Oncology Pharmacists Play a Unique Role in Addressing SDOH in the Community Setting

Pharmacy Times interviewed Maya Leiva, PharmD, BCOP, APh, hematology/oncology clinical pharmacy specialist at Schar Cancer Institute, Inova Health System; associate professor of hematology and oncology - pharmacy practice, West Coast University; director of infusion services for Bass Comprehensive Cancer Center; and lead advanced practice pharmacist, US Federal Government (HHS/ASPR), about her presentation at the NCODA Fall Forum addressing social determinants of health (SDOH) in the oncology pharmacy setting.

Pharmacy Times: What was the focus of your presentation at the NCODA Fall Forum on SDOH?

Maya Leiva, PharmD, BCOP, APh: Yeah, so it was really kind of understanding the components of [SDOH], and how they impact a person's life and medical journey. I think the general oncology community has been starting to sort of engage with the term [SDOH]. But again, applying that to an oncology framework can be a little bit more challenging. So, I really wanted to be able to provide the participants with a deeper understanding of the lexicon associated with [SDOH], and kind of expanded upon their existing knowledge.

Pharmacy Times: What are some of unique aspects of SDOH that oncology pharmacists may see in the community oncology setting?

Leiva: Yeah, so that a great question because most patients with cancer are treated in the community oncology setting. So, because of that, we're seeing a wide array of patient populations, many of whom are very vulnerable patient populations. Also considering geographic regions, people may have persons with, again, a wide variety of the more complex [SDOH] and in terms of health literacy, primary language, access to income, and housing stability, things like that.

But one of the things I wanted to do specifically in talking about things related to oncology care, is positioning or describing [SDOH] in terms of an equity framework in cancer care. And we know that, especially within oncology, patients develop cancer often because of direct relationships to [SDOH]. And not having access to healthy food, not having access to green spaces, living in contaminated environments, not having access to basic screening, and then also other aspects of a person's identity, which we'll talk about in terms of sexual orientation and gender identity, but we know that inequity is due to conditions which can be very much driven by marginalization and stigmatization may have policy components, all the way up to disparities due to consequences, which can be involved with behavioral factors, other risk factors, and access to quality health care.

"But one of the things I wanted to do specifically in talking about things related to oncology care, is positioning or describing [SDOH] in terms of an equity framework in cancer care. " Image Credit: © Mongta Studio - stock.adobe.com

All of that, then feeds into outcomes for patients. In oncology, we’re very outcomes driven, which is great, but then we need to kind of go backwards, and look at well, why do people experience their cancer journeys differently? Based on essentially all aspects of their personhood, from race, ethnicity, sexual orientation, gender identity, socioeconomic factors, some of which are interwoven, because these are highly intersectional experiences for people. And, again, there are a lot of ways in which we can interrupt genetic factors and environmental exposures, but we can't do that without having, again, both the language and the data to be able to study these things and change that experience.

Pharmacy Times: What are some recommendations for oncology pharmacists when discussing sexual orientation and gender identity (SOGI) information with patients in the community oncology setting?

Leiva: I think first of all, it's a recognition that sexual orientation and gender identity are a sociodemographic component of personhood. I think a lot of times people sort of separate that out from other aspects of identity, like, “Oh, this is something that's nice to collect or nice to have,” and not necessarily something that is an essential part of someone's personhood. It is probably a combination of the most intimate parts of a person, and I think it's important because often we conflate sexual orientation and sexual behavior as kind of the same thing in our sexual activity. We know that again, there are different components of sexual activity that can drive risk associated with developing certain cancers, especially HPV-driven cancers. And understanding that these activities may be deferring access to health literacy, because we know that unfortunately, both providers and patients in the LGBTQ+ community, or providers who are providing care to those of us in the community, are often not well informed. Something as simple as a transwoman having a bottom surgery, having a vaginoplasty, she still has her prostate, and so prostate cancer screenings need to occur at those appropriate ages.

So, I think, again, one thing that pharmacists can do is just understand and accept that this is an essential piece of information, or pieces of information that need to be collected on every patient as often as possible. Because just like other aspects of a person's [SDOH], they can evolve and change from week to week. So, I can see a patient one week and maybe their housed, and the next week, they're not. I can see a patient one week, and maybe their pronouns are she/her, and the next week, their pronouns are they.

So, all these things are dynamic. And pharmacists have a moral and ethical obligation to help our colleagues, again, collect as much information as we can to be able to treat patients. And then when it comes to talking about SOGI data with patients, I think, again, it is just having that conversation with patients: We're collecting these pieces of information, because we want to know as much about you as possible to help us take good care of you. And sometimes we do get pushback. Generally, it is generationally driven, with older patients sometimes being the most reticent to provide that information, and younger patients, of course, particularly those who identify as Gen Z, they're much more likely to offer that up and often without even being prompted, which is cool to kind of see that evolution in the way we talk about these things.

But one concern I do have, and I think pharmacists are going to need to be prepared for this is that in states where maybe it is safe for those of us within the LGBTQ+ community to identify ourselves, pharmacists are probably going to have to do a lot more kind of comforting patients, but also reassuring them that their data is not going to be used improperly. Or that, their data is in fact protected. Because particularly in states where there is gender-affirming care bans for adolescents, or even in some cases up to the age of 26. I believe right now there are about 22 states where those bans have either been introduced or they're in effect. So, I do think that there's a lot of fear within the community about revealing those components of our identity. And again, pharmacists have a unique opportunity to explain to patients why it's important and reassure them that their information is safe.

Pharmacy Times: What is the value of the oncology pharmacist on the patient care team in relation to approaching and educating around SDOH?

Leiva: We are uniquely positioned and designed to reduce financial toxicities for both patients and health care systems. And we don't even think about this from a moral and ethical perspective. We think about it purely from a financial toxicity and science-based driven approach. Being able to address [SDOH], from identification to analysis to then going back and trying to engage with communities to change some of these conditions, we have an opportunity to lower the cost of care and improve outcomes.

It is not an accident that the United States spends the most money on health care in the world, and we have some of the poorest outcome, especially for persons who are socioeconomically disadvantaged or who are members of marginalized and vulnerable communities. So, I think we have opportunities to engage with our colleagues to say, “Hey, I'm not just concerned about this patient being able to afford the copay. I want to understand why this patient was having a hard time taking their medication, maybe they don't have access to food.” There are just all kinds of things that pharmacists can do to engage with our health care team, from again, collecting the data directly from patients, analyzing it, and coming up with a solution.

I saw a great cartoon once about how oncology pharmacist are like the ultimate problem solvers. We're always looking for a problem to solve. So collectively, this should be an exciting opportunity for us to try and identify all these problems and understand that they're going to be different for different groups of people, and this is where intersectionality comes in. People are going to have additional components of their identity that may make it even more difficult for them, or in some cases, more accessible for them to get access to certain services.

One of the other things too about pharmacists, especially in the oncology setting, is that we're trained in population based health principles. And our colleagues are not necessarily always thinking about it that way, they're often thinking about individual patients, as opposed to groups of people who we might be able to apply an intervention for and then hopefully help change that outcome. But I think, again, just utilizing the force that we have been gifted with, and also that ability to have both a microscopic and 30,000 foot view of the health care system, I think we can, again, ultimately improve morbidity and mortality for patients who are deeply impacted by these inequities that, I would say, generally cross all the different components of that healthy people circle with, I would say, social and community context as a [SDOH] being the most integral to a person's experience.

Pharmacy Times: What are some of the challenges that can arise if oncology pharmacists are not integral on the patient care team for patients with cancer?

Leiva: So, if you think of it a bit like you're playing—it's like Mad Libs, right? So, it's like having access to a book with all the words, when you have the complete care team. And then if you don't have a pharmacist involved, it's like playing Mad Libs, and you're missing words. And those words, in the absence of information, we often fill in the gaps with inaccurate information, and then it drives a person's care maybe not in the right direction. Or, even worse, we collect little bits and pieces of information, but we're not asking the right questions. And then by the time the patient is needing treatment or is on treatment, they may not necessarily be able to successfully participate in their care in the same way.

The other way that this is detrimental too is around clinical trial access. And so, I think there are bigger barriers of participation for historically marginalized communities. And if we don't have pharmacists deeply involved in, again, ensuring that we're collecting all facets of a person's potential ability to experience that medical care, that plan that we are giving them, then again, patients are not necessarily going to be successful.

I think we see this in terms of real-world evidence. When patients are on clinical trials, they tend to do much better. I mean, obviously, we're selecting the healthiest sick people that we can. But those patients who, when they make it to clinical trial, they're getting a lot of support, and a lot of times you're getting a lot of pharmacist’s support as well. Once they're off trial, they may not be getting the same kind of support, and especially for those historically marginalized and vulnerable communities, removing that support means that patients may not be able to successfully continue their treatments as well as they would have on a trial.

So, I think again, not having pharmacists accessible to patients and not having that multidisciplinary approach means you are going to be missing words and creating a Mad Libs situation for a patient that ultimately affects their care.