Cancer clinical trials are vital to improving cancer care, but participation may add an additional financial burden for individuals and families already struggling to bear the high cost of cancer ...care. Finding sustainable ways to reduce financial toxicity, particularly for low‐ and middle‐income patients, may help to improve clinical trial recruitment and retention.
The 2020 U.S. Census data show a rapidly diversifying U.S. population. We sought to evaluate whether clinical faculty and leadership representation at academic medical schools reflects the ...diversifying population over time. Using data from the Association of American Medical Colleges for the period of 1977 through 2019, we found notable progress in female representation among clinical faculty, with smaller gains among department chairs and medical school deans. Racial and ethnic groups that are underrepresented in medicine are designated as such because their presence within the medical profession is disproportionate to the U.S. Census data. Even with accounting for this underrepresentation, clinical faculty and leadership positions show even starker disparities. Thoughtful policy implementation could help address this persistent underrepresentation among medical school faculty and leadership positions.
An analysis of data from the Association of American Medical Colleges from 1977 through 2019 showed progress in female representation among clinical faculty, full professors, department chairs, and medical school deans. Much less improvement was observed for racial and ethnic groups designated by the AAMC as underrepresented in medicine.
The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly escalated to a pandemic with significant morbidity and mortality resulting from the associated coronavirus disease ...2019 (COVID-19).1 Approximately one-third of patients developing COVID-19 experienced severe complications, including acute respiratory distress syndrome, acute renal failure, acute respiratory injury, septic shock, and severe pneumonia.2 Populations particularly vulnerable to COVID-19 include older adults and immunosuppressed patients. Some of that may be associated with reduced age, but also reduction in the number of comorbid conditions that may exist in that sub-population. ...when we looked at some of the early data about which patients are going to have increased mortality from COVID-19, it was those individuals who had cardiovascular disease or diabetes. There was a reduction during that time period of May through June, which was about an 80% reduction in the number of mammograms that were done.7 We almost went down to zero, and we know that that can translate, unfortunately, into increased morbidity and mortality. When it comes to systemic therapies, in addition to those that actually reduce your blood counts and have impact on marrow or impact marrow suppression, there are also data to suggest that immune checkpoint inhibitors like the PD-L1 and the PD-1 Inhibitors may be associated with worse outcomes and may actually be associated with increased morbidity and mortality, although it's fascinating because there was another study seemed to contradict these results.9,10 But all the data that we have suggest that patients getting new checkpoint inhibitors as part of their care may be at increased risk.
Research conducted through clinical trials is essential for evaluating new treatment modalities, establishing new standards of cancer care, and ultimately improving and prolonging the lives of ...patients with cancer. However, participation in trials has been low, and this is attributable to various factors including patient financial barriers. Such financial barriers include the rising cost of cancer care; a lack of transparency in coverage policy; and the perception of ethical, compliance, or institutional impediments to patient financial support. ASCO convened a roundtable discussion with a variety of stakeholders to define the scope of the problem, as well as to identify clinical practice and policy solutions applicable at the institutional and system-wide levels. This statement summarizes key discussions from the ASCO Roundtable, as well as findings from the literature, and provides ASCO's recommendations for overcoming financial barriers that may otherwise prevent participation in clinical trials. These recommendations broadly address the following key areas: (1) improving the policy environment for coverage of clinical trials; (2) facilitating transparency among providers, patients, and payers for trial-related out-of-pocket costs; (3) refuting the specter of inducement to enable targeted financial support for patients; and (4) improving the available data on costs of cancer clinical trials.
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Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. ...provide evidence demonstrating the persistence of racial disparities in cancer.
This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.
Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. provide evidence demonstrating the persistence of racial disparities in cancer. This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.
Factors contributing to racial inequities in outcomes from coronavirus disease 2019 (COVID-19) remain poorly understood. We compared by race the risk of 4 COVID-19 health outcomes--maximum length of ...hospital stay (LOS), invasive ventilation, hospitalization exceeding 24 h, and death--stratified by Elixhauser comorbidity index (ECI) ranking. Outcomes and ECI scores were constructed from retrospective data obtained from the Cerner COVID-19 De-Identified Data cohort. We hypothesized that racial disparities in COVID-19 outcomes would exist despite comparable ECI scores among non-Hispanic (NH) Blacks, Hispanics, American Indians/Alaska Natives (AI/ANs), and NH Whites. Compared with NH Whites, NH Blacks had longer hospital LOS, higher rates of ventilator dependence, and a higher mortality rate; AI/ANs, higher odds of hospitalization for ECI = 0 but lower for ECI ≥ 5, longer LOS for ECI = 0, a higher risk of death across all ECI categories except ECI ≥ 5, and higher odds of ventilator dependence; Hispanics, a lower risk of death across all ECI categories except ECI = 0, lower odds of hospitalization, shorter LOS for ECI ≥ 5, and higher odds of ventilator dependence for ECI = 0 but lower for ECI = 1-4. Our findings contest arguments that higher comorbidity levels explain elevated COVID-19 death rates among NH Blacks and AI/ANs compared with Hispanics and NH Whites.
Inequity exists along the continuum of cancer and cancer care delivery in the United States. Marginalized populations have later stage cancer at diagnosis, decreased likelihood of receiving ...cancer-directed care, and worse outcomes from treatment. These inequities are driven by historical, structural, systemic, interpersonal, and internalized factors that influence cancer across the pathologic and clinical continuum. To ensure equity in cancer care, interventions are needed at the level of policy, care delivery, interpersonal communication, diversity within the clinical workforce, and clinical trial accessibility and design.
Black physicians remain disproportionately underrepresented in certain medical specialties, yet comprehensive assessments in radiation oncology (RO) are lacking. Our purpose was to report current and ...historical representation trends for Black physicians in the US RO workforce.
Public registries were used to assess significant differences in 2016 representation for US vs RO Black academic full-time faculty, residents, and applicants. Historical changes from 1970 to 2016 were reported descriptively. Linear regression was used to assess significant changes for Black residents and faculty from 1995 to 2016.
In 2016, Black people represented 3.2% vs 1.5% (P < .001), 5.6% vs 3.2% (P = .005), and 6.5% vs 5.4% (P = .352) of US vs RO faculty, residents, and applicants, respectively. Although RO residents nearly doubled from 374 (1974) to 720 (2016), Black residents peaked at 31 in 1984 (5.9%; 31 of 522) and fell to 23 (3.2%; 23 of 720) in 2016 across 91 accredited programs; Black US graduate medical education trainees nearly doubled over the same period: 3506 (1984) to 6905 (2016). From 1995 to 2016, Black US resident representation significantly increased by 0.03%/y, but decreased significantly in RO by -0.20%/y before 2006 and did not change significantly thereafter. Over the same period, Black US faculty representation significantly increased by 0.02%/y, whereas Black RO faculty significantly increased by 0.07%/y before 2006, then decreased significantly by -0.16%/y thereafter. The number of Black RO faculty peaked at 37 in 2006 (3.1%; 37 of 1203) and was 27 (1.5%; 27 of 1769) in 2016, despite the nearly 1.5-fold increase in the number of both RO faculty and Black US faculty overall (4169 in 2006 and 6047 in 2016) during that period.
Black physicians remain disproportionately underrepresented in RO despite an increasing available pipeline in the US physician workforce. Deliberate efforts to understand barriers to specialty training and inclusion, along with evidence-based targeted interventions to overcome them, are needed to ensure diversification of the RO physician workforce.
A concerted commitment across research stakeholders is necessary to increase equity, diversity, and inclusion (EDI) and address barriers to cancer clinical trial recruitment and participation. Racial ...and ethnic diversity among trial participants is key to understanding intrinsic and extrinsic factors that may affect patient response to cancer treatments. This ASCO and Association of Community Cancer Centers (ACCC) Research Statement presents specific recommendations and strategies for the research community to improve EDI in cancer clinical trials. There are six overarching recommendations: (1) clinical trials are an integral component of high-quality cancer care, and every person with cancer should have the opportunity to participate; (2) trial sponsors and investigators should design and implement trials with a focus on reducing barriers and enhancing EDI, and work with sites to conduct trials in ways that increase participation of under-represented populations; (3) trial sponsors, researchers, and sites should form long-standing partnerships with patients, patient advocacy groups, and community leaders and groups; (4) anyone designing or conducting trials should complete recurring education, training, and evaluation to demonstrate and maintain cross-cultural competencies, mitigation of bias, effective communication, and a commitment to achieving EDI; (5) research stakeholders should invest in programs and policies that increase EDI in trials and in the research workforce; and (6) research stakeholders should collect and publish aggregate data on racial and ethnic diversity of trial participants when reporting results of trials, programs, and interventions to increase EDI. The recommendations are intended to serve as a guide for the research community to improve participation rates among people from racial and ethnic minority populations historically under-represented in cancer clinical trials. ASCO and ACCC will work at all levels to advance the recommendations in this publication.
Cancer health disparities have been well documented among different populations in the United States for decades. While the cause of these disparities is multifactorial, the COVID-19 pandemic has ...highlighted the structural barriers to health and health care and the gaps in public health infrastructure within the United States. The most long-standing inequities are rooted in discriminatory practices, current and historical, which have excluded and disenfranchised many of the most vulnerable populations in the nation. These systemic barriers are themselves a public health crisis, resulting in increased mortality rates in communities of color from both COVID-19 and cancer. While implementing programs to temporarily improve cancer equity locally or regionally is laudable, it is imperative to develop a public health strategy focused on alleviating the root causes of health inequities to improve the health and well-being of every citizen and ensure readiness for the next public health emergency.
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