A cancer diagnosis today, while still scary and life-changing, signals a death sentence far less often than ever before. On the University of Colorado Anschutz Medical Campus, with its top doctors and advanced treatments, miracles happen every day. But for many people, that level of care remains out of reach.
It’s an inequity that Cathy Bradley, PhD, deputy director at the CU Cancer Center and associate dean for research at the Colorado School of Public Health, finds unacceptable. Bradley, an internationally recognized expert in health economic research, has made it her mission to help close the gap.
“While we have made great strides in our cancer treatment and cancer treatment delivery, not everyone can access these treatments, not everyone can complete them once started, and not everyone has the same level of outcomes,” Bradley said during a recent podcast with CU Anschutz Today.
Bradley’s research has influenced policy affecting everything from Medicaid to the Affordable Care Act in her attempts at “leveling the playing field” – often askew between rural and urban and minority and majority populations.
Her work focuses largely on insurance disparities and labor market outcomes, increasingly important as the age of cancer diagnosis drops. About 60% of the nearly 17 million U.S. cancer survivors today are of working age, she said.
“Cancer treatment is exceedingly expensive,” Bradley said. And for the many people reliant on employer health insurance, they must continue to work.
“I've interviewed thousands of cancer patients, and so often they say to me, ‘No one ever asked about my work.’ And it's such a big area of stress for them,” Bradley said. “Patients who are having a hard time at work don’t do as well in treatment.”
Bradley, who lost her best friend and others to cancer, focuses on the disease for many reasons, not the least of which is its magnitude. “In Colorado, cancer is the leading cause of death, so it’s an area where making a difference really does matter.”
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Disclaimer: Transcripts are generated using a combination of speech recognition software and human transcribers. It may contain minor differences from the audio, including some edits for clarity in print. Please check the recording and with the Communications team before quoting.
Deb Melani Welcome to CU Anschutz 360, a podcast about the CU Anschutz Medical Campus. We feature faculty, staff, and students, and their interesting and innovative work. I'm Deb Melani, a science writer in the Office of Communications.
Today, I have the pleasure of speaking with Dr. Cathy Bradley, professor and Associate Dean for Research at the Colorado School of Public Health and Deputy Director at the University of Colorado Cancer Center. Dr. Bradley is an internationally recognized expert in health economics research. Her work has focused on everything from the effects of cancer on labor market outcomes to the financial and ethnic disparities creating barriers to quality care for cancer patients today. Welcome Dr. Bradley, and thank you for being here with me today.
Cathy Bradley Thank you, Deb. Thank you for a very nice introduction.
Deb Melani Well, can you get us started by sharing what inspired you to join the CU Cancer Center?
Cathy Bradley Of course. About five and a half years ago. I was recruited to the University of Colorado Cancer Center and to the School of Public Health. And I was just intrigued by all the opportunity here on this campus, the excellent faculty and facilities, and the opportunity to do some very unique research with some really smart people. And it's such a pleasure to be here.
Deb Melani So has being here and part of the Cancer Center and the CU Anschutz Medical Campus helped shape your own research in any ways?
Cathy Bradley It's shaped my research in different ways than I had focused on in the past. I've always been interested in equity inclusion in terms of treatment and treatment outcomes, but I'd worked in areas where diversity meant mostly working with African-American populations, urban populations. And here in Colorado, it's very different. Our majority minority population is Hispanics, comprising 22% of the population, and there's large rural areas. So the problems are the same, but it's getting the help and interventions that have changed.
Deb Melani I know that we're unique in that we have both academic resources and clinical resources. Like you said, we're in the middle of Aurora, quite ethnically diverse. Does that play into your research?
Cathy Bradley Yes, I'm very interested in our ability to deliver equitable care, but also equitable outcomes. It's so important that we are able to treat an individual and to have them with the same success see the returning back to work, or quality of life, or long term survival without the level of side effects or interferences with their daily lives. And that can vary by how much insurance someone has, it can vary by how many community resources are available to them, and the types of treatment that they're able to access to get to complete. All of those things play a really big role in your survivorship.
So while we have made great strides in our cancer treatment and cancer treatment delivery, not everyone can access those treatments, not everyone can complete them once started, and not everyone has the same level of outcomes. And it's leveling that playing field, whether it be between rural and urban populations, or whether it be between minority and majority populations, are areas of interest of mine.
Deb Melani Can you talk a little bit about what you found in some of your research focused on these barriers as far as outcome and survival?
Cathy Bradley Yes. There are a couple of different areas. We see differences in survival by health insurance, and that's not a big surprise in the sense that those who are uninsured, or even Medicaid insured, are less likely to survive as long. And it's not to say public insurance is not as good, but those who have public insurance often were uninsured until they got diagnosed with cancer. So by the time they showed up and were diagnosed, their cancer had already advanced. They were already beyond where most treatments can be most efficacious. So the insurance came a little too late, or a lot too late in some cases. So we do see these disparities in outcomes.
Cathy Bradley Another area that's been very interesting for my research has been on labor market outcomes, the importance of work to individuals. And when we think about a person recovering from cancer or going through cancer treatment, and someone comes up to you and says, "How's he doing?" And your response is, "He's back at work." Automatically that triggers something in your thoughts. He's better. He's doing better. It's different. As opposed to saying, "He hasn't returned back to work yet." Or, "He's only working part-time." All those things are calibrated instantly in our mind about how well that person is doing.
So work has such a big intrinsic as well as extrinsic value to us and what it signals about our wellbeing. We know that minority populations treated with cancer don't return to work as quickly. They are not employed by employers who are as willing or as able to give accommodations to help them stay attached to work. Cancer treatment is exceedingly expensive. In order to get your health insurance, you've got to keep going to work. And that's if you're fortunate enough to have employer based health insurance. So this relationship is critically important on so many different levels.
What made you choose cancer as the disease that you researched the most?
Cathy Bradley So I'm trained as an economist and I was really interested in cancer because of several reasons. First, the data sets are better than anywhere else. We have cancer registries that record when you get sick, the stage at which you're diagnosed, so I know how sick you are, and what you're treated with. These data sets can be merged with other data to really give us a sense of what's going on with the cancer patient. Cancer's a disease that can't be ignored. You have to treat it. It's not like ignoring your hypertension, your high cholesterol. You can cheat a little bit on your diabetes. Cancer's not like that. You have to do something about it. So it's a very serious disorder and it is a very expensive one to treat and you can see exactly what's going on with the patients over time.
And then just the tremendous morbidity and mortality caused by the illness. In the state of Colorado, cancer is the leading cause of death. So it's an area where making a difference really does matter, and you can study it in a way that you can't study many other illnesses.
Deb Melani Have you been affected by cancer, personally, friends or family, and does that motivate your work in any way if so?
Cathy Bradley It absolutely does. My best friend passed away from a gioblastoma. I had a good friend die a year ago, also from a glioblastoma. My father-in-law died of pancreatic cancer. The list goes on and it's because it's a disease that is so prevalent. When we think about the number of people, one in two men in Colorado will be diagnosed with cancer, and one in three women will be. So it is a disease that is highly, highly prevalent in our population.
Deb Melani I just read today, breast cancer is increasing in younger women again. Are we seeing increases in younger people? And how does that influence your look at labor outcomes?
Cathy Bradley So, there are approximately 17 million cancer survivors now. About 60% of them are in working age. So, whereas cancer used to be an illness that was diagnosed after you retired and then person dealt with it in retirement, maybe had a shorter survival because they were already older, now we've done a better job of early detection. And as such, we've moved the age at diagnosis down. So that's a success story. We now are getting cancers at earlier stages in younger people and that's a good thing. Our treatments are better then. But now they're working age and they've got a long life ahead of them. So the goal of cancer treatment can't be to disable them.
Now that we're treating a different population, we have to think about them differently. They've got to go back to work. They've got to go back to caring for their kids, their parents, and the many roles that they play. So if you're diagnosing people in their 40s and 50s instead of their 70s and 80s, you've got a very different kind of patient, and you have to think of them in a very different way in terms of what it is, what treatments you choose. You can choose different kinds of treatment based on different side effects profiles. But we really have to think about returning the patient into their lives now that they're younger,.
Deb Melani We have seen great advancements in treatment, and we have that here on our campus. Can you talk about how that affects the labor market outcome, those much more advanced treatments?
Cathy Bradley In different ways. So in some cases, let's think about radiation. If we have advancements in radiation and we can give fewer doses over a shorter period of time, then we get people back to work. So labor market outcome, an important one is employment and hours worked. We can get them back into the workforce working more hours than before. So those kinds of advancements have really improved it.
The greatest advancements, I think, have been in immunotherapies, targeted therapies, that are now oral agents instead of infusion. And we don't really know how that affects work outcomes. So at a gut level, you can say, "Well, if you're taking a pill and you can do that at home, then that can't be as disruptive as going in for infusion therapy and taking this time away from work." But we honestly don't know over long-term. So these oral agents are often taken until evidence of disease progression. So meaning when your cancer comes back, and there's growth. So you're taking them much longer. It's not the same as a infusion therapy that starts and stops at some point. These drugs are taken longterm, and we really don't know how it impacts work. So it could cause side effects, some of which might be neuropathy. Depending on the kind of job you do that could affect your ability to do it. We just don't know long-term. So there's a lot to be learned about these agents and how they affect individuals once they enter the workforce again.
Clinical trials are a much shorter period of time. They're looking at a different safety and efficacy profile than how the drugs work in real life, outside of the clinical trial setting.
Deb Melani So you talked about how difficult the employer situation can be for these patients. Can you offer any suggestions on what employers could do to make it better? And also does our National Cancer Institute designation at the CU Cancer Center make a difference for patients and helping receive care?
So the first part of your question about employers and advice to employers, large employers just inherently have more ability to accommodate cancer patients. And most employers, regardless of size, whether small, medium, or large that I've interacted with, in general want to be helpful. It's just larger employers have more workforce. They have more resources. They can bring in help for individuals. They can accommodate them in terms of a flexible work schedule. They can do things for them that small employers that don't have a very deep bench to fill in work can do.
So an important part of being able to accommodate survivors, some, or patients that are undergoing treatment, is going to be communication. Offering an empathetic workforce and empathetic work site to be able to try to understand what is needed. Sometimes what's needed, and it seems silly now that we're in the middle of a pandemic, but it's a laptop so someone work from home and have flexibility because they want to continue working for any number of reasons. So it's having that conversation, what is it that you need, and being willing to try to be flexible in providing those accommodations.
That means a great deal to the patient that's undergoing treatment. And some of my own studies patients that are having a hard time at work don't do as well in treatment. They have more depression, they have more anxiety, their treatment lasts longer. And as we all know, when things aren't going well at work, it affects the rest of our lives as well. So it doesn't make things better, certainly, when work is not going well.
Deb Melani Right. And you've actually done some research into the effect of stress levels on these patients.
Cathy Bradley Yes.
Deb Melani Can you share what you found?
Cathy Bradley So that refers to a study that we're just getting started and it's actually on caregivers of cancer patients. Caregivers tend to go through the same kind of stress levels and anxiety, and sometimes even more so, and patients worry a lot about their caregivers. So if we take an employee caregiver who might now be responsible for the health insurance, for the family, and they might have picked up not only caregiving for their patient, but for the entire family. Now they're covering the full load of caring for family, trying to work, and balancing all of these different kinds of concerns. Their stress level goes up. Their health status declines. They start to use more healthcare services.
And that's something that we're now studying in a new randomized control trial that's funded by the National Cancer Institute. We are launching it here on the Anschutz campus and looking at stress levels of employed caregivers. We're offering them an intervention to help lower those stress levels. We're looking at biomarkers taken from both hair and saliva, as well as asking them to report their own levels of depression and anxiety. And we're looking at their employment outcomes and how all of these things come together and whether our stress intervention, which is done remotely, not surprisingly, not only because of the pandemic, but it's hard for working people to come in and get care. They can't sit down for an hour with a counselor to talk about ways in which they can lower their stress. They've got to do it 15 minutes before collapsing in bed. And online is the only way in which we can deliver it, but that makes sense for them.
So we're going to look at the effects and see if that is helpful.
Deb Melani And the intervention is basically counseling?
Cathy Bradley It's an online intervention of different kinds of strategies that you can use. Counseling is one of them. Some of them are more guided, self-guided, around breathing exercises. We also offer very practical advice, like what does the Americans with Disabilities Act allow you to ask your employer for? What does the Family Medical Leave Act provide you in terms of unpaid leave that is guaranteed by law and that you can get your job back? So we explain these very practical tools. We talk about communication, as well as things to lower your stress level.
Deb Melani Because that improves your outcome, including with patients.
Cathy Bradley Yes. And in fact, I mean, you raise an interesting point. We're looking at the impact of the stress out, of a stress reduction intervention on caregivers, and how that also improves patient outcomes.
Deb Melani So a lot of your research has also focused on cancer care differences between ethnic groups, which I think some people might not realize as big as it is. How significant is the problem. And can you touch on some of your findings in that area?
Cathy Bradley Yeah. So, and again, I'm an economist, so I'm looking at socioeconomic status, health insurance and different policies and how they vary by ethnic group. In this country, ethnicity is often a marker of lower socioeconomic status or un-insurance rate. So we know that in the state of Colorado, Hispanics have the highest rates of uninsurance relative to other groups. And as a result of the un-insurance, and living in lower socioeconomic situations or areas of high income inequality, meaning living in areas where some people are very, very wealthy, and some are very, very poor, and there's this wide gap between the two, can lead to worse outcomes.
And those are related to access. Access to treatment, access to supportive care. So much more goes into cancer treatment beyond your single interaction with your healthcare provider. What's going on at home? What goes on in terms of your supportive care and in your environment around you? All of those things have to be in check and have to have some level of equality in order to get better outcomes across different groups.
Deb Melani That reminds me, we didn't really address the National Cancer Institute designation. Does that help in these cases, for access?
Cathy Bradley It helps in a number of ways. By being a National Cancer Institute designated center, we're able to provide a very wide array of services. Cancer prevention and control is an important part of that designation. The comprehensive word comes from that aspect. You're considered a comprehensive cancer if you have a number of services, including prevention and control. By being a designated center, we have access to clinical trials, newer treatments and newer therapies, and supportive care that would not necessarily be available everywhere. And that's something that we can offer our patients above and beyond what you might find in community practices, or that we can partner with other practices to give greater access to newer therapies and care, as well as to supportive care.
And then any kind of interaction that we can do with employers through occupational health services or other ways, or rehabilitative services that we can offer here by the level and comprehensiveness of our services, can always improve outcomes.
Deb Melani And another group that you research is the rural versus urban. We have a lot of rural communities in Colorado. Can you talk a little bit about what you've found in that research?
Cathy Bradley Right. Yeah. And so Colorado is a really interesting state. Not only is it incredibly rural in parts, in the majority of the state, but it's separated by a mountain range. So during parts of the year, it's very difficult to traverse over to get the kind of care that you need. So that we see disparities that rural populations are diagnosed at later stages because they're not getting the same screening services. Their exposure to cancer risk factors, whether it be to pollutants, smoking rates are higher in rural areas, so their cancer risk is higher as well. They're less likely to be screened so diagnosed at later stages. And then just coming in for the kind of treatment that we offer here, at the latest treatment, can be very, very challenging.
Rural practices tend not to give the most recent targeted therapies as soon as other places, largely because they don't have access to the important things like biomarker testing to tell if a patient's going to respond or not to these treatments. So you have to be able to do the testing. You have to have the testing facilities in order to prescribe the treatment. Then you have to be familiar with the treatments to understand the side effects,when to step in, when to offer supportive care, when to pull the treatment back. And to monitor patient requires a much more intensive level of care that often isn't available out in rural areas. hey tend to adopt those therapies later. Once they're diffused in more urban areas that has more experience, it eventually trickles out to rural places, but at a much slower rate. And then they're dealing with a very different risk profile in their patients, often. Not always but often.
Deb Melani What about tele-health? I guess that brings me to another question. I assume there are a number of COVID-19 patients and survivors out there dealing with these same sorts of issues that you look at in cancer patients. Can you talk about that? And are there possibly any valuable lessons being learned with the pandemic that could translate into future healthcare economic policy?
Cathy Bradley Yeah, so tele-health has been something that's just absolutely taken off during the pandemic. And I think it's been a really good thing for our patients being out in rural areas and not having to come in. One of the things we learned is that you don't have to come in for every consultation, every follow-up visit, to have it all be face-to-face. And we've made some incredible advancements in tele-health and health care delivery through that mechanism. And we did not do it in the past. The payment models and reimbursement was dis-incentivized tele-health.
That's all been changed by the pandemic and now we're delivering a massive amount of care through tele-health means. And I think it's been a benefit overall to our patients. Now that we've learned that we can do it, we can do it safely, and that it can provide good outcomes for patients and they prefer it. And you can't blame them from coming from far areas in order to have their consultation and follow up with their doctors. I think that's a great area for further advancements in healthcare delivery and also in equity.
Deb Melani There are some equity issues with telehealth that we need to work out. Can you expand on those?
Cathy Bradley The state of Colorado, the last statistic I heard and it maybe, it's about a year and a half old, is 23% of the state is without broadband access. So we do have to think about how it is we deliver telehealth in areas that don't have broadband access in that we need to expand the kind of access we need. Not everyone has the same level of access, but we can work on that. That's something that we can address and has to be a priority.
Deb Melani You work among some of the world's best cancer care providers, and they see the rewards of their jobs up close and personally every day. Your work is much more on a macro level. Where do you find your rewards?
Cathy Bradley I mean, that's a great question. So there's a couple of different ways actually. It feels great to influence policy. And some of my research informed the parts of the Affordable Care Act in terms of how we think about the availability of health insurance outside of the employer based mechanism. Some of my work around Medicaid and disparities in Medicaid, influenced policy. So while I don't necessarily interact with an individual patient, I know that my research is affecting populations of people.
Cathy Bradley And then on a personal level, when I'm interviewing patients, I do primary data collection. I've interviewed thousands of cancer patients. And so often they say to me, "No one ever asked about my work." And it's such a big area of stress for them. And they don't want to walk in to their oncologists office and say, "You know what? I really can't make Tuesday." It's a tension, it's a real dynamic. They want to get the care, and they feel that, and they want the best care offered to them, and they don't want to start bargaining and negotiating over when they can get their treatments. And so they're just caught in the middle and then they've got to keep their jobs. And they're in that same negotiation situation of saying, "I've got cancer."
They want to put on a really brave, strong face of saying, "I'm going to get through this." So they can keep their jobs and keep their careers moving forward. We're studying that intersection, that no one else asked them about. So I do get to interact quite a bit with patients and to learn about their stories and I can tell their stories. And through my training as an economist do it in a way that it can be adopted into policy, and it's incredibly rewarding.
Deb Melani Well, we appreciate all that you do. And thank you so much again for being with us today.
Cathy Bradley Thank you. Thank you for the opportunity to be able to talk about this area of research and to be able to talk about the cancer center. It's a wonderful place to be and an absolute privilege.
Deb Melani Thank you.
Cathy Bradley Thank you.
[Music - Acknowledgments and Credits]
‘CU Anschutz 360’ is produced by the University of Colorado Anschutz Medical Campus.
Story editing and production by Deb Melani and Chris Casey. Mix and tech production by Kelsea Peters and Matt Hastings. Digital design by Sarah Adams and Jenny Merchant. A thanks to the rest of the office of communications team for support and edits.
And special thanks to Denver band Splitstep for our theme music, featuring School of Medicine student Matt Golub (Class of 2022), Daniel Carrillo, and Kevin MacKinnon.
We’d also like to thank our guests this week - Dr. Cathy Bradley.
You can read more on Dr. Bradley’s work - and the other latest stories and breakthroughs on our campus - at news...dot...cu anschutz...dot...e-d-u.
This is CU Anschutz 360.