"This trend held across the country," says Dr. Alimena. "Black women who didn't have brachytherapy had much lower survival rates, but if they did get brachytherapy, their survival was completely equivalent to that of white women. We found that women of
all races were less likely to receive brachytherapy in the southern and western United States, where there are far fewer physicians trained in brachytherapy and a paucity of radiation treatment centers. There is a higher concentration of Black women
who live in the South, so that is likely a factor."
While this research is helpful, Drs. Alimena and King know getting Black patients access to brachytherapy is only one factor in eliminating cervical cancer disparities.
"The human papillomavirus (HPV) causes roughly 90% of cervical cancers," says Dr. King. "While overall incidence of cervical cancer is declining because of HPV vaccination, disparities in screening and vaccinations persist. At Dana-Farber, our general
cervical cancer population is much more disadvantaged than our typical endometrial or prostate cancer population. They come from different parts of the state, and a lot of them have a lot more barriers to care and are getting diagnosed later."
Drs. King and Alimena believe that focusing more on targeted interventions, similar to what is being done in underserved communities adversely affected by the COVID-19 pandemic, could be key to lessening the cervical cancer gap.
"We did a spinoff study looking at age and race, and found that younger Black women under 40 were more likely to present with higher-stage disease and have worse survival outcomes than younger non-Black women," says Dr. Alimena. "It may be insurance barriers
causing this. Younger Black women are more likely to be uninsured or underinsured than older Black women, who at age 65 have access to Medicare." As a result, the younger women are not being diagnosed until they reach late-stage situations.
Dr. Alimena feels partnering oncologists with primary care physicians in the community, who can encourage their patients to follow-up on abnormal Pap smears with colonoscopies, may help. She is part of another proposed study that will test this theory,
utilizing the help of two Dana-Farber patient navigators.
Even in those cases when a cancer is found, treated, and eliminated, Dr. Wright says, health disparities can present new problems. One example she cites is uterine cancer which often presents with vaginal bleeding. Nearly 60% of endometrial cancers are
caused by being overweight or obese. If caught early, it can usually be cured with a hysterectomy. But for the predominantly Black, Latinx, and socioeconomically challenged patients who survive this type of cancer, the same factors that often lead
to it – obesity and a poor diet due to a lack of access to quality foods and physical activity – remain health risks when it is gone.
"Many women with early-stage disease feel they are in the clear after surgery, but they are still in great danger of experiencing diabetes, heart disease, and other obesity-driven cancers," says Dr. Wright. "For obesity-driven tumors, a diagnosis of uterine
cancer is like a heart attack – a wake-up call demanding major lifestyle changes – but many women are not in position to do this on their own."
As with cervical cancer, Dr. Wright believes, the answer lays in community engagement. She and colleagues are working on an initiative through which Black and Latinx uterine cancer survivors trained by Dana-Farber will serve as health coaches to fellow
people of color treated for the disease, helping them adopt a healthy diet and conditioning program.
"This will be a peer-driven program in a supportive environment," says Dr. Wright. "Survivors will be encouraged to make smart choices, get moving physically, and lose weight by people who look like them and know the challenges they have been through."
Saying 'YES' to Improved Care
Younger patients are also the focus of another project that hopes to improve care and lessen disparities. Young, Empowered, and Strong (YES) is an internet-based research
tool that allows patients diagnosed with breast cancer between the ages of 18 to 39 to use an app-like portal on their smartphones to monitor their symptoms and side-effects. Based on their answers to a series of questions, users are linked to provider-approved
supportive care management strategies and interventions they can do themselves.
Designed to save patients unnecessary clinic visits and calls to their clinicians, the YES portal also eliminates the persistent barriers of transportation, work schedules, and childcare conflicts. Those enrollees who cannot afford a smartphone to use
with the program will be given one, and the project will address not only socioeconomic and racial/ethnic disparities, but also gender equity by allowing participants to most accurately identify themselves. Study leaders will closely observe to see
if YES is an effective tool for those who do not identify as cisgender women.
"We have a lot of information on breast cancer disparities by age and race," says Ann Partridge, MD, MPH, co-founder and director of the Young and Strong Program for Young Adults with Breast Cancer at Dana-Farber, who is overseeing the effort. "This unique study aims to understand and improve how we engage and support our young patients coming from all backgrounds, however they identify."
After a successful pilot program, the YES portal is now being rolled out to two groups of young Dana-Farber patients in studies led by Dr. Partridge: newly diagnosed and metastatic breast cancer patients will have access to the portal for five years,
while another group of breast cancer survivors will be using it for one year. The one-year study, a multicenter trial also underway at the Ohio State University and Columbia University, will aim to recruit 25% of patients from diverse racial, ethnic,
and gender backgrounds.
For breast cancer survivor Noel Roma, who serves on an advisory panel that provided input to Dr. Partridge used in the design of the YES portal, this is an excellent example of Dana-Farber and the Susan F. Smith Center going to the source to help eliminate
"During the pandemic, a lot of us got an educated window into how horrible these inequities and disparities are," says Roma. "I've been really impressed with how Dana-Farber is stepping up to address them and the patient's input. The advisory group is
very well-represented with regards to race, ethnicity, gender equity, and sexual orientation, and we all share one thing in common; we were all diagnosed with cancer, and we all want to help other people facing it."
Noel Roma, a breast cancer survivor treated at Dana-Farber, serves on an advisory board offering advice on the design of the Young, Empowered, & Strong (YES) portal.