The opportunity to write this commentary on cancer disparities comes at a sorrowful time for me. Despite practicing as a surgical oncologist for more than 20 years and understanding the unequal burden that cancer visits on the Black community, I was woefully unprepared for the premature death of my colleague Lori L. Wilson, MD, FACS, Associate Dean for Faculty Development and Diversity and Chief of Surgical Oncology at Howard University School of Medicine, on October 14, 2022. She left us far too soon after a protracted illness with metastatic breast cancer.
Although we are in a time of great excitement with groundbreaking discoveries revolutionizing cancer prevention, detection, and treatment, a reality overshadows this good work—the continued existence of racial inequities. Although overall cancer mortality rates have decreased for all racial and ethnic groups, with the most significant decrease among African Americans, Black individuals continue to have the highest cancer mortality rate.1 Research has shown there are direct correlations between the socioeconomic inequities that affect this minority group and increased health risks, poorer outcomes, and worse overall quality of life.
Removing the Barriers to Health Equity
Many barriers can impact a person’s ability to prevent and survive cancer. The barriers are complex, and the intersectionality among social, economic, and cultural influences impacts cancer rates and outcomes. The time to act is now, so what can we do to address the unequal burden of cancer? Here are some suggestions.
Advocate for federal investment in research programs that provide an understanding of cancer disparities and develop evidence-based strategies to address them: As noted in the American Association for Cancer ResearchCancer Disparities Progress Report 2022, federal investment in the National Institutes of Health, National Cancer Institute, National Institute on Minority Health and Health Disparities, and the Centers for Disease Control and Prevention is critical for understanding cancer disparities and developing evidence-based strategies to address them.2 Robust, sustained, and predictable federal funding for these programs is vital to determine which policy changes help promote health equity, recruit underrepresented patients in cancer research, and support a diverse workforce.
Cultivate a diverse workforce pipeline to ensure a more inclusive cancer care delivery team: Addressing cancer disparities requires more than enrolling more Black patients into cancer registries and clinical trials. Although there are myriad causes of cancer care disparity, two of its underlying causes are provider implicit bias and a lack of diversity among clinical trial investigators. Historically, ensuring adequate representation of minority patients has not been a priority when selecting clinical trial sites. Recent data demonstrate that providers harbor implicit biases in offering therapeutic options to Black patients.3 Although training modules and retreats from the situation are reasonable first steps to address this issue, the best way to eliminate implicit bias in the care team is by diversifying the oncology workforce. These efforts require intentional approaches to training health-care professionals across all phases of care.
“The best way to eliminate implicit bias in the care team is by diversifying the oncology workforce.”— JOHN H. STEWART IV, MD, MBA, FACS
Tweet this quote
Expand the presence of clinical trial navigators at sites with great potential to recruit minority patients for clinical trials: Patient navigators bridge the gap between the patient and the health-care system by providing enhanced education and facilitative services to the patient. And clinical trial navigators serve to increase clinical trial participation through clinic-based education about clinical trials. Small studies have reported clinical trial enrollment between 61% and 86% among study-eligible minority patients who accessed clinical trial navigation.4-6
Establish a transformational relationship with the community to drive innovation: Harold P. Freeman, MD, considered the “father of patient navigation,” identified the “discovery to delivery disconnect” as a critical determinant of cancer inequities. He highlighted the necessity of extending scientific discovery to the community, in his paper “History and Principles of Patient Navigation.”7
Our efforts to address cancer health disparities must intentionally focus on addressing the intersectionality of health at the individual, population, and environmental levels. Furthermore, we must change our focus to a broader stakeholder constituency that includes community partners.
Although the emphasis on the “bench to bedside” approach to clinical trials has arguably generated much success over the past 50 years, a gap exists in bringing many of these investigations to underserved populations equitably. As described by Kathy Tossas-Milligan, PhD, Assistant Professor, School of Medicine Health Behavior and Policy at Virginia Commonwealth University, a community-to-benchtop model involves community members in defining catchment-relevant issues that drive the research and policy agendas.8 An essential aspect of this model is the democratization of the data from these investigations. This approach creates a virtuous cycle in which the communities’ needs are addressed in partnership with cancer care delivery organizations.
We all believe that every individual should have a fair and just opportunity to live longer, healthier lives. This life should be free from cancer regardless of socioeconomic status, skin color, sexual orientation, gender identity, disability status, or geographic location. To accomplish this goal requires us to eliminate barriers and address community needs to ensure everyone has the same opportunity to be healthy and cancer-free.
DISCLOSURE: Dr. Stewart reported no conflicts of interest.
REFERENCES
1. Tong M, Hill L, Artiga S: Racial disparities in cancer outcomes, screening, and treatment. KFF, February 3, 2022. Available at www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-in-cancer-outcomes-screening-and-treatment/. Accessed December 19, 2022.
2. American Association for Cancer Research: AACR Cancer Disparities Progress Report 2022. Available at https://cancerprogressreport.aacr.org/disparities/?utm_source=digital&utm_medium=sem&campaign=disparities-report&gclid=EAIaIQobChMIwsPWt6if-wIVFI7ICh1brwUrEAAYASAAEgLjdfD_BwE. Accessed December 19, 2022.
3. Niranjan SJ, Martin MY, Fouad MN, et al: Bias and stereotyping among research and clinical professionals: Perspectives on minority recruitment for oncology clinical trials. Cancer 126:1958-1968, 2020.
4. Holmes DR, Major J, Lyonga DE, et al: Increasing minority patient participation in cancer clinical trials using oncology nurse navigation. Am J Surg 203:415-422, 2012.
5. Proctor JW, Martz E, Schenken LL, et al: A screening tool to enhance clinical trial participation at a community center involved in a radiation oncology disparities program. J Oncol Pract 7:161-164, 2011.
6. Wujcik D, Wolff SN: Recruitment of African Americans to National Oncology Clinical Trials through a clinical trial shared resource. J Health Care Poor Underserved 21(suppl 1): 38-50, 2010.
7. Freeman HP, Rodriguez RL: History and principles of patient navigation. Cancer 117(suppl 15):3539-3542, 2011.
8. Noel L, Phillips F, Tossas-Milligan K, et al: Community-academic partnerships: Approaches to engagement. Am Soc Clin Oncol Educ Book 39:88-95, 2019.
Dr. Stewart is Director of the Louisiana State University (LSU) Health New Orleans/Louisiana Children’s Medical Center Health Cancer Center and Professor of Surgery at LSU Health New Orleans School of Medicine.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
