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New, effective immunotherapies have drastically improved cancer treatment outcomes, but the rapidly expanding use of often expensive novel treatments for many different cancers has led to emerging evidence of racial and income-related disparities in care.

A paper in the most recent addressed disparities in access and outcomes from immune-based cancer treatment. In the following interview, Raymond U. Osarogiagbon, MBBS, chief scientist for Baptist Memorial Health Care and director of the Multidisciplinary Thoracic Oncology Program and the Thoracic Oncology Research Group at Baptist Cancer Center in Memphis, answered questions about the topics discussed.

What does the article add to the literature about disparities in immune-based cancer treatment?

Osarogiagbon: The article provides a framework from which to understand the origin of disparities and the optimal targets for corrective implementation. It also proposes that disparities are an inadvertent, but not inevitable, result of discovery. Therefore, we emphasize the need to be proactive in addressing the reality that disparities emerge and worsen with discovery.

Because immunotherapy is novel and still intensely under investigation, we need to understand the full range of potential benefits, the cost of treatments, and disparities in access that are already emerging.

Novel, especially highly effective, treatments tend to be expensive, to have recently emerged from clinical trials, and often remain subject to clinical trials activity to fully understand the range of risks and benefits. Endemic disparities in clinical trials access and participation often mean that the populations tested to prove the value of new treatments are heavily skewed away from minority, indigent, and other disadvantaged populations.

The expense of new treatments, such as immunotherapy, also exacerbates the access disparities in the same direction. Because of under-representation in clinical trials, the evidence of benefit and risk in disadvantaged populations creates great uncertainty in clinical practice upon approval of drugs and other treatments.

Why is immune checkpoint inhibitor (ICI) therapy highly susceptible to access and outcome disparities?

Osarogiagbon: ICI therapy is fairly new, is expensive, and the risk/benefit ratio in populations who are excluded or uninvolved in clinical trials raises ambiguity. Most immunotherapy clinical trials have less than 2% of participants from racial minority populations, yet such populations are often over-represented in the real-world population of patients with the relevant cancers in the U.S. Exemplifying the problem of disparities, data are emerging from real-world practice experience that racial minorities are significantly less likely to be treated with these life-saving/life-extending treatments. Paradoxically, Black persons seem to particularly benefit from immunotherapy.

Why is it important to keep disparities in mind at the individual, provider, healthcare system, and societal/policy levels?

Osarogiagbon: From the perspective of corrective intervention, the greatest impact and the most efficient approach to overcome disparities occur at the policy level, which is more effective than the organizational level, which in turn is more effective than the provider level. The least efficient approach to corrective intervention is the retail-level/patient-level with piecemeal interventions.

The main drivers of care and outcome disparities are social policies and the organizational response to them. Patients often have no control over what care they receive. Yet, disparities research has traditionally tended to focus more on the patient level -- mostly in descriptive fashion. This has the unfortunate side effect of creating a subliminal attitude of victim-blame.

What may be potential race- and income-based differences in access to immune checkpoint inhibitors?

Osarogiagbon: Immunotherapy drugs are extremely expensive: the uninsured and underinsured have difficulty accessing them. Doctors most proficient in their safe and effective use are still mostly at high-powered, academic cancer centers; socioeconomically disadvantaged and racial minorities do not have ready access to such centers. A lot of NCI-Designated Comprehensive Cancer Centers, even though heavily reliant on tax-payer funding through NIH grants, often do not accept Medicaid and uninsured persons.

What is your bottom-line message for practicing oncologists?

Osarogiagbon: Disparities in access, quality, and outcomes of care are not inevitable. They can ideally be prevented, eliminated, or at worst minimized. Disparities rob society of the full economic benefit of discovery. Healthcare systems and the providers who work within them are major causes of care and outcome disparities. As , we have met the enemy, and he is us.

Read the article here and expert commentary about the clinical implications here.