about race, which is a social construct. And then we talk about ancestry, because there are certain genes, certain subtypes of genes that are associated with people of specific ancestry, whether Asian, European, African.

So, the very interesting thing, when you ask this question about you and I are both Black in America, but what does our genome say? It's very pertinent because the African continent is one of the most diverse—it’s the most diverse—the African population is highly diverse and that's why it's really important to study them. So yes, amongst humans, people will make this point a lot. That why are we focusing so much on the genome? 99.9% of our genes are the same, but that 0.1% matters. That 0.1% leads to differences in skin tone. It leads to differences in hair color and other much more impactful things related to health. So we need to better understand it. And we talk more so about ancestry related genes rather than race, because race is arbitrary.

Dr. Monica Soni: Yeah. I love that. That new terminology, ancestry-related genes is so powerful. I also don't want to minimize this idea. Race is a social construct, but has had huge implications from sociopolitical perspective, from a historical perspective. And from a health outcome related perspective. So just help me think a little bit about how do you balance this idea of the history, structural issues, environmental impacts, and then ancestry related differences.

Dr. Onyinye Balogun: Yeah. So there are a number of different things at play when it comes to an individual's health. And I think we've talked a lot about these social determinants of health. People have heard it time and time again, and what that means are factors that can impact how you do health wise. So for instance, your neighborhood. What kind of neighborhood do you live in? Is it a neighborhood that's more highly polluted? Is it a neighborhood where you have access to healthy food? Where you have grocery stores that are nearby? Because people may be living in food deserts, where they may not have access to fresh fruits, vegetables, things that decrease your risk of obesity. And obesity is linked to multiple cancers, including breast and uterine tumors. So these social determinants of health matter, and we know that there are some instances where we can't really say, "It's because of race or rather ancestry that it's not that someone is Black or they're of African ancestry therefore they have worse outcomes."

We've seen a number of studies where when they looked closely and they balanced out factors like, okay, if we make everyone have the same neighborhood deprivation index, are the outcomes the same, or are they different? And a lot of times you'll see that it's more so socioeconomic factors living somewhere where you don't have ready access to healthcare. Living somewhere where there's higher poverty levels, and you may not have insurance. Where you may not be able to afford regular screenings, regular checkups. Where if you do need cancer care, you may not be able to afford it. So you'll come in when it has metastasized and spread throughout your body. So there are a number of instances where we can attribute those differences, not to ancestry, but to socioeconomic differences. But there are a number of studies where there's still inequities.

So I've seen a number of uterine cancer studies where even though they took out differences in insurance, they said, "Okay, let's look at all the women who do have insurance, let's look at all the women who went for regular checkups." Black women still tend to have worse outcomes. And so you have to wonder is it because of this propensity to form the more aggressive uterine tumors? Is that something related to their African ancestry or could it be other things that we're not even really able to measure well, like structural racism? Like going to your doctor and saying, "Hey, I've been bleeding. I'm really concerned." And they tell you it's fibroids, and you go back three times and they tell you it's fibroids until you go somewhere else and they find out that it's a uterine tumor. So these are all the things that we have to tease out. Sometimes the differences are due to socioeconomic factors. Sometimes socioeconomic factors do not completely explain the differences that we see.

Dr. Monica Soni: That's such a helpful example because I think we really struggle in this space. I have been hearing a lot of, well, let's just address the health related social needs. Let's just do transportation or let's just think about food insecurity or childcare is the reason why people aren't getting to the office. And actually maybe the most disheartening part of it is every time you peel back the onion, like the answer was yes, yes, and yes. It is both environmental. It is both historical. It is structural racism. It is access. It is food insecurity. It is also ancestry related genetic factors as well. It is the treatment phase. It is the patient peripheral. It is like all of the things.

And so just moving us to the next part of the conversation I want to ask you when it is so multifactorial and complex, how do we as healthcare leaders, folks in the healthcare industry, on the payer side, on the plan side, as practitioners, how do we start to think about the factors that are beyond just the walls of the clinic or the hospital? Where is our responsibility stop and start? And is it okay to say, "Well, someone else is going to think about the environment. Someone else is going to think about workforce concordance from a race, ethnicity perspective and language perspective. And we're just going to make sure the treatment phase is kind of appropriate."

Dr. Onyinye Balogun: You're hitting on a very sensitive topic that comes up because-

Dr. Monica Soni: That's my specialty.

Dr. Onyinye Balogun: I think we're raising this generation of people in medicine who are aware of social justice. Who don't just want to put on a stethoscope and diagnose. They want to get to the root of what are causing these problems. Go up river. Instead of just seeing people floating down, they want to go up river and address those issues. And I applaud it. And I think it's a personal decision. For me, we're doing these studies to better understand what might be the genomic factors at play when Black women, Hispanic women, women of Asian descent come in with certain cancers or develop certain tumors. And once we discover those things and their interplay with the environment, with social determinants of health, because like you've alluded to, it's not simple. A lot of times you're looking for a simple explanation and there's this beautiful and complex interplay of factors.

And it's up to us to tease those things out. But once, let's say, you've discovered, okay, they have this gene that makes them more susceptible to forming, let's say, uterine cancer, what do you do with that? And for me, it's insufficient to just upload it onto a website, write a paper about it and I'm done. I've done my part. I think you also want to engage other people, multidisciplinary research. Once you found that out, you need to bring in people, social scientists to say, "Okay, here's this interplay that I'm seeing, what can we do? What's exactly happening here." And then you have to bring in policy makers and say, "How can we then create policies regarding screening, public health guidance? When it comes to this, what kind of screening measures should be put into place?

What kind of preventative measures should be put into place? Should it be specific to certain populations? At what ages should it go into play?" So, yes, I'm a physician scientist and I do research, but I think it's important once you have that kind of data that you take it to the next step. It may not just be you. It can't just be you. And I think it's up to all of us to join arms and link efforts to figure out what do we do with this new information that we have.

Dr. Monica Soni: Yeah. I appreciate that so much. I've been in conversations with some really on the health plan side leadership there, and we've been talking about some of the shifting, USPSTF guidelines around lung cancer screening, or colorectal cancer screening. And recently in 2021, the guidelines changed for colorectal cancer screening to lower the age to 45, which was fantastic. Because what we'd sort of seen was the trends had changed. Folks were getting diagnosed earlier in more aggressive disease. But I felt a little bit prickly when I saw those guidelines, because data doesn't just suggest that folks are younger and it's more aggressive. There's certain subgroups that are disproportionately showing up. Black, Hispanic, men in some ways. And so we decided to do a one size fits all when really that's not what was needed. We needed targeted changes to screening based on what appears to be an elevated risk.

We don't know why ancestry-related factors, socioeconomic, a number of reasons why. But how can you then expect what is true limited capacity, right? We're not going to be able to do colorectal cancer screening for all. We don't do it right now for everyone at age 50. In some states, the rates are like 50% of folks who should be getting screened are getting screened. So when that's the reality, and then you say, "Okay, add more people in you're actually going to make things potentially worse rather than better, and that really was starting to kind of get me a little bit agitated.

So even if you have policy folks or guidelines saying one thing, I actually really think that our plan partners and clinical leadership can say something different. They can say, "We're not just going to accept this blindly for our population that we're serving based on the inputs that we have, we're going to recommend a differentiated approach."

Dr. Onyinye Balogun: I think you're talking about prioritizing, right? Prioritizing certain populations, or just making it clear that we acknowledge. We've learned these things in terms of looking at colorectal cancer trends and we're responsive to them rather than just across the board changes. So, I think people are reluctant to do that in medicine because they don't want to paint wide swaths and then have people say, "Well, something detrimental happened, and because they were Black, we did this or because they were Hispanic, we did this." And I understand where they're coming from, but there are ways for us to get across the message. There's language. So we could say, "Colorectal cancer should begin at 45. Consider beginning screening earlier in individuals of X, Y, Z populations, given these trends that we've seen."

But I think we're reluctant to... The phrase that comes to mind is race-based medicine, to practice race-based medicine, but there are detrimental effects of that. It's good to be careful to not say, "Oh, they're Black. So they must have this. Or they must receive this drug." But I think when it comes to things like these policies of screening and saying, "The people who tend to get triple negative breast cancer tend to be younger women who are Black and Hispanic." Perhaps we shouldn't just say let's move from 40 to 50. Perhaps we should put in some language, to highlight the fact that you may consider beginning at 40 in women who are Black and Hispanic, given that they tend to develop triple negative breast cancers at an earlier age. And we may have to do studies in order to really drill down on who would benefit most.

And there's a study that I love called the WISDOM Study that actually incorporates genomic factors, looks at also demographic factors, and is trying to tease out who benefits most from annual mammography and who would benefit most from biannual mammography. And those are the types of studies that we have to fund. Not something that's simplistic, but things that start to look at that complex interplay that you and I talked about. The genome, the environment, what else could be going on here that affects a person's risk of developing cancer or dying from it.

Dr. Monica Soni: Yes, that's right. I've been thinking a lot about what personalized medicine means. And I think it’s that. It's all of the factors, plus someone's preferences, their actual explicitly articulated preferences that should lead to both screening recommendations, treatment planning, end of life care. All of it has to incorporate all of the things and medicine is rarely easy. It is usually hard. And I think that's the direction we need to be moving in. So I want to thank you so much for sharing your incredible knowledge base, your thoughtful approach to what is a complex issue. What can be sometimes a politically fraught topic as well? But we sort of have to just name it and call it what it is and continue to evolve our thinking. So hopefully we'll be able to have you back here. Thank you so much for your expertise and really appreciate your time today.

Dr. Onyinye Balogun: Thank you so much for having me. It was wonderful.

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