ASCO 2021 Brings Increasing Recognition of Health Disparities in Cancer Care

Alyx B. Porter, MD, FAAN

Several studies presented during the 2021 ASCO Annual Meeting highlighted the severity of racial and ethnic disparities that exist in the treatment of patients with cancer, ranging from clinical trial enrollment to routine care visits, according to Alyx B. Porter, MD, FAAN.

Although the United States population is becoming increasingly diverse, representation of a diverse patient population in oncology trials is lacking. To quantify the extent of the disparity on precision medicine–based trial enrollment specifically, investigators queried Clinicaltrials.gov for the 4 most common cancer types––breast, colorectal, lung, and prostate––with race and ethnicity data and the Surveillance, Epidemiology, and End Results Program (SEER) database to determine the incidence of race and ethnicity in the United States cancer population. They then correlated those findings with disease site and median year of trial enrollment.¹

The difference in incidence (D-I) was defined as the median absolute difference in study racial enrollment and SEER incidence, with a negative value indicating underrepresentation. 

The results demonstrated an underrepresentation of minority racial groups and an overrepresentation of White groups in precision oncology trials, said Porter.

Specifically, the D-I was +5.4 for Whites (interquartile range [IQR] = -3.8 to 12.0; P = .004), -0.7 for American Indian or Alaskan Natives (IQR = -0.8 to -0.6; P < .001), -1.3 for Asians (IQR = -3.4 to 3.2; P = .858), -6.2 for Blacks (IQR = -11 to -0.1; P < .001), and -6.6 for Hispanics (IQR = -8.8 to 1.4; P = .001).

By disease site, Black patients were significantly underrepresented proportional to their cancer incidence among prostate (D-I: -6.2; P = .093) and lung studies (D-I: -5.7; P = .003), whereas prostate studies significantly overrepresented Whites (D-I: +10.0; P = .036). Lung studies overrepresented Asians (D-I: +0.5; P = .182), which was justifiable given the prominent role of targetable oncogene drivers in this population.

“The continued lack of diversity among enrollees may further widen the gap of disparity among diverse populations in the era of precision medicine,” said Porter, a neuro-oncologist and an associate professor at Mayo Clinic, in a virtual presentation during the 2021 ASCO Direct HighlightsTM webcast in Dallas, Texas, a program developed by Physicians’ Education Resource® (PER®), LLC.

In another study, investigators retrospectively reviewed data from the Flatiron Health Electronic Health Record on patients with advanced non–small cell lung cancer (NSCLC; n = 14,768) and found that Black/African American (n = 1288) patients were less likely to have ever received next-generation sequencing (NGS; 39.8%) vs White (n = 9793) patients (50.1%; P < .0001). The same imbalance among Black and White patients was found with regard to having received NGS prior to first-line therapy (25.8% vs 31.5%, respectively; P < .0001).²

Additionally, White patients with NSCLC were more likely to have participated in a clinical trial (3.9%) than Black patients with NSCLC (1.9%; P = .0002) as were White patients specifically with nonsquamous NSCLC (3.9%) vs Black patients with nonsquamous NSCLC (2.1%; P = .006).

“NGS was less likely to be done ever, but certainly prior to first-line therapy in African American patients than White patients,” said Porter. “It was also less common for Blacks or African Americans to participate in clinical trials for NSCLC [overall] as well as for nonsquamous NSCLC.”

On the basis that clinical trial enrollment does not cater to minority populations, investigators of another study sought to assess the effects of community outreach and engagement on trial participation in Black individuals in the Philadelphia, Pennsylvania area. 

Community-based efforts to promote participation in clinical trials included educational efforts about clinical trials in Black communities in Philadelphia, programs to increase access to cancer screening, and strategies to reduce transportation barriers^.3

Investigators also focused their efforts inward, providing education to clinical investigators regarding cancer health inequities in Black communities, requiring each trial protocol to have an adequate minority accrual plan, engaging primary oncologists and nurse navigators to promote trials for Black patients, among other efforts. 

“Comparing 2014 to 2018, there was a nearly 2-fold increase in enrollment in adult treatment trials [12.2% vs 23.9%, respectively], a 4-fold increase in non-therapeutic interventional trials [8.3% vs 33.1%, respectively], and a 1.7-fold increase in non-interventional trials [13.0% vs 22.5%, respectively],” said Porter. “Some trials still had poor enrollment, so there’s more work to be done in this space.”

Additionally, Porter pointed out that since the COVID-19 pandemic, disparities in cancer care have broadened to include services reliant on telehealth, citing a study that indicated a low use of video visits among Hispanic White patients, patients who require an interpreter, and patients who live in census blocks with lower income, among other populations.⁴ 

“Although telehealth has rapidly increased since the pandemic, we recognize this is a common way to give and receive care. Telehealth and secure messages were less often used in populations that are traditionally underserved,” said Porter, who concluded the presentation by emphasizing the importance of establishing trusting relationships between patients and providers as one of many critical routes forward in rectifying these disparities.

References

1. Aldrighetti CM, Niemierko A, Van Allen EM, et al. Racial and ethnic disparities among precision oncology clinical studies. J Clin Oncol. 2021;39(suppl 15):3014. doi:10.1200/JCO.2021.39.15_suppl.3014
2. Bruno DS, Hess LM, Li XI, et al. Racial disparities in biomarker testing and clinical trial enrollment in non-small cell lung cancer (NSCLC). J Clin Oncol. 2021;39(suppl 15):9005. doi:10.1200/JCO.2021.39.15_suppl.9005
3. Guerra CE, Sallee V, Hwang WT, et al. Accrual of Black participants to cancer clinical trials following a 5-year prospective initiative of community outreach and engagement. J Clin Oncol. 2021;39(suppl 15):100. doi:10.1200/JCO.2021.39.15_suppl.100
4. Neeman E, Lyon L, Sun H, et al. The future of tele-oncology: trends and disparities in telehealth and secure message utilization in the COVID-19 era. J Clin Oncol. 2021;39(suppl 15):1506. doi:10.1200/JCO.2021.39.15_suppl.1506