Loretta Nastoupil, MD, an Associate Professor who serves as Director of the Lymphoma Outcomes Database, Section Chief of New Drug Development, and Deputy Chair of the Department of Lymphoma/Myeloma at the University of Texas MD Anderson Cancer Center, reflects on the experiences that led her to study disparities in lymphoma, the importance of representation in practice-changing trials, and her hopes for the future.
Where did you grow up, and when did you know you wanted to be a physician? I grew up in New Mexico as the oldest of three kids. Unfortunately, my grandfather and nearly all his siblings died of cancer. I thought that someone in our family needed to understand more about cancer.
What led you to specialize in lymphoma specifically? When I was an undergraduate at Texas Tech, I was initially studying architecture, but I became intrigued by clinical lab science, so I switched my major.
What I found most interesting was looking at blood smears. To me, seeing leukemia or abnormal smears was intriguing. That’s when I knew I wanted to be in the oncology field, and I was particularly interested in hematology. I ultimately became interested in lymphoma because I felt it bridged the gap between solid tumors and hematology.
Was there a mentor who shaped your path? While I was doing my training at Emory University, Christopher Flowers, MD, MS, showed phenomenal clinical and communication skills. I wanted to emulate his knowledge base in lymphoma. I worked alongside him while I was at Emory, and he was pivotal in helping me get my career started at MD Anderson, where he is now my chair.
What led to your research on disparities in lymphoma? I grew up in rural New Mexico where access to health care was a major challenge. I have a family history of folks with cancer who did not do well. For instance, my grandfather died of prostate cancer at 62. I had a niece who was diagnosed with anaplastic ependymoma. As a fellow, I helped coordinate getting her transferred out of the state because they didn’t have the capacity at the time to handle her condition. She was 12 months old, and she had a large cerebellar mass that was causing hydrocephalus.
I was personally touched by growing up in an area where health care was sparse. When I moved to Atlanta, Georgia, as a fellow, that’s when I saw the racial disparities emerge. Often, patients who are minorities or have a lower socioeconomic status can’t access facilities that provide top-tier-type care, even if they live in a large metropolitan area.
When we started looking at lymphoma—where most patients can anticipate good outcomes, including a cure, as it pertains to diffuse large B-cell lymphoma—some of our Black patients were not achieving the same outcomes as our White patients.
When we looked at some of the life-changing therapies—like the incorporation of rituximab, which led to an overall survival advantage—the uptake in the Black community was much slower than in the White community. I’m continuing to work on understanding how to improve access and reduce barriers for our underserved populations.
What can be done to address these disparities? We need to make sure there’s awareness, because if people are not aware, they’re never going to start looking for solutions. However, sometimes we recognize that there’s a disparity, and that’s where we end.
How do we solve that problem from a societal standpoint, where often access to care is tied to the type of insurance you have? Are we getting good representation of minority patients on therapies that we think are going to be the most promising?
I’ve taken on the second part because it’s something I can solve, but I still try to look at policy changes. I work at MD Anderson, and you could be critical of my choice, because I work in a center where we generally don’t provide access to care for many patients who are underinsured. We do provide care to patients with Medicaid or Medicare, but in general, there are more favorable private insurances that we contract with.
If I look at the population of patients who are seen in our clinic, I ask if we do a good enough job of representing patients who are minorities, women, or older or younger adults in potentially practice-changing trials. I don’t promote putting them in first-in-human studies, but if we have good phase II or randomized, phase III studies that we think are going to be practice-changing, our population should reflect the demographics of the patients we see in clinic.
We’ve implemented a patient navigator to discuss clinical trials using the language that patients are most comfortable with. We think it can be helpful to have someone who looks and talks like you describe why it’s important to participate in clinical trials. We can get into understanding the barriers to participating and explore different grants that are potentially available to help soften the socioeconomic blow.
We’re partnering with some of our sister institutions that are affiliated with the main campus of MD Anderson, such as UT San Antonio and Harris Health Lyndon B. Johnson Hospital, which is our county hospital. The practice-changing studies at those centers serve a larger minority population than we’re able to serve here at the main campus of MD Anderson.
I’ve also been involved through the American Society of Clinical Oncology, which has a health disparities committee with several initiatives. Those initiatives involve bringing awareness to disparities, making sure that we’re recruiting minority oncologists from the premedical stage through training and that our guidelines acknowledge where minorities are grossly underrepresented in large, practice-changing studies, and how that impacts generalizing these treatments.
I’ve been involved with this work at both the local and national levels. There’s still a huge unmet need in terms of trying to get better health care delivered to communities that don’t have the access that my patient population does.
How can clinical trials shape care and address disparities? Clearly, I am biased—I’m a clinical investigator, that’s what I like to do—but I think there’s potentially better care delivered to patients who are participating in trials.
You have many people looking in on those patients. Our primary objective is to look out for the safety of the patient. Often patients get access to some of the more novel treatments, which we think are better than the currently available standards of care, by participating in these studies.
Even in the last five years, new treatments have emerged, some of which are even better than what we had been using for decades. This progress is only possible through patients participating in clinical trials.
I want to do everything I can to ensure everyone has access to those trials, and that we get better representation on those studies of patients who reflect our general population. This diversity will allow us to have more confidence that results will generalize when these therapies are approved.
How do you hope to see lymphoma treatment evolve? We still don’t have good ways to personalize medicine. We have some rudimentary tools and clinical prognostic scores, but those are not too precise.
I’d like to see tumor profiling used to generate treatments that are more precise to the biology of a given patient’s tumor. In chronic myeloid leukemia, for instance, identifying the translocation allowed the development of a pill that targets it. That disease was fatal for many patients, but it has become manageable nowadays.
If we can do a better job of tumor profiling and generate a score or signature that helps identify the most effective treatment for a given situation that would be major progress.
What do you enjoy doing outside of work? In the wintertime, I love to snow ski. In the summertime, I love to hike. If I have any opportunity to be outside, you will find me there.
What is one thing people might be surprised to learn about you? I have breast cancer myself. I’ve benefited from the system that I work in, but I’m passionate about the fact that we need to do a better job of improving communication to patients about the variety of treatment options and why it’s not always clear which is the preferred option. It’s important to avoid placing a lot of the decision burden on the patients, who sometimes feel woefully unprepared. That includes someone like me, who’s an oncologist but spent most of her time in the hematology world.
Loretta Nastoupil, MD, is an Associate Professor who serves as Director of the Lymphoma Outcomes Database, Section Chief of New Drug Development, and Deputy Chair of the Department of Lymphoma/Myeloma at The University of Texas MD Anderson Cancer Center.