ASCO’s Dr Lori Pierce 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 had long persisted in health care and beyond, the president of the American Society of Clinical Oncology (ASCO) opened the annual meeting 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 itself.

Equity is a theme across this year’s ASCO meeting, which is in a virtual format for the second year due to the pandemic. In 2018, when Pierce was selected as the 2020-2021 ASCO president, Clifford Hudis, MD, FACP, FASCO, ASCO’s CEO, said no one could foresee the role that Pierce would play when she would lead the organization during the pandemic. At this year's meeting, Hudis said that Pierce has proven 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 a wave of late-stage diagnoses as patients miss screenings and follow-up care, or regimens have to be altered due to pandemic protocols.

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 that 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 US 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.”

Last summer, ASCO issued an updated statement on cancer disparities and health equity, and last month Pierce followed up with a specific statement on closing gaps for Black patients with cancer. She cited passage of the Clinical Treatment Act, which takes effect in January 2022. ASCO advocated for the law, which will require Medicaid to fund the cost of patients’ participation 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: National Cancer Institute (NCI) Director 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, 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 different 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. It’s important, “to build a pipeline of talent.”

A Call for Innovation

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

They are: (1) a global network of “sentinel” health care facilities to rapidly collect and share data on emerging diseases—and avoid coverups of outbreaks, (2) a technology platform that would allow diagnostic tests, vaccines, therapies, and other disease-fighting tools to be developed as quickly and collaboratively as possible, and (3) a “rapid deployment force,” which he described as teams of international public health foot soldiers, who could make use of the tools if an outbreak occurred.

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. And too often, journal articles find more delicate terms 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. But health inequities among certain populations are not inevitable—they exist because some groups are denied protections and supports. Yet the words “institutionalized racism” are rarely used in the literature. Boyd 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.

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. “In May,” she said, “we began recruiting over 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, and education to mitigate biases.”

The news out of ASCO highlights that progress is being made, but that plenty of work remains. The University of Pennsylvania’s Abramson Cancer Center announced presentation of an abstract showing that a 5-year effort to diversity clinical trial participation had doubled the share of participation by Black patients, from 12% to 24%. But on the flip side, Foundation Medicine announced that a presentation to be made Tuesday will show that Black men, who are more likely to bear the burden of prostate cancer than White men are less likely to receive comprehensive genetic profiling, based on a real-world analysis of more than 11,000 men with prostate cancer.

“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, but rather points to socioeconomic factors such as access to comprehensive genomic profiling and clinical trial enrollment,” Brandon Mahal, MD, assistant professor, Radiation Oncology and assistant director, Community Outreach and Engagement, Sylvester Comprehensive Cancer Center, who is an investigator of the Foundation Medicine study, said in a statement.

Pierce’s approach has focused on the basics. She’s 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, ASCO conducted a survey that showed patients’ attention to weight management improved during cancer treatment. She 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, Dr Martin Luther King Jr. said 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.”