Although significant progress has been made in cancer incidence and mortality in the United States over the past 2 decades—the death rate fell 23% between 1991 and 2012¹—not everyone is benefiting equally. According to the American Cancer Society, blacks have the highest death rate and shortest survival of any racial/ethnic group in the United States for most cancers. Although the overall racial disparity in cancer death rates is decreasing, in 2012 the death rate for all cancers combined was 24% higher in black men and 14% higher in black women than in white men and women, respectively, and in some cancers, including breast cancer, the mortality gap is actually increasing.²

The factors contributing to inequality in cancer care in minority populations are many and include lack of access to high-quality care, low socioeconomic status, cultural and religious beliefs, language barriers, risk factors, and comorbidities. Lack of exposure to an ethnically diverse oncology workforce is also a barrier to good care, according to ASCO’s 3-year (2017–2020) Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce, published in the Journal of Clinical Oncology (JCO).³ “Lack of access to high-quality care that is understanding and respectful of diverse traditions and cultures plays a significant role [in contributing to racial and ethnic disparities in cancer care],” according to the JCO article.

There is a sense of trust and a comfort level that patients may experience simply from having a provider who comes from a similar ethnic or racial background.

— Karen M. Winkfield, MD, PhD

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Although blacks and African Americans make up 13% of the U.S. population and Hispanic or Latino Americans make up 18% of the population, only 9% of practicing physicians in the country self-identify as black/African American or Hispanic/Latino.^4,5 In oncology, just 2% of the physician workforce self-identifies as black/African American and 3% as Hispanic/Latino. In addition, the proportion of black/African American and Hispanic/Latino oncology fellows is consistently lower than many other fellowships in subspecialties in internal medicine.⁶

Recruiting oncology professionals from diverse backgrounds, according to ASCO’s strategic plan, “will improve attitudes toward and awareness of minorities in health-care institutions, bring increased intercultural responsiveness, and engender trust and comfort in patients, particularly in communities that have traditionally been underserved.” It will also result in expanding health-care access, fostering research and discovery in minority populations, and influencing policymakers to meet the needs of an increasing heterogeneous population, said the report.

Primary Goals

ASCO’s strategic plan is based on three primary goals: establishing a pathway for increasing workforce diversity; enhancing diversity within ASCO leadership; and integrating a focus on diversity across ASCO’s programs and policies.

To meet these goals within an ambitious timeline of just 3 years, ASCO has convened a work group comprising members of the Society’s Health Disparities Committee, Professional Development Committee, and Workforce Advisory Group.

To learn more about ASCO’s Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce, The ASCO Post talked with Karen M. Winkfield, MD, PhD, Immediate Past Chair of ASCO’s Health Disparities Committee and Director of Hematologic Radiation Oncology and the Office of Cancer Health Equity at Wake Forest Baptist Health in Winston-Salem, North Carolina. We also asked Dr. Winkfield about ASCO’s recent recommendations for reducing cancer disparities among sexual and gender minority populations.

Lack of Race Concordance and Cancer Outcomes

ASCO’s Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce report found that only 2% of the physician oncology workforce is black/African American and 3% is Hispanic/Latino. What is the impact of such a low representation of minority oncologists on health-care disparities and cancer outcomes in minority patients?

There have been several studies, including a 2003 report⁷ from the Institute of Medicine [now the National Academy of Medicine], which detailed the enormity of the problem of racial and ethnic disparities in health care and how they impact access to care. The report recommended improvements in medical care financing, allocation of care, availability of language translation, and community-based care as potential solutions to the problem. These are the same issues we are confronting today, 14 years later.

Through its Diversity in Oncology Initiative programs, ASCO has awarded more than $1.1 million in funding to 136 minority medical students since 2008.

— Karen M. Winkfield, MD, PhD

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Subsequent reports have shown that minority patients have a more favorable response to health-care providers if there is racial concordance. One area we would like to see improved is minority participation in clinical trials, because research is how we drive cancer care forward. We have to increase participation of minority patients in clinical trials, and one strategy to accomplish this is to improve workforce diversity. There is a sense of trust and a comfort level that patients may experience simply from having a provider who comes from a similar ethnic or racial background.

Although racial concordance improves patients’ well-being and their sense of satisfaction with their health care, we don’t have conclusive data that clinical outcomes, particularly cancer outcomes, are improved, but this is something we hope to see as workforce diversity increases. And workforce diversity doesn’t just help minority patients feel greater levels of satisfaction, it helps improve care overall. As providers, when we are in a diverse workforce, we learn from each other.

Barriers to Minorities Entering the Oncology Workforce

Why are there so few minorities in the oncology workforce? What are the barriers preventing minorities from entering the field of medicine and specifically oncology?

The barriers impeding the selection of oncology as a specialty during medical school are many. They include limited exposure to oncologic specialties; the fact that oncology training often focuses on the inpatient setting, giving students an uneven view of the specialty; and lack of minority physician role models.

When you look at the number of African Americans who have entered and graduated from medical school over the past several decades, it has remained stagnant, although the number of Hispanic medical students has seen an upswing. So, there is obviously a problem downstream, and we know our educational systems around the country are very uneven. We know wealth is a huge driver for having the resources to impact education, income, and health.

Many African Americans come from disenfranchised backgrounds and may not have had exposure to minority providers. I’m the first person in my family to go to college, and there are students I have mentored who were the first black males in their families to graduate from high school. We have to understand the context of minority students’ life experience—one size does not fit all.

ASCO Promotes Diversity in Oncology

What ASCO is doing as an oncology organization is saying we are going to do everything we can to make sure all brilliant minds have an opportunity to succeed as oncology professionals. It is vital for medical students, particularly those in their first and second years of training, to have an opportunity to be exposed not just to the inpatient wards, but the outpatient clinics as well, and to see the interaction between oncologists and patients and the ability physicians have to build long-term relationships with their patients.

It is such an honor for me to be in my patients’ lives at such a vulnerable time, but medical students don’t often get to experience these close relationships. What they usually see in oncology is a patient dying in the hospital. We have to be strategic in supporting and promoting diversity in oncology, and ASCO is helping do that through its Diversity in Oncology Initiative programs, which have awarded more than $1.1 million in funding to 136 minority medical students since 2008. The award has allowed recipients to attend ASCO’s Annual Meeting and has supported clinical research oncology rotations. To date, 105 of the recipients have become ASCO members.

Sexual and Gender Minority Populations

Recently, ASCO issued recommendations for reducing cancer disparities among sexual and gender minority patients.⁸ Please talk about the unique cancer risk and discrimination in the health-care system experienced by lesbian, gay, bisexual, and transgender patients.

The article ASCO published in the Journal of Clinical Oncology⁸ is a critical first step to outlining and addressing some of the issues sexual and gender minority populations face as they relate to cancer. Sexual and gender minority populations include those who are lesbian, gay, bisexual, transgender, and intersex. Individuals from these populations often have reduced access to health care and cancer screenings, usually due to lack of health insurance, but also because, as with racial/minority patients, there is an unconscious bias in the health-care system, which makes it difficult for these patients to “come out” to their providers for fear of stigmatization, which exacerbates the barriers to care. Lesbian and bisexual women have higher rates of obesity than women in the general population and are at greater risk for breast cancer, and gay men have a greater risk for anal cancer.

I want to specifically address the oncology issues unique to those who identify as transgender, because that is where we need patients to be able to self-identify without fear of discrimination. For example, if you have a female patient who comes into the office with a metastatic lesion to the bone, and it turns out to be prostate cancer, there has to be sensitivity about how to address the situation while allowing the patient to self-identify. Medicine tends to be pretty biased toward heterosexual couples, so we need increased sexual and gender minority cultural competency training for providers and increased outreach and educational support for sexual and gender minority patients to ensure higher quality cancer care for these patient populations.

The position statement ASCO released addresses five areas that affect both sexual and gender minority patients affected by cancer and the oncology workforce who identify as sexual and gender minority. They include patient education and support; workforce development and diversity; quality improvement strategies; policy solutions; and research strategies. Meeting these goals will help advance care for sexual and gender minority patients. ■

DISCLOSURE: Dr. Winkfield has served as a consultant for Novartis.

REFERENCES

1. Simon S: Cancer Statistics Report: Death Rate Down 23% in 21 Years. American Cancer Society, January 7, 2016. Available at https://www.cancer.org/latest-news/cancer-statistics-report-death-rate-down-23-percent-in-21-years.html. Accessed September 19, 2017.

2. American Cancer Society: Cancer Facts & Figures for African Americans 2016-2018. Available at https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2016-2018.pdf. Accessed September 19, 2017.

3. 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.

4. U.S. Census Bureau: Quick Facts. Available at https://www.census.gov/quickfacts/table/PST045216/00. Accessed September 19, 2017.

5. Association of American Medical Colleges: Diversity in the Physician Workforce: Facts and Figures 2014. Available at https://www.aamc.org/data/workforce/reports/439214/workforcediversity.html. Accessed September 19, 2017.

6. Brotherton SE, Etzel SI: Graduate medical education, 2015-2016. JAMA 316:2291-2310, 2016.

7. Smedley BD, Stith AY, Nelson AR: Unequal treatment: Confronting racial and ethnic disparities in health care. Institute of Medicine. Washington, DC: The National Academies Press, 2003.

8. Griggs J, Maingi S, Blinder V, et al: American Society of Clinical Oncology Position Statement: Strategies for reducing cancer health disparities among sexual and gender minority populations. J Clin Oncol 35:2203-2208, 2017.