Aug 29, 2022
Shannon Westin, Francesca Gany, and Theresa Hastert discuss the topic of food insecurity among patients with cancer.
TRANSCRIPT
Dr. Shannon Westin: The guest on this podcast episode has no disclosures to declare.
Hello friends and welcome to another episode of JCO After Hours, your podcast to get more in-depth on some of the amazing work that has been published in the Journal of Clinical Oncology.
I am thrilled to be here today with two fantastic investigators and researchers who are going to discuss a paper that is titled “Food to Overcome Outcomes Disparities – A Randomized Control Trial of Food Insecurity Interventions to Improve Cancer Outcomes.”
This was published online in the JCO on June 16, 2022. We're joined by the principal investigator Dr. Francesca Gany, who is the Chief of Immigrant Health and Cancer Disparities service at the Memorial Sloan Kettering Cancer Center in New York City.
In addition to Dr. Gany, we're also joined by Dr. Theresa Hastert, who's an associate professor in Population Science in the School of Medicine at Wayne State University in Detroit. And she published an editorial that went along with this article named “The Potential of Cancer Care Settings to Address Food Insecurity.” This was published in the JCO on July 1st, 2022.
Welcome, ladies. So excited to hear about this work.
Dr. Francesca Gany: Thank you! It’s great to be here.
Dr. Theresa Hastert: Thanks so much for having me.
Dr. Shannon Westin: So, what we're seeing more and more of is oncologists getting into other areas of expertise. For a long time, we've all been involved with treatment trials, and we've started getting into survivorship and health services. But I think that we really are realizing there are other issues for our patients that affect their cancer care and outcomes.
So, first, I just wanted to level set and see if maybe Dr. Gany, you can kick us off, can you define food insecurity and just kind of briefly discuss the prevalence patterns in women and men that are diagnosed with cancer?
Dr. Francesca Gany: Sure! So, food insecurity is essentially not enough access to food to help you maintain your health. And that could come from a variety of reasons, including not having enough money to buy food, living in a food desert, where there's not availability of food and other factors that could make food inaccessible to you.
This potentially has a tremendous impact on health. We see that with folks with cancer and folks who don't have cancer. We know with cancer patients, it's a particularly difficult issue because of the increased nutritional demands that come with a cancer diagnosis, the need for special diets, and decreased absorption of nutrients for certain folks. So, it's especially important that our cancer patients have access to enough healthy food, so they can have the best cancer treatment outcomes possible.
Dr. Theresa Hastert: I can add a little bit about the prevalence of food insecurity more broadly. So, in the US population, about 4% of Americans have what's called very low food security. So, that's where people actually reduce the amount of food they eat because they have a lack of money for food.
And by contrast, in previous work among cancer survivors, that number is closer to about 15% in sort of population-based studies and much higher in certain select patient populations.
So, if you're in an under-resourced population, and as some of Dr. Gany’s previous work has cited figures of more like 55 to 70% of cancer patients and survivors with low resources can be food insecure and not have enough money for food.
Dr. Francesca Gany: All of this has, of course, worsened with a COVID pandemic because just food insecurity rates have gone up overall and we have certainly seen an impact on our patients in the cancer centers in which we work.
Dr. Shannon Westin: And you can imagine with the high costs of drug pricing and all of the other issues around coverage of cancer care that people are having to make those types of decisions between food and shelter and basics and getting their treatment for their cancer, their treatment for their other related comorbidities. Am I on the right track?
Dr. Francesca Gany: Absolutely! In fact, we did a study that specifically asked patients whether they were not purchasing medications in order to be able to feed their families. And a very high percentage of them, up to a third of patients, said that they were foregoing some of their cancer meds in order to be able to feed their family.
We asked it the opposite way as well, whether purchasing their cancer meds meant that they were unable to feed their families and unfortunately, it was a similar percentage for those food insecure patients.
So, it has a tremendous impact on fully engaging in cancer treatment, and also being able to take care of one's family which of course is so important to our patients.
Dr. Theresa Hastert: So, in Detroit, we're in Michigan, which expanded Medicaid. So, in the work that we do predominantly among African-American cancer survivors, we find that most Americans are able to access care, like with the expansion of Medicaid, people are able to get treated for cancer. Paying for drugs is another thing but we still have a lot of food insecurity among this population. About 15% of our cancer survivors, African-American cancer survivors in Detroit are food insecure.
So, it's not an insurance issue in the sense. They have Medicaid coverage and they're able to get cancer care, it might not cover every out-of-pocket expense, they still have food insecurity. So, broadening insurance is not necessarily enough to help people avoid some of these follow-on impacts.
Dr. Francesca Gany: Yes! One very important issue is that looking at food insecurity at a moment in time with our patients is not enough because we know that as treatment progresses, financial hardship also progresses – financial toxicity of the cancer treatment.
So, it's really important not to do just an initial screen for food insecurity and for other social determinants of health because food insecurity is certainly a window into other essential needs that have to be met, but it's really important that we don't just ask once, but that we ask in an ongoing way because we know that as time goes on, it only gets worse.
Dr. Theresa Hastert: That's so important. I've talked to several providers who have these issues with patients, where it's the people who are sort of more middle class who are going into cancer and be like, ‘I'm fine, I’m fine, I’m fine” when first asked if they need assistance. And it's not for several weeks or months when they start racking up out-of-pocket costs, and then suddenly, they realize they're not fine. It can become very delicate also because people are used to being self-sustaining, and financially independent, and they're used to being able to maybe help other people who have financial needs to donate to charities and things like that. And there can be a shift for people when they realize, ‘’Oh, no, now I need assistance.’ That can be difficult for people to grapple with. And it's so important to keep checking in with patients throughout their treatment experience to see how they're doing.
Dr. Shannon Westin: I think this is really a great segue into kind of getting into the nitty-gritty of the publication. I would love for you, Dr. Gany, to give our listeners a little bit of information around the trial, the patient population that you chose, and the intervention arms.
Dr. Francesca Gany: Sure, I’m happy to do that! So, we started when we first saw the high prevalence of food insecurity among the patients, we were working with that are partnering with safety net institutions, we knew that we needed to do something.
And so, we did a study and we looked at emergency food resources in the top 50 zip codes that our patients lived in and then we did site visits, etc, to these emergency food resources and saw how inadequate they were for our cancer patients. They were inadequate because they didn't have medically tailored foods. Often, they didn't have culturally tailored food choices. Their hours of operation were very short and with all of the appointments that our patients had to keep, it made it really hard for them to reach the pantries. They weren't that geographically accessible so that was a deterrent to patients.
So, we realized that we have to do something that was much more convenient for our patients that would address their medically tailored food needs. And also, the difficulties they might have traveling to another site to get food.
So, we started a medically tailored food pantry of one initially, in which we partnered with a local food bank for New York pantry site that was close by to the hospital and worked with them around food choices for our patients, etc. And would work with them to pack the bags at their site and then we would bring the bags over to the hospital.
We found with our patients that there was tremendous uptake of this service, and tremendous appreciation and they reported improved quality of life and improved ability to get on with their cancer care.
This grew to now 15 pantries in both safety net facilities and also Comprehensive Cancer Centers because there are a sizable number of people in Comprehensive Cancer Centers, as you know we've been discussing that are also food insecure.
So, we had 15 pantries, but pantries - they’re a great piece of the solution - but we didn't feel that they were enough of the solution because even though they were medically tailored and patients had some choice, they didn't have total choice in what they were getting. And especially with cancer care, people's food preferences shift, etc. And what they need to be healthy shifts.
So, we explored two other options of home grocery delivery service where they would get to pick what groceries came to their home, and having the groceries come to their home eliminated the issues that come up certainly with having to carry heavy bags, etc.
It was some choice that this gave them but the windows of delivery were a little bit of a problem for the patients because sometimes the food delivery services would be coming at a time that didn't work for the patients.
And then, the third option was a voucher system, where people get basically a debit card, and they can buy whatever they want within, no alcoholic beverages, etc, but whenever they want to purchase with that voucher card. And we accompanied that with education around healthful food choices, nutrition during cancer, etc, which was translated into a number of different languages.
So, those ended up being three pieces of the arms of the study. The pantry had become pretty much the standard of care in all of the facilities we were working in. So, that was one arm. So usual, customary care. And then, we added to that because it was in the sites that we were at, we added a voucher arm as well.
And in the third arm, it was a home grocery delivery arm. Those were the three arms of this randomized control trial. All of the monetary amounts were the same for the three arms. So, the grocery bag cost the same as the amount they were given in the debit card, which costs the same as the home grocery delivery pretty much, or it was at least equivalent nutritional content and food content. So, those are the three arms of the study.
Dr. Shannon Westin: Great! Well, just cut to the chase and let the group know what did you find?
Dr. Francesca Gany: So, we found that after six months of participation, the voucher plus pantry arm had the greatest treatment completion rates, 94%, versus the home grocery delivery, 82.5%, versus the pantry alone, which was 77 and a half percent.
So, tremendous differences between these three arms. All three arms saw a significant improvement in food security status but those were the treatment completion rates across the arm.
We also looked at quality of life and depression symptoms across the arms at 6 months, and across all arms, patients had fewer depression symptoms in follow-up. And improved FACT-G quality of life scores. But the statistically significant differences were actually found in the pantry and the delivery plus pantry arm for both of those measures.
Dr. Shannon Westin: That is so interesting and so exciting to see this type of intervention making a difference for our patients. Was there anything that surprised you about your results?
Dr. Francesca Gany: So, the one that was a little surprising was why the quality-of-life results did not exactly mirror the treatment completion rates. And we are assuming that that has to do with the fact that with the pantry, there's a lot of in-person interaction with staff and with the home grocery delivery, actually, because many of the patients found it a little bit tricky to order the grocery deliveries online, they also had a fair amount of staff interaction. Whereas with the voucher, there was less of that.
So, perhaps that explains that we're not sure and we're doing a much larger randomized control trial now in which we're going to look at that. One really great finding was that around food choices and healthy food choices with the voucher because we wanted to look at that, we were controlling what we gave to patients with the pantry arm, and we were controlling that to some extent with the grocery delivery, especially because we were ordering with them.
But we were very interested for the voucher arm and across the board, people made very healthful choices with the voucher. Again, they all were accompanied by nutrition education, etc. And interestingly, limited English proficient patients and patients who were born abroad had the healthiest food choices.
So, this was a great way to intervene with all patients who were food insecure. And we saw that it had a tremendous impact equally regardless of country of birth, language, etc. And great extra finding that there were healthful food choices and that was especially true in immigrants and in folks who have limited English proficiency.
Dr. Shannon Westin: Great. It's so exciting. I think though, it brings up the obvious question that seems like a ton of work. So, how do we operationalize this in our clinic? How do we screen patients? How do we work with our cancer center directors or our clinic directors to be able to provide these types of interventions? Sorry, I know it sounds like it's a million-dollar question.
Dr. Francesca Gany: This screening is simple. For these studies, we use the 18-item USDA Food Security screener. That's a longer instrument but we wanted to make sure we use that for this study. But in actual clinical practice, the two item screener works. And we are working now on one question specifically for cancer patients that we're finding is also quite sensitive and quite specific, and that does not take a long time at all.
We should be screening everyone. We should be screening in an ongoing way. We should be tracking this as a very important patient outcome. What does take longer and which is a little bit daunting to folks is that once you find food insecurity, you need to treat it.
And so, we do a lot of work around how to treat food insecurity and how to treat it efficiently. In the end, I actually think that the food voucher is going to be the way to go because it requires less staff time. And people are used to paying for groceries with debit cards, and with cards, and that has not been an issue at all for our patients. And I do think from a clinical operations perspective, from a policy perspective, and from an insurer’s perspective, this should be part of the workflow. The vouchers are a really easy way to do it. We’ll of course have more data when the larger trial is done.
Dr. Shannon Westin: These points are so important around needing to be able to address food insecurity when you find it. The screening is very simple and providing food to somebody else is much less so. And it can actually be harmful to screen for something and then not do anything about it like that could actually increase patient's distress if you're making moves like you're going to help them and then don't, it can actually be harmful.
But I was wondering, Dr. Gany, if you could talk a little bit about how you got this off the ground, functionally speaking, at the beginning. Like, if somebody wanted to do something similar for their own cancer survivor, with their patient population, what kinds of steps can people be taking? Who did you work with? Did you get any pushback? Are there any lessons learned that you could share with people?
Dr. Francesca Gany: Yes, so I think there are more and more pantries actually now that are being implemented at cancer sites. So, I think that there is broader buy-in now on the systems part.
So, I think that's a little bit less of a heavy lift than it might have been a few years ago. We were in a very receptive place. They were really happy that we wanted to help the patients this way and were very facilitative.
And so, we partnered with a food bank for New York Food Pantry at our initial site, and we partnered at other sites, and then we became a food pantry site ourselves so that we could have access to as many varied products as possible, so that we could put together bags that were tailored, etc. And so, then patients could pick the items in the pantry that were tailored.
The couple of issues that arose was this one was a space issue, especially in New York City spaces at such a premium and the clinics were really worried about even giving over a closet. So, in one pantry, we have a few drawers in the conference room, and we pull everything out when we get there. We have a cart and we wheel it around, and we wheel to a spot, etc. So, we take care of it that way.
At another site, we keep everything in the basement. When we came to where there was more space, we wheel it up to the cancer clinic. Some sites had more space and that was great, we could set up the pantry to be permanently there and displayed.
The other issue that concerns sites was food safety, food management, vermin, etc. So, all of our folks are trained in food safety, food handling, and food storage, so that we store it in the safest way possible. And so, that there were no issues around that. So, that has really worked out.
One other thing is we've also introduced an intervention at some of the sites of food navigators. So, not only do they help patients with the pantries, etc., but they also work with folks around what are some of the other resources they can access that'll work for them in their communities near their home that have the right foods for them, etc. And that's helped. This was not in the study, but this is just in our clinical operation for this. That has helped as well.
Dr. Shannon Westin: It's so great. It's such a lot of work and it seems so essential. I think it's really going to be on us to take it back to our institutions and determine what works. I loved your line about it seems like the vouchers might be our best. I think we really need those kinds of real-world solutions that we can actually bring back to implement.
I guess my other question is, is there a role for policy change here? Is there something we can do kind of on a more national level to address these things rather than it being at the individual practice and institution levels?
Dr. Francesca Gany: Oh, my God, yes! That is our hope from these studies that at the healthcare system level, the insurer level, and then the broader policy level in New York. For instance, some of our patients are undocumented immigrants. So, they have less access to food programs that others might have access to such as SNAP.
By the way, we saw the same food insecurity rates in SNAP participants as we saw in non-SNAP participants because the benefits are not that hefty in SNAP, but that is an aside.
But for undocumented immigrants, let's say, when in New York when they are diagnosed with cancer, they are eligible for Medicaid for the treatment of emergency conditions. So, such an easy thing to do would be to do a food insecurity screener when you were doing the emergency Medicaid eligibility, and then help people right into a food program, a voucher program.
When we think of the costs of the vouchers, in this study, the costs were a little bit more than $200 a month. For the vouchers, the staff time does not cost that much. And when one thinks about the cost of cancer treatment, of cancer care, and what a teeny drop in the bucket this is compared to the cost of cancer treatment. This should be a no-brainer for policy folks because it is so little money compared to the bigger outlay with so much impact.
So, that's one example of how we see it rolling out in a policy arena. When you're screening for Medicaid, for the treatment of emergency eligibility, you ask a couple of food insecurity questions or the one we’re hoping to roll out and if somebody's food insecure, it’s just they automatically got the food voucher.
Dr. Theresa Hastert: I think, well, ultimately, being able to have people in with policy-level solutions for this would be amazing, it would be a huge step. In the meantime, I really think it is going to be a lot of individual people and individual cancer centers trying to connect the people in front of them with the resources that they need.
And in order to do that, I think we’ll really make the biggest progress when we do get buy-in, we get champions higher up in the cancer centers. When cancer center leadership takes it up and helps smooth paths, and when funders put efforts behind it, and I think they're doing this increasingly, put efforts behind addressing social needs among cancer patients and survivors, and also our accrediting agencies in terms of tracking, ‘Are you not only screening people? Are you hooking people up with resources?’
And of course, there's a balance between cancer centers that are set up to diagnose and treat cancer but if our patients are dealing with all these other issues, we need to be doing what we can to help address those issues so people can recover from cancer, can go on to live healthy, happy lives, could have the best outcomes.
Dr. Francesca Gany: Definitely. And some natural allies, the cancer centers, our folks in nutrition services, because they totally know how important it is for people to have access to nutritious food during their treatment. So, they're great allies, social work depending navigators, and community helpers depending on how the institution is structured. But it has not been hard for us to find champions at any of the sites that we've been at despite the space issues, etc. But we're super flexible. We make it work however we have to so that the site feels that it's value-added and that it's not interrupting their clinical flow.
Dr. Shannon Westin: This was great. Ladies, thank you so much for your expertise and for giving us some really, I think, concrete things that we could potentially do back in our institutions. And thank you to all of our listeners.
Again, we were discussing ‘Food to Overcome Outcomes Disparities – A Randomized Control Trial of Food Insecurity Interventions to Improve Cancer Outcomes.’ published online in the Journal of Clinical Oncology on June 16th, 2022. We're so excited that you took the time to listen, please check out our other episodes and check back soon for a new episode of the podcast. Have a great one, y'all.
Dr. Francesca Gany: Thank you!
Dr. Theresa Hastert: Thank you.
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