Presentation by Dr Edith Mitchell, Sidney Kimmel Cancer Center, Jefferson Health
While cancer survival has improved overall, the benefit has not been uniform across minority and underserved populations in the United States, and disparities in cancer care and cancer-specific survival among racial and ethnic minority populations continue to exist. At the 2023 West Oncology Conference, Dr Edith Mitchell from the Sidney Kimmel Cancer Center in Philadelphia, Pennsylvania provided a historical perspective on topic of racial disparities in cancer, and the current efforts to address this important issue. As a premise for her discussion, Dr Mitchell highlighted the importance of learning from our past to create a plan for the future that more effectively addresses the issue of racial disparities in cancer.
She noted the importance of working in collaboration with societies such as The National Medical Association (NMA), which is the oldest, and largest organization of Black physicians and health professionals in the United States. She noted the NMA was founded in 1895, a period in US history in which Blacks were excluded from professional societies. Dr Mitchell provided an example of active collaboration with the NMA, whereby Black primary care physicians worked to recruit and enroll more than 1100 patients on a breast cancer preventive clinical trial with the National Surgical Adjuvant Breast and Bowel Project (NSABP). She noted the benefit of this collaboration, in that these patients might otherwise have not approached a large academic cancer center to participate in such a trial. In addition, the collaboration facilitated a greater enrollment and more diverse population for interventional cancer clinical trials.
From a historical perspective, Dr Mitchell discussed the implications the Flexner Report of 1910, a landmark study that forced all but two of the existing seven Black medical schools to close, and one that is thought to have been partly responsible for a low number of Black physicians. The report actually suggested that, rather than being trained in specialties like surgery, Blacks physicians should instead “mainly serve as sanitarians whose purpose was protecting Whites from diseases like tuberculosis”. Many medical schools at the time used this information, and it is believed to have resulted in a very low admission of Blacks into the medical field.
Dr Mitchell described the contributions of the National Cancer Act of 1971, which allowed for the formation of the National Cancer Institute (NCI), as well as the National Cancer Advisory Board (NCAB) and the National Cancer Centers Program, for which there are currently 72 NCI-designated cancer centers in the US. This also established the Cooperative Group Program, which allows for collaborative cancer research efforts, such as the Southwest Oncology Group (SWOG) and the Surveillance Epidemiology and End-Results (SEER) program, a major research and epidemiological resource for cancer in the United States.
Dr Mitchell noted the contributions of Dr Jane Cooke Wright, a Black physician who was one of the “founding fathers” (or more appropriately, a founding mother) of the American Society for Clinical Oncology (ASCO), one of the most important resources for sharing medical information in oncology in the United States. She further noted, from the research perspective, Dr Wright was also instrumental in beginning the study of tumor biology in the laboratory, a field known today as “precision medicine”.
Dr Mitchell described the importance of Medicare in cancer, and highlighted the contributions of the NMA in creating the Medicare bill, first signed by then President Johnson in 1965. She noted that Medicare was a major force for racial desegregation of health care facilities in the United States, mainly because hospitals with two doors (one for White, one for “colored” persons) were forced to comply with the already-enacted Civil Rights Act, and had to remove such discriminatory trappings as a precondition for Medicare reimbursement. Notably, between 1961 and 1968, the hospitalization rate for Whites aged 65 and older rose by 38%, whereas the hospitalization rate for Blacks of the same age jumped by 61%. As such, there was a narrowing in the disparity for overall access to healthcare between Whites and Blacks of all ages, with the White/Black difference in hospitalization rates falling from 30% in 1961 to 17% in 1968.
With regard to the impact of Medicare on cancer, Dr Mitchell cited her study examining medical expenditures in cancer, noting that, among adults of non-Medicare age (40 to 64 years) private insurance accounted for 72.2% of total cancer care expenses for Whites, compared to 62.3% for Blacks. By comparison, Medicaid accounted for 21.1% of total cancer care expenditures for Blacks versus only 3.5% for Whites. Similarly, among patients 65 and older, Medicaid accounted for a much higher percentage of expenditures for Blacks (14.9%) as compared with Whites (0.9%), whereas Medicare accounted for 51.6% in Blacks versus 68.0% in Whites.
Dr Mitchell suggested that the causes of racial disparities in cancer care are multifactorial, and can impact all areas across the cancer care continuum, everything from prevention and early detection of cancers, through cancer treatment, quality of life, survival, and ultimately mortality. She further noted that racial disparities in cancer can also result from biologic differences in the tumor microenvironment, or the “soup” in which the cancer lives. To fully address the problem of racial differences in cancer care therefore requires us to consider all areas across the cancer care continuum.
Interestingly, with respect to diversity in the cancer care workforce, Dr Mitchell noted that the percentage of Black clinicians in the US has, in fact, not changed significantly over a period of decades, with only minor increases seen in the Hispanic/Latino clinician workforce. As such, she emphasized the need to train and retain more minority clinicians as a means to reduce healthcare disparities and to achieve better health equity. Dr Mitchell highlighted the term ‘DEI’ (Diversity, Equity, Inclusion), and noted that institutions need to acknowledge and accept their own shortcomings on the issue, and take action to increase diversity in their workforces to better align with all populations they serve.
Dr Mitchell reviewed some of the historical data on disparities in cancer mortality, noting that higher rates of cancer mortality for Black populations versus White have been recognized as early as 1975, with expansions to include and collect additional minority data beginning in the early 2000s. She emphasized that, despite a steady decline in overall cancer deaths, Black patients nonetheless continue to have higher mortality than non-Black populations.
In the face of these continued disparities in outcomes, and an increasing awareness of the inequity in cancer care, the question turns to what can be done. In this regard, Dr Mitchell reviewed some of the most important starting points, which include a more active and robust community engagement and outreach for our underserved populations, and expanding our efforts toward more inclusive and diverse representation in clinical trials. It is also necessary to acknowledge and address our own unconscious biases that may exist, which have clearly been shown to influence patient care for minority populations. She noted, for example, some patient-reported data suggesting a willingness among cancer patients to participate in clinical trials, but that they were never asked to do so. Unconscious biases may also serve to limit diversity, creativity, and innovation in the workforce, and can adversely impact patient perceptions of their care. Even the simple awareness and recognition of our own biases that may be present is an important step in mitigating their negative impact.
Dr Mitchell noted the significant impact of the Affordable Care Act (ACA) in reducing healthcare inequities and expanding access for minority and underserved populations with cancer. For example, there is data to suggest that, in those states which implemented Medicaid expansion as part of the ACA, racial disparities in healthcare were largely mitigated, treatment was more timely overall, and there was a greater benefit of expansion for Black versus White populations. She also noted the importance of research initiatives that aim to accelerate research and improve health, such as the “All of Us” study, which will collect data and tissues from some 1 million individuals for clinical research. The goal of initiatives such as this is to help researchers learn about individual differences in lifestyle, environment, and biology which can have an impact on health and disease, and Dr Mitchell strongly encourages clinical researchers to submit diversity-focused proposals to the National Institutes of Health.
On the topic of national cancer policy, Dr Mitchell noted the importance of the Biden-Harris Administration commitment to the ‘Cancer Moonshot’ initiative, which is aimed at reducing death from cancer by 50% over the next 25 years, and to improving the life experience of patients living or surviving with cancer. She also noted her work on the President’s Cancer Panel, which is aimed at closing gaps in cancer screening and improving equity and access in cancer care. The Panel outlined four critical goals: 1) To improve and align communications, 2) To facilitate equitable access, 3) To strengthen workforce collaborations, and 4) To create an effective information technology (IT) system. Dr Mitchell noted that a major focus of the panel was to improve screening and thereby detect cancer at an earlier stage for intervention, and even, if possible, prevent cancers from occurring.
In the final portion of her presentation, Dr Mitchell also noted disparities in care for sexual and gender minority (SGM) groups, who have increased incidences of certain cancers, as well as poor access to care. She described results from a qualitative analysis of oncology provider’s experiences with SGM patients, which showed, overall that most clinicians had minimal experiences with SGM patients with cancer, but they desire training. She suggested that training for the workforce can help to build trust within the SGM community and improve access to care, and noted that guidelines for SGM care in cancer are currently under development. A similar study conducted among medical students on this topic and presented at ASCO suggested that, while medical students were overall comfortable treating LBGTQ+ patients, they were, similar to their adult counterparts, not confident with their knowledge and training in this area. The findings suggest a need for additional medical school training in SGM topics.
Dr Edith Peterson Mitchell, MD, MACP, FCPP, FRCP(London) is Clinical Professor of Medicine and Medical Oncology in the Department of Medical Oncology, and Associate Director for Diversity Programs at Sidney Kimmel Cancer Center at Jefferson in Philadelphia, Pennsylvania
See more from the 2023 West Oncology Conference here.
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