Confronting Cancer Healthcare Inequities

Tracy Battaglia, MD, MPH is the first leader of the new Initiative to Address Cancer Inequities at YCC and while it might be a bit early to discuss specifics, she could not be more poised to tackle the pervasive issues in Connecticut.

After a prestigious career at Boston University (BU) and Boston Medical Center, the largest “safety net” medical center in New England, Dr. Battaglia says she is “very fortunate to build off of the strengths that already exist at the Yale Cancer Center particularly their strong community outreach and engagement program—a critical component to addressing health inequities.”

As a clinician-investigator internationally recognized for her collaborative action-oriented approaches in pursuit of equitable care, Dr. Battaglia is well aware of some of the challenges she faces in her new role. Inequitable healthcare, while recognized decades ago, became headline news early in the pandemic and remains so.

“The COVID pandemic and all the social injustices that were uncovered during that time period woke us up as a nation and demanded accountability on the part of healthcare systems, researchers, policy makers, and everyone," Battaglia said. “From my perspective it was like ‘It’s about time.’ People had been saying that inequities and disparities were important, but now there is an expectation and demand that you are actually going to do something about it.”

Recognizing the problem is a first step only, said Dr. Battaglia, who is Associate Cancer Center Director for Cancer Care Equity. “I do think, from my perspective, it’s still jargon. It’s words for many, without action.” Having a vision, committing resources, and doing the work collaboratively with the affected community is the more challenging next step and that is what drew her to YCC.

“I’m most excited about [YCC Director] Eric Winer’s leadership…. He has this vision to create this unparalleled clinical oncology program in [Connecticut] and within that vision is [the goal of] ensuring that clinical excellence gets to everyone, equally,” Dr. Battaglia said. “That’s the shining star that will guide this new initiative.

“To be able to do it right you need to invest in it…bring in the right partners, and sometimes challenge the traditional approach of care delivery,” Dr. Battaglia said. “A lot of people who use inequity words and the phrases don’t understand, really, what it takes to actually do the work. It’s not pretty. It’s messy and it takes intentionality, long-term commitment, and time.”

The pace of the work might not align perfectly with the pace of a traditional academic center, which is often driven by the sort of timelines, milestones, and benchmarks required by institutions such as the National Institutes of Health, Dr. Battaglia said.

“[Instead] sometimes we have to stop and slow down and listen and bring in people who are not traditional experts… bring them into the fold to help us design approaches, programs and research that will actually improve the care of those who are most at risk,” she said.

Dr. Battaglia is speaking from experience, as she explained in her December presentation at the Academy Health 16th Annual Conference on the Science of Dissemination and Implementation. There she reported on an ambitious $9 million, five-year pragmatic clinical trial, a recently completed study on introducing oncology patient navigators into six Boston academic centers to help breast cancer patients from historically marginalized backgrounds get timely and quality cancer care. The navigation intervention focused on identifying and removing individual social barriers to care, such as transportation, insurance, language, and childcare.

The study was supported by the infrastructure of the hospitals’ academic institutions—BU, Tufts, Harvard, and the University of Massachusetts—including strong regulatory data, informatics, community engagement, biostatistics, and more. “But even with all that, the catalyst was the community who came together and demanded action. This study was unprecedented, in that it brought together competing institutions, to improve care for a hard-hit population of patients who were not being served equitably. And the hardest part of it was getting all the stakeholders to agree on an approach and to actually implement it.

“A lot of time and energy went into developing relationships, coalitions, advisory groups,” Dr. Battaglia said. “[And there was] making sure the clinicians had a voice, navigators had a voice, and patients had a voice and then trying to integrate that to really change the way we were delivering care in the respective hospitals.”

The trial results were mixed. Successes included the establishment of a protocol across the six Boston hospitals, the implementation of tools to support navigation in the field, and sharing data across hospitals.

“Where we fell short was actually implementing the protocol and rolling it out in real life,” Battaglia said, noting that only about 50 percent of the patients eligible in the period got any navigation services at all. The study did show, however, that women who received the navigation protocol definitely did better, she said. “Their care was more timely and the quality of care was more complete.”

Some identified barriers included the lack of a consistent way to identify patients who needed navigation services, the burden of tracking and sharing data if it is not part of the existing electronic medical record, and a hospital leadership commitment to providing resources, and prioritizing changes in traditional workflow.

Dr. Battaglia says there remains a great deal of data to consider, but one outcome is certain and persuasive — navigation improves care for those most at risk for cancer care inequity, and there is a dire need for public policy to make oncology patient navigators sustainable in the current care system. This work contributed to the Biden administration’s decision to include navigation in the CMS (Centers for Medicare & Medicaid Services) physician fee schedule for 2024.

“So, we’re making progress because we’re sharing data,” said Dr. Battaglia, who is founding chair of the National Navigation Roundtable and participated in several National Cancer Institute cooperative groups and, most recently, on the working group of the President’s Cancer Panel that is exploring technology that may advance navigation programs.

“The only reason we were successful at collaborating to begin with…was because the community demanded it of us,” Dr. Battaglia said, adding that in addition to the COVID pandemic in the midst of the study, it also took on a personal element.

“In complete candor, I was diagnosed with breast cancer at the very outset of the study [and] that experience exemplified why we had to do this. When I was diagnosed with breast cancer, what happened? People rallied around me and got me right into excellent care.”

While thankful for their concern, Dr. Battaglia recognized the irony of getting the expert care she needed from a healthcare system she understands. “That’s the problem right? I became more acutely aware of the inequities and more acutely aware of the need to pull in people with more diverse backgrounds. To do equity research you need to acknowledge your lived experience…my approach to this changed with that.”

March was a busy first month for Dr. Battaglia, who has already been busy building relationships, coalitions and partnerships as she learns how best to support patients, providers, and practices across the state.

At the same time, Dr. Battaglia said, “YCC is also discovering new treatments and new approaches, but if we are not intentional about making sure they are reaching everyone then the inequities will get worse. My job in the first year is to partner with key stakeholders and identify [situations] that are ripe for action-oriented interventions.”