Diversity, Equity, and Inclusion in Cancer Care: It’s Time to Act
Panel Discussion Moderated by Dr Kristina Mirabeau-Beale, Genesis Care USA
Panelists:
Dr Kristina Mirabeau-Beale, Genesis Care USA
Dr Neil Iyengar, Memorial Sloan Kettering Cancer Center
Dr Sonya Reid, Vanderbilt University Medical Center
Dr Jennifer Klemp, University of Kansas Cancer Center
Dr Elyse Lower, University of Cincinnati
At the 2023 Best of Breast Conference held in Boca Raton, FL, Dr Kristina Mirabeau-Beale, a radiation oncologist from GenesisCare in Ft Myers, Florida, led a team discussion on differences in cancer outcomes among minority populations, current inequities in cancer care, and challenges faced by underserved populations with breast cancer.
The panel first considered a commonly encountered case: A 45-year-old pre-menopausal Black woman who presents with newly diagnosed breast cancer. Her cancer is classified as invasive ductal carcinoma (IDC), Grade 2, with positive estrogen and progesterone receptor (PR) expression (i.e., hormone receptor positive) with negative expression of human epidermal growth factor receptor 2 (HER2). Her family history is notable for a sister who was diagnosed with breast cancer at age 54, but her genetic testing profile is negative for any familial breast cancer association. The patient undergoes a lumpectomy procedure (removal of the breast tumor) with sentinel lymph node (SLN) dissection surgery performed. The final diagnosis is a 3.2 cm, Grade 1 IDC which has negative surgical margins, and 1 of 3 lymph nodes is positive. After surgery, the patient is set to undergo adjuvant radiotherapy (RT) and endocrine therapy (ET). Dr Mirabeau Beale then asked the panel what her expected outcome would be.
Dr Sonya Reid, a medical oncologist from Vanderbilt University Medical Center, first noted that worse outcomes have been observed among Black as compared with non-Hispanic White women with breast cancer, first in the TailoRx trial, as well as the more recently reported RxPonder trial, which showed a 5-year invasive disease-free survival rate of 87.2% versus 91.5% in these respective populations. She noted the reasons underlying these disparate outcomes are multifactorial, and can include social determinants of health and access to care, but also genetic factors related to race, which, as a whole, remain poorly understood. In RxPonder and other clinical trials, for example, patients are treated in a uniform fashion, so one would not expect to have access to care as an issue; despite this, however, the racial disparity in outcomes remain. In RxPonder the difference by race remained when patients were separated by menopausal status (postmenopausal or premenopausal). Importantly, when these results were corrected for body mass index (BMI), it reduced the difference, but did not completely eliminate the disparity in outcomes. Dr Reid noted that, while the results suggest Black patients had a higher BMI which could account for some of the difference in outcome, clearly other factors were also contributing.
Dr Neil Iyengar, a medical oncologist from Memorial Sloan Kettering Cancer Center agreed, and noted that such disparate outcomes highlight the contributions of an increasingly complex, and poorly understood set of factors. He noted that, while social determinants of health, access to care and to some extent, genomic factors and tumor biology have been a focus, data are emerging which suggest that the tumor microenvironment, or the “soup” in which the tumor sits, can also differ by race. The microenvironment can impact a number of aspects such as the density of immune cells around the tumor, and the propensity of the tumor to metastasize, or spread to other parts of the body. He noted an example from his own work showing that immune cell infiltration was higher, independent of BMI, for Black and Hispanic patients as compared with non-Hispanic White patients. Dr Iyengar envisioned a potential strategy for the future, whereby social and familial factors that can impact care can be merged with genomic information and other novel contributory factors, such as the tumor microenvironment, to develop a more targeted or individualized approach for cancer treatment based on race, as well as a better system to assess and define the patient’s risk.
Dr Elyse Lower, medical oncologist from The University of Cincinnati, stressed the importance of getting more Black patients on clinical trials, noting a lack of adequate representation. As such, she emphasized that steps must be taken to give patients greater access to trials, and concomitantly, efforts must be made to convince patients of the importance of clinical studies before questions of racial disparities can be meaningfully addressed. Dr Reid agreed, noting that the proportion of Black patients in the RxPonder was only 6%.
Dr Mirabeau-Beale highlighted some key facts, noting that compared to White women and despite similar diagnoses, Black women are about 40% more likely to die from breast cancer. She explained that while there are multiple factors, including tumor biology, genetics, access to healthcare, medication adherence, and other social determinants of health that can potentially contribute to these disparities in breast cancer outcomes between White and Black women, the exact mechanisms accounting for these differences are not fully understood. She further noted that, whereas cancer incidence and mortality overall are declining in the US population, there are clearly certain groups that remain at a disproportionally high risk for developing certain cancers and for cancer-related death. Advances in cancer treatment and interventions should thus aim to be impactful across the spectrum of all patients with cancer, not just some.
Dr Mirabeau-Beale reviewed some of the primary social determinants of health, which fall into different domains such as economic (employment, debt), neighborhood/location (housing, transportation, safety), education (health literacy, language), food (hunger, access to healthy food), community and social factors, and health care coverage/quality of care. She noted that all of these complex domains can have an impact on patients across the cancer care spectrum, from cancer surveillance and screening to early diagnosis and treatment, and ultimately to outcomes such as morbidity and mortality. The panel then considered the question of how, as community oncologists they can be more engaged with the community to provide more equitable cancer care.
Dr Reid thought it was important to be intentional, to examine where is your practice, what are the needs within the community, and what are the gaps. She noted the importance of, for example, if there is a high Hispanic community in your practice, to engage with community leaders and advocacy groups to have a presence and establish trust and a collaborative relationship, and not just when you are looking to recruit patients for clinical trials. Dr Iyengar agreed, and thought it was especially important to begin to incorporate these considerations into clinical trial design as well, given the aforementioned evidence suggesting that cancers may be biologically different based upon ethnicity. He thought that integration of these factors into clinical trial design may also help to stimulate recruitment and accrual into clinical studies for these higher risk populations.
Dr Jennifer Klemp, from University of Kansas Cancer Center, further noted the importance of creating an infrastructure and a climate that demands diversity and inclusion in trial design, and that these issues have already “moved up in the food chain” in terms of their importance for consideration from major funding sources, such as the National Cancer Institute (NCI). She also noted the importance of “owning” what you do (and what don’t do), well. She emphasized that while you may be a clinical expert in the science of cancer, “…if you don’t look like the patient in front of you”, you may not fully understand the full scope of the cultural and ethnic implications of their disease experience. She noted that just by recognizing these limitations of your knowledge and discussing them with the patient, you can help to break down some of those barriers in communication, and build a relationship of trust and collaboration with them.
Dr Lower agreed with the other panelists on the issue of trust, noting that at her inner-city cancer center, the population was very mixed, but approximately 50% Black. “We had to go to them… they were not going to come to us… even though our cancer center was in the middle of the city – we still had to make that outreach…” Dr Lower further noted that in the past, despite approximately half of her patients being Black, only about 10% were involved in clinical trials, and that, notably, her clinical trial team was all White. She described the importance of having “a similar face” to talk about the trials to, to go over the consent and other critical information. As a practical matter, she described how, by better mirroring their patient population in the clinical trial team, they were able to double their enrollment of Black patients in clinical trials within one year. Dr Lower was also very concerned about “money being thrown against the wall for diversity inclusion and equity” and emphasized the importance of having an infrastructure in place to provide the necessary guidance and a clear plan for where that money would be best spent.
Dr Reid described initiatives at her institution, not only to further Black enrollment in clinical trials, but also “getting more Black patients to even walk in the door of a major academic cancer center… it’s a struggle.” She cited the importance of, for example, having a Black patient navigator available, getting a needs assessment for the uninsured, or the under-insured, to try and fill the gaps for patients for getting on and staying on a trial, such as transportation, getting off from work, etc. She also cited evidence suggesting some inherent bias in providers not even asking their patients to get on a clinical trial, thinking the patient has more going on in their life, more comorbidities, etc., which may, or may not, actually be true. When considering their patients for participation in clinical trials at her center, Dr Reid encourages clinicians to take away that bias “and just ask… see if the patient will say yes or no [to participation in the trial], and if no, what are some of the barriers to participation that we might help to mitigate?”
Dr Iyengar agreed, and reemphasized the importance of being mindful in the design of clinical trials, to be better reflective and feasible in the population in which they hope to treat; for example, with regard to the issue of BMI being a potential contributor to poorer outcomes in Black patients, he cited a trial at his institution, specifically intended for the Black patient population, that aims to intervene not only with cancer therapy (chemotherapy) but also to address the possible comorbid metabolic conditions (e.g., obesity) with drug therapy which might be helpful to further improve outcomes. As a means to foster enrollment of Black patients in the trial, he noted that multiple focus groups were conducted in the community to determine strategy to generate interest and excitement in the study; this outreach enabled partnering with community leaders to help accrue patients and even to design the trial.
Dr Klemp also highlighted work at her own institution for outreach to the Hispanic community using bilingual social media programs and other innovative methods using neighborhood artistry and murals to stimulate interest in clinical trials. She also emphasized the importance of playing to your strengths, for example, judicious use of telemedicine approaches that are well suited to her rural community setting, and utilizing patient advisory and focus groups that are meaningful “not just a checkbox…”. Dr Mirabeau Beale agreed, noting the importance of being thoughtful and creative in engaging the community, and at her own institution, utilizing barbershops and Black churches to help with cancer screenings and other educational initiatives. She also highlighted the use of a community needs assessment tool¹ that can be used to give community leaders a snapshot of health policy and the current health environment in their community. It provides not just cancer data but also cardiovascular outcomes and maternal-fetal information, which can allow community engagers to identify potential areas for intervention.
In the final portion of the program, Dr Lower reviewed another problem of age bias across clinical trials, noting that, while cancer is most common in patients over the age of 65, only about one third (30%) of participants in clinical trials fall into this group. As such, cancer care teams may lack optimal data to guide therapeutic decisions in that age group. She noted the recent efforts of the American Society for Clinical Oncology (ASCO) and the NCI to address this problem, one of which is a fitness assessment for clinical trials that addresses eligibility not by patient’s age, but their fitness and functional status level. She highlighted a recent publication² that outlines some of the recommendations for improving clinical trial design to be more inclusive of older patients, which include the design of trials specific to older populations, the use of a parallel or embedded cohort of older patients, and the use of pragmatic and achievable study design elements. Dr Klemp and others on the panel also emphasized the importance of designing better and more efficient clinical trials that are not only more inclusive but that have achievable goals. “If you have to wait ten years for results of a trial… that data is already irrelevant…” Dr Lower noted. Dr Reid thought the amount of time needed for clinical trials to readout further emphasizes the need for being more diverse inclusive in clinical trial design. If, for example, Black patients are underrepresented, they are essentially being denied access to novel therapies which they may not be around to benefit from by the time the trial reads out and FDA approval is granted.
Summarizing, Dr Mirabeau Beale cited current efforts and calls to action to address inequities in cancer care in communities of color and other underserved populations by ASCO as well as the association of radiation oncologists (ASTRO). She noted ASTRO in particular had called out racism as a source of health inequity and disparate outcomes and cited a paper written by fellow radiation oncologists on the topic for additional reading.³ She highlighted some key areas where changes can be implemented to help alleviate inequities in cancer care. At the individual “patient in front of you” level, just being aware of your own biases and recognizing your limitations in communicating and relating to your patient can be helpful, and community outreach and engagement are also essential. Institutions should also implement mentorship programs and be cognizant of the community populations which they serve, encouraging active recruitment, hiring, and retention of physicians, to better align with these populations. Lastly, a recurring theme in the panel discussion was the need to encourage active recruitment and greater inclusion/representation of underserved populations in clinical trials, an essential step to ensure the validation and relevance of cancer treatments and research efforts across all ethnic groups.
Community Needs Assessment Resource: Available at: http://www.cdc.gov/HealthyCommunitiesProgramAccessed: February 15, 2023.
JNCI Monographs, Vol 2022, 60, December 2022, pg135-141.
Chapman CH, Gabeau D, Pinnix CC, Deville C Jr, Gibbs IC, Winkfield KM. Why Racial Justice Matters in Radiation Oncology. Adv Radiat Oncol. 2020; 5(5):783-790. doi: 10.1016/j.adro.2020.06.013.
See more from the 2023 Best of Breast Conference here.
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