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Equitable Cancer Care: Steps Toward Meaningful Change


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As President-Elect of ASCO, you are asked to choose a theme for your presidency. This can be a daunting task, as the theme will not only shape the discourse of your presidency, but also, more importantly, that of the Society. The subject should be one that reflects the needs of the cancer community at large and one that, as President, reflects your passion.

Equity of care has been important to me since my early years. As a child, you see things, the significance of which may be difficult to comprehend at the time. These events are tucked away in the recesses of your mind, to be revisited at a later date. When I was younger, I saw that, in some communities, people of color received their care almost exclusively within their own communities, which seemed fine to me. But, of course, that was not always fine. Segregation affected the ability for some patients to access high-quality health care outside their communities. Although equitable care has since been realized in many communities, there are still marginalized populations who do not receive equitable health care in this country and across the globe.

So, my theme—“Equity: Every patient. Every day. Everywhere.”—reflects my passion and ASCO’s mission for equal access to equitable care. This theme has become even more relevant over the past year with the onset of the COVID-19 pandemic, which has laid bare so many inequities in health care, and the frequent displays of racism portrayed vividly around the country and the world. This year has been a time for our professional society to focus its efforts on further strengthening its existing initiatives for equity of care and laying the groundwork for sustained efforts in the years to come.

Increasing Diversity in the Oncology Workforce

As highlighted in the ASCO 2020 Snapshot of State of the Oncology Workforce in America, only 4.7% of the U.S. oncology workforce is Hispanic, 3% is Black or African American, and 0.1% is American Indian or Alaska Native.1 Programs are, therefore, greatly needed to increase the number of minority oncology providers in the United States. Thanks to generous support from Conquer Cancer and the ASCO Foundation, ASCO has offered programs designed to further diversify the oncology workforce. Programs including the Medical Student Rotation, the Annual Meeting Research Award (formerly known as the Resident Travel Award for Underrepresented Populations), and the Diversity Mentoring Program have provided opportunities for trainees from populations underrepresented in medicine to appreciate the variety of career choices in oncology and the impact they can have.

This year, ASCO has added the Oncology Summer Internship pilot, which will be launched this summer, to further enrich the pipeline. This will be a 4-week immersive program for approximately 30 second-year medical students annually; students will participate in daily virtual cancer education seminars created by ASCO, while also learning from local leaders in their medical institutions and communities. Following student completion of the program, ASCO will continue to engage with students by encouraging their participation in ASCO’s career development programs.


“We must continue to critically assess and advocate for change of current policies where the status quo can often lead to inequitable care.”
— Lori J. Pierce, MD, FASCO, FASTRO

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As part of Conquer Cancer’s robust grant program that funds research across the spectrum of cancer care and across disease types, Conquer Cancer is raising research dollars for Young Investigator Awards (YIAs), Career Development Awards (CDAs), Advanced Clinical Research Awards, and Research Professorships in Health Disparities. These grants provide opportunities for investigators of underrepresented groups and any investigator focused on disparities research to be recognized and funded for meaningful work toward health equity. In 2020, seven YIAs, one CDA, and one research professorship were awarded focusing on disparities research. The selection process for the 2021 grants will be completed soon.

Creating a Health Equity Strategic Plan for ASCO

This past year, ASCO’s Health Equity Committee (HEC) published its policy statement on cancer disparities and health equity.2 In it, four broad recommendations for health equity were highlighted: ensure equitable access to high-quality care; ensure equitable access to research; address structural barriers; and increase awareness and action. The document is the first step toward creating a health equity strategic plan for the Society, which is currently in development.

Consistent with some of the recommendations, ASCO has formed a collaboration with ACCC (the Association for Community Cancer Centers) in an effort to increase participation of racial and ethnic minority populations in cancer treatment trials. Knowing that participation in clinical trials ensures receipt of the highest quality of clinical care and recognizing that, on average, 5% or less of patients on cancer clinical trials are members of underrepresented populations, this bold initiative is timely. Many groups have previously sought to improve underenrollment of minority populations on clinical trials, with varying rates of success. Members of the Steering Group of the ASCO/ACCC initiative have studied many of those experiences published in the literature.

Utilizing this literature review, as well as a review of new ideas submitted by ASCO and ACCC members, the group is conducting a study with up to 65 clinical trial sites that will implement and evaluate practical solutions to increase enrollment, particularly from racial and ethnic minority groups. Practical solutions will include a site self-assessment tool and education to mitigate biases. We plan to issue a joint ASCO-ACCC Research Statement in 2022 with guidance for best practices to increase diversity in clinical trials as well as to publish results from this initiative.

Advocating for Change

Consistent with the theme of equity in clinical trial enrollment, this year marked the milestone passage of the Clinical Treatment Act, which provides coverage for routine care costs incurred by Medicaid patients while participating in a clinical trial. Patients insured by Medicare and private insurers already receive coverage for routine care costs, but until the passage of this legislation, Medicaid recipients did not. This effort represents the culmination of years of advocacy work by ASCO volunteers and staff and is a testimony to the importance of representing the needs of our patients to bipartisan members of Congress and highlighting current clinical voids in care. This is a reminder that we must continue to critically assess and advocate for change of current policies where the status quo can often lead to inequitable care.

In line with educational recommendations from the HEC, ASCO launched a program this year to increase the understanding of social determinants of health and modifiable risk factors for cancer and their effects on cancer care. Social determinants of health have clearly been shown to affect patient outcomes across the spectrum of prevention, early detection, treatment, and survivorship care by limiting access to high-quality care. Therefore, education into their existence, particularly through the lens of the patient, is necessary and impactful.

This initiative features broadcast videos through ASCO’s social media channels, ASCO educational podcasts, and supplemental ASCO Connection blog posts or articles. The first episode, which aired in October 2020, featured a discussion on the basics of the social determinants of health, and subsequent episodes have included an overview of ongoing ASCO equity initiatives, how to take a history on the social determinants of health, and financial toxicities of care. The series will continue through August 2021 on topics selected by a task force of oncology trainees and early care providers, and the program will then transition into a longitudinal educational series for the broader cancer community.

Incorporating Equity of Care Throughout ASCO

One of the goals for the Society this year was to weave the equity theme seamlessly throughout the work of ASCO, so equity of care is incorporated throughout the fabric of the organization. That effort was indeed achieved in both the Road to Recovery Report3 and Clinical Care Advances report.4 The Road to Recovery Report seeks to build upon what was learned during the COVID-19 pandemic in clinical research and clinical care delivery, so we can emerge from the pandemic able to effectively and efficiently reach and treat even greater numbers of patients diagnosed with cancer.

Recommendations, such as the continued offering of telemedicine and remote/virtual consents and education into the most effective ways to utilize these technologies in clinical research and care delivery, were suggested. In addition, exploring options such as clinical trial testing and treatment delivery at local facilities more accessible to patients, rather than at centrally located academic centers, was strongly encouraged going forward. The Clinical Care Advances report identified many of the cutting-edge clinical research findings and novel treatment paradigms published over the past year that resulted in improved response rates and survival, often in patients with disease refractory to prior therapies. However, the report stressed the importance of ensuring that these therapies are available to all candidates in need of these treatments—independent of race, ethnicity, geographic location, educational background, and financial status. The importance of enrollment of diverse patients into clinical trials was emphasized, so all patients can receive high-quality, innovative therapies.

“Providing equitable care for our patients is our North Star, and it requires constant attention and reinforcement, with many principles foundational to social justice.”
— Lori J. Pierce, MD, FASCO, FASTRO

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So much has happened over this past year highlighting the importance of equity. The message is clear: Providing equitable care for our patients is our North Star, and it requires constant attention and reinforcement, with many principles foundational to social justice. To that end, ASCO has been featured in a number of thought-provoking discussions focused on racism and inequity of cancer care, including panels sponsored by The Atlantic, Politico, the U.S. Food and Drug Administration, Stand Up To Cancer, and the European Cancer Summit.

Recently, I participated in a virtual workshop as part of the National Academies’ National Cancer Policy Forum on the Impact of the Affordable Care Act (ACA) on Cancer Prevention and Cancer Care. The focus was on lessons learned from the design and implementation of the ACA over its first 10 years and how they can inform future health-care reform efforts. No doubt, there are aspects of the law that could have been structured differently and possibly led to even greater improvements in patient outcomes. That said, the ACA has extended coverage to millions of previously uninsured Americans. That has led to improved survival for people with many diseases, including cancer. The ACA has shown how, with collective national action, we can have a profound impact on all lives, not the least, patients and families facing both long-standing inequities—and cancer.

Equitable access to cancer care for every patient, every day, everywhere is ASCO’s priority. We are prepared to engage with Congress and the Biden administration toward realizing that goal.

Achieving Health Equity for Every Patient, Everywhere

Although it has been a challenging year for many, these challenges have led to a greater awareness for us all regarding the lack of equitable care for some populations and the need to be champions for equal access to care on their behalf. The commitment of our cancer community for this cause has been inspiring. With that commitment has come the understanding that efforts will need to be sustained over time to realize true change. It is clear that the direction of ASCO and its membership is one of determination and resolve. “Equity: Every Patient, Every Day, Everywhere” is in our crosshairs and will indeed be achieved.

Serving as the 57th President of ASCO has been the greatest honor of my career. I am truly grateful to the members of ASCO for the trust placed in me to represent this Society. I look forward to serving as Chair of the ASCO Board next year and to contributing in other ways in the years to come.

To learn more about ASCO’s health-equity efforts, visit https://www.asco.org/practice-policy/cancer-care-initiatives/equity-cancer-care-research

DISCLOSURE: Dr. Pierce holds stock or other ownership interests in PFS Genomics, holds intellectual property in PFS Genomics and UpToDate, and has held uncompensated relationships with Bristol Myers Squibb.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.

REFERENCES

1. 2020 Snapshot: State of the oncology workforce in America. JCO Oncol Pract 17:30, 2021.

2. Patel MI, Lopez AM, Blackstock W, et al: Cancer disparities and health equity: A policy statement from the American Society of Clinical Oncology. J Clin Oncol 38:3439-3448, 2020.

3. Pennell NA, Dillmon M, Levit LA, et al: American Society of Clinical Oncology Road to Recovery Report: Learning from the COVID-19 experience to improve clinical research and cancer care. J Clin Oncol 39:155-169, 2021.

4. Smith SM, Wachter K, Burris 3rd HA, et al: Clinical Cancer Advances 2021: ASCO’s Report on Progress Against Cancer. J Clin Oncol 39:1165-1184, 2021.


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