Asking the Right Questions

Across the continuum of oncology care, our patients' outcomes depend on many factors: living a healthy lifestyle, undergoing screening tests, receiving and adhering to treatment, and managing toxicities and comorbidities. These factors, in turn, depend on social determinants of health, such as access to care, safe housing, food security, and social support. Addressing the social determinants of health requires appropriate screening, involvement of multidisciplinary teams, extending payer benefits to these determinants, and providing services that fall outside of traditional medical care.

Within primary care, many professional societies are now recommending universal screening for social determinants of health. We are fortunate in oncology that routine distress screening is widely performed and often includes questions pertinent to these determinants. Yet, we have an opportunity to tailor questionnaires to better capture specific elements of social determinants of health, such as food security and housing needs. A recently reported survey of cancer patients in New York City showed that housing needs across six categories (cost, home loss, stability, conditions, accessibility, and safety) were often interrelated and emerged both before and after a cancer diagnosis.¹ A study of primary care patients found that 40 percent had food insecurity.² These studies highlight the need to ensure that we are asking the right questions of our patients. Fortunately, there are numerous validated social determinant screening tools that can enhance oncology screening tools.

With screening comes the responsibility to address identified needs. A survey of 154 physicians indicated that doctors are supportive of screening for social determinants of health, but 66 percent are not confident in addressing needs and believe that social workers are better equipped to do so.³ The oncology multidisciplinary team is well positioned to address these issues with participation of nutritionists, navigators, and social workers. These professionals do an extraordinary job of creating internal programs or identifying community resources to meet patient needs and are extending that expertise in ways that specifically address social determinants of health. For example, 2019 ACCC Innovator Award recipient New England Cancer Specialists partners with a food bank to address food security issues.

Participation by government and private payers is also necessary, and their involvement must extend beyond covering access to medical care. Even in Canada, where universal healthcare is available, patients who screened positive for social determinants had lower utilization of health services and worse management of disease.⁴ In the United States, payer involvement in social determinants of health is just beginning. UnitedHealthcare and the American Medical Association are partnering to standardize collection and integration of International Classification of Diseases, Tenth Revision data to assess these determinants. The Centers for Medicare & Medicaid Services now allows Medicare Advantage plans to cover meal delivery, transportation, and home cleaning services; however, lack of additional funding has dampened adoption and there is significant regional variability in funding for non-medical benefits to address social determinants of health.

Addressing the social determinants of health can lessen the burden of cancer, not only for those currently diagnosed but also for the 40 percent at risk due to modifiable lifestyle factors. Success depends on healthcare professionals, payers, government, and nonprofit agencies collectively acknowledging our responsibility and coming together to create solutions.