ASCO President's Address on Equity in Cancer Care: "History Has Its Eyes on Us"

After a year like no other, when COVID-19 laid bare the disparities that have long persisted in health care and beyond, the president of the American Society of Clinical Oncology (ASCO)
opened the group’s annual meeting on June 5, 2021, by calling it like she sees it.

Equality in care is not sufficient, said Lori Pierce, MD, FASTRO, FASCO, a radiation oncologist from the University of Michigan. Achieving equity—which means that patients have similar outcomes in cancer care, regardless of circumstance—is harder to achieve, in part because it requires overcoming the structural racism that exists not just in society but in health care specifically.

Equity was a theme across this year’s ASCO meeting, held in a virtual format for the second year due to the pandemic. As Clifford Hudis, MD, FACP, FASCO, the group’s CEO, introduced Pierce, he said that in 2018, when she was selected as the 2020-2021 ASCO president, no one could have foreseen the role she would play in leading the organization during the pandemic.

At this year’s meeting, Hudis said that Pierce proved to be the right person at the right time. “Sometimes it is said that leaders have to grow and rise to meet the moment, but that was not the
case this year,” he said.

Throughout her career, Pierce has worked to address equity issues in health care generally and cancer care specifically. The pandemic has highlighted gaps in access to care and outcomes, and from the start oncologists have braced for treatment regimen alterations due to pandemic protocols, and a potential wave of late-stage diagnoses as patients miss screenings and follow-up care.

In her remarks, Pierce drew on her own experience, growing up in the 1960s, of how laws may change but inequities persist. As a child, she was aware of the civil rights movement. “Although I
didn’t realize it at that time, I was observing segregation’s impact on health care,” she said. When she visited her father’s family in Ahoskie, North Carolina, “White residents had access to many
high-quality health care options” but “Black people were largely treated by a single African American doctor.

“Looking back, no matter how skilled he was, he was still one doctor treating an entire community—every person, every age, every condition. And that, by definition, is limited,” Pierce said.

“As I got older, attending college and then medical school, I became more aware that while the legal segregation I saw in North Carolina in the 1960s was over, health care inequality remained firmly entrenched in the United States and worldwide. As a resident in radiation oncology, and then as a breast cancer physician and researcher, I became increasingly committed to improving outcomes for all people with cancer.”

In August 2020, ASCO issued an updated statement on cancer disparities and health equity,¹ and in May 2021, Pierce followed up with a specific statement on closing gaps for Black patients with
cancer.² She cited passage of the Clinical Treatment Act, which takes effect in January 2022.³ ASCO advocated for the law, which will require Medicaid to cover the costs of any insured members who
participate in research; Pierce said the law should help boost the number of Black patients who participate in trials. Right now, Black patients account for about 15% of those with cancer in the United States but only about 5% of patients enrolled in clinical trials.

Before Pierce began her talk, she welcomed a trio of speakers to address the theme of equity: the director of the National Cancer Institute (NCI), Norman E. “Ned” Sharpless, MD; Julio Frenk, MD, PhD, MPH, president of the University of Miami and former minister of health for Mexico; and Rhea Boyd, MD, MPH, a pediatrician, community health advocate, and expert on the intersection of structural racism, inequity, and health.

NCI Seeks Diverse Workforce
Sharpless said the year 2021 marks the 50th anniversary of the National Cancer Act,⁴ and while survival rates have improved and tobacco use has declined, the NCI is aware that success has not
been felt evenly. Diversifying trials and improving outcomes starts with a modified workforce, and he said the agency is seeking input on how to recruit more Black and Hispanic scientists and how to
fund investigators from more diverse backgrounds.

“We know that the research workforce still does not reflect the population of the people we serve,” Sharpless said, noting that it’s important “to build a pipeline of talent.”

A Call for Innovation
For all the weakness of the public health infrastructure that COVID-19 exposed, Frenk commented, it also inspired tremendous scientific collaboration and energy. With the right support, the experience could inspire a generation of public health leaders. He called for the enactment of 3 “constructive proposals” that he said “may make the world safer and better prepared for the
next pandemic.”

First, he envisions a global network of “sentinel” health care facilities to rapidly collect and share data on emerging diseases—and avoid coverups of outbreaks. Second is a technology platform
that would allow diagnostic tests, vaccines, therapies, and other disease-fighting tools to be developed as quickly and collaboratively as possible. Finally, Frenk advocates for a “rapid deployment force” that he described as composed of teams of international public health foot soldiers, ready to make use of the tools in the aforementioned technology platform if an outbreak occurs.

Calling Out Racism
Boyd’s message was direct: We can’t end racism in health care if we don’t call it what it is. Too often, he said, journal articles find more “delicate” terms to use to avoid the ugly truth. Quoting the author Ta-Nehisi Coates, Boyd said that racism in health care is often a visceral experience: “Racism inflicts violence upon the body.”⁵ Health inequities among certain populations are far from inevitable—they exist because some groups are denied protections and supports—yet the words “institutionalized racism” are rarely used in the literature, Boyd pointed out. She cited a 2018
review of 50 high-impact journals over a 13-year period and found only 25 citations of the term in a
title or abstract.⁶

The Tools of Change
Pierce said health equity has “always been at the heart of ASCO,” and it can be achieved through
the pillars of research, education, and quality care. ASCO has formed a partnership with the Association of Community Cancer Centers to increase community-level participation in trials.⁷ “In May [2021],” she said, “we began recruiting at more than 40 clinical trial sites to test practical strategies designed to increase screening and participation of Black and Latinx patients. The strategies include a clinical trial site assessment tool [as well as] education to mitigate biases.”

While the news out of ASCO highlighted that progress is being made, it was clear that plenty of
work remains (see SP172-SP174). The University of Pennsylvania’s Abramson Cancer Center announced its presentation of an abstract showing that a 5-year eff ort to diversify participation in its clinical trials had doubled the share of participation by Black patients, from 12% to 24%^.8 On the flip side, though, Foundation Medicine presented results at the meeting showing that Black men, who are more likely to bear the burden of prostate cancer than White men, are less likely to receive comprehensive genetic profi ling, based on a real-world analysis of more than 11,000 men with prostate cancer.⁹

“Men of African ancestry experience the greatest burden of disease in prostate cancer, and this
research indicates that differences in cancer care are not solely based on biological factors. Rather,
[the diff erences] point to socioeconomic factors such as access to comprehensive genomic profiling and clinical trial enrollment,” said Brandon Mahal, MD, in a statement.¹⁰ He is an investigator of the Foundation Medicine study and an assistant professor of radiation oncology and assistant director for community outreach and engagement at the Sylvester Comprehensive Cancer Center.

Pierce’s approach has focused on the basics. She has launched a podcast series to teach oncology trainees how to talk to their patients about the “3 most important modifiable risk factors” in cancer: smoking, obesity, and alcohol. During her tenure, the results of a survey conducted by ASCO showed that patients’ attention to weight management improved during cancer treatment. Pierce also wants to learn from a successful colorectal cancer screening program in Delaware that has “virtually eliminated disparities” and saved millions of dollars.

“History has its eyes on us,” Pierce said. “We are at a pivotal time in the history of our society and the social history of the world. We must capitalize on the momentum and hold ourselves accountable.

“In 1965, the Reverend Dr Martin Luther King Jr said that a man dies when he refuses to stand up for that which is right. The lives of countless cancer patients worldwide rest on us speaking out. We must be bold in our commitment and actions for equitable care,” Pierce said. “It’s our time. It’s our responsibility. And I firmly believe it’s ASCO’s destiny.”

References

1. Patel MI, Lopez AM, Blackstock W, et al. Cancer disparities and health equity: a policy statement from the American Society of Clinical Oncology. JClin Oncol. 2020;38(29):3439-3448. doi:10.1200/JCO.20.00642

2. Pierce L. ASCO’s commitment to addressing equity, diversity, and inclusion of Black cancer patients and survivors. JCO Oncol Pract. 2021;17(5):255-257. doi:10.1200/OP.21.00257

3. ASCO applauds Congress for expanding clinical trial access for Medicaid beneficiaries. News release. American Society of Clinical Oncology; December 22, 2020. Accessed July 8, 2021. https://www.asco.org/about-asco/press-center/news-releases/asco-applauds-congress-expanding-
clinical-trial-access

4. Sharpless NE. Cancer Currents Blog: Commemorating and making history: the National Cancer Act 50th Anniversary. National Cancer Institute. February 8, 2021. Accessed June 8, 2021. https://www.cancer.gov/newsevents/cancer-currents-blog/2021/national-cancer-act-50th-anniversary

5. Coates T-N. Between the World and Me. Spiegel & Grau: 2015.

6. Hardeman RR, Murphy KA, Karbeah JM, Kozhimannil KB. Naming institutionalized racism in the public health literature: a systematic literature review. Public Health Rev. 2018;133(3):240-249. doi:10.1177/0033354918760574

7. Association of Community Cancer Centers [ACCC] launches institute to diversify cancer clinical trials. News release. ACCC; June 4, 2021. Accessed June 9, 2021. https://www.prnewswire.com/news-releases/association-of-community-cancer-centers-launches-institute-to-diversify-cancer-clinical-trials-301305775.html

8. Guerra CE, Sallee V, Hwang W-T, et al. Accrual of Black participants to cancer clinical trials following a five-year prospective initiative of community outreach and engagement.J Clin Oncol. 2021;39(Suppl 15):abstr 100. doi:10.1200/JCO.2021.39.15_suppl.100

9. Sivakumar S, Kim Lee J, Moore JA, et al. Ancestral characterization of the genomic landscape, comprehensive genomic profiling utilization, and treatment patterns may inform disparities in advanced prostate cancer:a large-scale analysis. J Clin Oncol. 2021;39(Suppl 15):abstr 5003.
doi:10.1200/JCO.2021.39.15_suppl.5003

10. New study results presented by Foundation Medicine and collaborators at ASCO21 on ancestry-based disparities in prostate cancer care underscore importance of equitable access to precision medicine advances. News release. Foundation Medicine; June 4, 2021. Accessed June 6, 2021. https://www.businesswire.com/news/home/20210604005280/en/New-Study-Results-Presented-by-Foundation-Medicine-and-Collaborators-at-ASCO21-on-Ancestry-Based-Disparities-in-Prostate-Cancer-Care-Underscore-Importance-of-Equitable-Access-to-Precision-Medicine-Advances