Scaling Precision Medicine Expertise for Equitable Cancer Care: Breaking Barriers, Advancing Patient Outcomes

At CPC & CBEx 2023 in Boston, a panel of experts discussed how precision medicine is helping to advance equity in health care. The expert panel consisted of Ivy Altomare, MD, senior medical director for Flatiron Health, Chapel Hill, North Carolina; Debyani Chakravarty, PhD, assistant attending molecular geneticist at Memorial Sloan Kettering Cancer Center, New York; James Hamrick, MD, vice president of clinical oncology at Flatiron Health, Atlanta, Georgia; and John W. Sweetenham, MD, FASCO, adjunct professor of medicine at the Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center, Dallas, Texas, and chair of the NCCN Board of Directors. 

To open the discussion, Dr Altomare recounted a personal story concerning her aunt, who was diagnosed with metastatic cancer. After being given the diagnosis and her treatment options, her aunt initially refused treatment due to the expected outcomes and probable impact to her quality of life. At the urging of her oncologist, however, she agreed to another biopsy for a retest of her tumor to determine whether it had acquired a mutation that would make her eligible for an emerging treatment that showed promise in treating tumors with such mutations. The new testing showed she did have the mutation, and she was eligible for the treatment. At 82 years old, she underwent treatment, and lived another 4 years, long enough to see the birth of three great-grandchildren and the graduation of her granddaughter from nursing school. Dr Altomare shared this story to illustrate “how precision medicine has transformed cancer care and outcomes for patients.” However, Dr Altomare continued, those rapid advancements in precision medicine have also made it exponentially more difficult for clinicians to know what the right treatment is in the face of constantly evolving guidelines and novel therapies. 

Dr Altomare turned to the problem of lack of diversity in clinical trial enrollment, which often results in data that is not representative of real-world populations. She opened the discussion up to the panelists for their thoughts with the question: “Knowing that all of these testing techniques, and therapies, have probably been tested in clinical trials where there has been an under representation of non-White patients, how do we apply that knowledge in clinical practice?” 

Dr Chakravarty explained that the issue of inequitable access to clinical trials and testing is resulting in inequitable access to drugs. According to Dr Chakravarty, “We have to take into account the communities that we’re treating—otherwise we’re just going to exacerbate the disparity.” Dr Hamrick agreed that bias in clinical trials is a serious issue, even when the data is otherwise sound. In an effort to address this disparity, Dr Sweetenham said UT Southwestern Medical Center, located within a majority minority population, is evaluating the use of clinical trial navigators, who are individuals that are tasked to improve access to clinical trials among underserved populations. While issues with cost/affordability and scaling the program to larger patient populations surround this labor-intensive initiative, Dr Sweetenham stated that it’s a step in the right direction.   

The panel then delved into the topic of technological tools to support decision-making and helping clinicians know when to perform genetic testing and when to provide precision medicine therapeutics. Dr Hamrick spoke about the usefulness of decision-support tools (DSTs) for dealing with the complexity of genetic testing and evaluating the results. DSTs help make genetic testing results easily digestible—a crucial point for busy oncologists who often don’t have the time to make sense of complicated genetic testing. “Doctors need something to review that’s binary: give me a positive or a negative,” he said, stressing the importance of “tools that . . . don’t take [doctors] out of their very busy workflow but layer in the crucial information they need to arrive at a decision.” DSTs enable the “democratization of care,” so decisions are not left up to a single individual who perhaps isn’t able to keep up with the constant developments in treatment because they’re busy in the clinic taking care of patients. 

Dr Hamrick also spoke about the importance of these tools to provide options, not directives, for providers: “The local customization piece comes down to the fact that . . . patients are different, and the way that care is delivered within practices and health systems has its own culture and its own nuance.” The ability to customize pathways and treatment guidelines locally gives practices a sense of empowerment and trust in the expertise they have in-house, without slowing down the delivery of care. 

On the topic of barriers to the adoption of clinical DSTs, several points were made. When looking at usage at the physician level, Dr Sweetenham said resistance to uptake of a tool comes down to three key things: First, too many clicks. “I don’t need to go through 20 clicks to let me know that what I originally intended to do is the right thing,” he said. Second, once a physician has decided on a therapeutic regimen, they want the pathway platform to populate the regimen for them to take that step off their plate. Finally, they want to know that insurance is going to cover the treatment for the patient: deciding on a course of treatment doesn’t help if the treatment won’t be covered, and it’s valuable for a physician to know this up front. 

Adoption of new technology also brings concerns at the institutional level, Dr Sweetenham continued. Data must be drawn from multiple sources and shared with multiple institutions to drive decision-making, which brings concerns around data security.  

At a practical level, “rubber meets the road when a busy physician is using the tool,” Dr Hamrick said. “And it is really hard to design a tool that doesn’t slow us down somewhat.” But he believes that physicians will use something if they know that it’s helping their patients. The challenge is getting the frontline doctors to see the validity of the tool. An internal advocate can be a crucial component of putting other doctors at ease and making them comfortable with using the technology. It takes an internal culture change to foster widespread adoption of a new tool. 

Dr Chakravarty agreed about the necessity of a “grassroots” campaign to speed adoption of a new tool. Once other clinicians sign on to the idea, they will see the value. Increasing adoption of technology tools that help more underserved populations get access to early genetic testing and, in turn, access to more clinical trials, is a crucial step in the quest to reduce inequity in health care.