Targeting SDOH inequities in hematologic malignancies

In this issue of Blood Advances, Fei-Zhang et al¹ describe the association of social determinants of health (SDOH) on hematologic malignancy outcomes by using the social vulnerability index (SVI) among 14 hematologic malignancies in the Surveillance, Epidemiology, and End Results database. The authors find that increasing SVI correlated with decreased surveillance period and significantly decreased survival across most hematologic malignancies. Additionally, socioeconomic status and housing/transportation vulnerabilities were the largest contributors to adverse outcomes.

SDOH are the conditions in the environments in which people are born, live, learn, work, play, worship, and age, affecting their overall health outcomes.² These factors are grouped into 5 domains: (1) economic stability, (2) education access and quality, (3) health care access and quality, (4) neighborhood and built environment, and (5) social and community context.² Existing literature describes the association of individual unfavorable SDOH with health inequities among hematologic malignancies. For example, children with acute lymphoblastic leukemia (ALL) living in neighborhoods with high poverty rates have increased risk of mortality, relapse, and oral chemotherapy nonadherence compared with children residing in neighborhoods with lower poverty rates.^3,4 In adults with ALL, those with lower household income have been shown to have inferior overall survival compared with those with higher household income.⁵ In a systematic review of SDOH and survival of adult hematologic malignancies, most studies assessed the impact of health care access and quality, and economic stability, on outcomes, suggesting challenges in integrating the various SDOH domains.⁶ 

The SVI was developed by the Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry in response to a need to address social vulnerability during natural hazards and public health emergencies.⁷ It features 16 US Census variables grouped into 4 SDOH categories (socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation) and combined into a single measure of overall social vulnerability. The advantage of the SVI as compared with individual assessments of SDOH is that it facilitates a comprehensive assessment of various intertwined SDOH community factors that contribute to barriers to cancer care and inequities.

Fei-Zhang et al’s study highlights the importance of conceptualizing SDOH comprehensively at the community level to identify community needs and inform future community-based interventions and policy changes. Although unfavorable SDOH are associated with poor outcomes, few interventions addressing social needs in cancer care exist.⁸ Of those that are currently being evaluated and implemented into cancer care, most seek to address food and transportation insecurity at the individual level.^9,10 A multilevel approach is required to develop and implement sustainable, generalizable, and scalable interventions targeting social needs among patients with cancer, including those with hematologic malignancies.¹¹ Collaboration with clinicians, health care system leadership, and community partners combined with advocacy to affect policy changes are essential to address inequities caused by unfavorable SDOH during cancer care.

The authors acknowledge limitations of their study particularly that the SVI may not fully represent all aspects of SDOH that contribute to inequities. Although the SVI includes community variables of poverty and health insurance, it does not directly measure food insecurity or health care access. The absence of these measures in this tool likely reflects that this tool was not designed to inform health equity research. Therefore, future work could enhance the comprehensive use of the SVI by integrating it with other community SDOH measures that include variables not measured in the SVI. Data regarding food insecurity, for example, are available through the US Department of Agriculture¹² and the Feeding America Map the Meal Gap report.¹³ 

In summary, Fei-Zhang et al’s work emphasizes the importance of investigating SDOH in hematologic malignancies by describing the association of increasing community social vulnerability with decreased overall survival and surveillance period among most hematologic malignancies. Further research is required to transition from describing inequities toward developing multilevel interventions to target unfavorable SDOH and promote cancer equity among hematologic malignancies.

Conflict-of-interest disclosure: The authors declare no competing financial interests.