Understanding Social Determinants of Health, With Karen Winkfield, MD, PhD

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses. Brielle Gregory Collins: Hi, everyone. I'm Brielle Gregory Collins, a member of the Cancer.Net content team, and I'll be your host for today's Cancer.Net podcast. Cancer.Net is the patient information website of ASCO, the American Society of Clinical Oncology. Today we're going to be talking about social determinants of health and how they can impact people with cancer. We'll cover economic stability, neighborhood, community, education, food access, and health systems. Our guest today is Dr. Karen Winkfield. Dr. Winkfield is a board-certified radiation oncologist and Ingram Professor of Cancer Research at the Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, and the executive director of the Meharry-Vanderbilt Alliance. She is also the Cancer.Net Associate Editor for Radiation Oncology and Health Equity. Thanks for joining us today, Dr. Winkfield. Dr. Karen Winkfield: Thank you so much for having me, Brielle. I'm so excited for this podcast. Brielle Gregory Collins: Yes, so are we. Before we begin, we should mention that Dr. Winkfield does not have any relationships to disclose related to this podcast, but you can find her full disclosure statements on Cancer.Net. Now, to get started, Dr. Winkfield, how would you define a social determinant of health? Dr. Karen Winkfield: Yeah, it's such a big concept, right? The social determinants of health, the economic and social conditions that impact and influence the way that people, individuals, and groups actually experience their health status. And so 1 of the ways that I like to define it is simply the way that the CDC and others [do]. These are the conditions and the environments where people are born, where they live, learn, play, work, and age. And so it's an entire social context that people find themselves in that really can impact and influence their health and well-being. Brielle Gregory Collins: Thank you so much for defining that. Now let's talk about some of the specific social determinants of health. So let's start with economic stability. What are some ways financial challenges can affect someone with cancer? Dr. Karen Winkfield: Money is key, right? I always tell folks that wealth equals health, and certainly, health equals wealth as well. I mean, we certainly feel like, man, we are on top of the world when we're feeling well. But unfortunately, in our society, money oftentimes is 1 of the things that helps us drive well-being and health in this country. So just the simple thing we saw with COVID-19 when people lost their job, for instance. Many people also lost their health insurance. In this country, health insurance is tied to economics, right? But economic stability goes beyond just insurance. It's about what is the budget? Do you have a family budget? There is a recent study that suggested that about 21% of individuals in the United States do not have an emergency fund, right? So that means that if, for instance, they were just living and they were working on a budget, if something happened - their car breaks down; there's a flood in their hometown - they have no financial resources that actually are available to them to help them overcome that emergency. And so economic stability is important. It's about where you work, if you are employed, what type of employment, are you a salaried employee, or do you only get paid the hours that you work? Which obviously has huge implications for cancer care, right? So if I am a cancer patient and I only get paid for the hours that I work, for instance, if I have a doctor's appointment that's at 10 o'clock in the morning and I have to maybe take 2 buses and a train to get there, or I have to drive 45 minutes, that's more than half the day that I am going to be there for a cancer visit or an appointment with a provider. And that means that I don't get paid for that, that nobody is covering that in terms of the finances. So it's really important to note that, yeah, it's about savings and things, but literally, the day-to-day, the employment that people have is really critical and the type of employment, what expenses people have. We know that cancer care is the number 1 cause of medical bankruptcy in the United States because a lot of the medicines are expensive. And so that economic piece is really critical to understand and for people to understand going into a cancer journey, number 1, where they are financially and what resources might be available to assist them throughout the course of their treatment. Brielle Gregory Collins: That's helpful to note too in terms of there are places people can turn to, to help with these things. Let's move on to a person's neighborhood, which is another social determinant of health. So how can where a person lives affect their access to cancer care? Dr. Karen Winkfield: Location, location, location, right? We think about that when we're buying a home, when we are thinking about if we have children, what school are they going to go to? It's about the neighborhood. It's about your ZIP code. And there are tons of evidence that suggests that your ZIP code matters more, frankly, than your DNA in terms of your outcomes, your health status. And so why that matters is you think about, "Well, how close am I to health care in general?" Right? And then you layer on cancer care. So, for instance, if I'm living in a neighborhood that is really close by my primary care team, that's great. But what happens if the cancer center, if I have a cancer diagnosis, is 45 minutes away or 10 miles down the road, but I have to, again, take 2 buses and a train, right? So your neighborhood determines what your access to a lot of things that impact health is going to be. So it's not just about the health care facilities themselves, but you think about, "Is my neighborhood safe? Are there places that I can walk? Is my neighborhood walkable?" In the homebuyers' market, they'll actually have walkability scores. Is this a place-- where I'm living, is it easy to walk around? Because we know that health and well-being is certainly tied to exercise, the ability to go out and walk around, but to do so safely, right? If you're worried about whether or not there's going to be violence or if there's a lot of pollution or other things that impacting your ability to walk around your neighborhood, that's important. So geography matters because of proximity to health care, but it also matters with respect to proximity to other things that impact your health, including grocery stores, whether or not there are fresh fruits and vegetables that are nearby. These are all the components of health and well-being that are impacted by your physical neighborhood. Brielle Gregory Collins: Okay. Got it. Thank you so much for explaining that. So community is another social determinant of health. And how does a person's community differ from their neighborhood? Dr. Karen Winkfield: Wow, that is such a great question. And I had to think about my neighborhood that I lived in in Boston. Love, love, love that neighborhood, fabulous green kind of setting. I was 2 doors down from this amazing pond that I could walk around, so walkability plus, right? Not too far from stores, plus. It was beautiful. But you know what? I never felt part of the community. So neighborhood is the physical location, the geography, if you will, but community is about the people, who's around you, who's supporting you. And so one may actually live in a great neighborhood but not have community in that neighborhood. The community might be elsewhere. So maybe the community is their church family, right, or maybe their community are the families that they connect with that maybe their children are going to school with. So the community is, who are the people that you identify with, whereas neighborhood is the physical structure, if you will, of where a person lives and works. Brielle Gregory Collins: Okay. Thank you so much for breaking that down. So community is basically a person's social group, the people that they spend time with. Okay. Got it. So how can community affect a person with cancer? Dr. Karen Winkfield: Yeah. There are lots of influences related to community that people experience. And so the way that I think about a cancer journey is you have to think about the entire cancer continuum, meaning, are there ways to prevent cancer? Are there ways to get screening for cancer? What are the types of treatments that I need to be thoughtful of, right? Those are the entire cancer continuum, from prevention all the way through end-of-life care. That's the continuum. And so you can imagine that there are certain communities, that community influence, that may impact your risk for cancers. For instance, are you a smoker? Many people who are smokers actually smoke because maybe they had a family member who smoked, or their friends smoke, and so they smoke, or they may even just be social smokers, right? They only smoke when they're going out to a bar or after a meal with friends. That's how your community can impact your risk for cancer, because we know that tobacco use is the number 1 modifiable risk factor for cancer. But here's another one that people don't think about, is obesity. Obesity actually is a very modifiable risk factor for cancer. People don't realize that being overweight or obese is actually a risk factor for cancer. So what happens if you're in a community where you guys like to go out and hike or you're very physically active? That's actually a prevention strategy. And so we know that community can impact one's risk for cancer, but what about the behaviors associated with cancer care? Well, I know that, for instance, in some communities, they don't like talking about the C word. They don't like talking about cancer. And so sometimes if you don't talk about things, you may not have the knowledge that you need to know how to protect yourself better, right, not only from reduction of risk for cancer but maybe also even, "Hey, there's screening that I can do. Let me make sure I get my mammogram,” or, “Who am I talking to in my community?" Or, "Hey, you know what? I have a cancer diagnosis. Let me share that with my people, right, so they can learn from my experience." So community, the people that you connect with, the people that you identify with, your social context, that's important because there are ways that you can influence both positively and negatively one's outcomes related to cancer. Brielle Gregory Collins: Okay. That makes a lot of sense. And we also want to talk about education, which is another really important social determinant of health. So how can a person's access to education have an impact on their cancer experience? Dr. Karen Winkfield: Just like we were talking about neighborhood and location, I use that example of people moving into a particular neighborhood if they have children because they want to make sure the school systems are great, right? Why is that? Because we know that getting educated, having a good education-- even if it's just a high school education, having a good education opens doors, right? It opens opportunities. And similarly, having education status actually opens up doors related to health and well-being. So what's fascinating is we don't oftentimes think about how much of our health and well-being is tied into our ability to read, right? In our society nowadays, everything is text or is on online or you’ve got to Google it. You go to the doctor's office, and they hand you a stack of papers that's 5, 10 sheets long, and you have to fill it out. What happens if you can't read, right? So there are people in this country-- probably 20% to 25% of the United States is functionally illiterate. And so that impacts one's access to care and also can impact one's access to information around their care, around their health care, around their well-being. So information is key, and that oftentimes is related to our education level or our literacy because, unfortunately, there are some places in the United States that one could actually go all the way from kindergarten through high school and graduate and still not be literate. Sounds ridiculous, but that's what happens. And unfortunately, it's 1 of these things where this is why school districts and schools matter. So the education is also related to language. And so as our community becomes more and more diverse - we have a lot more immigrant populations coming in - it's really important to think about language and how that impacts access to care. I was very surprised when I was the associate director of the Wake Forest Comprehensive Cancer Center that the number 2 most common language from an interpreter standpoint was Arabic. Who knew? In North Carolina. So Spanish was the first requested language, the top requested language from the interpreter services. But Arabic was number 2. And that was because we had a large number of Somalian refugees that were coming in who spoke Arabic as their primary language. So you can imagine being in a brand new-country, don't speak the language, and how do you even know how the country runs? Forget it if you have an issue that comes up where you need medical care. And that resonates for me because I remember I was on my honeymoon with my husband, and we were in Spain, and he got sick, and I didn't speak Spanish. And so we had to go to the emergency room not speaking that language. Language matters, and so that's why educational status matters. Whether or not you've had good early childhood education is key, what your literacy rate is, and certainly, having higher education oftentimes makes one more available-- and make themselves more available to the information that's out there on the web or other forms of printed materials that may actually impact one's ability to navigate the healthcare system better. Brielle Gregory Collins: What about a person's access to food and how a lack of access to good nutrition can impact someone with cancer? Dr. Karen Winkfield: Oh, Brielle, you are talking about something that has recently become more resonant for me. It was something I actually hadn't thought about, was this concept of food and food insecurity, until I heard a recent discussion at an annual conference that about 33% of individuals with cancer show up with some form of food insecurity. Now, what is food insecurity? Well, that may mean that you might not necessarily know where all 3 of your meals are coming from in the day, if you eat 3 meals a day, or it may be that you don't have fresh fruits and vegetables or access to that. Everything is canned because there's not a place where you can go and get fresh fruits and vegetables. There are places in this country that are considered food deserts, which means there might not even be a grocery store that's within a 10-mile radius, or even sometimes it's even much, much wider than that. And food is important. Remember, we just talked about obesity being a modifiable risk factor for cancer. So what is the cause of the obesity epidemic that we're seeing in the country? It's not necessarily that people are overeating, although that's 1 thing. But we eat so much processed food, right? We eat so much stuff in cans that has sodium content out the wazoo, or we don't know where our food is coming from or how it's been engineered. And there may be things in the food that we don't control that may actually be causing some of the obesity epidemic. You think about how many calories are in some of the fast food products that are out there. You get a meal, for instance, a bundled meal. That meal can have 1,200, sometimes up to 2,000 calories that a person is consuming in a single meal. But you know why they're doing it? Because it's cheap. If I can go and I can eat for $4 for a meal versus having to kind of go and find food and cook it and all that kind of stuff, sometimes it's cheaper for people to eat food that's been heavily processed and that may have things that are low nutritional value, but it satisfies them. And so they're kind of forced, if you will, to eat that because they may be living in an actual food desert where they don't have access to fresh fruits and vegetables at a reasonable price. And so that's important. So from a prevention standpoint, thinking about food is critical, but so is not being hungry while you're going through cancer care, right? We need protein. We need nutrition to help our body repair. Cancer therapy is stressful, right? Cancer therapy impacts normal cells, and so we need to make sure patients have the access to the foods they need to help their body to recover during their cancer journey so that they can really not only just survive cancer but to survive it well during the process. Brielle Gregory Collins: So it's not just about how much a person's eating. It's about what specifically they're eating and how what they're eating can help them through the cancer process. Dr. Karen Winkfield: Absolutely. Brielle Gregory Collins: Another social determinant of health is health systems. So what are some of the challenges health care systems can create for people with cancer? Dr. Karen Winkfield:  Yeah. This is a very complex issue, right? So health care systems have grown and developed over the last couple of decades to become more and more complex. A lot of it is also driven by the insurance and by the payers, right, meaning what your insurance companies will cover, what Medicaid and Medicare will cover. This is a huge issue for patients because there's oftentimes lack of transparency, frankly, in terms of what insurance will cover related to cancer care along the entire continuum. So let me give you 1 example, for instance, of colorectal cancer. We know that the Task Force just recently reduced the age of colorectal cancer screening from 50 down to 45. And the reason why is there are more and more younger people who are showing up with colorectal cancer, and so important to make sure that we have a screening available to younger people. Well, that's all good and well, but what happens when you don't have availability of a doctor who can actually do a colonoscopy, right? So colonoscopy is the gold standard, if you will, for getting colorectal cancer screening. But there are other things, right? So this is where information is important. So people can get a stool-based card, right, where it's looking for DNA or looking for blood. And that test can be done as well. But there's so many different complexities that it oftentimes is a challenge for people to kind of think through what's going to work best for them. Now, here's 1 of the things around the health care system in colorectal cancer that is a challenge for those of us who are in this space. So if a person goes for a colonoscopy and they're just going for a straight screening, it is covered by their insurance company, right? That screening is. Now, what a colonoscopy does, it takes a camera and looks inside the lining of the colon to see if there might be any polyps or any kind of abnormal growths that are inside the lining of the colon. So what happens if a doctor sees a polyp or something that's abnormal? Well, they go in, and they biopsy it or they remove it. What has just happened when the doctor does that, the provider does that, that has turned from a screening exam to now a diagnostic exam, and the insurance might not cover that. So what's the challenge is that you're going and you're encouraging people to go for screening, but the test itself is wonderful because, look, if a polyp was found and a doctor removes that polyp, that has just now prevented cancer. We know that for colorectal cancer, any polyp will eventually become a cancer, so you need to remove it, and that's why this colon screening is beautiful, because it's both screening and prevention. But our health care system is built in such a way that is complicated, where if you go in for a screening procedure and someone does a procedure that is potentially life-saving that now becomes diagnostic, it might not be covered. I mean, that's a complexity that most people aren't going to understand, and it's hard to explain. So that's just 1 example of how health care systems are messed up with respect to insurance, but we also have to think about the individual institutions. How welcoming are institutions to individuals, right? Is it scary to walk into your cancer center? Is it overwhelming? How is your signage, right? Who's sitting at the front desk? Are the people who are welcoming people, do they look like the community that you're serving? These are all systems-based things that can be done or that can really complicate, if you will, cancer care if it's not done in the right way. And so these are just a few examples. Even we can talk about the fact that there are some cancer centers that don't accept Medicaid. I mean, what is that? That means you're excluding a whole host of individuals because they may have lower income than other people. Does that mean that people who have lower income are not as important as people with more money or have the ability to have private insurance? Shouldn't be that way. But again, health systems issues that can cause barriers and create issues-- especially when we talk about clinical trials, which are part of cancer care. We want people to be enrolled and participate in clinical trials because that's what changes the way that cancer care is delivered in this country. The reason why we are curing some breast cancers, the reason why we are curing other cancers is because there have been clinical trials that have led to discoveries that have allowed us to say, "Wow, this is a new standard of care. We're saving lives." But that means that if you don't have access to certain cancer centers where the clinical trials are happening, you are not able to participate. And so these are the barriers, the systemic barriers, the health system barriers, just a few of them that actually can really complicate care and make it such that individuals who might want to participate in treatments that can potentially change the face of cancer care-- they're not able to do it right now. So we have some work to do in trying to figure out how to open up the access and remove those barriers. Brielle Gregory Collins: Right. Thank you so much for outlining that and for outlining all of these social determinants of health. So now that we've kind of talked through all of these different social determinants of health, how can addressing these social determinants of health help improve cancer outcomes? Dr. Karen Winkfield: The biggest thing that we could do is prevent cancer. That's the way to have the best outcome, right? So if we are to think about location, where people live, their ZIP code as being a driver of health and health status, then that means that we need to start thinking about the context that people are living and saying, "What is it that can be done both from an individual, family, community, and a systems standpoint to help improve health status of different ZIP codes?" You may have seen the maps where people have mapped out a lifespan on a map based on a distance, right, whether it be along a highway or on the subway system, in Washington, DC, looking at the Metro system. And so there's people who are living, like, in the middle of DC, and they have a lifespan of 83 years. But literally, you go up on the yellow line, and you go up to northeast DC, and that drops by 10 years. Where you live should not matter in terms of your health status, but it does. And so, again, by thinking about these social determinants of health, we can say, alright, what are the factors that are impacting access to care, that are impacting one's ability to prevent cancer or to reduce risk for cancers, meaning reduction of tobacco use, reduction of food insecurities, improving how you can walk around in a community or get exercise? What are people's employment status? Do people have to work 2 or 3 jobs just to make ends meet? If so, that means they're going to pay attention less to their health and well-being, right? Those are the sorts of things that we can think through to really help improve health status. Now, the other thing that's really important in terms of thinking about from a cancer perspective is one's ability to get access to screening. So, again, social determinants of health, what insurance product do people have, making sure that people have access to the screenings. And like I said, this colorectal cancer example that I gave you is 1 where, what the heck, you go from screening to a diagnostic just because there's a procedure that's done that really can help prevent cancer. These are the sorts of things that are really vital to make sure that we're addressing. And also kind of thinking about, again, location, how do we get people to and from the places where cancer care is is really an important consideration as well because if people can't get to where the cancer care is happening, then obviously, they're not going to get access to the treatments that they need, or it may delay their care. And we know that delays in care can oftentimes lead to worse outcomes as well. Brielle Gregory Collins: Right. Okay. And finally, where can people with cancer find resources to help them cope with the challenges of these social determinants of health? Dr. Karen Winkfield: So anyone who has a cancer diagnosis is obviously thrust into this massive system, right? It doesn't matter if you're in a local community center where you might meet with a surgeon and then have to travel 30 minutes in the other direction to go and meet with a medical oncologist, and maybe you drive another 100 miles to go to radiation, right? There's that. Or you can go to a big giant cancer center where everything is put into 1 single building. You're popping up and down floors, or maybe everything's on the same floor. Doesn't matter what system you're in. My first recommendation would be let people know what your concerns are, right? Let 1 of your providers know, for instance, "Hey, listen, I'm struggling with transportation," or, "I'm worried about my job," or, "I'm worried about X." Really important to feel comfortable with your care team, right? So that first step in terms of overcoming barriers is, do I feel comfortable with the people who are helping me through this cancer journey? And it's the entire team, not just the doctor. It's the nurse. It's the therapist. It's the entire team that, hopefully, you feel comfortable with so you can say, "You know what? I just need to be open, and I need to share what my concerns are related to X," right? Doesn't matter if it's finances or food or whatever; just talk to your team. And so 1 of the things that I'm trying to do is encourage providers also to ask people, right? So this is bidirectional. So, yes, we're talking right now directly to individuals who may experience cancer, or maybe the family member has experienced cancer. So, yes, please bring it up if you have concerns. But the other piece is providers need to do a better job asking kind of what people's concerns are as well. So that would be the first thing. Many centers will have social workers or other people who can help to navigate people through the system and be able to reduce some of those barriers. The other thing is I oftentimes will point people to wonderful resources online. So, again, not everyone has access to online kind of services. So this is why asking and having conversations with your care team is important because we don't want anyone to say, "Well, I don't have access to the internet," or, "I don't know how to Google," or, "I can't read." So please, please, please don't think that this is just comprehensive. I want to say please talk, right, opening your mouth and having conversations first, but certainly, online, there's some great resources. The American Cancer Society has wonderful resources. They've been providing a lot of transportation services for individuals with cancer for decades. I know that with COVID, some of that kind of was reduced, but it's a wonderful opportunity for volunteers even to say, "I'm going to give back. I want to be there to provide transportation services for individuals going through cancer journey." So the American Cancer Society has lots of resources. The other thing is Cancer Support Community is another online venue. You can pick up the phone and call them. But Cancer Support Community is another opportunity to kind of really have-- these are some resources that are available. And I must say probably 1 of the number 1 resources I tell people to go to is Cancer.Net. And you know why? It's because they actually have a full-on resource page, right? So you can go to Cancer.Net and actually look at the resources page, and they list some of these, including Cancer Support Community, right? So there are lots of different resources that can be available to individuals. It's just a matter of looking, and it's a matter of kind of knowing where to go. So, again, I point people to Cancer.Net because it oftentimes has lots of different places that people can go to, some of which are related to a specific cancer diagnosis, right? So Komen for Breast Cancer is 1, but many of them generic, like the American Cancer Society or Livestrong or Cancer Support Community. So I just recommend people go to Cancer.Net or 1 of those other online resources to help them find what might work for them. Brielle Gregory Collins: Thank you so much, Dr. Winkfield, especially for sharing your time and your expertise today. It was so great having you. Dr. Karen Winkfield: Well, thank you, Brielle. I'm so grateful for this opportunity. I'm so thankful that we're able to talk a little bit about social determinants of health and things that people can do to help reduce some of those barriers to cancer care. Brielle Gregory Collins: Yes, absolutely. And for our listeners, you can find more information on this topic at www.cancer.net/disparities. ASCO: If this podcast was useful, please take a minute to subscribe, rate, and review the show wherever you listen to podcasts. This Cancer.Net podcast is part of the ASCO Podcast Network. 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