Ruchika Talwar: Hi everyone. Welcome again to UroToday. I'm excited to present you even more health policy content from the AUA annual meeting. Today we're joined by Rishi Sekar, who's a Urologic Oncology Fellow at the University of Michigan. Thanks so much, Rishi, for being here with us today. Yeah,

Rishi Sekar: Yeah, really a pleasure to be here.

Ruchika Talwar: You're presenting a variety of really interesting work that revolves around urologic cancers and this concept of Social Vulnerability Index. So that's what I was hoping to dig into today during this conversation, but I wanted to start by just giving our audience a background. What is the Social Vulnerability Index or SVI?

Rishi Sekar: Yeah. So the Social Vulnerability Index is one of many indices of what's called social disadvantage, or adverse social determinants of health is probably a more common term for that. The Social Vulnerability Index was specifically made by the Centers for Disease Control and Prevention to assist communities in disaster response and allocation of scarce resources, and that includes public health responses, so it became pretty prominent during the Covid pandemic. It consists of components from the American Community Survey. So the SVI in particular includes 15 different variables that covers themes including socioeconomic status, housing, transportation barriers, minority status, language barriers, et cetera, kind of a host of variables and kind of compromises or aggregates a score for each community to reflect this idea of social disadvantage or social vulnerability.

The SVI specifically is measured at the census tract level, and there's all kinds of other indices actually that are based on the American Community Survey. This is one of many, but they all have unique characteristics and unique applications.

Ruchika Talwar: Got it. So to summarize, it basically takes into effect a host of factors including geographic location, things like income, education status, and assigns a score. Is that right?

Rishi Sekar: Yeah, yeah. And I think the important thing to point out, it's certainly a population level metric, so it's not measuring kind of an individual person's disadvantage. It's a collective representation of a community, the place where someone lives and works, et cetera.

Ruchika Talwar: That's really interesting because that concept hasn't really been explored much. I think we've seen some work that has to do with geographic location as it relates to, for example, distance from a tertiary care center. But I love the idea of SVI because it takes into account things that are really not in a person's control, for example, where they live, where they work, how that kind of influences their overall health. So really, really interesting stuff. Now, we've gotten the background on SVI. How can this help us understand things like outcomes in urologic cancers?

Rishi Sekar: Yeah. I think a lot of amazing work has been done on disparities in outcomes, mortality, recurrence, et cetera, and we've done a lot of work on studying variations in care and quality of care, but we haven't done a good job explaining why that exists. And I think measures like the SVI or understanding this community level measure of social determinants of health will help us dig down into the etiologies of these disparities. A lot of it's not related to the specific person. It's related to, like you said, the community they work in, the community they live in, and I think that'll provide an opportunity to really develop interventions to reduce these disparities through cancer care delivery, through health policy, through public health, because all that I think plays a big role. And I think us as urologists, or us as oncologists even, this is something we need to be aware of and think about and how we design our treatments and how we deliver our care.

Ruchika Talwar: Yeah, absolutely. Now, let's start to discuss some of your findings as they relate to urologic cancers.

Rishi Sekar: Yeah.

Ruchika Talwar: Let's start with bladder cancer. What research question were you looking at and what did you find?

Rishi Sekar: Yeah. So the research question I was interested in is utilization of neoadjuvant chemotherapy in patients with muscle invasive bladder cancer. My question really kind of came from my training where I worked with a lot of patients from rural areas, all over the Pacific Northwest, Alaska, Wyoming, et cetera, and kind of noticed that the challenges they faced in getting neoadjuvant chemotherapy, even being aware of it. So the question I asked was, does social disadvantage or social vulnerability impact receipt of neoadjuvant chemotherapy prior to cystectomy? And I specifically looked at the University of Michigan's experience, only looking at patients within the state of Michigan. So again, looking at the community we serve.

Ruchika Talwar: Got it.

Rishi Sekar: And interestingly, we found that patients living in the most disadvantaged communities were far less likely to receive neoadjuvant chemo. That was even adjusting for platinum chemotherapy eligibility, adjusting for clinical and other demographic factors, and it was about a 15% difference in-

Ruchika Talwar: Wow.

Rishi Sekar: -of neoadjuvant chemo. Now, the question is what do we do next and what does that mean and how do we fix that? So what we're hoping to do is really kind of work with our community partners, the oncologists within the University of Michigan, but also across the state that we have a collaborative network with to understand the patient and provider level perspectives on why this may be happening, because I don't think it's enough to really show the disparity. We do need to dig down to see what's actually causing it, and I think this is a step towards that.

Ruchika Talwar: Absolutely. I think, using this research question, you've been able to bridge that gap between description and action, and I think that's a lot of the issue with health policy related work that's done. We do a really good job of analyzing a problem, but it's a lot more challenging to develop quality improvement initiatives or targeted interventions that help resolve the disparity. So kudos to you, and I think that work is a big step forward.

Rishi Sekar: Thanks.

Ruchika Talwar: Now, tell me a little bit about the study that you conducted using SVI looking at prostate cancer.

Rishi Sekar: Yeah. So that study was a little different. I wanted to take more of a national population level look. So we didn't really look within our own community, but we looked at the country as a whole. So we used Medicare claims data and we identified patients with newly diagnosed prostate cancer, and I really wanted to understand how social vulnerability impacted their initial care. So did they get certain kinds of imaging, how are they treated? Surgery, radiation, observation, et cetera.

And then I've also started to look into various quality metrics for prostate cancer care, and again, maybe expectedly, unexpectedly, we're seeing a similar pattern. So patients across the country, if they live in a more vulnerable community based on the SVI, they're less likely to receive appropriate treatment and aggressive treatment and less likely to receive high quality care.

So unfortunately, we're kind of seeing a same pattern. I think it in a way kind of supports what we saw in the bladder cancer study. This is likely something we're going to see looking at various metrics, but I think, again, emphasizes the importance of addressing these problems, but also how many patients it impacts across the country.

Ruchika Talwar: Yeah, absolutely. Now, tell me a little bit about what we can do as organized urology to help solve some of these issues that you've identified.

Rishi Sekar: Yeah. I think that's the most important question, and honestly, that's the goal, to give you a good answer for that. But what I hope is that demonstrating these disparities and some of the ideologies that drive some of these disparities will help us as a community here at the AUA and just across the country to think about how are we allocating our urologist, our oncologist, how are we promoting high quality care in certain areas, really to ensure that every patient has the same opportunity to receive good care, and that's a challenge. It's not something that's going to be solved by just us urologists. It's going to take us working with our systems, with our hospitals to really focus on addressing the needs of the communities we serve. Rather than expecting patients to come into a hospital, we need to learn the patients we serve and bring healthcare to them.

Ruchika Talwar: Yeah, couldn't agree more.

Rishi Sekar: Yeah.

Ruchika Talwar: Congratulations on this really impactful work, and I'm excited to see what's next for you and how your paradigm-shifting work continues to improve the quality of urologic care.

Rishi Sekar: Great. Thank you so much.