Lori J. Pierce, MD presents on racial diversity in cancer research and cancer care and outlines social and health inequities in the U.S.
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Good morning, everyone. And Cathryn Bolan, a medical oncologist at scripts M. D. Anderson. I have the honour and pleasure this morning of introducing to you are Speaker Dr Lori Pierce. Dr. Pierce is the current president of ASCO, a radiation oncologist, professor and vice provost for academic and faculty affairs at the University of Michigan. Dr. Pierce will be speaking to us on the race toward equity, increasing racial diversity and cancer research and cancer care. It's our honor having Dr Pierce with us at this conference. If you have questions for her, please use the ask a question. Chat function during the presentation will be collating questions to address during the panel discussion later this morning. Welcome, Dr Pierce. Hello, Good morning. I wish I could be there, but I'm with you virtually, Um, And I am happy for the next few minutes to talk about working toward equity, increasing racial diversity and cancer research and cancer care. And I wanted to start out by just outlining just a few metrics to kind of show you some of the social and health inequities that we currently have in the United States. First looking at poverty levels and I'll start by saying This is data from 2018, so this is pre pandemic. I suspect the numbers would be higher if we did it currently. But if you look at white, non Hispanics, Hispanics or Latinos and black non Hispanics, we see over double the rates of poverty in the Hispanic population and in the African American population. If you look at for those who are uninsured again, you see significantly higher rates of uninsured patients, people who are Hispanic or Latino or African Americans compared to white, non Hispanics. And if we look at infant mortality rates again, looking at the white, non Hispanic for 1000 live first 4.6, you see higher values for Hispanics, and you see a much higher value for African Americans. We look at self assessed health status, looking at the proportion who have fair or poor health again. If this is your reference point, you see higher numbers for Hispanics and for African Americans, and certainly for Native Americans or Alaska natives. And if you look at life expectancy at birth for white non Hispanics, it's almost 79 years where you see it only 75 years for African Americans. So again, just a snapshot of some of the striking disparities that we see in the US And if we look at incarceration rates male inmates per 100,000 again, this is from 2018. I suspect the numbers will be higher. If we had 2021 data, you see a striking difference almost five times, actually slightly greater than five times for blacks compared to white non Hispanics. And I must say that one statistic that really hit home is this. If you look at 2014, Data's was the latest I could find for this particular in point, about 3% of all black men in the US for serving a sentence of at least one year in prison. Um, that is just unconscionable. But this is what we're looking at in the US now, if we take this to cancer, um, as this audience knows, there are huge disparities in both incidents and mortality rates by race and ethnicity. If you look at all sides of cancer and you look at males, you see that African American males, they are the group that has the highest incidence and mortality rate of cancer of any of the major racial and ethnic groups. If you look at prostate cancer and look at African American men again, you see a much higher rate, uh, incidence rate compared to non Hispanic whites. And you see a very high rate in terms of death over two times the death rate for African American males compared to non Hispanic white males. You look at breast cancer, unlike what we used to see where the incidence of breast cancer and African Americans was less than what we see in White's. The numbers are actually pretty similar now. But while there may be similar incidents rates there's a 40% increase death rate. Um, for black women with breast cancer compared to white. So again, these are numbers that you know. But I want to just put them in perspective for this talk. And if we look at cancers that are associated with infections, we see in many cases the Hispanics have some of the highest incidence and mortality rates, reflecting the risk profile of the country, their countries of origin, and also how long they've been in the U. S. So again, very striking differences primarily in Hispanics for the cancers are associated with infections. Shit. And so, you know, we look at these numbers, You look at these disparities and when we ask ourselves why and our health states are highly dependent on the social determinants of health and the social in terms of health have been defined by the World Health Organization as conditions in which people are born, grow, live, work and age and they are shaped by money and power. And they're shaped by money and power at a global at a national and local level. And they are clearly major drivers to health inequity. And this was just a figure that I found a chart that I found from the Kaiser Foundation I thought was a really nice way of actually just looking very quickly at the social determinants of health. And you see that there are some that have defined by economic stability, neighborhood and physical environment, education, food, community and social context and certainly the health care system. Um, do patients have coverage? Are they able to find providers? Um, are is there linguistic and cultural competency so that such that the patient physician relationship is fully intact and the quality of care and all of these factors impact health outcomes in fact, mortality, morbidity, life expectancy for sure, health care expenditures, health status and functional limitations. And so they all are very much involved in the outcomes of our patients. And just to show you some examples of the impact social in terms of health can have on developing cancer and determining outcomes, I found a couple of a few statements from a, um, a meeting that was sponsored by the National Cancer Policy Forum in October of 2019. Looking at applying big data to address the social terms of health specifically in oncology and some examples, people with lower levels of education are more likely to smoke cigarettes. Yes, we know that's true. Having access to high quality health care is a mechanism through which social terms of health affect cancer outcomes. Definitely true, the quality of the care that patients receive is often influenced by patient community and health system. Factors and social in terms of health affect over the full continuum of cancer prevention in cancer care. So they affect outcomes across prevention, early detection, treatment and survivorship. And there was a quote that I gravitated toward from Dr John Iranian who's actually at my institution at Michigan. And he said, We need to think not just about the biological factors that influence cancer outcomes and cancer risk, but the social, economic and cultural factors very much driven by politics and policies. And I'm actually going to come back a little bit later and revisit the idea about biological factors that they're not the only thing that affect cancer outcome. And at this meeting, um, Robert Wynn, who, of course, is the cancer director at B. C. U Use the term community comics. And he said, we must examine factors such as obesity, violence, poverty and stressing communities the built environment, which is the physical parts of where we work and live. The lack of exercise opportunities and environmental pollutants on cancer incidence and mortality. And these he coined the invisible factors and I completely agree with him. These are the factors that we know that there are things that are working against our patients, but they're really hard to kind of put your finger on. And he also brought up the topic of being aware of the intersectionality of interdependent factors and what he means by this is that a lot of these factors are absolutely connected such that if you focus just on one factor, but you don't focus on some of the others, you really won't see the needle move. You really have to have a comprehensive approach to give an example. You have a patient who is overweight, and you're advocating that they should modify their diet. Um, and, uh, to have that with diet and exercise. So that's important. But to exercise you didn't realize they're living in an environment that is not safe, that there's violence. There's gunfire. Um, and so it just shows you how these pieces are connected. And you really have to look at the big picture rather than focusing very narrowly on some of these factors. And I think this is actually reflected very nicely in this model again by Dr Iranian from Michigan, where he proposed a conceptual model of healthcare disparities. And you can see how these are all connected. You know that patient factors such as race, ethnicity, age, insurance, socioeconomic status by going to impact your health system, your workforce access to care. Um, you know, community factors such as property is going to affect both of these. All of these feed into quality of care and some directly feed into outcomes. So they're all connected. And you really have to sit back and really look at the big picture. So social determinants of health significantly impact health outcomes. Um, but structural racism impacts social in terms of health. So structural racism significantly impacts the distribution of the social determinants of health and the health profile in the U. S. Population, including health inequities. And there are many definitions of structural racism. I just have a couple here. One says that Dr Jones says it's a confluence of institutions, culture, history, ideology, codified practices that generate and perpetuate. That's the keyword perpetuate inequity among racial and ethnic groups. And then there's a second definition that are like totality of ways in which societies fostered discrimination by mutually reinforcing inequitable systems. And you see many here, including health care that in turn reinforce discriminatory beliefs, values, distribution of resources. And I always think that a picture is worth 1000 words, and I like this picture because I think it it makes it very clear what structural racism is and what it's not. And this is called the discrimination iceberg and taken from a paper that I found talking about Asian Americans and discrimination against Asian Americans. But the concept, I think, applies for all races and ethnicities, and that is you see this water line so you see readily observable events that are above the water line, and you see those that are very difficult to observe below the water line. And if we think of recent events, we can certainly think of the kneeling on the neck of George Floyd for eight minutes and 46 seconds. That led to just racial society to just just erupt as it should have, because this was such a hateful, hateful crime. Um, and that's an overt action that is clearly above the water line. But if you look at what's below, it's what's below the waterline. That's difficult to observe, that that's where the structural racism is. These are complicit actions that constitute structural racism that then make the overt actions, um, possible. So this is where we are, but this is not where we want to be. We absolutely want to take every step we can toward equity, and so what do we need to do very nice paper on the New England Journal in 2016 about structural racism supporting black lives. The role of health professionals. We need to accept, understand and accept the U. S history of racism. We need to own it, and we need to learn from it. We need to understand how racism has shaped our narrative about disparities. Um, we need to be able to have a dialogue. We need to challenge our implicit biases, but we all have biases and false beliefs. We need to acknowledge what they are, and then we have to improve them. We can't just acknowledge them and then say, Okay, we've got to We've got to take actions against them, Um, so that we don't let them control our approaches to our patients. We have to have a consistent vocabulary for race and racism. It's not just about race. It's also about racism. We've got to call it out. We've got to acknowledge it, and we have to look beyond biology for reasons that may be contributing to cancer outcomes. So this is where I wanted to come back to that point, and here's a really good example of how it's not all about biology. This is something called the Delaware Project. And for those of you who read J c O, it was a J C O. Paper, I think was around maybe 2011, talking about this initiative, eliminating colorectal cancer disparities in Delaware. And basically what this was is there was a huge disparity between whites and African Americans in terms of screening and cancer outcomes for colorectal cancer. And so Delaware is a small state. So they said, Okay, we've got it. We've got to take charge here. So they created a program where there was active colorectal screening throughout the state for adult and for those who can pay for it, had insurance, their insurance covered it. But for those who did not the state coverage, and when they looked at the incidence rates and looked at the survivals, they found that the survivals the death rates were almost all eliminated between African Americans and whites. So when you when you provided screening, diagnosed cancers treated them for those who need to be treated and didn't couldn't afford it, the state covered the cost of the treatment. So they were It was active care for all patients colorectal cancer. It almost negated the difference in survival. And I think it's a message to all of us, as certainly as clinicians. We emphasize important biology, and that's very, very important. We always have to look at those invisible factors because in many cases that is the overwhelming cause of the disparities. Um, and we need to incorporate essential pedagogy about racism and health into our teachings and medical schools. And many medical schools now are bringing curriculums up to include racism. But we also need to talk about our residency programs in our fellowship programs. There needs to be a cultural competence so that people feel comfortable engaging with patients from all ethnicities and all races, and this needs to be a lifelong commitment in terms of the competence in terms of acknowledging our biases. It's critical to have self reflection, and this is something that needs to be lifelong. We didn't get where we are overnight, and we're not going to make it go away overnight, so there needs to be a lifelong commitment to improving um, equity and big data. We need to have facts to bring about change, and that is a large benefit of some of the big data that we have that that provide real world data to supplement data from clinical trials because clinical trials can't give us all the information. As a matter of fact, there are limitations of clinical trials with regard to eligibility criteria. Trials have traditionally been very exclusionary, and a lot of the people of color have not met the criteria, the criteria eligibility. We're working on that now. In terms of broadening those criteria, they tend to lack geographic representation. Um, underrepresented patients receive cancer treatment communities tend to be more from academic practices, and they also tend to be of higher socioeconomic status and from urban suburban areas. And that was actually a note from Cliff Hudis from ASCO. So here we have big data that can help us to kind of even the playing field. By analyzing the results from from people from all walks of life and all locations, we can collect data from Mars. We have administrative claims databases. We have other large data repositories that can be more representative and are more representative of diverse population, and we can mine the data at multiple levels from a patient level from the condition level from our practice and a health system characteristics so that we are able to get a really comprehensive view of how health care is being delivered in this country. We need to have more diverse providers. We need to have more oncologists who look like the patients that we serve. And this was a paper that was published in 2020 looking at the trends in racial and ethnic diversity and interim medicine. Subspecialty fellowships from 2000 and 6 to 2018 and I want you want to go through. It's a busy slide. I'll take you right to the bottom line. If you look at the moment, that is the specialty. They had the lowest number of African American internal medicine medicines going into the special, um, and so there's much that we need to do to encourage more, um, students and residents and fellows, fellows, the students to and resin. Excuse me to go into fellowships for oncology. We need to make sure they understand all of the way that we impact our cancer patients and the wealth of interactions that we have with all of our cancer patients. And so what is Asco doing Asco has been doing a lot. So much of what ASCO is focused on is equity of care. Um, they've been doing a lot in the equity space for years. And, of course, ASCO is a very one of a very important part of what Asco does is advocating those Capitol Hill and also partnered with our state and local legislators. And I will say that a very recent big win for ASCO and for patients, broadly, was the clinical Treatment Act that was just recently included in some of the legislation for the pandemic that has now gone forward and ask A has had been advocating that for years. And basically that was that Medicaid was the only major insurer that didn't have to cover routine care costs for patients to go on clinical trials. So all the other private Medicare everyone else had to cover the routine care cost going clinical trials. But Medicaid did not. And that's a double whammy because most of the patients that receive Medicaid are the patients who are underrepresented in clinical trials. And so I'm now happy to say that thanks to efforts of a lot and primarily asco, that has now gone forward. Um, asco has worked historically with black colleges and universities to have outreach again to try to increase the pipeline for worthy candidates going into oncology. Um, we we continue to work to increase the underrepresented members of ASCO committees because, as you know, a lot of the work at ASCO son at the committee level, and we need to have everyone sitting at the table. Um, we ask. Oh, has continued to address health disparities and older adults Task force. Older adults are also patients who are not well represented. And so we have an older adults task force that is really, um, articulated key needs for patients in this group and also their fought their providers. We also have a task force on rural areas because again, these are our patients that can be left out of the mainstream, and their providers are not are not always able to attend ASCO meetings. And so we need to be able to facilitate access to the best of asco to facilitate tumor boards and have greater access for the providers and certainly for their patients. Um, we the Health Equity committee is currently assessing the needs of some of the providers of the underserved so again that we can understand what it is that we need to provide the providers so they can adequately care for their underserved patients. ASCO has been very active in terms of clinical affairs, thanks to grants from Susan Komen and the Stavros Niarchos Foundation. Through copay, we've been able to set up programs specifically for providers and underserved areas to improve the quality of care. And certainly the Conquer Cancer Foundation has provided funding thanks to grants provided by others so that we can have more medical students of color and more residents of color have them to come to the annual meetings so they can learn more about oncology and hopefully improve their increase their interest in going into oncology. And there are now multiple grants that are focusing specifically on research and underrepresented populations. So, as you know, has been doing so much for, uh, equity. Um, but I as my theme, I have brought equity as the theme for ask over 2021 and my theme is equity, every patient every day everywhere, and we have further increase the portfolio, if you will, of equity offerings that ask so some of the new initiatives that here we have a collaboration between ASCO and we'll see the Association of Community Cancer Centers, where we are focusing on strategies to increase participation of racial and ethnic minorities onto cancer treatment trials. Now this is not new. Committee groups have tried this before, and some have been relatively successful. But if you look in the literature, you see these occasional areas of success, but they're not being taken up and and embrace and use among clinical trials. So we do this partnership have brought together a steering group of many individuals, talented individuals who have focused on enrollment of minorities for their careers. Um, and we are bringing together strategies that we will then pilot in some of the Taper sites. And so once we see that we are able to increase, move the needle positively. We want to be able to write this up and to bring this to many of our trials and cooperative groups as a pathway, if you will, to broadly increasing minority participation in clinical trials. Another initiative, um, is we have put forward and we've already started a social determines of health training program for geared primarily an early career oncology providers. And this is a series of podcasts and videos and and papers that we talk about the social determinants of health and modifiable risk factors. So we want to educate more of our early providers, and this will be a enduring resource that any ask a member can can appreciate. And so we've already had. Three of these were doing 11 monthly, Um, and they've been topics such as how to take a social determinants of health history. You know, that's not something we learned in medical school, but you have to know how to be able to elicit that information from your patients so that we can make sure that we can adequately treat. We understand the barriers that they're facing so we can adequately treat them. So that's another initiative for this year. Another is, um, we have established the Oncology Scholars rotation, which, in addition to our medical student rotation addition to our rotation For residents, this is be an immersive experience. A four week experience for the beginning of second year of medical school for minority students at certain institutions where ASCO will create the entire, um, coursework the course entire curriculum, and the students will stay at their institutions. They will be able to work with leaders, cancer leaders at their institutions. But the curriculum will be developed by ask. And we hope that this immersive curriculum will again encourage more and more highly qualified, underrepresented minority medical students to go into careers in oncology. Another, um, initiative is I've wanted to connect equity and cancer care throughout ASCO Asco has had so so many programs and equity of care, but they've been somewhat silo and and so this year we've been able to connect many of these programs so that it's a seamless discussion. All there's so much of a focus now across the board and ask, Oh, and it's been just a very rich and very productive on discussion. And then we want to take that same type of seamless connections with equity to our annual meeting so that instead of having just stand alone sessions on equity of care, which often are not, um, well attended, not because I think people don't want to learn about it, but because there's so many other things we have to learn immunotherapy. I mean all these things we have to learn, and there's just 24 hours a day, seven days in a week. So we want to be able to embed equity more in some of the main sessions at the ASCO meetings so that there are many take home messages. The work of the Health Equity Committee has been pivotal in terms of guiding the ASCO, guiding the society in terms of health equity issues. And, as you probably know, they recently published in J. C. O. A policy statement from from the health equity group from the American side, Clinical oncology and the big items the groups were ensuring equitable access to high quality care was point number one point number. To ensure equitable access to research number three, a stress address, the structural barriers and then for increase awareness and action. Under each of these, you can see itemized bullets for what we need to do to make this a more robust effort, and this is being used as a pivot as a springboard to then create a strategic plan for the society. And that's what the Health Equity Committee is working on, right? And I'm happy to say that the board, um uh, agreed to an upgrade of the mission statement. And Dr Cost, of course, is as a seat as a seasoned member of the board. And you will note that it was unanimous to bring in the words equitable to the mission statement. So conquering cancer through research, education and promotion the highest quality, equitable patient care. I think that says a lot in terms of the focus of the society and the unanimous vote. So do we have all the answers for reaching equity? Of course not. No, we don't. But sometimes it's not about having all the answers, but rather it's about posing the right questions and searching for the answers together. And this is indeed a journey. As I said, this is not going to happen overnight. Um, but I think I am very optimistic that the momentum not just an ASCO but in this country and the world is for really, really getting to the bottom of the reasons for inequity and reaching out to reach equity. And I just want to close. I found this, uh, statement, and I just I just had to include it because it's so ironic that it's so relevant in 2021. This was a statement from Frederick Douglas in 18 57. It was a quote from one of the speeches that he was talking about slavery in America. But he was also talking about emancipation, of people of color in the West Indies and then the backlash that ensued when they were emancipated. And he said, Power concedes nothing without a demand. As physicians, we have to demand change. The status quo is not acceptable. We have people who are dying because of inequity. And so we have to be willing to advocate for our patients. We have to have to empower them, and we have to advocate for them because the status quo is not acceptable. So I thank you for listening to my talk and I asked you just imagine all the things we can do and all the excellent outcomes we could see if we truly had a little care. So just imagine, thank you
