By Anna M. Laucis, MD, MPhil

When Watson and Crick were awarded the Nobel Prize in 1962 for their contributions to the discovery of DNA structure,¹ a new era dawned. The world became fascinated by the genetic code and its scientific potential. Many notable scientific achievements were subsequently made possible due to the foundational work of DNA structure discovery.

But I will not be telling that story.

I acknowledge that many tremendous scientific advancements have become attainable due to the fields of genetics, epigenetics, and scientific inquiry of basic science processes in these areas, with the latest successes of CRISPR-Cas9 and genome editing technology as key examples.²

However, a sad and often neglected reality is that zip code, more so than genetic code, is a fundamental factor driving many patient outcomes including mortality.³ Zip codes are merely convenient socioeconomic surrogates for many other social determinants of health that are inherently difficult to measure and change. Social determinants of health are woven into the fabric of our societal structure, stained with the bloodshed of the Civil War and tattered by the history of slavery and overt racism, misogyny, and xenophobia in the United States.

Social determinants are nearly impossible to measure in their entirety because they are also caught in the web of myriad other community resources such as libraries, schools, and support networks, all of which are influenced by the relative affluence and educational levels of the people residing in any given community. These issues are also nearly impossible to change in isolation because addressing the issues of food deserts or safe housing, for example, means also addressing the difficult and multifaceted issues of poverty cycles, homelessness, mental health issues, domestic abuse, and elderly neglect, among many others. This intersectionality between social determinants of health makes them difficult to measure and change, but that should not deter us from trying to do so.

And let’s be honest, these issues are not “sexy.”

Even as a physician, it is humbling and a bit shameful to think that the parts of my job that I admittedly enjoy the least are the social work aspects such as coordinating transportation, calling a patient multiple times because they missed their appointment, or calling the prison or halfway house facility to try to get a patient to their appointment. I fully acknowledge that perhaps due to the infuriating nature of these tasks, they may be the last ones checked off my to-do list at the end of the night. Or more often, they may stay on my to-do list for many days due to limited hours or understaffing of some of these societal and transportation resources.

A classic example is caring for patients at hospitals where social work is under-resourced. In these settings, as a resident physician I have often spent countless hours personally calling the transportation and housing services in the area just to ensure that patients can come in for daily radiation treatments. It may be more palatable and exciting to think of all of the “flashy” technology in radiation oncology, which is what initially attracted me to the field. However, the difficult reality we must all face as oncologists is that if we fail to ensure that patients have reliable housing and transportation then our radiation and other oncology treatments will not happen. Period. It is not only important, but absolutely critical that we address social barriers to accessing health care.

An apt example of this is recent work published by Memorial Sloan Kettering Cancer Center on the profound and devastating impact of omission of radiation in patients with socioeconomic barriers to care.⁴ As highlighted by Dr. Fumiko Chino,⁵ who is a radiation oncologist and vocal patient advocate focused on the financial toxicity of cancer care, this study highlights that patients of minority ethnicities (Black, Hispanic, and Asian) were less likely to receive guideline-indicated adjuvant radiation for early stage endometrial cancer than their white counterparts.⁴ Unfortunately, this led to a highly statistically significant lower overall survival (HR 1.43; p < 0.0001) in minority race/ethnicity populations. While this is clearly appalling, it is imperative to recognize that the driving force of this immense disparity in radiation treatment and ultimately overall survival detriment was not necessarily race in isolation but other interwoven social determinant factors such as median household income level, access to health insurance, and farther distance to treatment facilities.

It is of utmost importance to recognize these other contributing social factors because, unlike our genetic code that cannot be changed, zip codes and other determinants including access to care (by providing better societal investment in health insurance and transportation options, for example) can indeed be changed. These are factors for which there are actionable steps. Meaning that, in the face of such horrifying racial and social inequities, we can and should and MUST actually do something about it!

Moreover, the fact that social determinants of health are difficult to characterize and change should not be a deterrent to trying to address them. We can at least begin by acknowledging that they exist and impact patient mortality more than most incremental scientific advances ever will. [Editor’s note: ASCO offers a free educational video series on social determinants of health.]

As we work diligently to address these issues, we have an opportunity to reflect upon our lived experiences with some of these challenging situations with a goal to advance towards a more equitable future. I have personally witnessed systemic injustices and biases that create destructive cycles that affect vulnerable communities. Through global health work in the low-income countries of Honduras and Guatemala, I witnessed how even the best scientific tools can become defunct if viable sociopolitical stability does not exist. These global health experiences ignited a passion for health disparities research and advocacy. What fuels this passion further now is research on social determinants of health that has shown me that these issues are local as much as they are global. How can we even try to solve global health disparities when we are not even aware of or solving these issues affecting communities in our own backyard? Recent research endeavors I have been humbled and honored to participate in during residency have examined local racial disparities in radiotherapy treatments and toxicities within a statewide quality consortium database of patients with cancer, with mentors including Dr. Shruti Jolly and current ASCO president Dr. Lori J. Pierce.^6,7

I now understand that measuring disparities is only the first step. We can and must advocate publicly to ensure that all patients regardless of their background have access to high-quality, evidence-based health care regardless of their zip code or their genetic code. We can and must do better. Our patients deserve it. Every patient deserves to be cared for equitably, to feel better, and to live a longer and healthier life. We should not only measure disparities but do our best to change them by finding and addressing the actionable social determinants of health. That’s not just our job as physicians; it is our calling and our promise to every patient.

Thankfully, there are tools to help us do this so that we do not have to start from scratch. As an example, an amazing resource is the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index.⁸ By acknowledging that certain populations are more vulnerable due to various social determinants of health, we can begin to start specifically targeting these communities and providing better supportive resources to help out societies in need and our patients.

I encourage everyone to go to the CDC Social Vulnerability Index website⁸ and look up the counties in your own oncology practice area to start learning about the social vulnerabilities and health inequalities in our own backyards. We can start to address these inequities in a more informed and actionable way, together.

Thank you for the opportunity to share my perspective. I would be happy to further discuss on social media (Twitter: @annalaucis) and feel free to contact me at anna.laucis@gmail.com for further discussion.

Dr. Laucis is a chief resident physician in radiation oncology at the University of Michigan Rogel Cancer Center. Follow her on Twitter @annalaucis. Disclosure.

References

1. The Nobel Prize in Physiology or Medicine 1962. Available at: https://www.nobelprize.org/prizes/medicine/1962/summary/. Accessed 4 March 2020.
2. The National Institutes of Health Genetics Home Reference: Your Guide to Understanding Genetic Conditions. What are genome editing and CRISPR-Cas9? U.S. National Library of Medicine. Available at: https://ghr.nlm.nih.gov/primer/genomicresearch/genomeediting. Accessed 4 March 2020.
3. Koenigshausen K. Forget genes: it’s your zip code that influences your health. World Economic Forum. Available at: https://www.weforum.org/agenda/2016/06/transforming-healthcare-for-the-low-income/. Accessed 4 March 2020.
4. Luo LY, Aviki EM, Lee A, et al. Socioeconomic inequality and omission of adjuvant radiation therapy in high-risk, early-stage endometrial cancer. Gynecol Oncol. 2021; DOI: https://doi.org/10.1016/j.ygyno.2021.01.041.
5. Chino F. Twitter post on the MSKCC study by Luo LY et al. Available at: https://twitter.com/fumikochino/status/1363877722657853440. Accessed 20 March 2021.
6. Laucis AM, Hochstedler K, Schipper M, et al. Racial Differences in Toxicity in Non-Small Cell Lung Cancer Patients Treated with Thoracic Radiation. IJROBP. 2020; 108:E148. DOI: https://doi.org/10.1016/j.ijrobp.2020.07.1317.
7. Laucis AM, Jagsi R, Griffith KA, et al. The Role of Facility Variation on Racial Disparities in Use of Hypofractionated Whole Breast Radiotherapy. IJROBP. 2020; 107:949-58. DOI: https://doi.org/10.1016/j.ijrobp.2020.04.035.
8. Centers for Disease Control and Prevention (CDC) Social Vulnerability Index. Available at: https://www.atsdr.cdc.gov/placeandhealth/svi/index.html. Accessed 19 March 2021.