Five Domains, One Outcome: How Social Factors Shape Cancer Survival

In an interview with Pharmacy Times, Iman Ahmed, PharmD, BCOP, clinical pharmacist specialist in hematology at the University of Michigan, discussed social determinants of health (SDOH) and their impact on patient outcomes, particularly in patients with leukemia. She provides key insights about structural racism, defined by income, education, and area demographics, as well as practical methods for pharmacists to follow to overcome these barriers. Her data were presented at the HOPA Annual Meeting 2025.

Pharmacy Times: How would you define SDOH in the context of hematologic malignancies? Can you discuss the 5 domains presented in your session?

Iman Ahmed, PharmD, BCOP: So, [SDOH] are the conditions in which people live, grow, work, and essentially play — and these can really affect a patient's overall health outcomes. Social determinants of health are generally defined within five domains: the first is education; second, economic stability; third, health care access; fourth, social and community context; and fifth, neighborhood and built environment.

Within these five domains are various examples. A person’s employment, income, housing quality, transportation access, and level of community support — these are all components of social determinants of health. They’re just broken into those five core domains.

Pharmacy Times: Could you walk us through some of the most pressing disparities you're seeing in the incidence and outcomes of hematologic malignancies?

Ahmed: There are a lot, and I’ll be discussing many in my presentation. But just to highlight a few: for example, in leukemic patients, there's a trend that Black and Hispanic patients tend to have worse overall survival. And that's after adjusting for treatment type, age, and even favorable cytogenetics. We’re still seeing worse outcomes, which raises serious questions.

One area I heavily delve into during my presentation is a study from the SEER database, which looked at overall survival for AML patients across four decades. While the survival curves increased overall, they didn’t improve for Black patients — in fact, the gap widened over time. Even in the last decade, Black patients continued to fare worse. So we really have to shift our focus and say, “Outside of health conditions, what else is contributing to these disparities?”

Another example — there are retrospective reviews that look at specific socioeconomic factors impacting patient outcomes. Studies have shown that patients with lower income, those living in predominantly segregated, mostly Black, neighborhoods, or in areas with high levels of digital poverty tend to have worse outcomes. These are real disparities. And honestly, I could highlight so many more if I had time.

Another study I’ll mention — and this one is especially striking — is a multi-center review conducted across 6 centers in Chicago. They created a composite endpoint to define “structural racism,” which they called “tract disadvantage.” It included metrics like education level, income, and the racial makeup of the area (predominantly Black vs. white). When they adjusted for structural racism, it actually mediated nearly all of the disparities in overall survival. That’s incredibly powerful — it shows just how deep a role structural racism plays.

Pharmacy Times: Are there particular patient populations that remain disproportionately impacted by these disparities?

Ahmed: I actually should not define these disparities by race, because that's actually not what I wanted to do in my presentation. It really should be defined by the social needs of a specific patient. And so the challenge is that many of these research studies define disparities by race and ethnicity, but the way we should actually be defining the disparities are patients who have transportation issues, patients who have poor housing quality issues, or low education. How does that play a role?

But anyways, needless to say, I’ll give you another example. There was a study that came out that looked at multiple myeloma patients. We know that in multiple myeloma, CAR T is such an effective treatment—it has an overall response rate of over 90%. But when you look at where CAR T is available, it is only available for 36% of minority patients. So if you have such an effective treatment regimen, but it's only effective for patients who can access it — and only 36% of minority patients are accessing it — then who is that really benefiting? Because it’s definitely not the whole population.

Pharmacy Times: How does systemic racism or structural bias intersect with SDOH to compound these disparities?

Ahmed: You know, I think it’s actually compounded by the fact that there is no true definition of structural racism and how it's defined in research. So a lot of the studies—when you look at them—make their own definitions. So the example of that study that I cited, they made their own definition of structural racism and how they wanted to define it in their study, which I think is a limitation, actually.

When we talk about the future of addressing health equity or achieving health equity through social determinants of health—targetable outcomes—the first thing we’re going to talk about is data and research — and having homogeneous definitions. So I think that that is one limitation and immediate confounder.

I will say that social determinants of health are obviously broken down into five different domains, which have many sub-bullets within them — but many of those also overlap. And I think that actually is what is used to define structural racism.

Pharmacy Times: What practical strategies can oncology pharmacists or hematology teams use to help mitigate the impact of SDOH in their day-to-day clinical settings?

Ahmed: I’ll say the first thing we can do as pharmacists is when a patient comes to your clinic, some institutions — maybe not all — have this 10-point questionnaire that you give your patients to say, “Okay, do you have any trouble with transportation? You know, food security? Do you have any issues with..”.”—a bunch of different questions that they essentially ask. And that 10-point scale is called the PREPARE tool. It’s not something specific to oncology.

I think we first need to develop one that’s specific to oncology — and the needs of oncology patients — and then we take that and really embed it into clinical practice. So now you have these social needs that your patient requires — how can you fulfill that? What resources are available?

And I think that a lot of times there’s a misconception that you have to be the expert in social determinants of health, or the expert in health disparities — but you actually don’t. You just need to be able to figure out if your patient has a social need — and more than likely, they do — because many times we see that patients have more than one challenge among their peers, exactly. And then: what resource is available?

And so I think that's kind of the bulk of what we can do. I think there’s a lot of work above the clinical level that also needs to be done, too.

Pharmacy Times: What changes—at a policy or institutional level—would you most like to see to better address the SDOH-driven disparities you've highlighted?

Ahmed: ASCO has a call to action, as well as the CDC plan to address this. They actually explicitly talk about how to work in advocacy. If you really think about it addressing health equity through social determinants of health–targetable actions would be at the policy level. Meaning: if we address these needs at the policy level, we can decrease the burden that this community faces.

For example, if you reduce the number of people that are living below poverty, the number of people who have low quality housing, the number of people who have low education — we can address some of these social concerns and social needs of patients that will ultimately affect their overall health and survival. So the policy work is key and important. I think it’ll help just alleviate some of that burden at the clinical level.