Cancer Prevention Month 2021

February 15, 2021

Information

February 14, 2021

Yale Cancer Center

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email: canceranswers@yale.edu

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00:00Support for Yale Cancer Answers
00:02comes from AstraZeneca, dedicated
00:05to advancing options and providing
00:07hope for people living with cancer.
00:10More information at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers with
00:16your host doctor Anees Chagpar.
00:18Yale Cancer Answers features the
00:20latest information on cancer care by
00:23welcoming oncologists and specialists
00:24who are on the forefront of the
00:26battle to fight cancer. This week,
00:28it's a conversation about outcomes research
00:30in kidney cancer with Doctor Michaela Dinan.
00:32Doctor Dinan is an
00:34associate professor in chronic disease
00:36Epidemiology at the Yale School of
00:38Public Health and Doctor Chagpar
00:40is a professor of surgical oncology
00:43at the Yale School of Medicine.
00:46Michaela, maybe we can start
00:48off by you telling us a little
00:50bit more about yourself and
00:52what exactly you do.
00:53I call myself a cancer outcomes or
00:55health services researcher so people
00:57aren't always familiar with cancer
00:59outcomes or health services research.
01:01They tend to be more familiar with
01:03basic or clinical Cancer Research.
01:05Basic Cancer Research relates to
01:07studies done in a lab with cancer cells,
01:10either in a Petri dish or in animals
01:12where researchers can directly manipulate
01:14and study cancer cells to learn
01:16more about basic biology of cancer.
01:19And then, clinical Cancer Research refers
01:21to when advances in basic science are
01:24being translated into actual medical
01:25tests or treatments and are then
01:28tested in humans to see if they work.
01:30My focus of research health services
01:32is the part that comes
01:35after this, after a new medical
01:37treatment or diagnostic tool is
01:38found to work in clinical trials,
01:41I study how it actually gets
01:43used in the real world.
01:44You have to remember that only around 3% of
01:48patients are treated on a clinical trial.
01:50And other people who take part
01:52in clinical trials are not like
01:54the general cancer population.
01:56In order to be enrolled in a clinical trial,
01:58you have to be healthy enough to
02:01qualify for participation and every
02:02clinical trial has a set of very strict
02:04inclusion and exclusion criteria.
02:06And if you don't meet every single one,
02:09you can't participate as you can imagine,
02:11the vast majority of patients who receive
02:13treatment are not part of a clinical trial,
02:16so trial participants don't look
02:18like everyone else who gets treatment
02:20for their cancer in the real world.
02:22Many people that are not included
02:24in trials are often older adults.
02:26People who have other medical
02:28conditions or people who don't live
02:31near an academic Medical Center or
02:33who can't make all the extra visits
02:35that are often required,
02:37or people that don't otherwise want to
02:39participate in trials for some reason.
02:41Health Services Research,
02:42which is what I do,
02:44looks at how cancer treatments
02:46happen quote in the real world.
02:48So for example,
02:49we get to ask questions like how is
02:52cancer treated within the entire
02:54country as opposed to just one center?
02:56Who has access to new treatments?
03:01What are the outcomes associated
03:03with these new treatments?
03:04How much does it cost to
03:06get these treatments?
03:07And are there racial or economic or
03:09other disparities in access to cancer care?
03:17Wow, I mean that sounds so relevant
03:19because when you think
03:22about the subpopulation, as you say,
03:24who get treated on clinical trials
03:27being so small and yet the outcomes
03:29of those clinical trials are
03:32applied to the entire population,
03:34it seems to be particularly important
03:36to see what happens out there in
03:39the real world on patients who
03:42may not have looked exactly like
03:44the people who were in the trials.
03:48Yes, that's exactly right.
03:49And the other point about clinical
03:51trials is that they tend to be
03:53highly controlled settings, right?
03:54So patients who are participating
03:56in a clinical trial not only have
03:58they gone through the litany
03:59of inclusion exclusion criteria
04:00that I've already mentioned,
04:02just to be enrolled,
04:03but once they are enrolled they are very
04:05closely monitored and followed in
04:07terms of their treatment and their
04:09outcomes that someone is
04:11keeping a very watchful eye on them.
04:13This is very different from a patient
04:15in the real world who's kind of
04:17coming into and going out of the
04:19healthcare system on a regular
04:21basis and may not be being followed
04:22as closely.
04:25So tell us a little bit more about
04:27your more recent research and what
04:29you've been doing in this realm.
04:32Sure, right now
04:35I currently have a study funded by
04:37the National Cancer Institute to look
04:40at oral Anti cancer agent utilization
04:42in patients with kidney cancer.
04:45So kidney cancer, like most cancers,
04:48can either be early stage or
04:50more advanced stage.
04:52Stage refers to how far a cancer has
04:56spread throughout a person's body.
04:58So for kidney cancer, early stage
05:00disease is confined to the kidney.
05:03Whereas for advanced or metastatic disease,
05:05the disease has learned to travel
05:07through the bloodstream and has
05:09spread to other parts of the body,
05:11such as the lungs, bones or brain.
05:15So early stage disease is typically treated
05:18with a surgery or if it's small enough,
05:23or in an elderly or unhealthy person,
05:24it is sometimes just observed.
05:26Advanced kidney cancer for most
05:29patients is not curable.
05:31However,
05:31the treatments for advanced kidney cancer
05:34have improved dramatically in recent years.
05:36One of the biggest changes has
05:38been the development of these oral
05:40cancer treatments or pills that
05:42target kidney cancer to help shrink
05:44or delay its growth.
05:46These oral cancer treatments have been
05:49allowing people to live years longer,
05:51even for people who have what
05:54traditionally would have been
05:55considered incurable kidney cancer.
05:58However,
05:58these oral treatments are relatively
06:00new to kidney cancer.
06:02The first oral agents for kidney
06:05cancer became available or were
06:07approved by the FDA in 2005 and 2006,
06:10but with many similar treatments
06:12having been discovered since then.
06:15In fact now
06:17the 10 first new drugs approved
06:19for kidney cancer in recent years,
06:217 out of 10 were oral agents.
06:25The interesting thing about oral
06:27anti cancer agents is that they
06:29represent a shift from how cancer
06:31treatment used to be delivered.
06:33So as most folks know, cancer treatment
06:36used to be almost always intravenous
06:39or given by injection at the hospital.
06:43So you know it required patients to
06:45come to a cancer hospital or clinic
06:47in order to receive treatment.
06:49However,
06:49oral agents are picked up by the
06:52patient from the pharmacy and taken home,
06:54and unlike intravenous treatments,
06:55these oral agents are not taken
06:58in front of a medical staff.
06:59Instead,
07:00they are taken at home by the patients
07:02when patients come to a cancer clinic
07:04and receive an intravenous chemotherapy,
07:06obviously, the doctors know that
07:08they're getting the treatment there.
07:10The same is not necessarily
07:11true for oral agents,
07:13however.
07:13Patients can forget to take
07:15their medications.
07:16They can forget or delay
07:17refilling their prescriptions.
07:18They may not follow the
07:20instructions as to when and how
07:22to take their medications exactly,
07:24or they may choose to stop taking
07:26their medication altogether,
07:27particularly if they are concerned that
07:29they might be having side effects from it,
07:31or if the cost of filling the
07:34prescription is too high.
07:35So my current research has been
07:37looking at the use of these oral anti
07:40cancer agents and kidney cancer.
07:41I'm looking at things like
07:43who are receiving them.
07:45Are there any racial or economic
07:46disparities in access to these drugs?
07:48Are patients doing as well as they did in
07:51clinical trials when taking these drugs?
07:53Because like we were just talking about,
07:55when a patient when these drugs were
07:57being first studied in a clinical trial,
07:59they were being studied in a
08:01highly controlled setting,
08:02whereas now in the real world,
08:04patients are on their own,
08:06taking them at home,
08:07and then finally,
08:09I'm interested in questions
08:10like can patients
08:12afford to continue taking these
08:13drugs based on the cost?
08:15Those all sound like really
08:17interesting questions.
08:18What have you found?
08:22What's interesting is that we have
08:25found that by 2015 a little over 1/3
08:28of patients with kidney cancer with
08:30renal cell carcinoma specifically,
08:32which is a subset of kidney cancer,
08:35were receiving an oral anti cancer
08:38agent for their advanced kidney cancer.
08:41We know that previous studies have
08:44shown that black patients have
08:46had about a 10% worse mortality
08:48associated with kidney cancer,
08:50and we know that this
08:52difference is not improved with
08:54the introduction of these
08:55oral anti cancer agents.
08:57We wanted to see if access to these drugs
09:00was a potential driver of these disparities.
09:03Surprisingly,
09:03when we looked we didn't see any difference
09:06in access to these drugs by race,
09:09ethnicity or any other indicators
09:11of socioeconomic status.
09:12However,
09:12we did see decreased use in these
09:15oral agents in patients who were
09:17unmarried, patients who were living
09:19in the South, and patients who
09:22were in older age groups and in
09:24this specific patient population
09:26that means patients who
09:29were in the age group 80 plus.
09:32We were surprised to see that
09:34access to these drugs was not
09:36different by race or ethnicity,
09:38so we next wanted to see if something
09:40else could be driving disparities in
09:42kidney cancer outcomes that we know exist.
09:45So we looked at adherence to these
09:47medications and what we observed
09:49was that about half of the patients
09:51we studied were adhering to the
09:53medication during the first
09:55three months of their treatment.
09:57So we were interested in the patients
09:58who live in areas with
10:00high levels of poverty were much less
10:02likely to take their medication almost
10:04half as likely as those who did not
10:07live in high poverty neighborhoods.
10:09Also,
10:09we found that patients that had to pay more
10:12than $200 a month for their medications
10:15they were about 30% less likely
10:17to be adherent as compared to
10:18patients paying less than $200
10:20a month for their medication.
10:22So when we take a step back from all this,
10:26what we think we're seeing is
10:28that although poor patients are
10:30able to start these drugs because
10:32we're not seeing any difference
10:34in their initiation,
10:35they may not be able to continue to
10:38take them or to continue to take them
10:41as often as they are prescribed,
10:44because we're seeing decreases in
10:46the adherence to these drugs and
10:49that could be affecting the
10:51differential outcomes that
10:53we know exist in patients with kidney cancer.
10:55So when you control
10:58for socioeconomic status and
11:01you look at the impact on race
11:04did you find that that was a
11:07driver that
11:10mediated the relationship
11:11between race and outcomes?
11:15I think that
11:21is a good interpretation of
11:22what we're seeing, right?
11:23So I think what you're asking is,
11:26when you look at everything
11:28in the same model,
11:30we're seeing that yes,
11:32poverty is driving this measure
11:34of adherence, but we're not
11:36seeing an association with race,
11:38but I think what you're
11:40getting at, which is correct,
11:42is that the kind of
11:44interaction between race and poverty,
11:46those are two very closely
11:49related.
11:53So yes, seeing an association
11:55in one might be attenuating
11:57the association in the other.
12:00Did you look at that?
12:03The reason I ask is
12:07because we've seen a similar thing
12:10across a number of disease sites.
12:12I did a study just recently
12:15looking at breast cancer survivors
12:17and their use of endocrine therapy,
12:21which is also an oral agent that
12:24women take for at least five years
12:27and very similar to your findings,
12:30did not find that there was
12:33necessarily a difference by race,
12:35which we had thought might have been
12:37a factor when looking at whether
12:40people took these medications,
12:42but we we were looking at the question
12:45of did you not take this medication
12:48as prescribed due to cost and we
12:51thought there may be a
12:54racial disparity in terms of that.
12:56But when we looked at it,
12:58we didn't find a racial disparity
13:01but really found a
13:02difference very much as you say
13:05in terms of poverty and in terms of
13:08whether or not people had insurance.
13:11I'm wondering if
13:14you controlled for poverty
13:17and whether we still see a
13:19difference in outcomes between black
13:21patients and Caucasian patients.
13:23So in our city we did not
13:26see a difference by race,
13:28but we did see a difference by poverty.
13:31So by both indicators of poverty and
13:34race were in the model and the
13:38association by race, as you said,
13:41for your city was not significant where it
13:44was for the indicators of poverty level.
13:48Does that make sense?
13:49So even though they were
13:50both in the model race,
13:51we did not find an association with race,
13:54but we did with poverty,
13:55and I guess the point that I was
13:57trying to make earlier is that
13:59we know you that
14:01unfortunately, in this country,
14:04poverty differentially impacts folks
14:12by race and ethnicity.
14:14This is such an
14:16interesting conversation,
14:17but we need to take a short
14:19break for a medical minute.
14:21Please stay tuned to learn more
14:24about cancer prevention with
14:25my guest Doctor Michaela Dinan.
14:27Support for Yale Cancer Answers
14:29comes from AstraZeneca, working
14:31to eliminate cancer as a cause of death.
14:34Learn more at astrazeneca-us.com.
14:38This is a medical minute
14:40about colorectal cancer.
14:41When detected early,
14:42colorectal cancer is easily treated
14:45on highly curable and as a result
14:47it's recommended that men and women
14:50over the age of 50 have regular
14:52colonoscopies to screen for the disease.
14:55Tumor gene analysis has helped
14:57improve management of colorectal
14:58cancer by identifying the patients
15:01most likely to benefit from
15:03chemotherapy and newer targeted agents,
15:05resulting in more patient
15:07specific treatments.
15:08More information is available
15:10at yalecancercenter.org.
15:11You're listening to Connecticut Public Radio.
15:15Welcome
15:15back to Yale Cancer Answers.
15:18This is doctor Anees Chagpar and
15:20I'm joined tonight by my guest Doctor
15:23Michaela Dinan and we're talking
15:25about cancer prevention and more,
15:28specifically, right before the break
15:31Michaela you were telling
15:32us about your research
15:34looking at disparities that we
15:36see in outcomes between African
15:38American patients and Caucasian
15:40patients with regards to kidney
15:43cancer and renal cell cancer.
15:45In particular,
15:46you were looking specifically
15:49then at oral agents and found that really
15:53race was not a driver of adherence,
15:56but really poverty was, so a
15:59couple of questions.
16:00Has anybody gone back and looked at the
16:04correlation between race and outcomes?
16:07That kind of drove your research to
16:11begin with and took a step back and said
16:15uncoupling that from poverty is
16:18it really poverty
16:19that is the driver of those outcomes,
16:23or is it really race and the poverty
16:27by association with nonadherence
16:29is a separate issue?
16:33Yeah, so the overall question of
16:36why is there differential outcomes for
16:39patients of black race with kidney cancer?
16:42That's a bigger question and the studies
16:45that have looked at that question
16:47some of them have certainly
16:50included measures of poverty in them and
16:53have still found a significant association
16:55between race and outcomes as well.
16:57You're right and
16:59our study was specifically a
17:03subset of that question.
17:05Because we were specifically
17:07interested in
17:09how are oral anti cancer agents either
17:12contributing or not contributing to this
17:15kind of pre observed disparity that
17:18we've seen in kidney cancer patients?
17:21So because oral anti cancer agents
17:24were a relatively knew technology
17:27in the kidney cancer space,
17:29we wanted to see whether or not
17:33they were contributing
17:35to an attenuation of
17:37this disparity in outcomes,
17:39or whether it was contributing
17:41to a potential widening of
17:44these disparities in outcomes.
17:46Because
17:47previous research of both mine
17:50and other folks looking at the
17:53emergence of medical technologies
17:55and cancers has shown that
17:57sometimes it can go either way.
18:00It can either help mitigate disparities
18:03or sometimes it can help widen disparities
18:06if there's
18:07an additional element of decreased
18:09access for certain populations.
18:12The other question that
18:14I had was when we were talking earlier
18:17before the break about the whole
18:20concept of health services research,
18:22one of the really important points you
18:25made is that health services
18:28research really looks at real world
18:30outcomes as opposed to trials.
18:33And clinical trials sadly do not necessarily
18:38include the population at large,
18:41and so when we think about clinical trials,
18:46particularly with oral agents
18:48for kidney cancer,
18:50did those include African American patients,
18:54and were the outcomes in those
18:58African American patients equivalent
19:01to Caucasian patients?
19:04I mean, could that partly explain
19:07some of these disparities as well?
19:09That's a great question,
19:12and again, it points to a broader
19:15issue where clinical trials in
19:18general struggle to be representative
19:21of the general population,
19:24and there are certainly efforts
19:26to make those clinical trials more
19:29representative of the general population.
19:31But that's something that continues to be
19:38addressed and certainly race is 1
19:41area where there have been efforts
19:43to make them more representative.
19:46I think 1 area where trials continue to
19:48struggle with their representativeness
19:50is with older populations,
19:53and I think that's something that's
19:55particularly relevant to cancer
19:57patients because a lot of cancers tend
20:00to have median age of diagnosis
20:03for the 65 plus patient population,
20:06and yet those people tend to be very
20:10under represented in trials.
20:13For instance,
20:14I think one great example of this is
20:19with an you emerging medical
20:21technology which is relevant to
20:24kidney cancer but also other
20:27cancers are immunotherapies
20:29or immune checkpoint inhibitors.
20:31And again,
20:32older folks in those clinical
20:34trials are under represented and
20:37yet there's this kind of assumption
20:40that these immune checkpoint inhibitors
20:43are going to be less toxic than
20:45the standard or previously
20:49used cytotoxic chemotherapies.
20:51And so you know,
20:52a lot of physicians have been operating
20:55under the assumption that the toxicity
20:59profiles of these immune oncology
21:02agents is less than traditional
21:04therapies and so have been more
21:07willing to give these therapies
21:09to older patients and yet it's
21:11not really based on clinical trial
21:14data because that clinical trial
21:16data doesn't readily exist,
21:18and so one of the things I'm interested
21:20in potentially looking at in the
21:24future is real world utilization of
21:26these drugs in patients who were again
21:29not going to be represented and in
21:32standard trials and whose outcomes,
21:34whose toxicity profiles may look very
21:37different than what is typically
21:39seen in a trial.
21:41I think that
21:43it's so important,
21:45especially when we think about the
21:47fact that these drugs may affect
21:50different people differently, right?
21:52I mean, I think we've seen this even
21:55in the cardiology world back in the
21:58day when only men were included in
22:01some of the the heart attack trials
22:04and we realized that women's
22:07heart attacks present differently
22:09than men's heart attacks and
22:11drugs may affect different
22:13genders differently,
22:14and similarly we may find that
22:16there are differences based
22:18on race and other things,
22:20and so trying to tease out what really
22:24is at the root of these disparities,
22:28it really does require some as you call
22:31it real world kind of investigation.
22:35Yes, and this is all
22:39so relevant right now in the times
22:43of COVID-19 where we have this very big need
22:49to get vaccines approved and treatments
22:52approved as quickly as possible.
22:54But again, we already know that COVID-19
22:58is affecting
23:02minority racial and ethnic patients
23:04differently than it is white patients.
23:08We know that there's differential
23:11outcomes.
23:15we know that there are differential outcomes.
23:28Covid is affecting
23:31minority patients much more severely
23:34than it is Caucasian patients.
23:36What I think is really important,
23:39thinking about COVID-19 is that
23:41you know the clinical trials
23:44that were done really did have a
23:47reasonably robust representation of
23:49minority patients
23:52and so it's led us to believe
23:55that the vaccines should work equally
23:58efficaciously for minority patients.
24:01For African American patients,
24:03as it should for Caucasian patients.
24:06But bringing it back to kind
24:09of health services
24:11research and real world science is
24:14this vaccine hesitancy
24:17and the fact that we're seeing,
24:20at least by anecdote, that
24:23there may be more reluctance
24:25to really embrace the vaccine
24:28amongst African Americans,
24:30who sadly are the most affected and who
24:35probably could use the vaccine the most.
24:41So how do you
24:42address that in terms
24:46of trying to understand
24:50data from clinical trials
24:52are applied in the real
24:54world?
24:56Yeah, it's an interesting
24:57conundrum.
24:59I think that in terms of people's
25:03willingness to take a vaccine,
25:05their willingness to kind of accept data
25:08from clinical trials as relevant to them
25:11I think that that largely depends on the
25:14messaging and inconsistent messaging.
25:17I think that part of the problem is that
25:21some of these issues
25:24are incredibly entrenched and
25:26systemic issues that are longstanding
25:29for some of these populations, right?
25:31And so
25:34they're not specific to necessarily
25:36one vaccine or one trial,
25:37but generations of a health care
25:40system that hasn't necessarily always acted
25:43in their best interest, right?
25:46So I think just going forward
25:49a consistent message of
25:51representation for everyone
25:53concerned for everyone,
25:54I think is going to be really important
25:57and I think that that's true of Covid.
26:01I think that's true of cancer,
26:04because one of the issues that we're
26:06talking about today is cancer
26:08prevention and some of the most important
26:11factors for cancer prevention are things
26:14that have been long known as perhaps
26:17one area where there's not been a
26:19ton of really large steps and advances, but
26:24things like not smoking things like
26:28maintaining a healthy weight,
26:29eating a healthy diet
26:31these are kind of the standards of
26:34cancer prevention across the board,
26:36and again, it's certain
26:38messaging to different
26:40populations to make sure that
26:42they are receiving the message.
26:44Make sure that they understand
26:46how important it is.
26:48It is something that needs to be considered.
26:53I think your point about
26:56systemic racism and the
26:58absolutely important tragedies that
27:00have happened in the US health
27:03care system over centuries really,
27:05that has propagated the lack
27:08of trust for minority populations
27:10in clinical trials is going to
27:13be a hard mountain to climb,
27:16but I think it is so important,
27:19particularly when we think about not
27:22only therapeutics and but as you say,
27:25about prevention.
27:26Whether we're talking about Covid
27:28or whether we're talking about
27:31cancer and so really thinking about all
27:34of the ways that we can prevent cancer,
27:38February being Cancer Prevention Month,
27:40have we seen any impact in terms
27:43of really driving forward
27:45some of those behaviors?
27:47Some of those primary prevention
27:50techniques that all of us know about
27:53in terms of cancer prevention.
27:56Are we making a dent?
27:59I think so.
28:03There's a long way
28:05to go and I think there's a lot more
28:08to be done in those
28:10primary areas that you mentioned.
28:12But for a lot of cancers we do see
28:15that the incidence of cancer is going down,
28:17not for all of them, but
28:20for some of them. Smoking
28:21related cancers to some extent
28:23it kind of fluctuates a little bit,
28:26but for sure we're seeing
28:27some improvements there.
28:31One of the easiest things to do
28:32for younger boys and girls is
28:34to make sure that they received
28:36their HPV vaccinations in
28:38the terms of cancer prevention,
28:40and certainly since
28:42the HPV vaccination has come on the scene,
28:45we've certainly seen decreases
28:46in HPV related cancers associated
28:48with utilization of that vaccine.
28:51And then the other area is that
28:53we're seeing this kind of
28:56increase in the number of cancer survivors,
28:59so even folks who are unfortunate to
29:02receive a diagnosis, cancer survival
29:04for many cancers is going up as well,
29:07and I think some of that you
29:09know a lot of that,
29:11is attributable to these advances
29:14in diagnostic or treatment technologies.
29:16But to some extent as well
29:18people trying to,
29:20you know, reduce or quit smoking,
29:22eat healthier diets,
29:23maintaining a healthy body weight.
29:25All of these things are
29:27only going to help.
29:29Doctor Michaela Dinan is an associate
29:31professor of chronic disease Epidemiology
29:33at the Yale School of Public Health.
29:36If you have questions,
29:37the address is canceranswers@yale.edu
29:39and past editions of the program
29:41are available in audio and written
29:43form at yalecancercenter.org.
29:45We hope you'll join us next week to
29:47learn more about the fight against
29:50cancer here on Connecticut Public Radio.