On June 29, 2023, the U.S. Supreme Court, in a 6-to-3 decision, essentially overturned affirmative action in college admissions, which had allowed, since 1978, for colleges and universities to consider race as a factor in student admissions.1 The ruling will impact enrollment decisions at public and private educational institutions, including medical schools, and could have a profound effect on the diversity of physicians and other health-care providers in training and on patient care as well.
According to the most recent U.S. census, 13.6% of the population is Black or African American, and 19.1% is Hispanic or Latino.2 However, only 3% of practicing oncologists self-identified as Black or African American, and 4.7% of practicing oncologists self-identified as Hispanic. In addition, 2.9% of Americans identify as Native American and Alaska Native, but they comprise only 0.1% of the oncology workforce. By gender, women make up 51.1% of the population but only 35.2% of the oncology workforce.3
Studies show that Black individuals have the highest death rate and shortest survival of any racial or ethnic group for most cancers in the United States, and they experience more illness, worse outcomes, and premature death compared with White patients.4 The factors contributing to racial and ethnic disparities in cancer outcomes are many and complex and include inequities in health coverage and access to care, social and economic inequality, as well as genetic and hereditary factors that may be influenced by the environment. Research suggests the lack of access to high-quality care that is understanding and respectful of diverse traditions and cultures also plays a significant role.5 Improving quality cancer care, especially in traditionally underserved populations, requires the recruitment of oncology professionals from diverse backgrounds, according to the ASCO Strategic Plan to Increase Racial and Ethnic Diversity in the Oncology Workforce.5
Clifford A. Hudis, MD, FACP, FASCO
In a wide-ranging interview with The ASCO Post, Clifford A. Hudis, MD, FACP, FASCO, Chief Executive Officer of ASCO, Executive Vice Chair of Conquer Cancer, the ASCO Foundation, and Chair of ASCO’s CancerLinQ, discussed the impact the Supreme Court’s decision overturning affirmative action will have on an already inadequate number of minority physicians in the oncology workforce; the impending oncology—and primary care—workforce shortage, especially in rural communities across the country; and ASCO’s global effort to meet the growing demand for oncology services.
Losing Gains in Workforce Diversity
How might the Supreme Court’s decision overturning affirmative action exacerbate the already low number of minority students training in medicine and, specifically, in oncology?
I do not know, of course, how this decision is going to play out. We do, though, have concerns that we might lose some of the important gains we have made in developing a diverse workforce that looks more like the diverse patient populations we serve. And the reason this is important is there are a number of studies and reports that have identified direct benefits of having a diverse oncology workforce.
Patients seem to have better outcomes when the workforce looks more like they do. This by no means suggests that individual patients necessarily have to have doctors who resemble them. What it means is a diverse workforce is more likely to increase cultural competency and the ability to deliver high-quality care to a broad patient population.
That’s why achieving workforce diversity is so important, but I can’t yet say what impact, if any, this decision will have on the number of minority students applying to medical schools. ASCO’s 2022 Snapshot: State of the Oncology Workforce in America report demonstrated there still is a relative lack of minority representation in the oncology workforce.6 For example, only 4.7% of practicing oncologists self-identified as Hispanic/Latinx, which basically coincides with the percentage of Hispanic/Latinx students applying to medical school—6.2%. The percentage of medical school graduates is a touch lower, 5.3%, because of attrition, and the percentage of oncology fellows in that population is just 6.2%.6
ASCO’s report along with other prior work has consistently shown that we already suffer from a relative lack of diversity in medicine generally and in oncology specifically. So, if the Supreme Court decision has any negative effect in this regard, it is going to make an already challenging situation worse.
ASCO’s report along with other prior work has consistently shown that we already suffer from a relative lack of diversity in medicine generally and in oncology specifically.— Clifford A. Hudis, MD, FACP, FASCO
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Infusing Equity, Diversity, and Inclusion Into ASCO’s Work
How will ASCO continue to advocate for increased workforce diversity and improve and expand mentoring opportunities and career development for oncologists and trainees across race, ethnicity, gender, and sexual orientation?
Let me start by pointing out that 100% of the work we do at ASCO is intended to improve the quality of care patients receive after a cancer diagnosis, no matter where they live around the world. I say that because the rest of my response ultimately relates to how we ensure that everybody has access to the highest-quality care.
As I have already noted, there is high quality of care when the workforce is appropriately diverse and reasonably representative of the populations we treat. That is the reason ASCO has always been committed to infusing equity, diversity, and inclusion (EDI) into all of our work.
As we have upgraded our strategic plan, we have placed this work as a cross-cutting goal along with making a global impact—and we are holding ourselves accountable. We have publicly released our own EDI Blueprint Report, which covers 22 initiatives we have launched across our mission pillars of research, education, and quality.7
The short answer to your question, then, is that after the Supreme Court decision, nothing has changed for us in terms of our commitment to equity, diversity, and inclusion in the workforce. Getting a bit more specific, in ASCO’s Education, Science, and Professional Development department, which runs our leadership development and education efforts, we have been promoting the development of a diverse oncology pipeline through a very specific program called the ASCO Oncology Summer Internship.
The 4-week program uses a hybrid curriculum and recruits students from populations that have traditionally been underrepresented in medicine, including ethnic and racial minorities as well as sexual and gender minorities. It is hosted each summer at a number of medical institutions around the country and introduces medical students who are between their first and second years of study to the field of oncology.
The program is a partnership between ASCO and selected medical schools. It is immersive, with engaging learning opportunities, including shadowing of physicians, peer-faculty networking, and virtual education, as well as in-person and longitudinal support for medical students interested in oncology.
Our goal with this program is to increase the representation of four historically underrepresented populations, as defined by ASCO’s Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce: Native American/Alaskan Natives, Black and African Americans, Hispanic/Latinx individuals, and Native Hawaiian/Pacific Islanders.8 We are seeking to expose and introduce students from these numerically underrepresented populations to the field of oncology, so they will consider selecting it as a career. After reaching that goal, the next goal is, of course, for these students then to qualify for fellowship, qualify for residency, and succeed on their merits.
ASCO also has a program called Medical Student Rotation for Underrepresented Populations, which provides financial support for medical students from underrepresented populations who are interested in a career in oncology. Students get to experience a minimum 4-week clinical or clinical research rotation, which can take place in a private practice, hospital, or academic setting, with a focus on either direct patient care or research.
In addition, ASCO has the ASCO Journals Editorial Fellowship (ascopubs.org/fellowship), which introduces oncology fellows to the peer review, editing, and publishing process for medical research manuscripts.
Our goal with these programs is to expose early-career folks to the field of oncology with the hope that more of them will choose careers in oncology than in the past.
Combating Workforce Shortages in Rural Communities
In 2007, ASCO predicted that the demand for oncology services would increase by 48% between 2005 and 2020, but that the supply of services oncologists provided during that period would rise by only 14%.9 A decrease in the oncology workforce translates to delayed diagnosis and worse outcome for patients. What is the current status of the oncology workforce, and how is ASCO working to increase it?
As an oncologist, I do not understand why there is or could be a workforce shortage when oncology is such an exciting and rewarding specialty! But an ASCO workforce report noted there are just over 13,000 oncologists currently engaged in patient care, and with a little more than 20% nearing retirement age, 6 shortages are a concern, especially in rural parts of the country.
To some degree, we address the challenges of both workforce diversity and the workforce shortage by actively engaging medical students in their early-career decisions across the board, with hopes they will choose to work in oncology. Beyond that, we are leveraging our existing workforce as efficiently as possible. An example of that is a program we created aimed at increasing access to care in less populated areas of rural America.
In 2022, we launched a pilot program in Montana based on a hub-and-spoke care delivery model that has allowed us to establish relationships with Montana-based organizations to increase access to high-quality cancer care in rural and remote areas of the state. If the pilot program is successful, it should serve as a model we can expand in a sustainable way to help address the workforce shortage in other parts of the country and maybe even around the world. This is also a potential way to build and train the nursing workforce, for example, which would supplement and increase capacity in care delivery at rural sites.
We are seeking to expose and introduce students from … numerically underrepresented populations to the field of oncology, so they will consider selecting it as a career.— Clifford A. Hudis, MD, FACP, FASCO
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Reaching a Tipping Point in Primary Care Shortages
The percentage of physicians in adult primary care has been declining for years, and it has now reached about 25%, a tipping point at which many Americans will not be able to find a family doctor.10 Please talk about how a shortage of primary care physicians may impede oncology care.
It is a big problem because primary care is often the first and most critical gateway in health care generally. Many primary care physicians work closely with oncologists and specialists from other areas of medicine to coordinate and provide appropriate medical care across the United States.
The shortage of primary care physicians means the burden of needed patient care will be placed on others, and that strains the entire workforce. Since primary care physicians are often the first point of contact for people in the health-care system, if they are not there, we have to assume some people will slip through the cracks and either not get screened for cancer, or if they do get screened in more general care systems, the follow-up may be less timely or less complete. Others will not have their symptoms or signs of cancer identified in as timely a fashion, and all of this will add up to a greater burden for society as a whole—and worsened outcomes.
This is why it is important for us to invest more funding and efforts to recruit individuals into the primary care generalist workforce. It will indirectly support the work of the oncology workforce.
Caring for Long-Term Cancer Survivors
The number of cancer survivors in the United States has reached 18 million, and that number is expected to top 26 million by 2040. However, studies show that most of those survivors—at least two-thirds—will have ongoing physical, psychological, and supportive care needs that are not well managed by current models of cancer care.11 With workforce shortages in both oncology and primary care, who will care for the increasing numbers of cancer survivors?
The problem is not new. The health-care system has long struggled with recruiting and retaining the medical workforce in various settings, and right now, we are also confronting burnout, changing demographics, and many other challenges.
There are a number of things we can do about this problem, and maybe individually these tweaks do not make such a big difference, but added up they could. One area for sure that can make a difference is increasing the training of support professionals, and that includes but is not limited to nurse practitioners, physician assistants, and other allied care providers, such as clinicians focused on palliative care, social workers, and patient educators, along with many others. With all of these opportunities, there is a chance that some parts of follow-up in survivorship care can be efficiently carried out by those professionals.
For many patients, the care experience they have with their oncologist can be among the most intense and engaging they have ever had. If you are otherwise medically lucky in life, that can often be the case. And that strong and emotional bond cuts both ways. Oncologists generally enjoy seeing their patients through survivorship as well. It is a reminder of why we do what we do. So, I think it is a particularly challenging issue for us in oncology, because it is not only about supply and demand. It is also about the rewarding aspects of forming meaningful relationships with patients who you don’t want to give up seeing regularly.
Improving Cancer Care Globally
The World Health Organization estimates that 4.3 million health-care workers will be needed to meet a growing global shortage of medical professionals.12 About 40% of ASCO members practice outside the United States. How are ASCO’s international programs helping to facilitate the professional development of cancer clinicians, researchers, and nurses to reduce the growing global cancer burden?
With rising income and standard of living increasing around the world, the demand for high-quality cancer care is likely to grow even faster in the years ahead than we might have predicted based on population growth alone. The global population is becoming healthier, wealthier, and living longer, and one of the consequences of aging is that more cancers will be diagnosed.
That is a macro trend over decades, but it adds even more emphasis to the importance of your question. It is the reason that along with our EDI efforts, making a global impact on improving cancer care is one of ASCO’s two cross-cutting goals touching everything we do across the organization.
How we aim to help improve global access to care is, first, through ASCO’s international strategy to address disparities and improve cancer care no matter where patients live by engaging our members both to share and learn in collaboration with other international societies. We formalize those collaborations with signed memoranda of understanding, and we also collaborate with other nongovernmental cancer organizations.
Our members can help with these efforts. They can volunteer to assist in our international activities, including our educational courses and workshops, grant reviews, and research support, and also through remote and in-person mentoring and standard high-quality oncology training programs that we deploy in communities around the world. We also offer quality care improvement opportunities and global courses in palliative care, clinical research, multidisciplinary cancer management, and team-based care.
Finally, ASCO has the International Development and Education Award (IDEA), which provides targeted support for all career oncologists who come from low- and middle-income countries. Through that award, we want to share knowledge and build bonds between awardees and long-standing, deeply engaged ASCO members by pairing the IDEA recipient with a leading member mentor. The award enables recipients not only to come to the ASCO Annual Meeting, but also to visit their mentors’ institutions. These relationships can be rich, rewarding, and long-lasting. And as of the end of this past year, we provide members from low- and lower-middle income countries complimentary ASCO membership with all its attendant benefits, which includes a subscription to our flagship publication, the Journal of Clinical Oncology.
Getting Involved
Lastly, I want to say that improving care for patients with cancer also requires advocacy efforts. Members can learn more about our advocacy initiatives on our website, ASCO.org, through our social media channels, and through the ASCO ACT Network (asco.org/ACTnetwork), where members can connect with their legislators.
DISCLOSURE: Dr. Hudis reported no conflicts of interests.
REFERENCES
1. Nittle N: The Supreme Court ends affirmative action in college admissions. The 19th, June 29, 2023. Available at 19thnews.org. Accessed October 13, 2023.
2. U.S. Census Bureau: Quick facts. Available at www.census.gov. Accessed October 13, 2023.
3. 2021 Snapshot: State of the oncology workforce in America. JCO Oncol Pract 17:249, 2021.
4. American Cancer Society: Cancer disparities in the Black community. Available at www.cancer.org. Accessed October 13, 2023.
5. Winkfield KM, Flowers CR, Patel JD, et al: American Society of Clinical Oncology strategic plan for increasing racial and ethnic diversity in the oncology workforce. J Clin Oncol 35:2576-2579, 2017.
6. 2022 Snapshot: State of the oncology workforce in America. JCO Oncol Pract 18:396, 2022.
7. 2022 EDI Blueprint Report: Building the foundation for high-quality, equitable cancer care for all. Available at https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/ASCO-EDI-Blueprint-Report.pdf. Accessed October 13, 2023.
8. ASCO: Diversity in Oncology Initiative. Available at https://old-prod.asco.org. Accessed October 13, 2023.
9. Southall J: Oncology practices struggle ‘to run at all levels’ amid workforce shortage. Healio/HemOnc Today. Available at www.healio.com. Accessed October 13, 2023.
10. Rosenthal E: The shrinking number of primary care physicians is reaching a tipping point. KFF Health News. Available at kffhealthnews.org. Accessed October 13, 2023.
11. Cancer care: Beyond survival. Lancet 399:1441, 2022.
12. World Health Organization: Framework for action on interprofessional education & collaborative practice. Available at www.who.int. Accessed October 13, 2023.
