Research shows that when chemotherapy is delayed, a patient’s chance of survival falls significantly. Dr. Mariana Chavez MacGregor joined our podcast to talk about her work with underserved and underinsured patients—those who are most likely to experience delays—to develop personalized ways to improve healthcare access and, ultimately, outcomes.
A JAMA Oncology study suggests that patients with a time to chemotherapy after surgery of 91 or more days had a 27 percent increased risk of death from breast cancer. Those who are at risk of these delays are often Hispanic and Black, Medicare and Medicaid beneficiaries, patients with more comorbidities, and those of low socioeconomic status.
Dr. Mac Gregor is an associate professor at the University of Texas MD Anderson Cancer Center, holding a primary appointment in the Health Services Research Department and a joint appointment in the Breast Medical Oncology Department.
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Read the transcript below:
Chris Riback: Dr. Chavez Mac Gregor. Thank you so much for joining me. I appreciate your time.
Dr. Mariana Chavez Mac Gregor: Happy to join you and all your audience.
Chris Riback: Could we start with both what I assume is the simple and just frustratingly complex question that keeps you up at night and defines such a significant portion of your career. Why is breast cancer treatment sometimes delayed?
Dr. Mariana Chavez Mac Gregor: Well, that’s, as you said, a question that motivates me and that does keep me up at a night sometimes. I think that as a breast medical oncologist, I have seen firsthand how sometimes patients delay the initiation of their treatment. I have particularly focused on studying delays to initiation of adjuvant chemotherapy, which is the chemotherapy that starts after surgery. Meaning, patients who are already part of the healthcare system, they have a cancer diagnosis, they undergo oncological surgery, and then they delay the initiation of their chemotherapy. What my group and I noticed first, is that those delays matter, meaning a patient delaying the initiation of chemotherapy, particularly for triple-negative or HER2+ tumors, have worse outcomes than a patient that starts treatment, let’s say, within a month or two from surgery.
Dr. Mariana Chavez Mac Gregor: So, knowing that delays are detrimental for patient’s outcomes, then the question becomes: why are patients delaying treatment or who are the patients more likely to delay treatment? So that was a next step in our line of research and we identify patients using different, large national databases that represent what’s happening. We’ve seen over and over again that racial and ethnic minorities are more likely to delay their treatments, women at extremes of age, either those that are very young or very old, are more likely to delay treatment. Patients with more comorbidities, patients with low social economical status, low education levels are at higher risk at delaying their treatments, telling us that there’s some social determinants of health that are very likely associated with those delays. Not surprisingly, we saw that patients that are uninsured are more likely to delay the initiation of treatment.
Dr. Mariana Chavez Mac Gregor: Then we wanted to go even deeper because identifying which populations are at higher risk of delays doesn’t tell us the complete story. It’s not giving us the why and what I have been doing with the help of the Conquer Cancer Foundation and BCRF is working on the why and with a team of collaborators, we’re actually doing qualitative research. The difference in this type of research is that we are going to the story of the individual patient. We’re identifying patients that have gone through treatment delays and hearing their stories and trying to identify patterns in their stories to help us understand things at the individual level, but then extrapolating to really what is happening that can help us explain this delay, so then, of course, we can plan solutions.
Chris Riback: Yes, and I want to ask you about those patterns because that’s where a society wide set of solutions, I would assume, could be put into place. But as I was reading about this, particularly at this time of COVID, we all are getting a real time, even deeper education around many, many of the inequities around access to health care, around issues of comorbidity. So many of the things that you just described and we’re hearing about that.
By the way, I want to ask you as well, I’m sure that COVID is making everything even more complicated in your world and we’ll talk about that too, but just to hone in on one point that you made, these are women, these are patients who have had the surgery and you’re not talking about the sets of patients who have put off care and we all do it, who have delayed for whatever reason. But these are patients who have already had the surgery and now this is the next step, the chemotherapy. Was that even more surprising or frustrating to you because these are the women who are kind of right at that stage where they’ve gone through this particular challenge, now have the opportunity to start, we hope, making improvements, and yet there are barriers to their care.
Dr. Mariana Chavez Mac Gregor: Yes. I think there are, of course, many different ways to study treatment delays. There are many different time intervals that we can study. This was one that we thought was feasible and consistent, but with our findings, you can only wonder what would be the impact of patients delaying even a diagnosis because of fear or lack of access to health. So you can only wonder and imagine that the implications in terms of their outcomes are going to be even worse. Of course, I work at a large academic institution as a woman and as a breast cancer doctor, I am encouraged by the new drugs that we have access to and how we’re improving treatment for breast cancer patients. But from a very simple perspective, I think we should also think about how the great treatments that we already have can be delivered to the entire population on time, because maybe we’re missing a great opportunity to impact the lives of many, many cancer patients.
Chris Riback: So where does that begin? Where does that conversation begin? Maybe this gets to what you were talking about a moment ago, trying to decipher the patterns by talking to the individuals. What patterns are you seeing?
Dr. Mariana Chavez Mac Gregor: Right now we are in the phase of analyzing some of these interviews. As you can imagine, when a participant and a patient share their stories, there is a lot of material to go through. But part of that analysis has been really interesting. What we are seeing and some of those survivors that are hearing might identify with this, but we are identifying a pattern of shock, of either it is overwhelming information that can paralyze some women into that next step, right? They’re hearing that they have to go through chemotherapy and suddenly it’s like their life, it’s in shock. There are fears, there’s a stigma about cancer. There is worry that it’s, of course, valid regarding the finances, regarding job security, regarding the responsibilities that specific patient’s living at the time. Of course, those are very different for a patient with little kids compared to another one that is young and wants to have kids and wants to think about preserving for fertility. Or to older women that are the primary caretaker of a family member.
So that role in that moment gets, of course, shaken by the news of chemotherapy. We’re seeing that in some patients it takes a while to get them to the action, to get ready to do it. We are seeing through different layers of analysis, in one way or the other, how crucial and fundamental support is. Support can come from other breast cancer survivors, from family, from friends, from community, from a place of worship or members for those that practice a specific type of faith. But that support from others becomes very, very relevant. Something that has been very interesting, and in that regard I think maybe we as providers are the ones that can solve this. We have found very little insight in terms of the delay, meaning all of the participants that we’re interviewing experience initiation of chemotherapy delay. All of them. It was part of the criteria to invite them to be part of this study.
The majority of them think about them as having experienced a delay in the initiation of their treatment. I think that might then fall into us as providers. Maybe we don’t talk about the importance of timely treatment enough. So, I think that is very interesting and that tells us about the shared responsibility that we have of interest. We, of course, have seen some or have heard some stories related to travel to the hospital to receive treatment or to insurance. But again, let’s remember that these participants that we’re interviewing, all of them, are already emerged.
Chris Riback: They’re in the system.
Dr. Mariana Chavez Mac Gregor: Correct. These are not patients that are thinking about, “Should I get a mammogram?” Or, “Oh my God, what do I do? I have a lump. I don’t have a doctor.” Right? We are talking to women that already knew they had cancer, that underwent breast cancer surgery, that had a team of doctors. Some of them want a second opinion, et cetera, but it is a highly selected group of women if you think about that way.
Chris Riback: Yes. What also sounds to me in listening to you that would just make it such a complex problem for someone like you or other providers to unwind is, is this a social problem? Is this a societal problem? Is this a public policy problem? Is this a health problem? Is this a psychological problem? Is this a cultural challenge? I mean, where do you begin in thinking about how to get to the heart of the why?
Dr. Mariana Chavez Mac Gregor: I honestly think this is multi-dimensional. All the factors that you’ve mentioned, I am convinced they play a role and they might play a more or less significant role for each individual patient. But, of course, I think there are common themes. Social inequality, we know that affects healthcare outcomes. That is not new. We see it over and over again in breast cancer and other diseases, and we can talk about this, but of course, we’re seeing that with the COVID pandemic. So social inequalities matter. Language matters. Navigating the healthcare system, it’s quite complex. You almost need even more than a PhD to understand an insurance bill. It’s very complicated, can be overwhelming. I think, of course, policy matters. There’s a project that relates to this, that I am doing. We just submitted this data to the San Antonio Breast Cancer Symposium and are starting to work on the manuscript.
But what we are doing is we’re looking at a very large national database and we’re evaluating the time to treatment, time to initiation of chemotherapy, the same group of patients, right, to be consistent. Finished surgery, looking at the initiation of their treatment and then looking at the differences between whites and Hispanics, and whites and African Americans among women diagnosed with breast cancer in states that underwent Medicaid expansion in 2014. So this is a policy because you were asking about policy. So, the question is can we, with policy, decrease the time to chemotherapy initiation, one, and two, can we, knowing which are the populations that are more effected, maybe with this policy decrease this gap? Our analysis so far, what it’s showing us is in this group of states, if we compare free Medicaid expansion and after Medicaid expansion, there was a decrease in the time to chemotherapy initiation.
Dr. Mariana Chavez Mac Gregor: So, the proportion of patients that delayed treatment decreased, and we saw delay regardless of race and ethnicity. So we saw benefits across all the subgroups that we studied. It’s a little complicated analysis, we call that a difference in difference analysis. But what we saw is that big gap between whites and African Americans and whites and Hispanics shrank in those patients after the Medicaid expansion, suggesting that these policies that have a set goal decreasing disparities and increasing access to care are really giving the results that are meant to have. That tells me that this shared responsibility that I was talking about, of course, physicians and providers and medical oncologists like me are responsible to discuss this with our patients to inform them about the importance of timely treatment initiation. But that as a society and as policymakers, there’s also a responsibility to facilitate that access to care.
So I think it’s psychological. I think it’s medical. I think it’s policy. It’s quite complex and many of the members of your audience, I’m sure they can identify about this almost snowball of things that a woman has to go through just to get there. I’m sure that some cases can be smooth, in some cases it’s a longer journey, but I think we do have a shared responsibility and only implementing strategy that touch on all these dimensions. We are going to be able to expedite treatment initiation, because if we think about strategies and some of this we’re going to try to pilot in a small study with patient navigators, for example. Well, there’s so much that a patient navigator can do if they don’t have the buy in from the providers, or there’s so much a patient navigator can do if a participant does not have access to healthcare. So, I think it has to be multi-dimensional.
Chris Riback: What is a patient navigator?
Dr. Mariana Chavez Mac Gregor: So patient navigators can be nurses or a social worker.
Chris Riback: I see, so people who help a patient through the process.
Dr. Mariana Chavez Mac Gregor: Correct, and that literally help you navigate that enormous sea of things. Right?
Chris Riback: Understood.
Dr. Mariana Chavez Mac Gregor: Understand scheduling, makes sure that things don’t fall through, that if you need help with transportation, for example.
Chris Riback: Yes. That’s major. I know.
Dr. Mariana Chavez Mac Gregor: Language. I mean, it may sound minor, but if you need public transportation or your finances are not allowing you to pay parking for every week the hours that you’re going to spend at the hospital, you’re more likely to not go. Access to support groups. So those are some of the things that a patient navigator can do, almost like walking you through the journey. As I was saying, I think patients are going to have different needs. Some might have needs with language. Some might have needs with travel. Some might have needs with facilitating visits with all their providers, because if they have a lot of comorbidities, sometimes we as doctors need them to get those other comorbidities under control before we start treatment. Right?
So there’s also the medical part of it. There might be times that I cannot start treatment because there’s an open wound because the surgery didn’t heal, and it may not have healed because that patient has poorly controlled diabetes because she’s not able to have regular follow-ups. So, it can be very, very complex, and I’m afraid that solutions are going to have to be, as I said, multi-dimensional. Because if they’re too superficial, we might not see the change that I think we all want to see.
Chris Riback: Yes. It sounds extremely complicated. The sliver of hope and I’m a hopeful person by nature. In listening to you and thinking about the times that we are in. I mean, when you talk about ideas like shared responsibility and the importance of public health and the role that public policy can play in challenges like the ones that you’re describing, we are living through a moment, with COVID in particular, where I think many, if not most of us, are understanding the role that public health can play and a coordinated policy can play and must play in terms of keeping people safe, healthy, and going about their lives. So in thinking about that and thinking about the COVID situation, first of all, you may or may not agree with the statement I just made. So if you think that I’ve got that wrong, please let me know. Then secondly, how has the COVID situation complicated all of the complications that you’re already describing?
Dr. Mariana Chavez Mac Gregor: I do believe that we all are living in unique, challenging times. The COVID pandemic, it’s clearly affecting the entire world and some people have been greatly affected in terms of health and job security, et cetera. Something that has been very interesting from the perspective of the disparities research that I’m interested in is a lot of people are noting while we all can are vulnerable to COVID, some groups are dying more from it. This is something that it’s been seen not only in the United States but across the world. We know that more African Americans and Hispanic minorities are dying of COVID. We know that the elderly, we know that cancer patients, but there is a social distribution if you want to call it that. This has been a lot of interest for a lot of people, including the news media.
Dr. Mariana Chavez Mac Gregor: What I think it’s very important to mention is that while this is tragic, this is not new. This same phenomenon that we’re seeing with COVID, we have been seeing for a while in breast cancer, in other cancer, in chronic diseases. So, there is a disparity in outcomes. A lot of researchers from BCRF, many of them also supported by the Conquer Cancer Foundation, have described and tried to understand the disparities that are very clear for breast cancer. So we are just seeing in greater magnitude, or maybe closer to us, what happens in many other conditions. Now, the current COVID crisis, it’s posing many challenges for patients and, of course, for the healthcare system. Talking specifically about cancer patients, we are seeing a lot of cancer patients that aren’t getting their treatment. If not interrupted, at least delayed. In this case, it’s not because patients are doing anything wrong or we’re doing anything wrong. It’s just the circumstances.
Dr. Mariana Chavez Mac Gregor: In Texas, for a while, there was a government mandate to decrease certain types of surgeries because the hospitals were at capacity because we needed to have PPE for medical personnel, a number of reasons. These are public measures aimed at protecting the overall population, but that at the individual level may have costs or are costing for some patients not to receive the expedited treatment that they would have otherwise received. Similarly, we think about our screening programs. Every year and every month, actually, thousands of women participate in screening programs and they are diagnosed with early-stage breast cancers. Well, what if now, giving the situation, we are not able to get our mammograms sometimes? I can tell you, I personally was due to have my mammogram in June. It’s July. Maybe it’s just a month. I don’t think it’s such a serious problem, but it’s becoming harder to access the healthcare system because the healthcare system is saturated and carrying a very sick patient. Similarly, individuals that have lost health insurance, giving loss of jobs, so they’re not able to look for help.
Dr. Mariana Chavez Mac Gregor: So, I do think, while I have not studied it or measured it, I think we are going to see some of these unintended consequences from the COVID pandemic in breast cancer and in other cancers and medical problems. Unfortunately, that is my fear. Now, trying to be, I think, optimistic, as you said, there are of course a lot of organizations like BCRF, many healthcare institutions that are trying to work extra hours, to open our doors, to make sure that we’re available to provide patients the care they need and their reassurance that even in the circumstances, we’re going to give them the best possible care.
Chris Riback: Yes. So much. Now what you just described would be the last thing that anyone needs: More obstacles and challenges in what’s already, as you’ve described, a really challenging and complex situation. So, it is fascinating to listen to you and hear you talk about the ways that you seek to help others. Can we talk for a moment about you? As far as I can tell, you’ve studied in Mexico, the Netherlands, St. Louis and then Texas, which to be fair, by many people’s count, that actually would be a country on its own. So let’s call it four different countries. How many languages do you speak?
Dr. Mariana Chavez Mac Gregor: No, not that many. Not that many. I was born and raised in Mexico. My family’s there. That’s where I did medical school. I always wanted to be a cancer doctor and I became convinced that I wanted to be a breast cancer doctor when I was in medical school, and I was probably around 21 or 22 years old. So that became my dream. I went then to the Netherlands to do a Master’s in Clinical Epidemiology, and I worked with a wonderful group evaluating breast cancer risk factors as a way to prepare myself and to position myself better to get the best possible training here in the United States. That’s how I got fortunate to be accepted to the Internal Medicine Residency Program at Washington University in St. Louis, and then medical oncology training at MD Anderson. I’ve been faculty here for now almost nine years, and the tenure associate professor. I love what I do. I’m committed to my patients and I do love to travel and learn from different cultures and places. That is something that keeps me moving.
Chris Riback: Yes, I’m sure that it does. In thinking about it, that can’t be a mistake. The area, the particular area and the particular issues that we’ve been talking about within breast cancer and treatment that you have taken on personally, I can’t imagine that that is separated from your own personal history, your own growth, the places that you’ve lived, the people that you’ve met, the cultures that you’ve studied. Is that right? I mean, is this a natural progression for somebody of your spirit who would have spent so much time in so many different locations?
Dr. Mariana Chavez Mac Gregor: I think it is. Of course, I have a total bias with trying to understand distribution of health and disease in different populations. As I said, I’m from Mexico, I’m committed to the health of Hispanics. It is who I am. It is where I’m coming from. Of course, it’s a very important area of research where I can see that we can make a difference and that has really filled me with passion and with a sense of purpose. But I think you’re right. It’s closely linked to who I am, to where I grew up, or the things that I’ve seen. I have been fortunate to care for a very large number of patients and I’ve seen extremes of very privileged patients and patients in very difficult circumstances, and I have to help them all.
For me, it’s how can we as a society, as a healthcare system make sure that all patients get the best possible care? Because that’s what we all want, to be able to get the best treatment for all breast cancer patients, to give them the best possible outcomes, regardless of who they are, where they’re from, what language they speak. I think that’s the ultimate goal that we all have, and that BCRF has had supported. I am incredibly thankful for all their support. A lot of this I couldn’t have done without the support of them. That, of course, comes from so many of the patients and survivors and family members and audience that you reach. So thank you so, so much.
Chris Riback: Thank you. What you just described about your goals and what you want to do certainly comes across so strongly in getting to talk with you. Dr. Chavez, Mac Gregor. Thank you. Thank you for your time. Thank you for the work that you do.
Dr. Mariana Chavez Mac Gregor: Thank you. It’s been my privilege.
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