A comprehensive assessment of social determinants of health for metastatic breast cancer.
Authors: Abu-Khalaf Maysa M. , Ilori Tolulope , Vaughan-Briggs Celeste , Keith Scott W. , Shimada Ayako , Lopez Ana Maria , Leader Amy , Cammy Rebecca , Jaslow Rebecca J. , Silver Daniel P. , Zibelli Allison M. , Scarpaci Anthony Pool , Rodriguez Joanna , Mitchell Edith P. 
Published: June 2023

e18562

Background: We evaluated the utility of an electronic medical record (EMR)-based risk stratification tool of social determinants of health (SDOH), financial toxicity and social barriers to identify metastatic breast cancer (MBC) patients (pts) at risk of inequity in cancer care. Methods: We enrolled 40 female pts within 60 months (mo) of a MBC diagnosis (dx). Pts had an encounter with social work (SW) at baseline that includes: 1) Eleven SDOH domains 2) Financial toxicity 3) CMS validated psychosocial assessment (Ax). A 2nd Ax within 3 mo was optional. SW documented interventions offered to pt. Retrospective chart review included pt demographics, treatment (Tx) and clinical outcomes. Descriptive statistics were calculated for pt demographics, clinical outcomes, SDOH acuity scores, and interventions offered by SW. Clinical outcomes were summarized with frequency counts and percentages. All analyses were performed with SAS 9.4 (SAS Institute Inc., Cary, NC). Interactions between race and SDOH risks were explored by logistic regression analysis but limited by sample size constraints. Results: Of 40 enrolled pts, 39 completed baseline and 24 completed 2nd Ax. Mean age 61 y (range 31-85); 20 White (W) and 19 Minority (MIN) [18 Black, 1 Asian]. Median time from MBC dx to baseline Ax was 7.3 mo (2.7-19.5) for MIN pts and 16.2 mo (3.8-28.8) for W pts. Mean time for SW to complete baseline Ax was 32.7 min and 2nd Ax was 26.7 min. Of 11 SDOH domains, MIN pts were more likely at risk in 6 domains compared to W pts: Financial Resource Strain (MIN 63% v W 45%), Housing Stability (MIN 16 % v W 0%), Depression (MIN 11% v W 5%), Physical Inactivity (MIN 84% v W 65%), Transportation Needs (MIN 26% v W 10%), and Food Insecurity (MIN 42% v W 10%). W pts were at greater risk compared to MIN pts for Tobacco Use (MIN 47% v W 60%) and Lack of Social Connections (MIN 53% v W 65%). Both groups reported similar risk for Stress (MIN 74% v W 70%). Every pt was at risk in at least one SDOH domain. Eleven (58%) MIN v 5 (25%) W pts were at risk in the 5 or more SDOH domains. At the baseline Ax, the most common interventions provided by SW: financial (MIN 36.8% v W 25.0%), food (MIN 42.1% v W 0%), transportation (MIN 21.1% v W 0%), and mental health referral (MIN 5.3% v W 15.0%). MIN pts were more likely to have delay in starting 1st line Tx > 21 d with a median time of 29 mo (range 20-52) v 19 mo (range 9-54.5) for W pts. Within 3 months of a referral, 13 MIN (68.4%) v 6 W (30%) pts had a palliative care encounter, and 6 MIN (31.6%) v 5 W (40%) pts met with a genetic counselor. On regression analysis, no associations were detected between SDOH risk or SDOH risk-by-race interactions with time-to 1st line Tx or time to palliative care encounter. Conclusions: In our catchment, MIN pts with a MBC dx were more likely to face multiple SDOH risks compared to W pts. The impact of interventions to address SDOH and social barriers on cancer care outcomes should be evaluated in a larger cohort of MBC patients determined to be at risk.