Philosophy may seem a long way from cancer care delivery, but not for medical oncologist and public health researcher Dr. Veena Shankaran.
“I’ve always been science-minded, but I also love to read and write and think, and that drew me to philosophy,” said the co-director of the Hutchinson Institute for Cancer Outcomes Research, based at Fred Hutch. Shankaran received an undergraduate degree in philosophy before pursuing a career in medicine, oncology and cancer outcomes research; she joined the Hutch health economics team, now known as HICOR, in 2009.
Her role as HICOR’s co-director, she said, finally allows her to combine both passions.
“I’m a clinician using research to improve people’s lives and understand all aspects of their experience,” she said. “This research allows me to think more philosophically about the human condition and what it means to go through cancer and what effects people. It’s philosophy, applied to cancer care.”
In the clinic, Shankaran treats patients with gastrointestinal cancers, with a particular focus on stomach and esophageal cancers. While she’s often able to deliver therapies that reduce cancer’s symptoms, it’s become increasingly difficult to alleviate the financial suffering caused by the disease.
“I went into this research because I kept hearing about the financial and social devastation people were going through,” she said. “Patients aren’t able to work, and then they lose their sense of purpose. They’re not able to pay bills or pay for childcare. They’re going into major debt — even bankruptcy. And there’s all of this shame about discussing finances. These are all things we need to address.”
Shankaran does just that through her HICOR research. Her first study with the health economics group used data from the Fred Hutch-housed Washington state cancer registry to determine that 40 percent of patients with early stage colorectal cancer had experienced major financial hardships.
“I was really surprised by that result,” she said. “Many of them had this major financial upheaval for a curable disease. I started thinking about the long-term impact, the trajectory of their life from there.”
Shankaran and her colleagues link cancer patients’ credit data with insurance claims, medical records and other information to get a clear picture of the financial changes cancer patients experience over time.
"We're trying to understand the problem in a thorough and methodical way," she said. “Once we correctly understand the problem, we can move to interventions which can be done in the clinic or at a policy level.”
Shankaran is working with a team of collaborators at Microsoft to create an app that will help cancer patients better track their treatment side effects in an effort to reduce preventable hospitalizations.
“According to a HICOR study, 50 percent of patients going through chemotherapy end up in the emergency room," she said. "We have to do better. We hope that by using this technology, we can help decrease ER and hospital visits for these people.”
Another project involves evaluating the effectiveness of financial navigator programs — for both patients and their surviving caregivers, who are often left with a mountain of bills after a loved one dies.
As HICOR's co-director, Shankaran aims to mentor more junior faculty, involve more patients in the research and delve into projects that she feels need attention.
“One big challenge in our area is access to care,” she said. “We have a geographically broad and diverse population here. It’s not necessarily ethnically diverse but there are lots of rural areas and many pockets of non-English speaking patients that sometimes struggle with getting access to care.”
Cultural and/or societal taboos that prevent the discussion of treatment cost with caregivers can also be a barrier. But talking with doctors about finances — or lack thereof — can inspire them to select therapies that are just as effective but less expensive, she said, and/or prompt caregivers to point patients toward financial resources, which Shankaran said are underutilized.
“Less than half of eligible patients actually use financial assistance resources available through pharma and foundations,” she said. “We’re hoping to bring people up to speed with what’s available to help them get access to care; and maybe in so doing, we can improve their financial status, their quality of life and help reduce the overall burden of cancer care.”
And while HICOR spends a good portion of its time trying to better understand cancer care’s financial toxicity, the end goal is to develop strategies to mitigate it.
“We’re hoping to change practice and policy,” she said. “It’s not just drugs that improve people’s lives and survival. These other things are also important.”
— By Diane Mapes, Feb. 1, 2019