Our Communications Manager, Katie M. Kanagawa, interviewed Dr. Alyce S. Adams, Stanford Medicine Innovation Professor and Professor of Epidemiology & Population Health and of Medicine, about her work on chemotherapy-induced neuropathy, and her role as the Director of Stanford Cancer Institute’s new Office of Cancer Health Equity and Community Engagement (CHECE).
Can you start by telling us a bit about yourself? How did you get here (to Stanford Epidemiology & Population Health)? Was there something in particular that attracted you to the fields of science, health and disease?
I became interested in disease as a child witnessing my elderly relatives suffer from disability related to diabetes, hypertension and other chronic conditions. I was struck by the acceptance of these outcomes among the family and the presumption that this was just the way it was.
Over time, I became increasingly interested in how health policy and health systems influence these outcomes and how we might use science to guide equity-focused policies and practices. I have been conducting observational and interventional research to address these questions for the last 20 years, and recently began to grow frustrated that there was so much that we didn’t understand and our attempts often had limited impact. I became intrigued by looking to other fields (psychology, neurology, computer science, engineering, education) for solutions. I chose to come to Stanford because of the transdisciplinary environment, and because of the commitment of leaders in research and medicine to making health equity a critical research priority at Stanford Medicine going forward.
Let’s turn to your research. I understand you have spent some time working on chemotherapy-induced neuropathy. Can you give us an overview of this research? What is the important problem you are working to solve and how have you approached solving it?
My interest in neuropathy actually started in diabetes, where up to 50% of all adults with diabetes for 10 or more years are expected to develop polyneuropathy. Despite the fact that polyneuropathy is a leading cause of lower extremity amputation among diabetes patients (a complication that is increasing in incidence in the U.S., despite overall improvements in diabetes quality of care), diabetic polyneuropathy is frequently underrecognized, diagnosed and treated in clinical settings.
My colleagues and I were using mixed methods, a cluster randomized pragmatic trial, and machine learning to improve care and outcomes for members with diabetic peripheral neuropathy at Kaiser Permanente Northern California when an oncologist colleague in the NCI Cancer Research Network encouraged us to consider looking at chemotherapy-induced peripheral neuropathy (CIPN) using similar methods. That brief encounter led to a current R01 funded by NCI to develop and validate predictive models to quantify the risk of severe CIPN, incident chronic CIPN and assess how CIPN risk information might be used to inform clinical decision-making about cancer treatment and survivorship care planning.
What has driven you to pursue this work at this point in time? What have you loved most, or found the most rewarding, about it?
Most, if not all, of my current projects are driven by my work with patients, caregivers and other stakeholders. By engaging stakeholders in our work from its inception, we are able to craft research questions that are both rigorous and aligned with the priorities of those affected by the research. What I find most rewarding is going on this scientific journey with the stakeholders, learning from one another and coming out on the far end with new insight for improvements in practice and policy. And when we fail, which is part of the research process, it is the encouragement of our patient and stakeholder partners that give us the energy to keep going.
You are also researching disparities in access and adherence to chronic disease medications. Can you tell us about the disparities you have encountered in this work, and how we might begin to address them?
Differences in prescribing, uptake and adherence to chronic disease medications by race, ethnicity and socioeconomic status have been demonstrated across numerous chronic conditions and are dynamic, changing over the course of the disease, as well as within individuals as they age. Much of our early work focused on evaluating the impact of coverage policies on access to clinically essential medications and the impact on health equity. What we found was that while increased access was necessary, it was not sufficient to eliminate gaps based on ethnicity or income. Importantly, in some cases, expansions in coverage resulted in an exacerbation of disparities, as subgroups most in need were often last to take advantage of improved coverage generosity. At the health system level, we found that several factors (e.g., copays, type of medication prescribed) were important mediators of disparities in adherence. However, the impact of these factors varied over the lifespan and across subgroups. Importantly, strategies to address these gaps that depended primarily on technology (e.g., alerts in the EMR) were unlikely to be effective without sufficient attention to contextual factors (including structural factors at the system and community level) that hinder/drive behavior change.
What do you hope to accomplish with this work? What larger impacts do you hope to make, scientifically and perhaps societally speaking, and who do you hope will benefit from this work?
Through this work, we hope to increase the capacity of decision makers at all levels to understand the risks and benefits of various options and to make informed choice based on preferences and community needs.
Let’s turn our focus to your work as the Director of Stanford Cancer Institute’s new Office of Cancer Health Equity and Community Engagement (CHECE). Can you tell us about the work you are pursuing in this role, and the project or initiative that you are most excited to take on at this time?
It is my pleasure to join the amazing team at SCI focused on community engagement. Our knowledge and expert team includes Dr. Lisa Goldman Rosas, Dr. Beverly Mitchell, Ms. Whitney Greene-Nymo, Ms. Pamela Ratliff, Dr. Lidia Schapira, Dr. Rachel Mesia, Ms. Ellen DiNuccio and Ms. Maria Rizzo-Locsin. We are excited about new opportunities to expand our collaborations with scientists, community partners, policy-makers and other cancer centers to catalyze research and community-based initiatives aimed at improving cancer outcomes and promoting health equity in our catchment area and beyond. I am particularly excited to work with knowledgeable staff and faculty members (including Dr. Lisa Goldman Rosas (E&PH)) on enhancing our capacity for monitoring cancer in the catchment area, catalyzing community-driven research partnerships, improving access to cancer clinical trials, and translating research into changes in practice and policy.