Expert Stresses Importance of Transportation Security to Improve Cancer Care

Krisda Chaiyachati, MD, MPH

There is a lack of research regarding how to improve interventions and access for patients with cancer who are limited.

Transportation insecurity can emerge from poverty, not having secure employment, lacking the access to services, not having social support, and more, according to Krisda Chaiyachati, MD, MPH. For patients undergoing active cancer treatment, transportation insecurity can lead to poor health and worse outcomes for patients, including cancer recurrence or worse mortality rates.

To combat the issue, the survey aimed to evaluate how cancer centers assess and manage transportation insecurity among their patients. The NCCN Best Practices Committee (BCP) was used to screen patients for transportation insecurity, coordinate transportation, and fund transportation initiatives, in hopes to address some of these challenges in the future.

According to the NCCN BPC survey and Chaiyachati, the key findings include that while a lot of cancer centers have started creating processes for screening, coordinating, or funding transportation, few centers have a standardized approach. There is also variability regarding how centers cover these transportation services.

“One limitation is that there are lots of other cancer centers, and there are lots of ways in which health systems are addressing this. This is a subset of a lot of the cancer treatment locations that are out there. One could believe that these cancer centers are trying to get the most well resourced, the best funded, most research dollars, and donor dollars, and this may be the cream of the crop of what is happening. At the same time, there's a huge problem to solve for and for those institutions to try to understand,” said Chaiyachati, adjunct assistant professor of medicine at the University of Pennsylvania, in an interview with Targeted Oncology^TM.

In the interview, Chaiyachati discussed some of the social determinants of health for patients with cancer and some of the challenges patients undergoing treatment face, including transportation insecurity.

Targeted Oncology: Can you discuss the importance of addressing patients' social determinants of health?

Chaiyachati:We have pretty good evidence and there are really 2 things when we think about people's outcomes or how they do. One is the medical need that they have with the disease itself and how you treat it, but really connected with that is just how their lives impact that. That is largely spoken of as their social determinants of health. All these different dimensions, finances, education, their social supports, help individuals seek the care that they need, or have enough resources to get the care that they need. The 2 combined, their disease state and their social needs put together, are the things that we observe to see how people do.

What are some of the challenges for patients undergoing active cancer treatments?

The most obvious part about cancer treatment is that it's life threatening and not treating it can have dire consequences. Oftentimes, we think about cancer in the sense that people are trying to move mountains or do anything they can to treat the disease, but that may not always be true. That is kind of a broad swath there and that's certainly a patient decision or patient choice.

At large, people are actively seeking therapies or treatments for their cancer. When we think about the ways in which social needs can impact that, it can be dire. [One] can imagine how much they're moving mountains, changing their jobs, pausing their jobs, moving finances around, just so seeking the care that they need or want and desire. When those social needs become an impediment or a blocker, we want to think about, how can we remove those things so that people can achieve the best outcomes [possible]? Oftentimes, that's a choice of life or death.

Can you discuss transportation insecurity specifically?

Transportation is 1 of many different dimensions here. We've been thinking about transportation a lot for all kinds of different conditions. We've done some studies here in the primary care setting. We've thought about it here for some more routine visits, and probably the big lesson that we've learned here is that transportation can be a key ingredient, but really, it comes to head when the treatment is important, and transportation really becomes a blocker. What I mean by that is that I'm a primary care doctor but sometimes if [patients] don't want to come see me to manage their weight or manage their blood pressure, they just say it was [because of] transportation. Truth be told, it's probably like 10 other things and transportation is the easiest thing to hang their hat on.

But we have this hypothesis here and some decent evidence to show that when the treatment is an emergency or life threatening, something like cancer, if somebody says transportation truly is a barrier, it truly is a barrier for them in that specific situation. Again, as I have referred to from the beginning of this, [patients] would move mountains to be able to make it to [their treatment]. When it really is a barrier, we want to think about, what are some solutions or what are some ways in which we can help support patients and get there? To begin, we have to understand how big the problem is here, and when it matters.

Can you explain the purpose of the NCCN survey you were a part of? What did it hope to address?

Quite frankly, it was scratching the surface of trying to understand where the community is now. Not just in the cancer community space, but in the larger healthcare space, there's always been this chicken or egg conundrum here where social needs are impacting people's ability to seek care, but the evidence isn't strong enough that many centers or many locations are not providing those interventions. Basically, they say, people say that, but I haven't seen strong evidence yet to indicate that if I did something about it, it would actually create an impact or move the needle on care.

We have a stronger belief here in the cancer space. One of the things we wanted to try to understand was, what are cancer centers starting to think about here in this space? How are they starting to remove layers of the onion here? At the heart of this chicken or egg, are they starting to do interventions? Are they starting to test out different interventions in order to get to the truth of, do these interventions work or do these interventions help here? The purpose of the NCCN, a collective group of some of the largest and leading institutions in the country, is to see what they are doing in the social needs space, and particularly in this transportation space?

What were the findings from the survey?

The things that we have found from the survey were that lots of cancer centers were collecting the data, but in an ad hoc kind, like as it's happening, there is a conversation between a patient and a social worker, or nurse, or a clinician, and they would be able to identify those things and mark them off. Some places had transportation services that they were trying to implement and integrate into the flow of care, but patients weren't being systematically screened. One might ask, why is that a problem? One of the challenges is that without systematic screenings, we still don't know how large the problem is here and we may not be reaching all the populations or the people that are in need.

It is a bit of a double-edged sword, as some people are saying, oh, you're going to offer free transportation? Sure, I'll raise my hand even if I do not need it, I will tell you I do. But that's not the point. The actual point we're trying to get to is that there are people that are almost ashamed of it or didn't even know that it was something they should be raising their hand for or something that a cancer center should be doing or could be doing for them. Those are the kind of the things that you would unearth with systematic screening.

The other thing from a research standpoint or a policy standpoint is, if one can systematically screen and identify the number of times that transportation needs occur, implements an intervention that provides some transportation and study the impacts of it, we could get to more of a ground truth of, if we do this end to end process, screening, and program evaluation, can we understand how big of a transportation problem there is? We put a dollar amount and showed that one only needs to allocate less than 1% of their budget towards supporting transportation needs. For those specific patients, it makes a huge difference in their cancer care. That's the kind of pathway I think we could be on to start to understand what is going on, but only through a kind of more systematic and systematically implemented screening do I think we can get to this ground truth.

What can further be done to address transportation needs for patients with cancer?

I think it will take a community. One is that I think a lot of institutions are learning how they can make an impact on social needs for patients? I think there's a legitimate conundrum or question that's out there like, should they be the ones handling it themselves? What are those dimensions? It can be job security, it can be financial resources, it can be covering for housing and rent stability, it can be for transportation, it can be all different dimensions that you might think impact people's cancer care or cancer treatment outcomes here.

At the same time, it's not like there aren't members of the community already addressing these things. What we've lacked here is an interconnectedness between the healthcare ecosystem, the social service ecosystem, and really community sources that already exist out there. How can we create a better kind of integrated web between those, and/or there may be certain interventions that a healthcare system or healthcare provider organization like a cancer center should do directly.

One of the reasons that transportation is a little easier to study is because it is a ride. It's not overly complicated, yet at the same time, where does that ride come from and how do they connect with that resource? I think that is a challenge that needs to be solved. At the same time, could that be solved specifically by a cancer center? Also, 1 of the things is that there have been a lot of conversations about rideshare companies, which inherently are tech-based industries. Even the traditional, call the ambulance, call the van-share rides, all become more tech enabled over time. How technology companies or rideshare companies become a part of this ecosystem is to be determined, but I think if they can lower the cost and provide more reliable transportation, they may be an important tool to leverage. None of those sugarcoats purely understanding the ground truth of, does transportation matter? If you do something about it, does it change outcomes?

Are there any limitations of the study?

One limitation is that there are lots of other cancer centers, and there are lots of ways in which health systems are addressing this. This is a subset of a lot of the cancer treatment locations that are out there. One could believe that these cancer centers are trying to get the most well-resourced, the best funded, most research dollars, and donor dollars, and this may be the cream of the crop of what is happening. At the same time, there's a huge problem to solve for and for those institutions to try to understand. Also, the broader base of cancer places where people can receive cancer care, and how we can help support those. Those models are going to look a little different depending on how much donor money there is, what the community is that they're from, what the transportation networks are around them, and how did those all integrate? There is a long road ahead about how each of these locations may be solving or need to solve the problem in order to kind of get us to an answer.