Addressing Disparities in Cancer Care Among Transgender Patients

J Clin Pathways. 2023;9(4):1.

There is no topic today that is being more heavily debated and politicized at all levels of society than the topic of transgender individuals. Both sides of the discussion are extremely passionate about their views, escalating to a level such that the discussions, in my opinion, become inappropriate and nonproductive. One commentary examining the topic suggested that perhaps the greatest benefit can be achieved by simply de-escalating the discussions and attempting to gain a better understanding of the subject. It is very clear that as the US addresses issues of transgender rights and the broader landscape around gender identity continues to shift, the American public holds a complex set of views around these issues. In a survey published in June 2022, roughly 8 in 10 US adults said there is at least some discrimination against transgender people in our society, and a majority (64%) favor laws that would protect transgender individuals from discrimina­tion in jobs, housing, and public spaces such as restaurants and stores. At the same time, 60% say a person’s gender is determined by their sex assigned at birth, up from 56% in 2021 and 54% in 2017, and there is also a fair amount of support for specific proposals that would limit how transgender people can participate in certain activities and navigate their day-to-day lives.

Inequities experienced by transgender individuals have been observed to carry over into the provision of health care services. Transgender and gender-diverse populations face mul­tiple cancer care inequities and disparities across the cancer care journey, such as delayed cancer diagnosis, denial of care, and worse clinical outcomes. In one of our feature articles, Donckels et al examine the potential to update current quality measures to drive care quality improvement for transgender individuals (page 3). Potential changes may include updating quality measures and clinical guidelines to be inclusive of transgender individuals, stratify­ing existing quality measures by gender identity to identify disparities, and developing new quality measures to address the specific care needs and outcome inequities experienced by transgender people.

We are seeing a growing prevalence of performance-based financial models among pay­ers and provider groups. This is due to the high-cost trends associated with oncology care, and, in part, the inability of the payers to solely control cost while maintaining the quality of care. Early payer oncology clinical pathway programs demonstrated that collaboration with providers was key to the success of any program. Our second feature article presents the early results of the Cigna oncology value-based pathways (VP) program implemented in January 2021 (page 8). The program incorporates several value frameworks and consid­ers the perspectives of multiple stakeholders, including patients, providers, and payers. The program spans 51 clinical pathways and encompasses 50% of cancers. Over an 18-month period, the VP program increased the on-pathway regimen rate by 5.2%, leading to a cost savings of $24 million or $0.13 per member per month in a commercial managed popula­tion. Additionally, 28.3% of total cases were moved to on-pathway regimens, regardless of whether there was a peer-to-peer discussion with the provider, indicating the VP program’s durable educational impact.

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