ASCO Investigates Disparities in Cancer Care: Representation in Oncology

Dr. Sands:
Even though it’s well known that different cancers can disproportionately affect certain patient populations more than others, recent analyses of clinical trials substantially underrepresent black and Latinx populations in particular. On top of this, only 3% of practicing oncologists today identify as black, and less than 5% identify as Latinx. So why aren’t cancer trails and even medical practices designed to ensure representation of all ethnic and racial groups? And what’s being currently done to address these disparities?

Welcome to Project Oncology on ReachMD. I’m Dr. Jacob Sands, and joining me to discuss ASCO’s mission to increase a quality in cancer care and research is ASCO’s current President, Dr. Lori Pierce. Dr. Pierce is a Professor of Radiation Oncology and Vice Provost for Academic and Faculty Affairs at the University of Michigan. Dr. Pierce, it is a pleasure to welcome you to the program.

Dr. Pierce:
My pleasure to be with you.

Dr. Sands:
So, Dr. Pierce, as President of ASCO, you have the opportunity to look over a plethora of issues and matters to really focus on during your term, and you chose equitable care within oncology and research as a particular focus. Are you able to share with us your thoughts about some of that and the challenges looking forward?

Dr. Pierce:
Sure. You’re right. I could’ve picked any number of topics to have as my theme, but it was very clear what I was going to choose. Equity of care has been of long-standing importance to me, and because I’m African American, and as an African American oncologist, you see the disparate outcomes for people of color. Actually, in almost any metric you look at, you see that people of color have a worse outcome and cancer is no different. So I was very, very focused on having equity as my theme. And I also knew that that would be a perfect theme for ASCO. If you think about ASCO, everything the organization does focuses on all patients receiving high-quality cancer care.

And as you may know, I chose this well before the pandemic. When you are voted and become President of ASCO, you have a year, you’re president-elect and it’s during that year that you articulate what your theme will be and so, you know, I said it was gonna be equity. And then a few months later came the pandemic and then, of course, the very high-profile acts of racism that were carried on our televisions almost every night, so  it was the right theme. This was the right time, but it was just coincidental, if you will, that I picked it before all of the recent current events.

Dr. Sands:
Well, an important component of this for patients in many cases is being able to have physicians and providers that they can really identify with. Which really raises the topic of  having physicians that are within these different ethnic and racial groups, as well. So can you outline some of the positive work that’s being done to help reduce this under-representation amongst physicians and providers within medicine?

Dr. Pierce:
Sure. So with an equity theme and trying to improve equity, I always say it’s like peeling an onion, there’s so many layers, and you’re absolutely right that trying to increase the number of providers of color is a very important component to having equity of care because many patients feel more comfortable with physicians that look like them. That said, I always say that you shouldn’t have to have a black physician if you are a black patient to feel comfortable with your caregiver. We should all be focusing on culture sensitivities, culture awareness that allow us to relate to patients that are different races than what we are.

But I think in order to really move in the right direction, we have to have more programs that bring oncology into the awareness of some of our trainees and ASCO has been doing a lot on this for a while. They have a medical student program where medical students apply, and when they’re accepted to the program, they are paired with mentors and they use a stipend that allows them to come to the annual meeting. There’s a resident program, as well, that allows residents to work with attendings in oncology and support their research and also bring them to the annual meeting.

And then there’s a new program. It’s called the Oncology Summer Internship and basically this is an internship, which will be a four week immersive oncology experience for rising second-year minority students to really get a very strong footing for the potential for careers in oncology. And it’s a case where ASCO will put together a didactic set of lectures over four weeks to really explore all the options and careers in oncology. The students will stay at their home institutions so that they can shadow faculty at their institutions, but it’ll be a hybrid, if you will, between ASCO and their institutions. ASCO will provide a stipend to encourage minority students to really take a very strong look at oncology, so I think these are the kinds of programs that we need to really, really reach trainees at the right times in their careers to make them think about oncology.

Dr. Sands:
With all that being said, can you speak to the importance of leaders at these educational institutions, hospital networks and other systems, not only being aware of the under-representation but also actively engaging and empower perspective healthcare workers to enter the field of oncology?

Dr. Pierce:
Yeah, it is so important that the tone is set by our leaders to articulate that this is foundational to our institutions. That diversity is important on so many levels. We need to have more providers and populations underrepresented in medicine so that we look more like the patients that we serve.

But also it’s a case where diversity is healthy for an institution. The more diverse a workforce you have, the more richness of the range of opinions and the experiences, and you think more broadly, and I think it’s important to have different perspectives that it enriches us all and that’s at physicians, attending physicians, residents, med students, nurses, PAs, the whole team. Obviously we are products of our experiences and we need to have as diverse a set of experiences to really understand the world as it is now, to understand our patients, and to be able to be more effective of providers. So it’s a win-win the way I think about it. 

Dr. Sands:
For those just tuning in, you’re listening to Project Oncology on ReachMD. I’m Dr. Jacob Sands and I’m speaking with Dr. Lori Pierce, the current President of ASCO, about the under-representation of people of color in oncology.

Now, Dr. Pierce, I like to think at a minimum that those within medicine are aware of the under-representation of minorities. We have countless studies that have proven a lack of diversity and identified barriers. So what can we do to combat this issue? It’s been defined, where do we start now, or what are the next steps in moving forward and solving this?

Dr. Pierce:
So, that’s the multi-million dollar question. And so when you have something that’s so, enormous, you have to go just back to basics. We need to listen, we need to talk. We need to think, you know? If you think about all of the things that have happened, in our country, throughout the world, but primarily in our country in the past few months with the pandemic, with all the displays of racism, we have to acknowledge that there is systemic racism in our society. And we have to acknowledge that there is systemic racism in medicine. I strongly think that we have to own it, rather than deny it. I think with medicine there is an acknowledgement of race but there has been a denial of racism, and we have to realize that these are two separate entities, yes there’s some overlap, but they are distinct, and with racism, if you keep one group down, you’re never going to be what we all can be and that’s across medicine and across society.

If you look at the outcomes of cancer, not everything’s due to biology; biology’s very important, don’t get me wrong, of course biology is very important, but there are these invisible factors that when people are talking about more and more, which is a good thing, which is social determinants of health. And they account for so much of the difference, so many of the disparities that we see today. And I think yes, we’re going through a very bad time in our country, but we are emerging with a dialogue, and we’ve been here before, we’ve had ups and downs and we’ve had very severe times in our country because of racism, but I’m cautiously optimistic. There is a dialogue that I am aware of that I have not been aware of before. And I think we are learning from this and I think that dialogue will definitely get us to where we need to be.

Dr. Sands:
So then bringing all that kind of back down to provider in the clinic taking care of patients, what’s  the thing that they can focus on and really make sure to be doing or be aware of in helping to solve greater trial enrollment for people of color within oncology and also just better care within the healthcare system?

Dr. Pierce:
I’ll go back to what I said a few minutes ago. We really have to listen. And we have to listen to our patients because yes, there are so many of these invisible factors that we would not be aware of if we didn’t listen and we didn’t ask the right questions to understand what the barriers are that our patients are facing.

So, we’re physicians, we all were taught how to take a history and usually it’s check, check, check, you know, of things that we ask, but we need to think about what we’re asking and we need to enrich our questions to really get at some of the barriers that our patients are often facing because we have all of these incredible treatments but if they can’t come in to get ‘em ‘cause they don’t have transportation, they can’t get off from work, whatever, you’re obviously not going to be successful in being able to help your patients. So that effort in particular I think is quite insightful for how we need listen and how we need to ask the right questions.

We need to, of course, have more diverse patients enroll in clinical trials. And this is something we’ve known for a long time, we’ve had so, so many papers, and the literature showing the low numbers, underrepresented minorities on clinical trials and you quoted the numbers up front. But it’s time to really take that apart and figure out where’s the problem, where are the barriers.

And then also, I call your attention to a paper that I’m sure that you know that was published recently by Dr. Unger, et al, from SWOG and Hutch, really looking at those patients who are asked to participate are there differences by race, and there were no differences at all. So once a patient’s asked to participate in a trial, they will participate regardless of race and I think that’s a very important point because so much focus has been placed on the distrust in the African American community for healthcare and I think that’s a very important topic and something we should always be aware of. But this paper tells us if you ask cancer patients to participate, they will do so at equal rates, whether they’re black or white, it was somewhere around 53, 55%, would choose to participate. And so that tells us that the trust issue is not insurmountable. If you talk to the patients and you listen to the patients, patients will choose to go in trials if they’re asked to do it. So it really puts the onus back on the provider and the infrastructure to make sure that you have the appropriate resources to be able to ask patients to participate regardless of race.

Dr. Sands:
I have one last question for you, Dr. Pierce, as the President of ASCO, you know, this year’s meeting is again a virtual meeting due to COVID-19, so tell me, what are you most excited for about the conference this year?

Dr. Pierce:
So, there’s gonna be great research, great educational opportunities, but that’s always the case at the ASCO meeting, so that’s kind of expected and so yes, we will meet that expectation.

What I am especially excited for is that this year, the emphasis has been put on weaving equity into most of our sessions. Typically for a lot of the equity sessions, they have been stand-alone sessions, and they haven’t been well-attended, and I don’t think it’s because people aren’t interested, I think people are very interested, it’s just that you only have 24 hours in a day, you know, seven days in a week and you have all of these other sessions to go to that are competing sessions. So, I understand that, and these are sessions that we need to be at, we need to learn, but why can’t we blend in equity in those sessions so it’s a two-for-one deal, if you will. And I’m cautiously optimistic that this will work and if so, I think this will be the beginning of the way we will hear data analyzed at our annual meetings going forward.

Dr. Sands:
Well, I look forward to ASCO; I do miss the in-person meetings, but one benefit of virtual is it does make it more accessible to everybody. So I certainly encourage everyone to log in and check out ASCO this year.

But that brings us to the end of today’s program. I wanna thank my guest, Dr. Lori Pierce for joining me to discuss the underrepresentation of African American and Latinx individuals in oncology. Dr. Pierce, you highlighted the importance of leaders being engaged and working to reduce disparities, and we are so grateful for your leadership in ASCO. Dr. Pierce, it has been an absolute pleasure to have you on the program.

Dr. Pierce:
This was fun. I enjoyed it. And I hope it’s helpful to your listeners. So thanks so much.

Dr. Sands:
I’m Dr. Jacob Sands. To access this and other episodes in our series, visit ReachMD.com/ProjectOncology, where you can Be Part of the Knowledge. Thanks for listening.