In the past decade, researchers discovered several genomic mutations that help drive lung cancer. The main ones occur in the EGFR, ALK, ROS1, NTRK and BRAF genes, and now there are several therapies that work by directly targeting these changes.

In an interview with CURE®, Andrew Ciupek, who holds a doctorate in cancer biology and serves as clinical research manager at the GO2 Foundation for Lung Cancer, a patient advocacy group, discussed the importance of biomarker testing and retesting for all patients with non-small cell lung cancer to determine if their tumors harbor any targetable mutations.

®: How has genomic testing come into play for non- small cell lung cancer?

Ciupek: It’s become almost an essential part of non-small cell lung cancer treatment, and the reason is the approval of targeted therapies that we have seen. To know which targeted therapy may be an option for a patient, one first needs to know if a patient has one of those mutations or changes. That’s where biomarker testing comes into play. The doctor can do a test on a tumor to look for any mutations or changes, and if they match to a targeted therapy, the patient can be started on that. Without biomarker testing, someone may not know if they are receiving a treatment that may work for them. We tell everyone that it’s really important to have this conversation about biomarker testing.

What can be done for someone who has already received a diagnosis?

A lot of biomarker testing is done on tumor tissue, but testing can be done with blood, which is called a liquid biopsy or blood-based testing. (Liquid biopsy) can help patients who have already received a diagnosis and may have started their treatment. A lot of times, a second biopsy is difficult to do or is not feasible, (but) blood-based testing can be done at any time during treatment. If someone hasn’t had biomarker testing at diagnosis, or even if they had testing before, getting tested again, particularly if they are on a therapeutic option that may not be working as well anymore, is important. Sometimes the cancer can change, and new changes or mutations can appear that may not have been there before. It’s not just a one-and-done type of thing.

Can you provide an example of a biomarker and the accompanying targeted therapy?

The main mutations that we have Food and Drug Administration-approved targeted therapies for include EGFR, ALK, ROS1, NTRK and BRAF. If biomarker testing

is done and the doctor finds out that a patient is EGFR- positive, that patient can be started on a targeted therapy called Tagrisso (osimertinib). What we find is that Tagrisso is a better therapeutic option than a lot of other things if someone has an EGFR mutation. It actually does better than immunotherapy for patients with an EGFR mutation, so knowing that information can put a patient on a better therapeutic path.

Are there any clinical trials that patients with some of these biomarkers should know about?

Although targeted therapies may work for patients for a very long time, the cancer may start to grow again, unfortunately, or the drug may not be working as well. Clinical trials are looking at drugs that will work after the first targeted therapy stops working. The second reason to consider a clinical trial is that we have an approved therapy for only a few mutations, but many, many mutations can occur in a non-small cell lung cancer tumor. A lot of active clinical trials are looking at targeted therapies for mutations or changes that we don’t have a therapy approved for yet. When someone has biomarker testing and results come back, there may be a change for which we don’t have an approved therapy, but that may point them toward a clinical trial that has a therapy in development.

Andrew Ciupek, Ph.D., is manager of clinical research for GO2 Foundation for Lung Cancer, where he leads implementation of research studies within the foundation’s Care Continuum Centers of Excellence and acts as a navigator for its treatment and clinical trial navigation program, LungMatch. Originally a translational cancer researcher, Ciupek transitioned to patient advocacy to have increased impact on driving patient-centered research. 

Articles

Speaking Out

An expert sheds light on the importance of genomics in treating lung cancer.

Don't Overlook Biomarker Testing in Lung Cancer

Kristine Barrows felt anxious about her visits to Cancer Treatment Centers of America (CTCA) in Chicago. Even with a family member behind the wheel, the four-hour round trip from Barrows’ home in Ingalls, Indiana, on top of medical exams and consultations with multiple specialists, left Barrows physically and mentally exhausted. Her anxiety mounted after the COVID-19 pandemic struck the United States in March.

Even though she knew CTCA was taking measures to protect patients’ health, Barrows, who received diagnoses of stage 1 breast cancer in 2010 at age 39, type 2 diabetes in 2012 and stage 4 breast cancer in 2016, would face a high risk of potentially fatal health complications if she contracted the virus.

When a nurse called to ask Barrows if she wanted a video visit with her doctor instead of an in-person appointment, Barrows eagerly said yes. “They talked me through how to download the software and even did a test session the day before my appointment to make sure I was comfortable using the technology,” she says.

During the video visit in April, Barrows’ endocrinologist assessed the effectiveness of her treatment plan by reviewing blood sugar readings accessed digitally through continuous glucose monitoring. With this system, a sensor implanted under the skin tests glucose frequently and sends results to a monitor. “My numbers looked good, and I wasn’t having any problems,” Barrows says.

That kind of diabetes follow-up usually occurs during a one- or two-day cluster of appointments at the cancer center that includes visits with experts in oncology, pain management, counseling and radiation, as well as integrative services such as acupuncture and massage, Barrows explains. This time, “the entire appointment took less than 20 minutes, and I didn’t have to sit through Chicago traffic afterward. It was great!” she says.

The idea of using technology to provide health care services, or telehealth, was first considered almost 100 years ago, when a 1924 

magazine featured an illustration of a doctor using a futuristic audio-video device to diagnose a patient’s case. The actual first known use of telehealth took place a couple of decades later, in the 1940s, when radiology images were sent more than 20 miles over telephone lines.

Telehealth services gradually expanded over the years, focused primarily on video visits to make medical care more accessible to residents of rural communities. Still, physician-patient video visits have been slow to catch on, with lack of insurance reimbursements among the main drawbacks. Historically, private insurers, as well as Medicare and Medicaid, either would not cover services like video visits or offered substantially lower reimbursements. Some patients were also reluctant to use the technology because they believed that in-person care was the best care.

The unprecedented spread of COVID-19 and nationwide directives to stay home quickly changed many people’s perceptions of telehealth. “Health care facilities and providers had to adopt, accept and accelerate this new medium of care to meet the acute and chronic care needs of patients immediately,” says Elaine Smith, a licensed marriage and family therapist and manager of behavioral health for CTCA in Atlanta.

That has included providing insurance coverage for telemedicine where it didn’t exist before the pandemic and relaxing laws that restrict doctors from remotely treating patients located outside the states where they’re licensed, although those changes may be temporary, says Dr. Judd Hollander, associate dean of strategic health initiatives at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

The bottom line, according to Smith: “For people with cancer, it’s extremely important that there are no interruptions to treatments or other vital services.”

Although often used interchangeably, the terms “telehealth” and “telemedicine” refer to slightly different concepts. “When we talk about telemedicine, we’re typically referring to two-way, audio-video communication between a patient and their clinician,” says Dr. Reggie Saldivar, director of telehealth for the supportive care service at Memorial Sloan Kettering Cancer Center (MSK) in New York. “‘Telehealth’ is an umbrella term that encompasses health-related services utilizing digital technologies. Telemedicine is a type of telehealth.”

Many individuals have been using telehealth services for years, perhaps without giving it much thought. Examples include a patient emailing a provider through a portal, Barrows using a medical device to send blood glucose readings to her endocrinologist and a doctor accessing test results stored securely in a patient’s personal electronic medical record.

These telehealth services, as well as others, must meet Health Insurance Portability and Accountability Act (HIPAA) requirements to keep personal information secure and confidential. Electronic medical records have always been expected to meet these requirements. Zoom meetings with colleagues are probably not HIPAA compliant, but medical centers that turned to the webinar platform during the pandemic use HIPAA-secure versions to protect information; other HIPAA-compliant apps include Doxy.me and GoToMeeting.

The pandemic may have hastened the country’s use of telehealth services, but many medical and cancer centers have been developing and using these services for years. Here’s a look at a few recent telehealth innovations designed to protect the health of people with cancer.

In Philadelphia, Jefferson Health is using a modern triage approach to screen patients before they come to the emergency department. “They can use the JeffConnect app to have a video consultation directly with a physician anytime of the day or night,” Hollander says. The university is home to the National Academic Center for Telehealth, which focuses on improving the patient experience through technology.

“If a patient needs to be seen at the emergency department, we can take their medical history and symptoms during the video consultation, arrange to meet them at the door when they arrive and escort them directly into an isolated exam room. They don’t have to touch a door or check in at the front desk,” Hollander says. Patients also can go straight to the cancer center, avoiding the emergency department. In addition to reducing the risk of COVID-19 exposure, triage protects people with weakened immune systems from exposure to flu and cold viruses, as well as other germs.

Patients admitted at Jefferson Health, especially those with COVID-19, receive a hospital- issued, sanitized computer tablet so they can stay in touch with their care team and even loved ones who aren’t allowed to visit. “Right now, while personal protective equipment is scarce, the tablet offers a way for providers to check in on infected patients without physically entering the room unless necessary,” Hollander says. Patients might miss the face-to-face connection, but they benefit from more timely communication with physicians. “Instead of waiting for your physician to make it to your room, you can talk to your physician from wherever they are in the hospital,” he says.

MSK is launching a similar approach using bedside televisions, Saldivar says: “Clinicians can do a video call directly to the patient’s bed, allowing for remote consultations.”

Accessibility of clinical trials has always been an issue for people who don’t live near large medical centers, which offer the majority of trials and are usually situated in metropolitan areas. Strict protocols, including weekly physical examinations and the expectation that enrollees will pick up self-administered experimental drugs in person, make participation prohibitive for many noncity dwellers.  

Although the pandemic put a temporary halt to some clinical trial enrollments, many studies already underway continued with slight adjustments. “Trial participants are now monitoring health stats like weight, blood pressure and heart rate at home. And we’ve switched to telemedicine, or video visits, to inquire about side effects and other concerns,” says Dr. Jordan Berlin, associate director of clinical research at Vanderbilt-Ingram Cancer Center (VICC) in Nashville.

During the pandemic, the Food and Drug Administration OK’d mailing self-administered experimental medications to trial participants. Should this change become permanent, more people who live in rural communities and states with limited health care resources could benefit from greater access to promising new therapies. “I believe that telemedicine has the potential to make clinical trials safer,” Berlin says. “Patients who monitor their numbers at home tend to pay more attention to the readings and are faster to alert us if something seems off. We’re actually monitoring participants more closely now, even though we’re physically seeing them less frequently.”

A total of 76% of hospitals use technology to keep tabs on patients at home, according to the American Hospital Association. For instance, last year, VICC launched a program that allows patients receiving chimeric antigen receptor-T cell infusions to get nightly telemedicine checkups at home (or a hotel room if the patient lives more than 30 miles from the hospital). Typically, these patients would be confined to the hospital for a week or longer, but under this program, they visit the hospital twice a day for checkups and then use hospital-grade equipment to take their own vitals during nightly telemedicine visits. VICC also offers a remote radiation oncology survivorship program: Patients go to a clinic in Clarksville, Tennessee, for routine evaluations; 50 miles away, at VICC, a health care provider uses a specially designed stethoscope to listen to their hearts and lungs and a video-enabled dermatology scope to examine skin affected by radiation treatments.

Telehealth also offers a viable way for patients with cancer to meet with psychosocial support practitioners, from psychiatrists to social workers, without risking exposure to COVID-19, and to get genetic counseling.

COVID-19 put the kibosh on caregivers accompanying loved ones to medical appointments. This situation ratcheted up both patient and caregiver distress, but long-distance caregivers have always struggled with this problem. “Distance caregivers, or those who live more than 100 miles from the patient, report higher levels of anxiety and stress than local caregivers,” says Sara L. Douglas, a nurse practitioner who holds a doctorate in education and serves as the Gertrude Perkins Oliva Professor in Oncology Nursing and assistant dean of research at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland. “About one-third of people with cancer rely solely on distance caregivers to arrange transportation to medical appointments, schedule in-home care, order medications and medical equipment, and provide other critical care needs.”

Douglas is leading a National Institute of Nursing Research-funded study that explores how strategies including videoconferencing can ease this caregiver burden. Two-thirds of the participants used videoconference technology to attend a loved one’s in-person doctor appointment. “Video participants said they enjoyed getting to meet the doctor face-to-face, hearing information firsthand, having the ability to ask questions and being able to see their loved one at the appointment,” Douglas says. Patients said they felt reassured that their caregiver was present, if only on a screen, and felt less pressure to remember precisely what their doctor told them about their condition and treatment.

Despite most hospitals using some type of technology to connect patients and providers, telehealth is an evolving field. “The research on telehealth for patients with cancer is currently in its infancy, but my guess is that these services will prove to be safe and effective for the majority of patients,” Saldivar says. Findings thus far highlight telehealth as a positive addition to care. In a 2019 review of 233 studies focused on telehealth for acute and chronic care consultations, Agency for Healthcare Research and Quality investigators found that virtual appointments either improved outcomes or were equal to in-person visits. Telemedicine reduced hospital mortality and time in the emergency department and may have shortened hospital stays and lowered costs, improved emergency care outcomes and reduced the number of outpatient visits, the agency found.

Not all medical care can be done remotely, of course, and not everyone is comfortable receiving care from a distance. For instance, those who live in remote areas and are most inconvenienced by long drives to medical facilities are the same people who are least likely to have reliable high-speed internet access.

Connectivity wasn’t an issue for Chuck Kreuzer, who lives near Waynesburg, Pennsylvania. The 55-mile drive to the University of Pittsburgh Medical Center Hillman Cancer Center often meant a full day away from the auto body shop he owns and manages. Kreuzer was 47 when he learned he has thrombocythemia, a rare blood disorder. Since receiving the diagnosis in 2016, Kreuzer gets blood tests every three months, followed by a visit with a hematologist.

In March, that visit took place via video. Kreuzer never had to leave his shop, and his wife, Lisa, joined the appointment and asked the doctor her prepared list of questions. “The video visit wasn’t rushed, but it didn’t feel quite as personable or natural as an in-person exam,” she says.

Although Kreuzer appreciated the convenience of not battling Pittsburgh’s traffic and the safety factor of not entering a medical setting during the start of a viral pandemic, he still wants to see and be seen in real time by his doctor. “If my numbers come back out of range, I would feel more comfortable discussing what that means with my doctor in person,” he says. “Also, because this cancer increases my risk for an enlarged spleen, I would feel more reassured if I had a physical exam at least every other visit.”

From the perspective of health care providers, the challenges involved with providing telehealth include choosing and learning to use a platform, making sure there is proper information technology support and figuring out how to deal with scheduling glitches, Saldivar says. It may take some time to work these issues out, but there will likely be continued innovation and expansion in this field.

Telehealth experts understand patients’ and doctors’ concerns and know that technology will never completely replace in-person medical care. “For patients undergoing cancer care who might be asked to come to a clinic multiple times a week, a telemedicine visit can save quite a bit of time, money and stress,” Saldivar says. “Ultimately, we want to be sure that the telehealth services we’re providing are safe, effective and just as good as an old- fashioned face-to-face visit.”

Features

Despite distance and a pandemic, telehealth keeps patients with cancer in close touch with their doctors.

Telemedicine in Cancer Care: So Far and Yet So Close

The impact of COVID-19 on our lives has been substantial. It is a once-in-a-lifetime pandemic, but that doesn’t make it any easier to bear for patients with cancer and those who love and care for them.

Increased awareness, practicing precautions such as social distancing, keeping our hands clean and wearing masks represent a few of the measures many of us are taking to stay well. Yet, even as we follow these new rules for preserving our health, we’re finding that other crucial protections have been compromised. We have seen a dramatic decline during the pandemic in hospital and outpatient visits for screening and nonurgent cancer care. The delay of these procedures has led experts to raise concerns that an increase in deaths from cancer may be part of our future. Potentially adding to that trend will be the loss of health insurance that has accompanied job termination for many during the pandemic. The reality is that, without insurance, cancer care is not affordable.

The American Cancer Society Cancer Action Network recently 

 asking patients with cancer about the experiences and concerns they are confronting. The results of the most recent survey showed that 46% of patients have experienced a decline in their financial security and ability to pay for their care, and nearly 25% worry that they may lose their insurance as a result of the pandemic. Mental health is also affected: Because of the combined medical and financial stress, nearly half the respondents have perceived a major or moderate effect on their mental well-being.

These are not minor considerations. The reality is that most of us don’t have an effective safety net when it comes to paying medical bills. One day you are employed and have health insurance, and the next you are unemployed and worried about whether you can afford food and rent, let alone an insurance extension from your employer — if one is available. And let’s not forget that even with insurance, cancer care is expensive, far beyond the means of many of us.

The pandemic has taught us a lot. It has shown us the weaknesses in our system at many levels. We need solutions that will protect us in times of need. Options could include reopening insurance exchanges or providing help with paying premiums. Inevitably, some will argue that the time has come for us to rethink how we as a nation pay for health care.

No matter the solutions, I suspect we can all agree on one thing: No one should have to forgo cancer care, particularly during an infectious pandemic and an economic disaster, because they can’t afford it. If we can solve that dilemma, then perhaps something good will come out of a moment in time that has been so frightening for so many of us.

House Call

The results of the most recent survey showed that 46% of patients have experienced a decline in their financial security and ability to pay for their care, and nearly 25% worry that they may lose their insurance as a result of the pandemic.

Losing Health Insurance Due to Job Interruption During Pandemic Could Jeopardize Cancer Care for Many Patients

Genetic counseling and testing for hereditary cancer risk have been integral to patient care for many years. The process gives patients information regarding their risk of developing certain types of cancer and guides recommendations for screening and prevention. Genetic testing can also offer patients information that can be shared with their family members to determine if they, too, are at increased risk of developing cancer.

Since the 1990s, when this kind of testing became available, the ability to more broadly screen and interpret the results has evolved extensively. Patients who underwent testing many years ago may wonder if they should be tested again. In fact, one of today’s sophisticated tests may be in order, particularly for those who previously screened negative for cancer predisposition genes or whose testing looked at a limited number of genes.

Risk factors for hereditary cancer include the following:

Early-onset cancer, often prior to age 50.

Ashkenazi Jewish ancestry with a personal and/or family history of breast, ovarian, prostate and/or pancreatic cancer.

The same or related cancers in two or more close family members.

Genetic testing is typically most informative in a family if it begins with a relative who has a personal history of cancer that suggests hereditary risk. Because awareness of such cases is not always possible, genetic testing may still be warranted for an individual who has not had cancer but has a significant family history.

Who Should Consider Additional Genetic Testing?

Historically, genetic testing for cancer risk focused on only a few high-risk genes associated with specific types of cancer. More recent advances in technology allow patients to undergo genetic testing using what is known as multigene panel testing. This type of testing provides for analysis of many genes at once using a single blood or saliva sample. Because many different genes may cause the same or a related type of cancer, multigene panel testing can be an efficient option. This testing typically looks for mutations in genes with a high or moderate risk of contributing to the development of cancer. The testing may include genes associated with several types of cancer, which may be particularly useful for a patient with a more extensive personal and/or family history of the disease or those with limited information regarding their family’s cancer history.

Some patients may have undergone genetic testing for hereditary breast and ovarian cancer that was limited to the high-risk genes known as BRCA1 and BRCA2, or they may have had testing for hereditary colon cancer that was limited to the genes associated with Lynch syndrome. If those prior results were negative, it is often reasonable for those individuals to consider more comprehensive testing using a multigene panel. Positive results could indicate a genetic mutation that is known to cause an increased risk of developing cancer, giving a patient and their family members updated information about risks and recommendations.

If the results from panel testing are negative — no mutation in any of the genes was identified &mdash; this finding should be interpreted in the context of a patient’s personal and family history of cancer, and increased cancer screening may still be recommended. Another possible result: a variant of uncertain significance, which means that a change in one or more of the genes evalu- ated was detected, but it is not clear whether that change raises the risk of cancer. The majority of uncertain variants will eventually be reclassified as benign because data about those genetic mutations, including informa- tion from individuals with those variants who were followed over time, will shed light on their meaning. If information about a mutation or variation of uncertain significance changes, genetic counselors can contact patients to update them on any steps that should be taken.

A patient who previously tested positive for a BRCA1 or BRCA2 mutation, for example, is less likely to now test positive for a mutation in another breast cancer gene that would significantly change their screening and/or prevention recommendations. However, it may still be worthwhile for that patient to discuss prior genetic test results and personal and family history with a genetic counselor to determine if updated testing via a multigene panel is warranted.

Can My Genetic Test Results Be Used Against Me?

It is important to understand that knowledge about the cancer risks and screening recommendations for many genes will continue to evolve and change. The results of multigene panel testing can be complex, with significant implications for patients and their family members. Therefore, it is recommended that all patients review their personal and family history with their physicians and ask for a referral to a genetic counselor to discuss prior results and the possible need for additional testing with a multigene panel.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and health insurers from using genetic information, including family history and genetic test results, to discriminate against patients. For certain groups of patients, other laws or policies may provide similar protections. However, GINA does not protect patients from discrimination by life, disability or long-term-care insurance companies. For more information, visit 

TIFFANI A. DEMARCO, M.S., CGC is a certified licensed genetic counselor and director of the cancer genetics program at Inova Schar Cancer Institute in Fairfax, Virginia. 

Diagnosis Cancer

Individuals who were screened for hereditary cancer risk in the past might benefit from getting tested again using today’s more sophisticated panels.

The Test of Time: Genetic Testing For Hereditary Cancer Risk

The physical damage from cancer is horrible. I hated surgery, blood draws, chemo aftermath (did a semitruck run me over?!) and how my memory was shot. Although some folks not affected by cancer recommended that I “chill” (easy for them to say!), being homebound during treat- ment for an aggressive form of breast cancer was tough.

When I could barely hobble to my bathroom, I grimaced at the thought of another painful bout of diarrhea or constipation. Desiccated eyes, baldness (everywhere!), withered sexuality and the loss of actual body parts fed my internal chaos. Alone with my hamster wheel of a brain, I mourned not feeling normal, worried about money and bills, and wondered if I had caused my cancer by eating too many cheeseburgers, wearing sparkly makeup or playing in asbestos-laden buildings during childhood. As I became an expert on stay-at-home restlessness, it felt like I crawled my way to sitting still.

Because our society stigmatizes illness, grief and death, communicating about cancer takes work. The good news: Results of numerous studies show that writing about thoughts and feelings in the face of unexpected events such as cancer lowers stress and anxiety. As a professional food writer, I was used to writing about chefs and restaurants. Cancer made me feel desperate, so I started jotting things in a notepad 24/7 to process and organize my thoughts. With that, I began to feel better.

Eventually, I invited my friend, cartoonist Don Asmussen, creator of the San Francisco Chronicle comic strip “Bad Reporter,” to collaborate. Don has had two experiences with cancer and is hilarious and witty. Our book is “The Wig Diaries,” an irreverent compilation of essays that do not shy away from the horrifying, embarrassing and saucy, such as wig shopping on drugs, going naked with only one nipple at the hot springs and finding myself attracted to a married member of my medical team.

As a writing teacher, I have seen students get their own spark from using writing prompts. When the coronavirus shut down many parts of our country, I realized people were stuck at home with their thoughts and fears in the same way I had been as a patient with cancer. I decided to launch a book called “Write It Down: Coronavirus Writing Prompts.”

“Write It Down” has 186 short exercises that provide inspiration and structure for writers of all skill levels. It’s like a fun food buffet — pick and choose what excites you. Because a lot of people love food, there’s a section for that, whether you want to go down pizza memory lane or fantasize about a cook making you whatever you want to enjoy with whomever you want. Dig into these other sample prompts:

What’s your secret weapon? Are you organized? Strong? Fierce? Forward-thinking? Smart? Calm? Hardworking? Funny? Describe ways in which you’ve recently used this secret weapon.

Write about an underwater scene with a cast of marine life characters — perhaps a drama, romance or science fiction piece.

When was the last time you had a great, rolling belly laugh? What happened?

Coronavirus remains incredibly challenging for us all, but writing things down offers a great way to move forward. The “Write It Down” prompt categories include:

I was happy to hear from a cancer survivor who shared how “Write It Down” has benefited her: “I appreciate the process. I’ve been struggling with journaling ever since I had kids and got busy, but using writing prompts works really well for me. I think this journal is the beginning of a new trend for me.”

It’s good to enjoy things that we love. I am excited to help others in this way, because I know there can be real healing in writing.

Bookshelf

An author who journaled while homebound after cancer treatment has created a book of writing prompts for those who are staying put during the COVID-19 pandemic.

Journaling Through Confinement

Strategies for shortening the time from diagnosis until surgery for Black patients are essential for reducing racial disparities in melanoma outcomes, according to results published in the 

Journal of the American Academy of Dermatology

In the study, Black patients with melanoma waited longer to receive surgery than non-Hispanic white patients. Racial differences persisted after categorizing patients by insurance type and melanoma stage.

“We already knew that Black patients with melanoma have a worse prognosis and that longer time to treatment is associated with worse survival, but we didn’t fully under- stand the relationship between race and time to treatment after controlling for various other factors,” first author Raghav Tripathi, a medical student at the Case Western Reserve School of Medicine in Cleveland and a researcher at University Hospitals Cleveland Medical Center, said in a press release. “A more thorough understanding of the factors associated with worse outcomes for Black patients is critical in reducing racial disparities in melanoma outcomes.”

Using the National Cancer Database from 2004 to 2015, researchers retrospectively reviewed 233,982 cases of patients with melanoma, 1,221 (0.52%) of which occurred in Black patients. According to Tripathi, using a large health care database and a sample size of this magnitude allowed researchers to include enough Black patients to investigate racial disparities in skin cancers.

Black patients were found to have longer waits for surgery in stages 1 through 3 melanoma and also a greater amount of time between diagnosis and receiving immunotherapy. They did not wait longer than white patients for chemotherapy, nor did Black patients with stage 4 melanoma wait longer for surgery. After controlling for gender, age, median household income and insurance type, Black patients were found to have more than twice the odds of waiting from 41 to 60 days for surgery, more than triple the odds of waiting 61 to 90 days, and more than five times the odds of waiting over 90 days. On average, the time until surgery for melanoma was 23.4 days for Black patients compared with 11.7 days for non-Hispanic white patients.

Patients with Medicaid had the longest wait (a mean of 60.4 days), whereas those with private insurance had the shortest (44.6 days). Racial differences remained within each insurance type, indicating that insurance status does not fully account for such disparities.

According to the researchers, difference in disease characteristics by race may affect the wait for surgery in patients with melanoma. For instance, Black patients more often have acral lentiginous melanoma, which typically appears on the soles of the feet or under the nails. They also tend to have a greater Breslow depth and stage — measures of the tumor’s invasion &mdash; when they receive diagnoses of other melanoma subtypes, which generally predicts a worse prognosis. These cancers require more complex surgeries that take longer to arrange.

“Our data suggest that increased TTDS (time to definitive surgery) in Black patients with melanoma may be an independent explanatory factor for racial differences in melanoma survival, alongside factors such as later stage at presentation, biological differences in melanoma characteristics and differences in health care utilization,” the authors wrote.

Tripathi added that Black Americans often have limited awareness about skin cancer because it is relatively rare in that population.

Nevertheless, the authors highlighted the need to better understand the precise nature of the association between wait for surgery and race, as well as the various components underlying worse outcomes for Black patients with melanoma.

“Ultimately, we hope this study will draw attention to the importance of further understanding the various components of TTDS and worse outcomes for Black patients with melanoma,” Tripathi said. “Additionally, this study suggests that targeted approaches to improve TTDS for Black patients with melanoma are integral in reducing racial disparities in melanoma outcomes.”

Summer 2020 | CURE

Don't Overlook Biomarker Testing in Lung Cancer

Telemedicine in Cancer Care: So Far and Yet So Close

Losing Health Insurance Due to Job Interruption During Pandemic Could Jeopardize Cancer Care for Many Patients

The Test of Time: Genetic Testing For Hereditary Cancer Risk

Journaling Through Confinement

Investigating a Health Gap in Skin Cancer

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