Highlights from ASH: Conversations about Multiple Myeloma with Thomas Martin and Monica Soni

In December 2022 the annual meeting of the American Society of Hematology took place in the vibrant city of New Orleans and brought together tens of thousands of participants from across the world to present and discuss the results of studies that ranged from initial hypothesis to practice-changing results.

In this episode of The Onco’Zine Brief Peter Hofland talks to two people about their research and the impact the outcomes from these studies may have.

First, Hofland talks with Thomas G. Martin, MD.

Martin is the Associate Director of the University of California San Francisco Myeloma Program and Director of the Unrelated Donor Transplantation program for adults at UCSF Medical Center.

Martin's research interests include developing treatments for myeloma and leukemia as well as expanding the use of bone marrow transplants. He has a special interest in umbilical cord blood transplants, and he is involved in efforts to improve outcomes for patients who have transplants from unrelated donors.

In this episode Hofland and Martin talk about updated results from a Phase 1b expansion study evaluating subcutaneous administration of Isatuximab-irfc (Sarclisa®; Sanofi) by an on-body delivery system in combination with pomalidomide (Pomalyst®; Bristol-Myers Squibb Company) and dexamethasone in patients with relapsed/refractory multiple myeloma. How does subcutaneous delivery vs. intravenous administration of Isatuximab benefits patients? Hofland and Martin also talk about the results of a Subgroup Analysis of the IKEMA trial.

Then, With Monica Soni, MD, Director of Specialty Care for the Los Angeles County Department of Health Services, the second-largest municipal health system in the United States. She is also an assistant clinical professor within the UCLA Department of Medicine.

Soni is commitment to improving quality, equity and affordability in health care.

In this episode Hofland and Soni talks about the results of a study in which the investigators looked at the utilization of bone-modifying agents (BMA) in the treatment of multiple myeloma, particularly among Medicaid patients.

What invesrigatriors found was shocking!

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Clinical trial
Multinational Clinical Study Comparing Isatuximab, Carfilzomib And Dexamethasone To Carfilzomib And Dexamethasone In Relapse And/Or Refractory Multiple Myeloma Patients (IKEMA) -NCT03275285

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Episode Transcript

(00:12):
This is the Angazine Brief with PeterHoffland. Last December, the annual Meeting
of the American Society of Hematology tookplace in the vibrant city of New Orleans
and brought together tens of thousands ofparticipants from across the world to present and
discuss the results of studies that rangefrom initial hypothesis to practice changing results.

(00:38):
In this episode of the Angazine Brief, I talk with two people about their
research and the impact the outcome fromthese studies may have on the treatment of
patients diagnosed with cancer. Doctor Martinis the Associate director of the University of
California San Francisco My Aluma Program anddirector of the Unrelated Donor Transplantation Program for
Adults at UCSF Medical Uner I'm alsotalking with doctor Monica Sony. Doctor Sony

(01:03):
is the director of Specialty Care forthe Los Angeles County Department of Health Services,
the second largest municipal health system inthe United States. She is also
the Assistant Clinical Professor within the UCLADepartment of Medicine. On Peter Hoffland and
this is the Youngsiine Brief. TheAngasine Brief is developed in collaboration with our

(01:23):
online journal Oncosine where you can findadditional information and the latest news about cancer,
cancer diagnosis and treatment, and cancerprevention. For more information on how
to support this program, visit ourwebsite at oncosine. And if you're living
in the United States, you wantto receive our newsletter, text the word
cancer to six six eight six sixand we will make sure that you'll receive

(01:45):
our newsletter, which includes an overviewof the latest news in oncology and hematology.
This is the Agazine Brief. Forthe latest news about cancer and cancer
treatment, visit our online journal onGazine at www dot kazine dot com.

(02:09):
On the phone with me is doctorThomas Martin. In this episode of The
youngashiin Brief. We talk about themultimum miloma and new treatment options for patients
diagnosed with this disease. Doctor Martin, Welcome to The youngishiin Brief. Thank
you, Thank you for having mein today's episode of the show. I
wanted to start with asking you aboutsome of the interesting results from clinical studies

(02:30):
presented during the annual meeting of theAmerican Society of Hematology. But before we
talk about these studies, why isthis meeting so important? Ashes really are
yearly meeting that goes over all theimportant advancements that have been made for that
year. And to tell you thetruth, we are making advancements every six
to twelve months or some new news. There's some new breaking data that's really

(02:53):
important, and it's in frontline treatmentof my aloma. It's an early relapse
treatment of myle and also in treatmentof relapse or refractory the patients that really
have no other options. So muchimportant data is presented in all those domains
at ASH this year, and it'severy year that it's like that. Now
when you look at multiple miloma,what makes this disease so difficult to treat?

(03:15):
Well? My aloma we think thesedays is more of a chronic illness.
But the big problem is twofold one. There are some patients that have
very aggressive disease, and those thathave very aggressive disease often their survival is
limited to the three to five yearrange, and we need better therapeutics for

(03:35):
that group of patients. And thesecond is we don't cure patients with multiple
aleoma at this point in time.Even those that have less aggressive disease,
they continue to have relapses down theroad and continue to require therapy, and
so we need better therapy for theearly relapse patients. We need better therapy
to hopefully cure patients at some pointin time. If I understand this correctly,

(03:57):
you refer to important unmas medical needs. Now, are there other unmetematical
needs in relapse or refractory multiple miloma? The other unmet medical need are the
patients who have gone through now whatwe're calling the big four treatments, the
protosome inhibitors, the immunomodulatory drugs,the CD thirty eight antibodies, and the
BCMA targeted therapies. Patients that havegone through those four classes of drugs now

(04:23):
are the unmet medical need, andthat is what we're looking at right now
when we review some of the developmentspresented at ASH right correct During the annual
meeting, updated results from a Phaseone B expansion study evaluating subcontinuous administration of
is a taximap by an unbodied deliverysystem in combination with vomlydamite and deximato stone

(04:44):
in patients with relapse refractory multiple milomawere presented as a bit of background for
our listeners. Is a taximap isa monoclonal antibody that targets a specific episode
on the CD thirty eighth receptor onmultiple miloma cells. It's design to work
through multiple mechanisms of action including programtumor cell death or apoptosis, and immune

(05:05):
modularity activity. And CD thirty eightis highly and uniformly expressed on the service
of multiple myeloma cells and making ita potential target for antibody based therapeutics such
as isotoximap. But let's go backto how isotoximap is administered. Today.
The drug is delivered intravenously, butthe results of this phase one B study

(05:26):
suggest that sub continuous delivery of isotoximapmay have benefits over the current approach.
Tell me a little bit about theseresults. Yeah, So the administration of
CD thirty eight antibodies, and thereare two of them that are you'll approved
for use in the United States andEurope and elsewhere. One there are two
MAP it's available IV and SPY subcutaneousinjection and ISOTOXMAP that is available right now

(05:51):
by IV injection, And so itis now being tested with subcutaneous injection,
and it's much more convenient for patientsfor them to receive a subcutaneous injection.
It's also a little safer, there'sless infusion associated reactions. So the delivery
mechanism of esotuxmab through this onboard pumpthat patients can attach to their skin and

(06:14):
the nursing services can do that willdeliver the drug over time. It actually
delivers in a very safe and effectivemeans. The combination of pomela index meth
zone with esotuxmab was initially approved basedon the Arcarious study and it's a very
good triplet combination for patients that haverelapse or a fractory my aloma. What
is the difference in outcome if youcompare intervenious administration with subcontinuous delivery, what

(06:40):
are the benefits? I wonder,for example, if this is more convenient
for the patient, does it improvethe health related quality of life of the
patient? And going a bit further, does this mean, for example,
that patients can stay at home ratherthan going to an infusion center, hospital
or clinic for treatment. That wouldbe ideal. If patients actually could place
this on by themselves at home,that would really be ideal. And we

(07:03):
have to work out a number ofthings for that to happen, and including
reimbursements from insurers, and there's abunch of steps that have to happen.
But it is certainly plausible that thatcould be a strategy for doing this therapy,
and it would make it very convenientfor patients, especially will taking an
oral medicine and they can put thison themselves to be really convenient. The

(07:24):
outcomes presented at ASH are very interestingindeed, but this was still a phase
one B expansion study, so muchwork needs to be done, right,
but it is an interesting development.Yeah, and the phase one B is
just to prove that it's safe andthat also you have similar efficacy as in
the large randomized phase three KIOUS study. Yes, during the annual meeting results

(07:46):
of the subgroup analysis of the KEMAtrial we're also presented. You were involved
in this trial, So tell mea little bit more about the key findings
from this subgroup analysis. Yeah.I've been involved in a chema trial really
from the beginning. We did thephase one trial of issa tux map plus
carphilisom have index math zone at UCSFand that led to the Phase three IICHEMA

(08:11):
trial. Now in these data havebeen presented previously where there was a marked
advantage to patients receiving the triplet ofEESA tux map plus carphilisom of index meth
zone versus curphilsom have index method.It was a large, multi center trial.
Over three hundred patients were involved,and it showed that the triplet had

(08:31):
a marked improvement in PFS, amarked improvement in overall response rates, and
a marked improvement in those patients andhaving a very deep response achieving MRD negativity,
so a very active rate regiment ofICHIMA. Let's take a break.
This is the Youngasine Brief. Ifyou're just joining us. In today's episode
of the Youngasine Brief, I'm talkingwith doctor Thomas Martin, Associate director of

(08:52):
the University of California San Francisco MilomaProgram and director of the Unrelated Donor Transplantation
Program for Adults at UCSF Medical Center, about some interesting study results presented at
the annual meeting of the American Societyof Hematology. I'm Peter Hoffland, and
this is your Youngest Seeing Brief.Each day, researchers make new discoveries that

(09:22):
bring us closer to the moment whenall cancer patients can become survivors. Some
days they take small steps. Others, huge discoveries lead to giant leaps forward.
This progress, both small steps andgiant leaps, happens with the help
of clinical trials. Clinical trials area fundamental path to progress and the brightest

(09:43):
torch researchers have to light their waytowards better treatments, and if you've been
diagnosed with cancer, they may beyour brightest ray of hope. Clinical trials
introduce new hope in addition to thecurrent standard of care by allowing researchers to
provide participants access to cutting edge andpotentially life saving treatments. So if you're

(10:03):
interested in exploring new treatment options whilehelping to light the path for other patients,
clinical trials may be the best choicefor you. Speak with your doctor
and visit stand Up to cancer dotorg slash clinical Trials to learn more about
clinical trials. Together, we canstand up for all of us. This

(10:28):
is the young Gazine Brief with PeterHoffland and welcome back. This is the
Youngers in Brief. If you're justjoining us. In today's episode of The
Youngers in Brief, I'm talking withdoctor Thomas Martin about study results presented at
the Annual meeting of the American Societyof Hematology. When you look at the

(10:52):
outcome of the study, what wasthe original goal of the study, especially
in these group of facients. Yeah, the original goal was actually just to
test what the progression free survival wasfor the triplet ESA KD versus the DOUBLET
KD. And we knew that DOUBLETKD had a PFS that was going to
be about eighteen maybe to twenty months, and we are hoping to improve that

(11:13):
by at least six months or more. And in fact, part of the
update of this trial was to lookat after forty four months of follow up
what the actual PFS was, andit actually turned out to be thirty six
months versus nineteen months, so italmost doubled the PFS in the triplet versus
the DOUBLET. Now that triplet inthe one to three prior lines of therapy,

(11:39):
that's one of the most um,you know, most impressive PFS durations
that we've seen in the one tothree prior lines of therapist's very very active
regiment. And that's you know,and that's you know, a feather in
our half were actually doing this curphilismhave index meths on trial. As mentioned,
these was a subgroup of sub analysis. But how does this outcome compare

(12:01):
it to the entire study. Sowe did a sub analysis to try to
evaluate in this very high risk patientpopulation those that have early relapse was the
benefit of issa KD still there forthe patients that had early relapse versus those

(12:22):
that had later relapse. The earlyrelapse I said earlier that those are the
functional high risk patients. Those areone of our toughest patient populations. And
we defined early relapse of those thatrelapse you know, less than twelve months
from the initiation of their most recentline of therapy and those that had tour
more prior lines of therapy, patientswho relapse less than eighteen months if they've

(12:45):
had one line of therapy and relapsewithin twelve months of autologous stem cell transmine,
and those are standard definitions and againidentify as a high risk population.
And the late relapse theres are thepatients that relapse more than twelve months from
the initiation of their most recent lineof therapy or those that relapse eighteen months
for patients that just after eighteen monthsor patient had just received one prior line

(13:07):
of therapy, so we broke itup into two different groups. Now they
were pretty balanced. Those groups arepretty balanced when we looked at them.
There was some minor imbalances that youwould expect because there was a high risk
group and then you know aazo hierrisk group with the later the later relapse
patients. And we showed a significantimprovement in PFS in both the early relapsers

(13:33):
as well as the late relapsers.So this data, I think was really
important data for us to look at. If we looked at the PFS in
the patients who had early relapse inthe EESA kd ARM, it was about
twenty five months. In the kdARM, it was seventeen months. If
we looked at the late relapses,the PFS actually was forty three months.

(13:54):
In the kd ARM it was twentytwo months. So ESA k D showed
significant benefit no matter if they wereearly relapse or late relapse patients. But
really the impressive result for me wasthat even in the early relapses high risk
population, we had twenty four pointseven months PFS. That's actually a really

(14:15):
important number and it's a really goodnumber compared to what we would expect for
this population. Two important data pointsinclude progression free survival and depth of response.
Tell me a little bit more aboutthese outcomes. If we actually look
at the depth of response in thesepatients and we look at basically the patients

(14:37):
who are the early relapsers versus thelate relapsers, we did see a higher
number of patients that achieved a completeresponse or better INA KD versus KAD and
the early relapse patients it was thirtyone percent versus twenty four percent. We
saw a little bit better in thelate relapse patients SA KDO was fifty three

(14:58):
percent versus thirty one percent in theKDRM. We would expect that again because
these early relapse patients are the moreaggressive patients. But we also are able
to see some MRD negative patients inthe early relapse, which I honestly didn't
think we were going to see manyMRD negative crs, and that was eighteen

(15:18):
percent of patients INA KD versus elevenpercent of patients in KDARM. In the
late relapse, there's the MRD negativecrs or about thirty one percent versus witha
KD versus fourteen percent with KD.So again in both scenarios early relapse and
late relapse are getting a better depthof response, and then the duration of

(15:39):
responses is definitely longer. And that'smeasured really by partly by the pfs again
which the numbers I showed told youearlier about twenty five months and sa KD
for the early relapsers versus seventeen months, a big difference. How is this
going to impact a three pence ofmultiple miloma? Is this practice changing?
That's a great question. We havea lot of options for patients who have

(16:03):
received primary induction therapy and either haveone or two or three lapses. We
we have a lot of options forthat patient population. And so when we're
all thinking about what's a good regimentfor our patients, we have to think
about the patient characteristics and what theresults have shown. In those people that
are lena litimide sensitive, we knowa really good regiment for them as a

(16:29):
CD thirty eight antibody plus len alitimind dex meth zone as first relapse.
We now know that if those peoplethat are lending refractory and patients that are
sensitive, another good regiment is aCD thirty eight plus carphilisom inbendx meth zone
and asatuximap plus carphilisom inbendex meth zonehas demonstrated in the overall population a PFS

(16:52):
of thirty six months versus nineteen monthsa big advantage. And then if they're
an early relapse or this is areally important PFS of essentially twenty five months
versus seventeen months. That in theseearly relapsers, this is a great regiment
to select for them and to expectthem to have a PFS of about two
years. That gets them two yearsdown the road, it gets us to

(17:14):
the next generation immunotherapies because this populationtypically has a survival that's essentially less than
three to four years. So thefurther we push them down the road in
remission, the better chance they havethe option of the ability to go to
other options and other novel immunotherapy.So this is I think a very important
finding and this is a good regimentfor the early relapse patients. To keep

(17:40):
things in perspective, progression freezurvice fullyis important but shows health related quality of
life and safety. Can you tellme a little bit more about this?
So when we looked at the safetyinvolved in this study, the two agents
themselves have individual adverse events that youtypically see with carphilism have been you technically
see without putting the two together,did not cause any increased risk or any

(18:03):
increased safety concerns. In fact,they're very well tolerated. In fact,
the majority of patients actually were ableto receive all the agents throughout the therapy,
So this is an extremely well toleratedregiment where the dose density, the
ability to get all all the treatmentsand all the doses was over ninety percent.
It was pretty amazing actually, asone of the best for a relapse

(18:26):
again, a relapse or fractory regimentand patients. I have plenty of patients
that are on this combination and Ihave you know, people are working,
people are doing, people are functional, people are able to do things without
having a lot of side effects fromthis combination and no big safety signals.
I do think that if you're patientsdiagnosed but multiple miloma, the possibility of

(18:48):
lesser side effects is really important.So this is definitely good news. Doctor
Martin, thank you so much forbeing here with me today. Thanks for
having me. Doctor Thomas Martin isthe Associate director of the University of California,
San Francisco, Myloma Program and directorof the unrelated donor Transplantation Program for
Adults at UCSF Medical Center. Afterthe break, we're back with doctor Monica

(19:12):
Sony. Doctor Sony is Director ofSpecialty Care for the Los Angeles County Department
of Health Services, the second largestmunicipal health system in the United States.
She is also an assistant clinical professorwith in the UCLA Department of Medicine and
at the Charles Arthrue University Department ofInternal Medicine, where he is focused on

(19:32):
residency divertification and pipeline development. DoctorSony's commitment is to improve quality, equality,
and affordability in healthcare, minimizing healthrelated disparities in care DEI free and
that is what we're going to talkabout today. Don't go away, stay
tuned. Sarcoma are You've never heardthat word before, but for the forty

(20:02):
people diagnosed with sarcoma every day,it is a life changing word, life
changing and devastating because sarcoma is cancer. Sarcoma is a cancer of bone and
soft tissue, more prevalent in childrenthan in adults. More than six thousand
people lose their lives to sarcoma eachyear. Treatment options for sarcoma are limited,
and new therapies are desperately needed.More research and increased awareness is necessary

(20:26):
to find a cure for a cancerthat you probably didn't even know existed until
now. Through awareness, advocacy,and research, the Sarcoma Foundation of America
is determined to help those affected bythis forgotten cancer. To bring hope to
the children and adults whose lives areforever changed by a word they had never
heard before. Please help us inthe fight to find the cure for sarcoma.

(20:49):
For more information on sarcoma and thework of the Sarcoma Foundation of America,
please go to Cure Sarcoma dot org. This is the young Caazine Brief
with Peter Hoffland and welcome back.In this episode of The youngersin Brief.

(21:17):
I'm talking about doctor Monica Sony.I'm Peter Hofland and this is the Youngers
in Brief. On the phone withme is doctor Monica Sony. Doctor Sony,
welcome to the Youngershin Brief. Youare the director of Specialty Care for
the Los Angeles County Department of HealthServices, the second largest municipal health system
in the United States, and thatin addition to a lot of other activities,

(21:41):
including being an assistant clinical professor withinthe UCLA Department of Medicine and at
the Charles or Drue University Department ofInternal Medicine, where you focused on residency
diversification and pipeline development. Now inthis program, we're going to talk about
the results of a study in whichyou and your co worker looked at the
utilization of bone modifying agents in thetreatments of multiple mileoma, particularly among Medicaid

(22:07):
patients. And as a bit ofbackground, when it comes to the treatment
of multiple mileoma, bone modifying agentsare widely regarded as the gold standard.
These drugs, some of which areavailable as generics, do more than just
avert pain. They are life savingor they can be life saving. Right,
So, ideally, adherence to thetreatment with bone modifying agents from multiple

(22:29):
mileoma should be at one hundred percent. So when you began to study,
you expected to see that adherence tothe treatments would be at least around eighty
to nine, maybe with a fewexceptions due to patient preference. But when
you saw the real numbers, youwere shocked because that was not the case,
right, You found that bone modifyingagents were underused and that this was

(22:53):
especially among the medicaid population. Sowhen you read the study results, then
there are a couple of questions thatcome to mind. One of them is
why does GAVE exist and why areeconomically disadvantaged people not getting the therapists recommended
to protect them from major side effectsof cancer? And another question, are

(23:14):
payers and clinicians alike concerned about thisinequity? But before we're going to talk
about this artisny okay, tell mea little bit more about yourself. Yes,
well, thank you for having me. As you said, Monica Sony,
I'm an internal medicine physician who reallyhave been trained in public systems and
the safety nets, so places whereyou see up close and personal historically underresource

(23:36):
communities having poor health outcomes. ButI've also seen amazing care delivered in those
contexts and really whole person care.I'm now assoc. Chief Medical Officer at
New Century Health and so my focusis really on cancer and cardiovascular disease.
You know, they're two top reasonsfor death in the US at least,
and so kind of pulling together subjectmatter expertise for vulnerable populations and in this

(24:00):
specialty space is what I've been spendingmy time doing. I live in LA
another high density area with a lotof complexity, and so I day in
and day out think about these issues. Can you tell me a little bit
more about the complexity of multiple miloma? I mean, from a treatment perspective,
multiple A LOOMA has gotten incredibly,incredibly much more complicated over the last

(24:23):
few years. New therapies, expensivetherapies, the really therapies that make a
difference in the lives of patients whohave multiple miloma. The challenge is that
there's still good, old bread andbetter, gold standard stuff that patients should
be getting that you would kind ofconsider foundational. And that's what we spent
our time looking at, not thenew sexy stuff, but really the old

(24:45):
traditional medications that work, which arebone disease modifying agents. And we actually
looked at our own data, whichlast year we supported care for over one
hundred thousand oncology patients, so prettyrobust data set, and we took a
look to see, Okay, ourpatients getting the care that is recommended the
standard of care. Tell me alittle bit more about the treatment with bone

(25:07):
modifying agents. Why, for example, is this important and how does it
benefit of patients? But in additionto that, how does insurance coff rates
play a role in treatment decisions?And another question it's probably hard to answer,
is there a difference between treatments betweenpatients or medicaid versus patients who have

(25:27):
commercial insurance. Yes, absolutely,so we know that those drugs work,
right, they prevent skeletal fractures,bone pain, and actually there's some data
that people actually live longer if theyreceive them. And what we found was
when you look at the overall populationof patients we supported, only about sixty
percent we're receiving that gold standard care, so a big gap that has actually

(25:51):
been published by others in real worlddata. What we found which had not
been published before is that the gapswere larger depending on the type of insurance
the patient had. So if youhad commercial insurance versus Medicare versus medicaid,
you were more or less likely toactually receive that that therapy, those bone
modifying agents. So really shocking finding. Well, that's absolutely the case.

(26:14):
Now when you look at the studyoutcomes, not all patients support tweet is
equally right, Yeah, this waswhere it was tricky. So the angle
that we have that we look atfrom a data perspective is did the physician
or the practitioner actually offer it tothe patient. So, in these are
drugs that are covered by insurance,they are reimbursable, but the rates are

(26:37):
different between commercial and Medicare and Medicaid, and the reimbursement rates for Medicaid are
the lowest, and so we doknow that there are differences in practice behavior.
So again I'm super empathetic to providers, but it looks like the physicians
themselves, the practitioners are not offeringthat therapy to medicate patients at the same
rate as they are to other patients. That is what's sort of an unbelievable

(27:00):
part. You mentioned that ideally,and we mentioned it also at the beginning
of the program. One hundred percentof patients who need these therapies should be
able to get them, but thatis not the case. Right, Yeah,
that's exactly right. Commercial was aboutsixty five percent, Medicare was about
sixty and Medicaid it was fifty onepercent. So what are the consequences of

(27:22):
this difference the health related disparities you'veseen in this study. Yeah, the
consequences that you then have a populationwith more fractures, more bone pain,
and loss of life. Right,so lower survival, So we can conclude
that there are real negative consequences,right, Yeah, huge dramifications. Tell

(27:44):
me a little bit more about patientsdiagnosed with multiple myeloma? Is there a
population link? What I mean bythis is if you look at black patients
versus Hispanic patients or white patients,are there major differences in diagnosis and treatment?
How does this impact patients overall?Yes, yeah, multiple miloma.
Absolutely, black patients are overrepresented comparedto the baseline population. So it's a

(28:10):
it's a very tricky space. Yousee that. I think it's I may
not beginning my numbers exactly right,but around eleven percent of all multi patients
are black. That's obviously more thanthe general population. And you know,
the other place that we didn't talkabout yet is clinical trials for multiple alomas,
less than two percent have black patients. So you have a patient population
that really is enriched unfortunately in thisdisease state, not being studied at the

(28:33):
same rates, not being treated atthe same rates, and definitely the death
rates are higher for black patients.The receipt of transplant is lower for black
patients. I mean, there's alot of disparities within the sub groups that
you are calling out. Now,you're a doctor and you may see this
problem close up from where you areyour perspective. What can be done to

(28:53):
eliminate these problems? What can bedone to get rid of this disparity,
this disparity you see, this isa space where actually we have a lot
of evidence. So you're right,it's complex, it's multifactorial. One thing
is not going to solve all ofthe problems. But do we know what
can absolutely, So let's start withaccess. We know that the Affordable Care

(29:14):
Act and expansion of Medicaid actually increasedoverall survival right for patients with cancer,
increased screening earlier date to diagnosis.So that is one thing. Right,
we still have states that did notexpand the ACA. I'm not saying that
from a political slant. It justmakes a difference for patients, right like
it actually closes a disparity. Sothat's one right, It's coverage, workforce.

(29:37):
There's a lot of evidence now thatactually if there is racial and or
ethnic or language concordance between provider andpatient, outcomes are better, So we
kind of can't pretend that it's allthe same. It's not all the same.
There's relational aspects of it. There'strust. We saw this with COVID
and vaccine hesitancy. That relationship soimportant. So that's another part. Thinking
about our workforce recruitment, tension,diversity there, that's the other part of

(30:03):
it. And then I think,you know, there's a lot of work
around unconscious bias, making sure thatfolks are not inadvertently mistreating certain populations.
Of course that's a critical part aswell. And then I would be remiss
if I didn't talk about what Iwill talk discuss the sort of environmental determinants.
Right, do you have access tohealthy food or do you live in
a food desert which causes OBC whichis an increased risk for cancer? Right.

(30:26):
I don't want to pretend like thatyou can't. You don't solve for
those things. Those are just asimportant as the other things I talked about.
You have to do all of thosethings to try to eliminate disparities.
Let's take a break. This isthe angashin Brave. If you're just joining
us in today's episode of the AngashineBrave. I'm talking about doctor Monica Showny.
Doctor Showny is the director of SpecialtyCare for the Los Angeles County Department

(30:49):
of Health Services, the second largestmunicipal health system in the United States.
About some interesting study results presented atthe annual meeting of the American Society of
Hematology. I'm Peter Hoffland and thisis the younger same brief. My name

(31:15):
is Jinhuijan. I'm the chair ofa computational biology department as children's Research hospital
that I feel so excited about seeingthe potential impact not only on the kids
treated as in Jude, but acrossthe world. One of the major advantage
we have in saying Jude is thatbecause of resources we have, we were

(31:36):
able to utilize the most comprehensive wayof profiling genos through the study. As
a data scientist, I feel verypassionate about sharing data. We also want
to enable talented scientists to analyze datausing the innovative tools and making new discoveries
on top of world we have made. And I think this is a great

(31:59):
use of the trial we got fromour donors. Finding cures saving children.
Learn more at St Jude dot org. This is the agazine Brief with Peter

(32:22):
Hoffland and welcome back. This isthe Angasine Grief. If you're just joining
us in today's episode of The AngasineGrief, I'm talking about doctor Monica Sony.
Doctor Sony is the director of SpecialtyCare for the Los Angeles County Department
of Health ser offices, the secondlargest municipal health system in the United States.

(32:43):
About some interesting study results presented atthe annual meeting of the American Society
of Hematology. I must say,this sounds very complex, and it sounds
that there are many different factors involvedin eliminating the health related disparities, and
interestingly, everything is directly related totreatment. For example, the importance of

(33:04):
food and nutrition has been observed inpatients with type two diabetes. For example,
I remember study a few years back, and this was about type two
diabetes, so unrelated to cancer.But the studies show that teaching these patients
how to read and understand food labelsof the products they bought in the grocery
store help them make good decisions aboutfood and nutrition and this had a very

(33:30):
positive effect on their health. Now, again, as I said, this
may not directly impact patients diagnose multiplemiloma. But it is just one example
how patients can benefit from help thatgoes beyond treatment. But all of this
is very complex, and as yousaid, it is not just one thing
we need to do or need topay attention to or close attention to.

(33:52):
Actually we need to pay attention toall these factors, right, yes,
And actually I'll give you the parallelstudy of this. So a group out
of New York primarily focused on lowincome populations who had cancer and had screened
positive for food insecurity. They putthem into a randomized trial. They either
gave them access to food pantry,they gave them a voucher, or they

(34:13):
had kind of food delivered. Thereare three different arms, and what they
found was that actually the cancer treatmentcompletion rates went up when you actually provided
for some access to food. Sowe one hundred percent know that those upstream
factors have downstream implications. Another issuenot often mentioned is that the economically disadvantaged

(34:34):
people, but these may also impactother patient populations. Taking off from work
for treatment may be very difficult,or asking a parent, child, or
friend to take off from work totake them to a clinic may not always
be possible. So how important isit to understand this and should these impact
treatment decisions. Yes, there's somegreat studies out coming out about time toxicity.

(34:59):
Right. We talk about clinical physicaltoxicity, financial toxicity, but time
toxicity for the individual and their communityaround them so important. It's been looked
at in pancreatic cancer after surgery,how many days if people even spend at
home versus in a healthcare facility.We actually have another publication coming out in
NCCN soon that looks at even hypofractionation in radiation therapy and how many days

(35:24):
you can save a patient actually fromhaving to go into the office without any
sacrifice and outcomes. So this isa critically important part of what we need
to be thinking about absolutely patient's wholelife. Your study was very specific showing
that authorization levels for treatment with bonemodifying agents among medicate patients, it was

(35:45):
very low. Now in your opinion, and maybe this involves the broader oncology
community. What is the most importanttakeaway from this study? Maybe a conphrase
It is a little bit different inthe day to day practice. What shoot
an oncologist or hermatologist keep you mindwhen he or she meets with a new
patient what is the right thing todo or a de factor you've mentioned earlier

(36:07):
in the program, creating such acomplex environment that one single doctor can't influence
this on his or her own.Yes to me. When you start to
see big gaps like this forty percentof patients not receiving standard therapy, that's
not an individual error anymore, right, That's a systems issue. Means we
have not set up the healthcare systemand the practice in a way to facilitate

(36:29):
the right thing being done at theright time. So I try to focus
attention away from that doctor didn't dothe right thing too more. Why isn't
our healthcare system facilitating that? Soexamples of things that have been proven to
make a difference. Is sort oflike a checklist mentality, right, Like
what's built into the electronic health recordon entry to clinic? On asit to

(36:50):
clinic, did you make sure thatfrom multiple miloma every patient you got the
drug, they got their vaccines,that got referred to palliative care if they
have meta static disease. All ofthat stuff is codifying it. Making it
easy to do the right thing isthe direction I want all of our health
systems to go in. And thenteam based care. An individual practitioner can't

(37:10):
do this all on their own.So thinking about, to be honest,
reimbursement reform so that you have thesocial worker funded and the community health worker
funded, and the navigator who canhelp the patient with evidence base receipt of
evidence based therapies. Now, inaddition to your study, a similar outcome
was presented at the annual meeting ofthe American Society of Clinical Oncology. When

(37:32):
you look at these outcomes, doesinsurance coveras really impact treatment decisions? I
think we would be naive if wedidn't say that. Of course, a
patient's coverage impacts what happens from atreatment perspective. There are some ways that
we've created that ourselves. Right,each ensure, even within medicare advantage,

(37:53):
can choose different drugs to be onformulary. We have prior authorization expectations that
you use drug a drug be soabsolutely the physician and the practitioners are aware
of the patient's insurance. I thinkthe most nefarious interpretation of that is that
they're then doing different things based onreimbursement structures, and that if you're going
to get paid more for one personversus another, do you triage them,

(38:16):
do you prioritize them? I hateto imply that, but it's sort of
hard not to when you look atthe numbers like that, Right, This
is a national study across multiple states, multiple different provider archetypes, academic and
community and multi specialty, and wereally found sort of the same outcome that
others have found as well, Andso I just can't erase the fact that,

(38:38):
yes, we're treating patients differently basedon their insurance coverage. Doctor Sony,
thank you so much for joining metoday in Younger, Same Grief.
I think we learned a lot today, but unfortunately, I'm afraid that these
will not be the last stand thatwe're talking about disparitation healthcare and access to
treatment. Again, thank you somuch for joining me. Thank you for
having me in this episode of TheAngusian Brief. I spoke with doctor Thomas

(39:09):
Martin, a socio director of theUniversity of California San Francisco Myeloma Program and
director of the unrelated donored Transplantation Programfor adults at UCSF Medical Center. And
I spoke with doctor Monica Soni,who is the director of Specialty Care for
the Los Angeles County Department of HealthServices, the second largest municipal health system

(39:30):
in the United States, about someinteresting study results presented at the annual meeting
of the American Society of Hematology onPeter Hofland. And this is the Youngusian
Brief for us here at the YoungersianBrief, we want to thank you,
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(40:35):
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(41:20):
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