The Impact of Social Determinants of Health on Cancer Survival

With an aging population, the incidence of chronic illness surpasses the research advances to cure them. Among these chronic diseases, cancer stands out as a particularly challenging disease that was highlighted in the recent Presidential State of the Union address. With progress in cancer treatment, patients may be living longer, but with severe consequences to their quality of life and survivorship due to the psychosocial stress surrounding their diagnosis and treatment. Studies on psychological well-being in cancer patients have highlighted that these patients suffer from significant depression and anxiety.^1,2 Cancer symptoms including pain, fatigue, and sleep disturbance add to psychosocial stress^3-5 and decrease quality of life and survival.^6,7 Aside from these cancer symptoms, patients may also have predisposing psychosocial factors prior to their diagnosis that affect their cancer outcomes—including their socioeconomic status and previous major adverse life events.

Among the cancer symptoms, cancer pain is most difficult to treat; pain places the patient at high risk for opioid dependence, which worsens their survival.^6,8 Cancer patients represent a growing group of people who live with chronic pain. More than 50% of cancer patients have inadequately controlled pain.⁹ Under-treatment of pain is a widespread problem worldwide.^9-11 Cancer patients with poorly controlled pain are much more likely to suffer from opioid dependence or addiction,^12-15 which further perpetuates psychosocial stress, leads to poor outcomes, and adds to the growing national opioid epidemic that was also brought up in the State of the Union address. Whereas dependence is a physical need for opioids to control pain, addiction constitutes an overwhelming need to use opioids for its euphoric effects and an inability to control the amount used.

A major determinant of opioid addiction is previous major life stressors,¹⁶ including socioeconomic status. We are beginning to realize the impact of these major life stressors on health beyond their association to depression or anxiety.^17-20 Recently, researchers have defined a stress-related gene expression biomarker, called the conserved transcriptional response to adversity (CTRA), which involves increased expression of pro-inflammatory genes and decreased expression of genes involved in the immune response.²¹ With the lockdown during the COVID-19 pandemic and its effects on social interactions, the same research group determined that social isolation resulted in a 30-50% reduction in immune cells, leading to an immunocompromised state.²² This body of work establishes for the first time a molecular pathway in which psychosocial well-being impacts the physiology of chronic diseases.

Given the complex interactions of life stressors, social isolation, and socioeconomic status with symptoms and opioid dependence in cancer patients, cancer research that focuses on the cancer process alone might fail to capture these other major determinants of survival in patients. It is increasingly clear that proper whole person care requires acknowledgement of psychosocial stressors that have traditionally not been measured. Research on the biological role of these social determinants of health on cancer outcomes has a potential profound impact on our two national health crises: cancer and opioid abuse.

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References:

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