According to the American Cancer Society, the number of cancer survivors at the start of 2019 was 16.9 million Americans. They predict this number will increase to over 22.1 million individuals by the beginning of 2030. As the cancer-survivor population increases, follow-up care will be key to improving quality of life and survival.

Specifically, follow-up care involves regular medical visits to address the late/long-term effects of treatment as well as continuous monitoring/screening for early detection of cancer recurrence or new malignancies. While these practices are becoming increasingly standard, not everyone has access to high-quality follow-up cancer care. Studies have shown that individuals with low socioeconomic status (SES) often receive inadequate follow-up care. This leads to poorer cancer outcomes for these patients compared to those with higher SES.

Socioeconomic Status (SES)

Socioeconomic status is a measure of a person’s social standing or importance in relation to other people within a society. SES is often defined by the following:

• School education level
• Income levels
• Occupation

Assessing the SES of individuals in various disciplines is essential for revealing inequalities related to resources and issues regarding power, privilege, and control. Even though healthcare providers should strive for unbiased understanding and treatment, the effects of SES are evident even in the healthcare system.

Health disparities affecting the general population are also present among cancer survivors. They include disparities by race or ethnicity, geographic location, age, physical, mental, cognitive disability, or comorbidity status.

For example, rural cancer patients don’t have the appropriate access to cancer centers. Elderly lung cancer survivors receive a lower standard of care – discordant with official guidelines – if they have lower income, more comorbidities, or belong to a racial or ethnic minority. Black patients who are cancer survivors do not have culturally appropriate support services for their post-treatment period. When adjusted for clinical characteristics, patient characteristics, treatment modalities, tumor extent, and year of diagnosis, oral cancer patients under the age of 65 with low individual SES have a 1.46 – 1.64 times higher risk of death than individuals with high SES.

All of these problems contribute to a lower quality of life and survival rate after cancer treatment.

Follow-Up Care Discussions

Follow-up care discussions are an essential component of continued cancer care. Such discussions should cover the long-term effects of cancer treatment as well as the requisite tests/screening procedures to evaluate cancer recurrence and evidence of new disease. Importantly, responsibilities for follow-up care recommendations must be assigned among teams of healthcare providers (such as primary care physicians, oncologists, or other specialists).

Population-based studies suggest that socioeconomically disadvantaged cancer survivors are at a high risk of not having proper follow-up care discussions with providers. It is noted that low-income survivors and those with lower educational levels specifically are less likely to receive adequate follow-up care. Cancer patients that don’t have a college education typically report suboptimal provider communication.

Breast cancer survivors, survivors that require psychosocial care, low-income African American survivors, and un- or under-insured survivors are the most at risk of being uninformed. African American survivors of colorectal cancer report being unfamiliar with the recommended protocol for follow-up surveillance (annual colonoscopies). Cancer survivors, in general, have a higher risk of depression and similar psychosocial distress, yet according to one study review, 50% of them did not report/discuss this with their healthcare providers.

Moreover, medical practitioners who care for underserved/low SES survivors often fail to emphasize the importance of increasing exercise, improving diet, or ceasing tobacco use post-cancer treatment. This is unfortunate because these survivors are more prone to lack of exercise, poor diets and substance use/abuse. That too, these survivors typically live in areas that are far from well-equipped cancer hospitals, and therefore may be reluctant (or financially unable) to travel long distances to receive needed follow-up care. In these instances, the survivorship care falls on the local primary care providers who may lack the experience or expertise in treating survivors of certain cancer types.

Follow-Up Cancer Screening

Cancer survivors require regular screening for early detection of cancer recurrence or the occurrence of new cancers. The biggest obstacle to regular testing is cost and/or lack of health insurance. In the United States, one in three primary care patients is underinsured. This impacts survivorship care and the ability to create standard protocols for all cancer survivors.

It is notable to highlight women who survive breast cancer as 25% of breast cancer survivors do not receive the appropriate follow-up mammography surveillance. Furthermore, a woman with public insurance is less likely to receive a mammogram than a woman who is covered by private insurance.

However, barriers to follow-up screening are not limited only to financial ones. Patients of low SES may face any number of the following issues that ultimately precludes their ability to access needed follow-up care. These include:

• Low health literacy
• Lack of a usual source of primary care
• Limited proficiency in English
• Limited knowledge
• Mistrust in the healthcare system
• Low self-efficacy

Public Health Mission

We have compiled a list of action items that we believe need to be implemented by public health authorities if we are to resolve the socioeconomic disparities in cancer follow-up care.

• Collecting data on low SES survivors to recognize their unique needs
• Exploring the medical, psychosocial, and economic consequences of cancer diagnoses combined with other chronic conditions
• Determining the required training and composition of multidisciplinary teams for survivorship care that will effectively support underserved survivors
• Developing, disseminating, and implementing effective programs based on collected evidence
• Processing and evaluating the outcomes and costs of integrating the effective programs into systems
• Developing models to promote these programs and their sustainability and scalability

The need for comprehensive systems that support compliance with preventive care, surveillance protocols, and healthy behaviors in underserved populations is enormous. Public health plays a crucial role here. It must encourage meaningful engagement with communities to raise awareness, improve knowledge, and motivate action.

Bridging cultural divides is essential in these matters. Healthcare providers need to learn specific ways of addressing issues related to cancer survivorship that do not unintentionally alarm or offend members of racially or ethnically diverse groups. Language is not the only barrier of such disparities, sensitivity to cultural norms and understandings amongst ethnic groups play an important role in healthcare engagement. It is clear that Hispanic survivors won’t approach the necessity of regular screening with the same mindset as Asian survivors, who will again think differently than African American survivors.

Flexibility in conversation and adapting to the individual rather than utilizing a universal approach for each patient are also important practices to keep in mind.

Conclusion

An individual’s socioeconomic status is normally determined by a variety of tangible factors, such as their income level, education level, employment status and occupation. Race or ethnic heritage is not a socioeconomic characteristic, although in a diverse country such as the United States, it undoubtedly plays a role in social mobility and SES.

In the last few decades, it has become apparent that patients with low SES do not receive the same healthcare quality as those with high SES. This is true for all healthcare segments, including follow-up cancer care.

Unfortunately, for cancer survivors of low SES, this disparity has far reaching consequences. For example, cancer survivors of underserved neighborhoods report not having follow-up care discussions with their providers or being confused about its importance. It was also found that these survivors were less likely to participate in their follow-up care if their insurance status did not cover it, or if the medical facility is far away from their home, or if they simply don’t trust the healthcare system.

Cancer survivors of low SES also tended to avoid surveillance screening which is an integral part of follow-up care. They may have been uninformed, or other barriers might exist preventing them from accessing routine screening. As survivors with low SES rarely satisfy their long-term follow-up needs, their quality of life and their longevity are severely impacted.

It is up to public health officials to change this. Effective programs that personalize follow-up cancer care and meet the cancer survivor on their own terms need to be developed and implemented across the healthcare system, especially now that the overall US population is aging and the number of cancer survivors is increasing.

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