The Crossroad of Social Determinants of Health and Inequalities in Hematologic Malignancies

A Disparity Beyond Biology

Multiple studies cited by Dr Ahmed demonstrate that Hispanic and Black patients generally have poorer outcomes in hematologic malignancies than their non-Hispanic White counterparts. A review of Surveillance, Epidemiology, and End Results program data showed that Hispanic and Black patients tended to have worse 5-year relative survival rates compared with White patients across a gamut of hematologic malignancies, including non-Hodgkin lymphoma, multiple myeloma, acute myeloid leukemia (AML), Hodgkin lymphoma (HL), and acute lymphocytic leukemia.^4,5

Acute Myeloid Leukemia

Dr Ahmed noted that in AML, a malignancy for which appropriate treatment is an important predictor of survival,⁶ studies show that Black and Hispanic patients have worse outcomes than their non-Hispanic White counterparts, despite often presenting with more favorable prognostic factors.^7-9 So what could be creating these disparities in outcomes?

Differences in receipt of appropriate treatment may correlate with these disparities. Studies show that Black and Hispanic patients with AML are less likely to receive appropriate and/or intensive therapy than their White counterparts.^10,11 In addition, although AML treatment and diagnostic measures have improved over the past few decades, one study showed that the overall survival gap between younger Black and White patients with AML widened over the decades, in favor of White patients.¹² Although a higher proportion of these Black patients lived in metropolitan areas compared with White patients, fewer Black patients were insured, more had Medicaid, and a larger proportion lived below the poverty level. When the investigators adjusted for treatment disparities, complete response rates were equally high regardless of race/ethnicity, but survival still decreased over time for Black patients.¹² In addition, even in studies controlling for disease biology and age, disparities persisted.⁸

“So there must be something different besides the treatment offered that’s also affecting survival rates in different...patient populations,” said Dr Ahmed.

The Role of Structural Racism

Structural racism, defined as “systematic disadvantage experienced by certain groups of people,”¹³ is a powerful mediator of survival in hematologic malignancies.

A multilevel analysis across 6 Chicago cancer centers showed that structural racism—including segregation and poverty—was a stronger mediator of AML survival disparities than disease factors or access to care.¹³ Structural racism was defined as a composite variable including racial segregation, disadvantage, and affluence at the census tract level. Results showed a higher risk of death for patients who lived in more disadvantaged and less affluent areas compared with those living in more affluent areas. Adjusting for these neighborhood-level variables nearly eliminated racial survival gaps.

“The most profound part to me was that patients who lived in highly segregated areas, specifically if you lived in an area with over 80% Black individuals, you had worse overall survival,” said Dr Ahmed. “That is really important to note, because we need to consider what are the communities that our patients are coming from, and how does that affect survival?”

Disparities Across Hematologic Malignancies

Dr Ahmed outlined disparities across additional hematologic malignancies, showing that certain disparities span the individual malignancy types. Survival and mortality or risk for death were worse for minority patients versus their White counterparts in diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), HL, and multiple myeloma.^14-18 Certain SDOH variables were also linked to worse outcomes across the malignancies, with lower socioeconomic status (SES) correlated with worse survival in DLBCL, FL, HL, and multiple myeloma; and unmarried status linked with worse outcomes in DLBCL and multiple myeloma.^19-23 Receipt of treatment at a nonacademic versus academic center correlated with worse outcomes in DLBCL.²⁴

In addition, despite marked improvements in treatments, many minority patients are not equally benefiting from these advances. DLBCL and FL survival has improved overall since the introduction of rituximab, yet outcomes remain worse for Black versus White patients and for those with lower neighborhood SES.^14,15,20

Barriers to Diagnosis: Disparities in Multiple Myeloma

Multiple myeloma disproportionately affects Black individuals, with incidence more than twice that in White individuals.²⁵ And although barriers to diagnosis exist across all groups due to symptom overlap with other conditions, said Dr Ahmed, minority patients face additional challenges, including being less likely to undergo a complete initial diagnostic evaluation, longer time to novel treatment initiation, limited access to novel therapies, and fewer open clinical trials in high-minority areas.^26-28

Top patient-cited reasons for the delay in seeking care include economic factors, health literacy, and structural reasons, according to a patient survey in a low-income, underserved area.²⁹ “The biggest area we could probably contribute to as pharmacists is the health literacy part,” said Dr Ahmed.

The Compounding Effect of Multiple Social Needs

One of the most sobering findings was that patients with multiple social needs—such as transportation barriers, food insecurity, or lack of childcare—have worse outcomes. Studies show that patients with hematologic malignancies who had even 1 of these SDOH faced delays in treatment initiation, and more social needs correlated with increased mortality; non-Hispanic Black and Hispanic patients were disproportionately burdened.^30,31

A Framework for Action

Borrowing from a cardiovascular model,³² Dr Ahmed presented a conceptual framework for how upstream SDOH (eg, income, education, environment) create midstream barriers (eg, stress, nutrition, housing, experiencing discrimination) that lead to downstream disease outcomes such as a diagnosis of a hematologic malignancy and survival disparities. Pharmacists can apply this type of lens to understand where interventions may be most effective for their patients.

Mitigating Barriers to Health Equity in Hematologic Malignancies

Treatment advances alone cannot close survival gaps, and resources do exist to guide the pharmacist’s approach to doing so. The Centers for Disease Control and Prevention’s SDOH framework for addressing these concerns comprises 6 pillars³³:

1. Data and Surveillance
2. Evaluation and Evidence Building
3. Partnerships and Collaboration
4. Community Engagement
5. Infrastructure and Capacity
6. Policy and Law

Dr Ahmed highlighted which of the framework’s pillars she deems most important for hematology/oncology pharmacists in addressing health inequities.

Data and Surveillance

Standardize SDOH data collection. Institutions should adopt consistent SDOH data collection processes, including consistent definition of terms, across the cancer continuum. The lack of consistent processes can limit comparison across populations, which is important for making appropriate recommendations, said Dr Ahmed.

Develop oncology-specific risk tools. To integrate SDOH into clinical practice, validated oncology-specific risk scores are essential. The National Association of Community Health Center’s Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool is an example of this, albeit not oncology-specific. PRAPARE asks patients questions to assess social needs and barriers to care.^34,35

“Developing one that’s specific to our [hematology/oncology] patient needs can help us be more strategic in the resources that we’re providing,” noted Dr Ahmed.

Partnerships and Collaboration

Achieving SDOH-targeted outcomes programs requires long-term collaboration with community-based organizations and government agencies, largely because diverse funding is needed for related research and to create stable, sustainable programs. Pharmacists should collaborate with colleagues to leverage resources, share expertise, and build support across the healthcare system, noted Dr Ahmed.

Community Engagement/Education

Educating healthcare professionals to understand how to identify SDOH for each patient and available resources is vital to mitigating the burden of SDOH, said Dr Ahmed. Institutions should incorporate social health interventions into the clinical workflow and electronic medical record, she recommended.

“If I could have one take-home message, it is that you do not need to be a health equity expert. You don’t need to be an SDOH expert. What you would need to do is be able to identify patients who need the most social support and research that is available,” she noted.

Policy and Law

Engage in policy and advocacy. Policy-level advocacy is essential to addressing SDOH, and pharmacists can play an important role in supporting related initiatives at the state, federal, and healthcare system levels, noted Dr Ahmed. Alleviating the burden of social needs—such as housing quality, poverty, and educational gaps—via policy can improve patient outcomes downstream.

Progress Is Happening

During her HOPA presentation, Dr Ahmed asked the audience, “Does your institution have established resources available to address SDOH at your practice? If so, what are some examples?”

Audience members shared that special funds, social workers and financial navigators, nutrition/food banks, additional referrals, and gas cards are offered at some of their institutions, but one respondent noted that although available, resources can be very limited.

Conclusion

Health equity is not a passive goal; it demands intentional, informed, and systemic action. With ample evidence that SDOH affects health inequities in hematologic malignancies, hematology/oncology pharmacists are well-positioned to champion this shift.

Although SDOH interact with race and ethnicity to affect disparities in hematologic malignancies, Dr Ahmed cautioned, “remember, please, remember—race is a social construct, and there are more genetic variations within a race than there are in between races. Underlying social conditions and structural racism do contribute to disparities in hematologic malignancies more than individual drivers, such as biological factors.”

By acknowledging and addressing SDOH—from clinical to social to policy aspects—pharmacists can help ensure that the benefits of modern hematologic therapies reach every patient, regardless of zip code, insurance status, or race/ethnicity.

Editor’s Note: This article was created with assistance from artificial intelligence.

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