Ira Zackon, MD, New York Oncology Hematology, speaks with the Journal of Clinical Pathways about the abstract he presented at the 2023 ASH Annual Meeting & Exposition titled “Racial and Socioeconomic Disparities Among Patients with Chronic Lymphocytic Leukemia (CLL) Treated in the US Community Oncology Setting.”

Transcript:

Ira Zackon, MD: I’m Dr Ira Zackon. I am a senior medical director with Ontada, which we conduct real-world research, retrospective research. And I’m also a practicing hematologist with New York Oncology Hematology, which is upstate in Albany, New York.

Please give us a brief summary of your study and its key findings. 

Dr Zackon: We did a study in chronic lymphocytic leukemia, or CLL, with a particular focus on any differences in patient characteristics and outcomes based on race or social determinants of health, in particular socioeconomic factors. So and this was over the period of time that we have you know, really changed the way we treat CLL. With the introduction of BTK inhibitors in 2014, and then BCL2 inhibitors and incorporating more antibody-directed therapy. You know, we’ve improved the outcomes and lives of patients with CLL. But we recognize that it’s not just therapy that there are some social determinants of health that can impact those outcomes. And so our study looked back from 2015 through mid-2023. So about an 8-year period to kind of overlap this era in which we've been changing the way we treat CLL. And this was sourced in the electronic health record of the US Oncology Network. So it’s community-based care, with, you know, that network being the largest aggregated group of oncology and hematologists in the community setting. And then just across the geographic territories of our country. And so we identified over 12,000 patients with CLL, and when we looked at race, 91% were White, 5% were Black patients, and 4% were Other. And this directionally approximates what we might expect in the general population for at least CLL as a disease. But when we look within the population, we could see some important differences. So in Black patients with CLL, the mean age of diagnosis was 2 years younger than the White populations, 68 years old versus 70 years old, but importantly, more Black patients presented at advanced stage CLL, stage 3 and 4, whereas it’s not unusual to diagnose this at an earlier stage.

And so that was 55% at stage 3 or 4 compared to 45% in the White population. And then the two social determinants of health we looked at were level of education and level of household income, being less than 30,000 or more than 30,000, and this relies on structured what we call structured data in the electronic health record. So it’s entered into fields that we can easily extract that data for the purposes of research and analysis.

But it depends on the practice to enter the information and we actually captured that data in only 25% of the patients. But we still saw differences of overall, a higher proportion of lower level of completed education, and the lower level of income being less than 30,000 annually in the total household income.

Now, importantly, then, we looked at overall survival, and we measured overall survival from the time of their first visit to a particular practice, and what we saw over this kind of 8 years of data, and we saw that in the Black population the rate of death events or mortality was 61% compared to only 43% in the White patients with CLL. So an almost 20% difference, and that really is a significant gap. Now, and then when we go back to look at adjusting the overall survival data for these different differences in the population, when it came to the household income and adjusting for that, then we saw that the hazard ratio of increased risk for mortality was no longer statistically significant. But household income remains statistically significant even with the missingness in, you know, that overall data.

So you know, we concluded from this that, one, in the contemporary era of CLL therapy going back to 2015, that in our database of community-based oncology, CLL patients who are Black do have a less favorable overall survival. They live less, you know they live less long with this disease, and part of that could be driven by social determinants of health in a particular income. But this is a very high level, you know, analysis. So that doesn’t get down to the details of perhaps what’s underlying that. And that’s really the next step of research is to really go back, and you would have to abstract unstructured data to get more details of both the disease, any differences in prognostic factors that we understand in CLL, any differences in the treatments that were delivered, both the types of treatment and the duration of treatment. And then, you know, beneath that social determinants of health get to a more granular level of different aspects of our life. Whether it’s not just financial constraints but transportation needs, social support at home or not, mental and emotional health issues, spiritual health issues, really a more, broader picture that can help us hopefully identify at least at the population level, maybe, what are what are the more significant drivers of these differences, and therefore what kind of solutions can we bring to bring you know, fully equitable care and hopefully the same outcomes for all of our patients with CLL.

Can you elaborate on the specific socioeconomic factors considered in your study, and how they were determined to be associated with outcomes in patients with CLL? 

Dr Zackon: We really selected these two measures because we have structured data that we could easily then, you know, extract from the database in the EHR, recognizing that they’re really high-level looks, right? So they were helpful in their correlation. And then in particular, you know, this overall survival difference. But to really get at, you know, what does it really mean? Like what is underneath that financial factors is certainly, we know that income can limit your resources, you know, how much you can spend on this or that, or what you can do. But we what we’ve done in the, and this is just within the last 6 months, within the electronic health record, we now have what's called the NCCN distress thermometer, which is, it’s just going to be used clinically regularly as part of routine patient care, to get a gauge of the, in a sense, the temperature of distress. But underneath that, what will be completed is these more details of not just financial distress, but other transportation issues. Do you live alone, or do you have a partner? Or do you have social support in your life? Any stressors of mental or emotional health? And so really trying to get at, you know, that deeper level of data that we could then, on a going forward basis come back to hopefully paint a more detailed picture that would be more informative to help guide us, right? So where should we focus those efforts of information? Right now at the practical level, you know, at practices, you know, it’s meant to then alert to a need, and typically engage them with other members of the care teams, such as social workers. And we’ve also incorporated a software that can, based on the patients that go, to direct them to particular resources closest to their community, and might then help with the particular needs identified.

Your research emphasizes the need for further investigation into the reasons behind racial and income disparities in CLL outcomes. What specific aspects or factors do you believe future research should prioritize to gain a comprehensive understanding of the underlying causes of these disparities in the modern era of CLL therapy?

Dr Zackon: First, we have to still come back to the disease, and let’s say, our data set, to be sure that we don’t see any fundamental differences in the disease itself. Not just the stage, but for example, you know p53 deletion or mutation. And you know, IGBH mutation status. These are known important prognostic factors. So we wanna know that there’s no differences there. And we do have to look at the treatment landscape. So, were patients treated? We had another abstract that looked just at BTK inhibitors, which really, you know, are foundational right now in terms of how we treat both first or subsequent lines of therapy, depending, and we didn’t see a difference between Black and White patients with CLL, also, in terms of the actual therapies delivered. So that was at least encouraging. But then you have to get underneath, you know, to these different aspects of social determinants, really, because they’re really a more holistic look at any individual’s life. And we don’t have that data. So we can’t really say, from our study, you know, what’s underlying that short of you know, a larger category of income limitations that can drive a lot. But you need to understand what segments, perhaps most to resource, you know, to help patients’ access to care and getting the optimal outcomes, you know, that are just related to getting the right treatment for the disease. 

Are there any final thoughts you’d like to share? 

Dr Zackon: I would just say, you know, we focus a lot on diseases and the treatments we have. And those are, you know, obviously important in terms of advancing people’s lives. But it's not just what we do, it’s how we do it. And so it really does take a team of providers, whether they be doctors, nurses, advanced practice providers, and your social workers and support team that you have to deliver care, and addressing issues that we can identify. But that requires, you know, a good relationship with patients across the diversity. You know, there has to be a level of relationship you can trust that you can have those kind of conversations that help to understand more these factors in their lives, so that we can incorporate that into, you know, how we care for them, and that how makes not only a difference in the quantitative income we hope, but just in the quality of that health care experience, which is really also important for the best outcomes.