Exploring Social Determinants of Health in Breast Cancer Care with Dr. Sonya Reid
By BCRF | March 6, 2023
By BCRF | March 6, 2023
Despite their tremendous potential, advancements in medicine don’t reach all communities equally. This reality is complicated by social, personal, and informational barriers. Why are Black women 40 percent more likely to die from breast cancer than white women? And why is it such a challenge to make clinical trials reflect everyone who faces breast cancer?
That’s where Dr. Sonya Reid comes in. Dr. Reid and her team are working to address these disparities in breast cancer diagnosis and treatment through research.
Dr. Reid is an assistant professor of hematology/oncology at Vanderbilt University Medical Center. Her three-year Conquer Cancer–BCRF grant was made possible by The Estée Lauder Companies' Charitable Foundation Awards. Dr. Reid is also focused on improving healthcare delivery to underserved communities and increasing the representation of minority patients in clinical trials. She is actively involved in breast cancer research in Jamaica.
Chris Riback: Dr. Reid, thank you for joining. I appreciate your time.
Dr. Sonya Reid: Thank you for having me.
Chris Riback: I read a powerful quote where you said, "I've always been intrigued and appalled by the significant racial disparities among patients with breast cancer. Black women are more likely to be diagnosed at a younger age with breast cancer. Black women also have more aggressive disease and have worse mortality." To understand the importance of your Conquer Cancer study, which I really look forward to getting to talk with you about, I think it's important to first establish the context and the fact that Black women are 40 percent more likely—you correct me if I have that stat wrong—to die from breast cancer, compared to white women. It's a remarkable starting point. How do you reconcile that statistic?
Dr. Sonya Reid: Yes, it's disheartening when you think that overall the mortality rate from breast cancer is actually reducing. But then when you look at a certain population of patients, that is Black patients, we see that there is a significantly higher burden of death among that population. And I think that's just appalling. We know, however, it's not one thing that's causing that statistic. It's definitely complex. We know it ranges from differences in social determinants of health, for example, where people live, how people live, the access to healthcare that patients are able to receive. Where they get their healthcare, we know matter, right, and whether or not they have insurance. We know all that plays into it as well. We also know that tumor biology as well as genomics could potentially have an impact or play a part in what we see as this overall disparate outcomes when it comes to survival among females with breast cancer.
Chris Riback: It's such a potential mix. I mean, you're talking about nature versus nurture, genetics versus social inputs. How does that end up getting unwound?
Dr. Sonya Reid: I don't think we can say it's one or another, right? I don't think it's only nature or it's only nurture, as you said, right? But what I will say, race is a social construct. Most of the racial disparities that we are seeing in breast cancer and in other types of cancer and in health overall is really based on a lot of societal discrimination that we see when it comes to access to care as well as comorbidities that start from prevention, screening, and all the continuum of care that we see. So that's the first thing. I always like to frame that: Race is a social construct. And it's something that I have to even remind myself as a researcher when we start thinking about questions and how we approach a research question from the beginning.
However, we do know that there are certain aspects of breast cancer, for example, even incidence. We know that Black females are more likely to be diagnosed at younger ages. They're more likely to get triple-negative breast cancer. So we know that there's some differences inherent in the type of breast cancer that certain patients get versus others. Does that mean that they will have a worse outcome because they're more likely to have triple-negative breast cancer? I don't know if we know that answer at this point.
There's a lot more research that needs to be looked at to say to ourselves, for example, "Triple-negative patient that's Black, triple-negative patient that's white, if they receive the same level of care, the same quality care, will these patients have the same outcome?" And I think that's a lot of what fuels me and a lot of the questions that I'm interested in—really trying to make sure that we don't blame one or another, but really then drill down to say, yes, there may be differences in biology, but once we appreciate those differences and once we know and understand what's driving some of those differences, if we understand how to address those differences, can we then level the playing ground to allow those patients to have the same level of care?
Chris Riback: It's such a fascinating approach for someone like me to hear about from someone like you. You're a researcher, you're a scientist. I would think about the genetics. I would think about hearing, how can we get at the heart of the genetic makeup and how could potentially CRISPR be a tool so that we could start to affect the genetic approach going forward? But it's both, is what I'm hearing from you. It's, yes, let's get at that genetic answer, but you're a scientist, you're a researcher, you're not about to ignore the potential social inputs as well.
Dr. Sonya Reid: Absolutely. And I think, as I mentioned the fact that we know race is a social construct and a lot of the data that we have today always does Black versus white, and look at it across Black, white, Asian, other, Hispanic, non-Hispanic, white, et cetera. But what I think we have missed is the opportunity to look at ancestry in a lot of our studies. And I think it has been done now more recently, where we're really trying to understand, being Black, looking at it from a race standpoint, we know it's different if you're from West African ancestry versus East African ancestry, for example. We know that there are differences in incidence and even mortality rates depending on where your ancestry originates. I actually think that's something that we maybe need to layer on, not just looking at race, but also trying to understand, are there underpinning from an ancestry standpoint that could be contributing to some of these differences we see in incidence as well as mortality rates?
Chris Riback: So you need to be an oncologist, a sociologist, a genealogist, and with some of the locations perhaps that you get to go, a bit of an outdoor explorer as well. I don't know how -
Dr. Sonya Reid: Yes, a little bit. A little bit.
Chris Riback: Terrific.
Dr. Sonya Reid: It's complicated, right?
Chris Riback: It's complicated. But I would assume also that that really keeps it even more interesting and must fuel the curiosity that must drive somebody like you.
Dr. Sonya Reid: Absolutely.
Chris Riback: That's what I expect. So let's get, if we can, to the main event. What is your Conquer Cancer study? What questions does it seek to answer? What is your hypothesis? How is the study structured?
Dr. Sonya Reid: Great question. So my Conquer Cancer study, which is funded by BCRF, is essentially trying to understand differences among patients with hereditary breast cancer. So essentially, we're recruiting patients that have breast cancer and a germline mutation in either BRCA2, BRCA2, PALB2, CHEK2, or ATM. And we are creating this very diverse cohort, which essentially we're leveraging our partner groups that have more diverse representation of patients to make sure that we have approximately a 20 percent or higher minority enrollment rate was one of our targets that we set out to achieve.
But we're trying not to only understand the differences across these different mutation carriers, but really trying to understand how that may differ across different race and ethnic groups. So once these patients are enrolled, we will then do tumor profiling. So patients will have DNA and RNA sequencing done on their tumors for us to truly understand even tumor development and how we can perhaps refine treatment in the future for patients with hereditary breast cancer.
Chris Riback: Where are you in the study?
Dr. Sonya Reid: I think we're more than halfway with enrollment. And I will say we have met our accrual goal when it comes to diversity. So that's something that we're super proud about, but of course, still more work to be done. So we continue to partner with our different research collaborators and patient advocacy groups, because we truly want to ensure that we don't only understand how these differences may be accounting to maybe some of the disparities that we're seeing in outcome, but truly do a deeper dive as it relates to how does this differ across different ancestry, because that's another future goal of this endeavor, for us to then look at not just race, but how does that intersect as it relates to ancestry of these patients that are diagnosed with hereditary breast cancer?
Chris Riback: So Dr. Reid, the obvious question that anyone would want to know, what's next?
Dr. Sonya Reid: So that's a big question. And I think I alluded to some of that as it relates to the ancestry studies that we will be performing. But another passion of mine is really increasing the diversity in clinical trials. And for example, I'm a part of a pilot study that we're doing here at Vanderbilt in breast center, where we're truly trying to engage the community to increase the patients, the diversity of patients that actually come through our doors at Vanderbilt, right? Because we do know that in order to increase diversity in clinical trials, it really matters when we think about the patients that you're seeing. We know that most patients that get treated for breast cancer actually get treated in the community. About 80 percent are treated in the community, yet most of our clinical trials are in academic centers.
So I think that's one lens that we need to make sure that more clinical trials are actually in the community where patients are being treated. But as an academic center, which is where I practice, one of my endeavors that I'm working alongside some of my colleagues here to focus on is how can we be patient-facing, have those inputs in the community to increase minority patients that come through our door, and then increase minority patients that get onto clinical trials? Hopefully then this concept would be something that we could roll out across different disease types here.
Chris Riback: Why is it such a challenge to increase the representation of minority patients in clinical trials? Is this a challenge of supply or demand? It would seem to me, sadly, that there's no shortage of supply.
Dr. Sonya Reid: Right. No, great question. And even with my Conquer Cancer award, it's embedded in the fact that we're leveraging different organizations, different patient advocate organizations, as well as different research organizations that we know have more diverse representation, because again, my intentional focus with this study is to make sure we actually over-represent Black patients in this study. And so far, I would say that we're meeting that target where we have more than the 13 percent Black patients in this study, which is something that we're super proud of. But again, that takes intentionality. From the get-go, we decided to align ourselves with different groups that we know we could leverage because we truly want to understand, how do these different clinical pathological differences that we're trying to unravel, how does that look across different racial ethnic groups? Unless we are intentional when we're starting out different projects, I think we will continue along that cycle where we exclude these groups, if we're not intentional about included them in our research projects.
Chris Riback: Earlier in the conversation you were discussing that the ways to get at the heart of the role or not role, or the amount of factor or not amount of factor, of race in breast cancer instances and outcomes was you described wanting to understand the genetics and the biology, but then off of that establishment or some level of establishment, then also move into the social components. Does this study help advance you in that first part in terms of the biology of the understanding? And then the other part, how do you connect what we're talking about right now to the first part of the conversation? Did I interpret that correctly?
Dr. Sonya Reid: Absolutely. So because now we will have this cohort essentially that we expect by the end to be over 200 patients with breast cancer and a germline mutation, we will then be able to sequence their tumors to try to understand from an actual tumor standpoint, looking at the somatic mutation, again, now we're looking at even tumor development. Does that differ across different racial ethnic groups? And of course, we're able to understand these things better when we have a representative sample. So we will be able to look at patients' tumors, of course, we'll have treatment information, we'll have clinical information from beginning to survivorship essentially. But one of our future goals is also to be able to look at ancestry, because we would then be able to look at RNA sequencing data and then leverage that to then look even within this cohort to understand how ancestry impacts some of the differences or similarities that we may see across patients with hereditary breast cancer.
Chris Riback: And I know that maybe it's a related priority of yours, is improving healthcare delivery to underserved communities. Is that where this leads? Is this a baseline for affecting-
Dr. Sonya Reid: Yes, yes.
Chris Riback: Tell me about that, please.
Dr. Sonya Reid: Yes, because a lot of times we think about hereditary breast cancer, how does one know that they have hereditary breast cancer? If you are not tested, if you are not offered genetic testing, you would not even be a part of this study. And we know that minority patients are not offered genetic testing as they should, for whatever reason. I think that's a whole other conversation. And we know that once they're offered and it's explained that they're just as willing to want to understand whether or not they have a gene that could change their treatment course.
The bottom line is not only for this study, but to answer your question as to access to care, et cetera, I think we need to really try to make sure that we're making information available to the community, so community awareness and patient education as it relates to: What is genetic testing? What is hereditary breast cancer? What does that mean? Can that help me? Can that improve my outcome? Answer is yes. But why didn't I receive testing? And how can I now get it?
So part of our study, and a lot of the groups that I partner with, that's actually a part of our initiative, to make sure that we are not just educating patients, but once a patient is interested, they actually offer testing for free. We know that we have a group of patients that not only have they not been offered genomic testing from germline to even tumor sequencing, that really changes one's treatment path, but they're also not offered clinical trial as equal as their white counterparts.
So I think we need to make sure when we're tackling that whole thing, when we think about access to quality care, we need to make sure that we understand the reason why this is so critical. Because we now have over the years, have kind of, I would say, maybe even keep widening these disparities. We now have PARP inhibitors, where PARP inhibitors are a treatment for patients that have a germline mutation in BRCA1 or BRCA2 as it relates to breast cancer. So we know that treatment with a PARP inhibitor will improve outcomes, improve survival. These patients will live longer, is what this means, if they know that they have that mutation.
But if a patient doesn't know that that treatment even exists, because guess what, they were not tested, that patient then don't get offered it. Now we have an advancement, and the disparity continues to widen. So I always say whenever there's a treatment advancement and we don't ensure that all patients, whether rural, urban, Black, white, can get access to that advancement, in this example, a PARP inhibitor, when you have a BRCA1 or 2 mutation, if we're not able to make sure that that advancement reaches all our patients, we will continue to see widening disparities in breast cancer, unfortunately.
Chris Riback: Well, and that's just a terrible gap, because now you're talking about something where there actually is something that could be done where the positive impact on the patient is not being made, not because the cure or the help hasn't been found. It's because they don't know about it, the communication isn't there, the testing. It also makes me think, you mentioned it very, very quickly, but I know from other conversations how important and deep of a role these partnerships play, because getting to those communities ... I assume that you're in Nashville right now as we're talking.
Dr. Sonya Reid: Yes.
Chris Riback: But obviously you work at Vanderbilt. You're not on the ground. You might be on the ground at certain periods, but you're not on the ground at these locations 24/7. Those partnership relationships are everything, aren't they?
Dr. Sonya Reid: They are. And these patient advocate groups are our champions. They are the true heroes, because the groups not only allow us to partner, but they also inform how we carry out our research. They're the ones that a lot of time allow us to say, "Maybe we didn't think of this right. Maybe this is the true question." And a lot of times, I think what we have realized as a research group these days is that engaging them earlier in the conversation to actually help us as we develop a lot of our research questions and strategy, it's critical for us to really move the field forward.
Chris Riback: Well, that is spoken like a true researcher who knows that great questions can come from anywhere.
Dr. Sonya Reid: Absolutely.
Chris Riback: I'm sure you're keeping your ears open for them all the time. So let me ask you then another question, which is about you. Let's talk about you. How did you get into this? And I mean, going back. I know that you grew up in Jamaica, but maybe you can talk about that. And was it always science and math for you, or did you have other interests that were going to take you in a different direction until the science community grabbed you and didn't let go?
Dr. Sonya Reid: Wow, that's an interesting one. It has always been science. I think that I knew. I actually always knew I wanted to be a doctor from very early. I don't think I had honed in on what type of doctor. But yes, so science was always there, and going into medicine was always there. What I will tell you, I never thought I would fall into this passion, I always call it, because I never really thought about it initially, that there was a career maybe looking at disparities and breast cancer and all that. That's really, I guess, something that more evolved over time. But I really think it started with my upbringing in Jamaica, if I'm being honest. Because growing up in an island where a lot of times opportunities for quality care is not afforded to our patients because of lack of resources, to put it very plainly, a lot of times patients just cannot afford different treatment, maybe it’s not even available in the country, then they just can't afford it.
So I was faced with that growing up, and understood it very clearly. I went to medical school in Jamaica, so I saw that firsthand, spoke to patients in hospice settings, where sometimes patients in hospice, in my mind, I'm like, "Did they need to not get treatment?" In my mind, when you read the textbook, you would think, "Oh, but there is a treatment for this." But they couldn't get in to get treatment, or they got diagnosed at late stages because they didn't get access.
So just different issues that really weighed on me, I believe as early as medical school, where I saw that just lack of resources essentially caused patients to die. And then I came to the United States for my residency training, and I saw a lot of the same issues.
Chris Riback: Interesting.
Dr. Sonya Reid: And I think that's when a bell went off in my head, to be honest, because I thought to myself, "In this country where it's a developing country you see some of these disparities.” But when I came to the US and you think, "Oh my gosh, there's so many resources here," but then I saw patients that had no insurance or under insurance, or Black patients in the county hospital here in Tennessee, that it's almost as if I was right back in Jamaica. And I think it was appalling. I think at that point I was like, "How could this be, in this day and age, patients are not able to access a healthcare system because of just who you are?" So I guess that is full circle, really finding something that fueled me. And I really thought if I could be one person to try to be a part of the change, and that's how I decided to go into breast cancer and breast cancer disparities.
Chris Riback: You're taking your ideas, which are at the center of your work, but you have a team. You have partnerships in various countries, in various communities. You're reaching out to various groups. So you are a person in the ecosystem, let's say. But what I've learned among the things that I've learned from these conversations is I know you all feel the same way, that you're one person, but you have such a powerful network. And that just grows everything exponentially.
Dr. Sonya Reid: Absolutely.
Chris Riback: Speaking of networks, how would you characterize, what role has BCRF played in your research and this Conquer Cancer grant supported by The Estée Lauder Companies' Charitable Foundation Awards?
Dr. Sonya Reid: The Breast Cancer Research Foundation has been amazing. So this project would not have been funded without the Breast Cancer Research Foundation. So that's for starters, that it has funded this idea that really started out as a junior faculty, just someone supporting your idea and funding that idea to allow me to have protected time to do this research is huge. I am very honored to be able to partner with such an organization. In addition, being able to collaborate with other BCRF awardees had been great because you can hear everybody else's idea that practices across the different states and really pull from that energy and those collaborations. And I think that has been truly impactful as well.
Chris Riback: Yes, it's a very, very powerful, fascinating, and energized network for sure. To close, and it's funny because nearly all the comments I read about you and from you in preparing for this conversation mentioned this, and then you just used the word a moment ago, and that's passion. It totally came across how passionate you are about your research. It came across in what I was reading. And it now has come across, of course, in this conversation. Why does passion matter? I mean, Dr. Reid, this is science. Many of us are led to believe that science is meant to be a dispassionate study of reality. Why does passion matter?
Dr. Sonya Reid: I think science is fun. I truly think that. I think it's something that fuels discovery. It fuels the reason why I keep doing what I keep doing, keep fueling when I'm in that clinic with that patient and we're running out of options. It actually fuels me to do more research to try to figure out how could we better treat these patients? That way I'm not here 10 years from now trying to tell someone that I don't have any better option for you. So I think that passion truly keeps science alive. It keeps hope alive, because when you're dealing with a disease like breast cancer that we have seen it, right? Mortality rates have continued to decline, albeit because of better screening, better treatment.
But I think when we're not able to give those treatment advances or those better strategies to all of our patients, I think that's something that without passion and with us just keep allowing it to just pass us by and we hear it, it's almost like it reels off your tongue nowadays. I told someone recently, if I hear that 40 percent higher mortality rate one more time, I may scream, because you hear it over and over again. And I think we have been hearing it for a while now. And it feels like it's not going anywhere. Unless we have enough people that are passionate enough about that to make a difference, then we'll be here in years to come as well.
Chris Riback: Well, I hope that we are here in years to come, but talking about new topics and new advancements, many of which will have been constructed and advanced by you and your team. Dr. Reid, thank you. Thank you for your work. Thank you for your time. Thank you for your passion.
Dr. Sonya Reid: Thank you for having me.
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