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ICI Health Disparities
Mitigating Health Disparities in Immune Checkpoint Inhibitor–Based Therapy: A Pharmacist’s Perspective

Released: July 06, 2022

Expiration: July 05, 2023

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Since the first immune checkpoint inhibitor (ICI) was approved by the FDA for advanced melanoma in 2011, these agents have revolutionized the management of numerous cancers in advanced stages—most recently in the early-stage setting. However, data from the Surveillance, Epidemiology, and End Results registry indicate that the racial gap in melanoma-specific survival has worsened between White populations and Black, Hispanic, and Asian populations since the introduction of ICIs. This gap highlights the health disparities that result in groups of people who systemically have experienced obstacles to attaining better health based on their race, ethnicity, religion, socioeconomic status, sexual orientation, gender, or other identity traits.

In this commentary, I discuss strategies at the patient, provider, and healthcare system levels for overcoming health disparities as illustrated in 3 patient scenarios.

Case 1
Our first case is a 56‑year‑old Black woman who is newly diagnosed with metastatic hormone receptor–negative/HER2‑positive breast cancer. She presents to her pharmacist for chemotherapy teaching before treatment with pertuzumab, trastuzumab, and docetaxel. When the pharmacist approaches her oncologist and asks if the patient would be an appropriate candidate for a clinical trial comparing standard chemotherapy alone vs standard chemotherapy plus atezolizumab, the oncologist replies that he “hasn’t had a lot of luck with these patients enrolling on clinical trials.”

This case reveals how even healthcare professionals with the best intentions still have implicit biases. By using terms such as “these patients,” the provider reveals his assumption about the ability or interest of an entire group to participate in clinical trials. As healthcare professionals, we have to ask ourselves whether low enrollment of racial minorities on clinical trials is due to patients not being interested or the result of implicit biases in our providers that reduce access to clinical trials for patients who otherwise would qualify.

Regarding patient interest, data from recent meta analyses show no marked differences by race or ethnicity in patients who agreed to clinical trial participation: 64.9% of Hispanic, 61.7% of Asian, 57.6% of Black, and 53.4% of White patients agreed to participate. This indicates that some minority patients are not enrolling on clinical trials for reasons other than lack of interest. These reasons include access, as the meta analyses found that structural barriers—such as transportation to trial sites, time restrictions, and other logistical challenges—precluded participation for 56% of patients.

How can healthcare professionals help patients cope with the cost and extra monitoring required by a clinical trial? Healthcare system–level interventions include patient navigators in oncology care models who, if appropriately educated and equipped, can help patients clear those barriers. There also is a growing interest in sponsored trials that support health equity. To further improve access, healthcare professionals should discuss clinical trials as options with all patients. As part of this, healthcare professionals need to be educated on culturally competent communication and cancer care.

Case 2
Our second case is a 67‑year‑old White man who is newly diagnosed with non‑small-cell lung cancer and is supposed to start pembrolizumab plus cisplatin and pemetrexed, a standard-of-care regimen. The patient is self‑pay. His oncologist is concerned about the cost of this regimen and is considering omitting pembrolizumab, despite ICI‑containing regimens being preferred.

Unfortunately, pharmacists encounter this scenario quite often. The good news is that we have some options for patients who are self‑pay. At the healthcare system level, patients may be able to enroll in different types of payment programs. Social workers and nurse navigators also can help patients navigate some of the other costs incurred beyond drug therapy. By including all members of the multidisciplinary care team, you ensure that there are many people with different perspectives and abilities who all can work together to improve access to cancer care.

Many pharmaceutical companies also offer assistance for patients who have limited or no insurance. Historically, there has been the idea that having no insurance is better than having bad insurance. Less than adequate insurance actually can hamper patients’ ability to afford therapy. By working with our colleagues in the payer space and industry space, healthcare professionals can make sure that policies are in place to help all patients get appropriate access to care.

At the patient and provider levels, it is important to encourage patients to complete and submit their applications for drug assistance and health insurance. Many patients assume they will not qualify, so helping them complete their assistance applications, educating them on different treatment options, and counseling them on financial toxicities may help. Nurse navigators, social workers, and financial counselors play a vital role here as part of the multidisciplinary oncology team.

Case 3
Our third case is a 58‑year‑old Hispanic woman who is receiving ipilimumab for metastatic melanoma. On a follow-up phone call, the patient says that she is fine. However, a message from her husband indicates that she is having significant difficulty with diarrhea and rash but is hesitant to be taken off effective therapy.

This is a scenario that pharmacists regularly encounter in practice. Many patients know that staying on therapy is the best way to maximize benefit, so they may be hesitant to report anything that might jeopardize their ability to continue therapy. This is an area where it is very important to address medical mistrust. It also is an opportunity for us to see the value of effective counseling at the start of therapy, particularly explaining to patients that immune-related adverse events (irAEs) such as rash and diarrhea do not mean they are not getting the benefit of the ICI. In fact, some data suggest that the opposite is true.

Regarding this patient’s rash specifically, we have some important data on racial disparities in diagnosis and treatment of cutaneous irAEs. First, a 2022 systematic review found that 73% of dermatomyositis rash images included in databases and medical textbooks showed very light skin colors—a clear underrepresentation of darker skin tones in medical education literature. This could lead to poor recognition of cutaneous events by healthcare professionals and patients. A recent retrospective review looked at cutaneous irAEs by self-reported race in patients who received ICIs at 1 institution from 2016‑2019. Compared with White patients, racial/ethnic minority patients were half as likely to be diagnosed with cutaneous irAEs but 6 times more likely to be referred to a dermatologist. These findings highlight differences in diagnosis and management of cutaneous irAEs among people of different races and ethnicities. Education for both patients and providers is key for early recognition and appropriate management.

At the healthcare system level, it would be helpful to establish screening for patients who may either be predisposed to different irAEs (eg, due to autoimmune conditions) or have social determinants of health that could impede their ability to understand and advocate for their own health benefit. Then, we would need to implement processes to have more frequent follow-up of at-risk patients so healthcare professionals can identify and mitigate irAEs more promptly.

Your Thoughts?
What health disparities have you encountered among your patients receiving ICI-based therapy? How do you plan to address these disparities? Please leave your thoughts in the comments box.

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