Narjust Florez, MD

Associate Director, The Cancer Care Equity Program

Thoracic Oncologist, Lowe Center For Thoracic Oncology

Dana-Farber Cancer Institute

Assistant Professor of

Associate Editor, JAMA Oncology

February 2025

Cancer Survivorship: Equal but to the same

In cancer, survivorship focuses on the health and well-being of a person with cancer from the time of diagnosis until the end of life

Physical

Emotional

Mental

Social

Financial

Influenced by:

• Patient comorbidities
• Performance status
• Social support (married vs. single)
• Geographic location and socioeconomic status
• Cancer-related symptoms
• Toxicity associated with therapy
• Schedule burden

Sugimura et al. Chest. 2006

Pozo et al. Cancer Control. 2014

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Delays in Diagnosis and Gender Bias

6x times less likely to get lung cancer screening

Twice as long to get diagnosed with lung cancer

Physician bias: “You cannot possibly have lung cancer”

“It’s Anxiety”

Current screening guidelines do not incorporate sex-differences and instead are optimized for older white men

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Specific Aims

In collaboration with Massachusetts General Hospital, LEAD is the first mixed-methods study to:

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Aim 1. To determine if sex and age differences exist in time from symptom onset to lung cancer diagnosis. Hypothesis: Younger patients (<50 years) and women with will experience significantly greater diagnostic delays than older patients or men

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Aim 2. To explore system-level clinical barriers that contribute to diagnostic delays for women and younger patients with lung cancer via semi-structured individual interviews

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• We will also evaluate differences relating to race/ethnicity, educational level, and family history of lung cancer in relation to diagnostic delays

LEAD Study Overview

Differences in Adverse Events

• More paclitaxel induced neuropathy
• Platinum based nausea and emesis
• Diarrhea (IBS) vs constipation
• Joint specific adverse events

Sex Differences in Tolerability to Anti-PD1 Therapy

• Women were more likely to experience IRAEs compared to men
• Women were more likely to be prescribed systemic steroids
• No other characteristic was associated with increased IRAEs

Duma, Narjust, et al. The Oncologist 24.11 (2019)

Tolerability of Cancer Immunotherapy from the Patient Perspective: Evaluating Symptomatic Adverse Events of Immune Checkpoint Inhibitors with Electronic PRO-CTCAE in a Diverse Patient Population with Lung Cancer

SHAWL Study

Sexual Health Assessment in Women with Lung Cancer

• Most of the data regarding sexual dysfunction in patients with lung cancer precede the approval of targeted therapy and immune checkpoint inhibitors

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• Sexual health in patients with lung cancer is under-reported and therefore, understudied

Schover et al. European journal of cancer supplements (2014)

Duma, Narjust. "Specialty See All."

Results

• Participants: 249
• Age range: 29-84 years,
• In targeted therapy: 45%

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77% of patients reported moderate to severe sexual dysfunction

Florez et al, presented at the 2022 World Conference on Lung Cancer, Vienna, Austria, unpublished

When comparing before and after lung cancer diagnosis, marked differences were noted in decreased sexual desire/interest (15% vs. 31%) and vaginal pain/discomfort (13% vs. 43%)

Lung cancer survivorship in women

• Social challenges – responsibilities at home
• Financial toxicity
• HIGHER divorce or separation rates

Duma, N et al. 2020. Clinical lung cancer, 21(3), pp.e115-e129.

Women, Family & Cancer

Women cast aside their needs to care for family and relatives who are diagnosed with cancer and other diseases

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The whole family, and children especially, suffer when a mother suffers or dies of cancer in the prime of life:

• Child mortality
• Children’s education
• Socioeconomic advancement
• Elderly care
• Workforce impact

Ginsburg, O et al. The Lancet (2017)

Samarasekera, U et al. The Lancet (2017)

Surviving Lung Cancer

Stigma Associated with Lung Cancer – Women

Isolation

Suicidal ideations

Poor outcomes

An International Campaign #HearHer! - #Escuchala!

Outreach Efforts

What is important to your patients?

What are their expectations about survivorship?

#1 Patient and Provider Education

ASCO Center to Advance Palliative Care

Different Perceptions About Cancer Survivorship

It can mean traveling the world!

Cooking Dinner for the Family

#2 Early Integration of Symptoms Control Management

New approach: Early, simultaneous integration is evidence-based

Ferrell et al, JCO 2008

#3 Caregiver Education and Integration

#4 Financial Toxicity is part of cancer survivorship

How To Address Financial Toxicity?

Cultural Differences About Expressing Needs

Warsame R, et al. J Oncol Pract, 2019.

Source: Canva (premium)

Lung cancer survivorship in young individuals

Florez et al. Unpublished, please don’t share.

• A 40% reported not having any or only a little money available to pay for LC treatments, and a majority (55%) had little to no idea how much to spend on treatments.

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• 35% felt considerably financially stressed, and 32% reported that their cancer had been a significant financial hardship.

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• Half of the participants reported significant worry about future financial problems.

#5 The Many Faces of Cancer

Our patients are more than their cancer diagnosis.

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Do you really know your patients?

#6 Remedies Are Part of Culture and Survivorship

Tervalon and Murray-Garcia. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of health care for the poor and underserved, 1998

• Everyone who works cross-culturally and cross-linguistically will make mistakes

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• In a world with diverse cultures and languages, it is crucial to be flexible, to take responsibility for mistakes, and to be open to learning/adapting as cultures and languages evolve

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• Doing so helps build the trust, relationships, and communication that are key to effective global public health efforts

Reminder

Q & A