Diversity Gap Persists for Racial and Ethnic Minorities in Oncology

Shibu Varghese, MA

Despite many diversity initiatives over the past 10 years, a lack of meaningful representation of certain racial and ethnic minorities continues in the oncology workforce, experts say. Achieving diversity will require hospitals and medical schools to move beyond current programs and address more challenging issues such as conscious and unconscious bias. Medical schools will need to welcome, attract, retain, and enhance a diverse student body, and hospitals will have to do the same for those who are already physicians practicing in oncology.

Diversity in the workforce is import-ant for many reasons that go beyond racial and ethnic identification, oncology leaders say. “We want different opinions, different tactics for therapy, and different expertise and knowledge that can help our patients. It’s not about the color of their skin but about the diversity in their background and their expertise and what they bring to the table,” Shibu Varghese, MA, senior vice president of people and business operations and chief diversity officer, at The University of Texas MD Anderson Cancer Center in Houston, Texas, said in an interview.

The value of having a racially and ethnically diverse workforce in health care fields has been established on a national policy level since a 2004 report from the Institute of Medicine (now the National Academy of Medicine) advocated for broad changes that would improve participation for members of under-represented minorities. These groups were defined as populations whose presence in the health care ranks does not reflect US demographics.¹

Scientific evidence supports the importance of diversity among health care professionals, the panel reported, saying that greater diversity “is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, better patient-provider communication, and better educational experiences for all students while in training.”¹

Robert Winn, MD

A diverse workforce allows oncology care providers to engage and increase participation among patients and build trust within various communities—a goal that should be prioritized, said Robert Winn, MD, director of Massey Cancer Center at Virginia Commonwealth University, in Richmond.

“In addition to this drive to look at basic and translational science, in addition to coming up with new molecules and medicines, we also ought to be thinking about the practice of reengaging and being involved with our communities to rebuild their trust,” he said in an interview. “It’s great to come up with a molecularly targeted therapy. It’s great to come up with immunotherapy. It’s great to come up with a vaccine for COVID-19 [coronavirus disease 2019]. But if it doesn’t go into people’s arms, you’re only helping some and not all.”

People of color have a long history of distrust of the medical system because of perceptions of racism. For example, findings from a study among residents of predominantly Black neighborhoods in Chicago about breast cancer treatment found mistrust and perceptions of racism and neglect.² Some participants cited the Tuskegee syphilis study, which was conducted by the US Public Health Service in Tuskegee, Alabama, from 1932 to 1972 to examine untreated syphilis in Black men. Even when penicillin became available in 1947 to treat syphilis, treatment was withheld from participants.³

Patients tend to develop trust and a comfort level with providers of a similar background, Karen M. Winkfield, MD, PhD, executive director of the Meharry-Vanderbilt Alliance, in Nashville, Tennessee, said in an interview.

“It’s been shown that individuals who have similar backgrounds to the provider taking care of them do better. They feel better about their communications, and they are more willing to accept what the doctor is saying.”

Karen M. Winkfield, MD, PhD

The Oncology Workforce Today

In the oncology field, progress has been made in terms of diversity, but the workforce has not kept pace with the nation’s demographics. In 2019, just 3.1% of practicing hematologists and oncologists identified as African American compared with 13.4% of the US population, according to study findings presented at the 2020 American Society of Clinical Oncology (ASCO) Virtual Scientific Program. For those of Hispanic ethnicity, the percentage was 4.7% compared with 18.3% of the population. A third group comprised of Native Americans, Alaskans, native Hawaiians, and Pacific Islanders represented 0.2% of the oncology/ hematology workforce compared with 1.5% of the population.⁴

Overall, 12,826 physicians were actively practicing as medical oncologists, hematologic oncologists, or hematologists in 2018.⁵ The numbers of underrepresented minorities who are part of that workforce marked an improvement over statistics reported in 2015, when just 2.3% of practicing oncologists identified as Black or African American and just 3% as Hispanic or Latino, according an ASCO report.⁶

Nevertheless, these minority groups are forecast to grow as a percentage of the overall US population; by 2020, people identifying as Black or African American are expected to comprise 17.9% of the population and those of Hispanic or Latino origin are expected to make up 28.6%.⁷

Oncology professionals say medical institutions should amplify their efforts to increase students’ exposure to oncology and address challenges minority students face in the educational system as a whole.

One such challenge is conscious and unconscious bias, which exists at all levels in medicine, Winn pointed out. Early in his career, Winn, who is Black, said that he was mistaken for a maintenance worker, and that some patients expressed discomfort at having him as their physician.

“People are still surprised that I am a scientist or that I am a cancer center director,” he said. “My entire career from when I was a medical student to even now has been littered with people being surprised. I don’t want a society that is color blind because that means ultimately you don’t see me. I do want a society that understands that being an African American or a woman or someone who is different doesn’t necessarily mean anything.”

Systemic racism disproportionately effects communities of color, Winkfield said. “It starts with kids in K-12. We need efforts that help to set them up for success later on, providing the tool sets to advance to college. Once they are in college, there are ways to influence them to consider careers in medicine or science.”

Winn said his aspiration is that the oncology workforce will look like the diversity that exists in America. “I’ll recognize it when we don’t run away from our differences but embrace the differences among us because we understand our core humanity is what keeps us together,” he said.

One hurdle for increasing workforce diversity in the oncology field is the fact that these specialties rank lower than other areas of medicine in recruiting fellows, Ana Velázquez Manana, MD, MS, a clinical fellow at University of California, San Francisco, said while presenting the workforce data at ASCO 2020.

The percentage of fellows from underrepresented minorities was 9.98% in hematology/ oncology, lower than for 7 other internal medicine subspecialties, led by 17.47% in the endocrine field, according to study data. Analyses also show that the proportion of minorities recruited to hematology/oncology fellowships did not significantly increase from 2006 to 2018, Manana said. “Minorities are underrepresented in all steps of the hematology oncology pipeline, when compared to the US population,” she said.⁴

FIGURE. Underrepresented Minorities in Oncology Workforce Pipeline4

One reason for this continued underrepresentation is that minority students often are not exposed to hematology/oncology or radiation oncology fields during their medical training, Narjust Duma, MD, a coauthor of the study, said in an interview.

“Many students make their decisions about which specialty they are going to apply to based on their exposure in the last 2 years of medical school,” said Duma, an assistant professor of medicine, hematology/ oncology at the University of Wisconsin, Madison.

Medical students often choose primary care. An Association of American Medical Colleges survey found that 41% of Black or African American physicians, 36.7% of Hispanic physicians, and 41.5% of Native American or Alaska native physicians practice primary care.⁸

Narjust Duma, MD

The Need for Mentors and Role Models

Winkfield said role models willing to reach students at all educational levels are needed. “It’s important to know there are people who look like you who are doing really good things and working in oncology and making a difference in their community. That could be something that encourages people to consider a career in oncology,” Winkfield said.

Duma is working to be a force for change. She speaks at local high schools and is cofounder of the Latinas in Medicine Group, which was established in 2019. The organization, which promotes the advancement of Latinas in medicine and has more than 5000 members, will soon launch its first study evaluating the Latinas in Medicine experience during medical training.

“It is, unfortunately, a vicious cycle: There are few oncology role models and mentors for minority students so minority students are pulled to other specialties in which there are more role models and more mentorships,” Duma said. “It’s important to have a mentor who knows how to navigate obstacles. Academic medicine is a wonderful place, but it has a lot of challenges. Having someone understand the cultural differences can help you deal with that heavy emotional load that we often have.”

MD Anderson Cancer Center is another institution that has made a commitment to diversity and inclusion. About 14 years ago, the organization formed a diversity council to provide input on policies related to inclusion in all aspects of the workforce; they also established an employee advisory council that represents the employees at large. Additionally, 2 years ago, MD Anderson put in a place a policy that required managers to consider a diverse pool of candidates for each position and required training on unconscious bias.

With focused intention and support from our executive leadership, the institution has increased gender diversity and minority inclusion among the president’s direct reports, as well as in roles of vice president and above. Varghese said one of the organization’s goals is to develop partnerships with historically Black colleges and universities and high schools in underserved communities.

“A lot of what we have done in the past 10 years is look at hiring practices but that is limited by the lack of high school students who were interested in and prepared for careers in medicine and research,” he said.

MD Anderson has developed relationships with high schools and colleges in underserved communities and partnered with industry to help advance science, technology, engineering, and math programming.

In 2017 MD Anderson created an initiative, called The Partnership for Careers in Cancer Science and Medicine (PCCSM), to attract students to pursue careers in oncology with specific emphasis on students from underrepresented groups in science and medicine. The PCCSM partners with local high schools, programs, colleges, and medical schools to encourage students who have a strong interest in biomedical disciplines but may be overlooked by traditional selection methods. These students are often underrepresented minorities, from low-income families and/or first-generation college students.

The 2020 program was cancelled because of the COVID-19 pandemic, but during the four years the program has been offered—2017, 2018, 2019, 2021—MD Anderson has had a total of 127 participants (39 high school students; 76 college students, 12 medical students). Each year the program has grown to include more students, starting with 11 in 2017 and expanding to 51 in 2021.

These were composed of 86% underrepresented minorities (42% Black and 44% Hispanic) with 73% being female.

“Several studies have shown that diverse teams better address the toughest challenges and produce better outcomes than homogeneous teams, including in medicine and science,” Varghese said. “The lack of diversity in the cancer research workforce could impede our efforts to find innovative and groundbreaking solutions for a disease that touches 1 out of 4 Americans. Therefore, increasing the diversity in the oncology field is critical to sustaining our competitive edge over cancer.”

ASCO’s Commitment to Diversity

ASCO has committed more than $1 million to increasing diversity in the oncology workforce and engaged in efforts such as providing clinical research oncology rotations for medical students and providing residents with the opportunity to attend the ASCO Annual Meeting.⁹

Starting in 2008, ASCO formed a Diversity in Oncology Initiative, convening a Health Disparities Committee task force in 2015 that developed a strategic plan for racial/ethnic workforce diversity. Then in 2017, ASCO increased its commitment to diversity by developing a strategic plan to create more opportunities in oncology for minority populations and help address the barriers people from underrepresented minorities may face.

These efforts built upon the ASCO Diversity Mentoring Program, which was designed to encourage medical students and residents from racial and ethnic populations that were underrepresented in medicine to pursue careers in oncology. It has since matched 80 medical students and residents with mentors and is working to launch the 2020-2021 Diversity Mentoring Program.

More recently, in February 2021, ASCO appointed Sybil R. Green, JD, MHA, RPh, as diversity and inclusion officer, a new position, to help achieve the organization’s goals of equity, diversity, and inclusion. ASCO also established an internal Equity, Diversity, and Inclusion Task Force to examine potential inequities in the work force. Green currently serves as the task force’s cochair.

More recently, in February 2021, ASCO appointed Sybil R. Green, JD, MHA, RPh, as diversity and inclusion officer, a new position, to help achieve the organization’s goals of equity, diversity, and inclusion. ASCO also established an internal Equity, Diversity, and Inclusion Task Force to examine potential inequities in the work force. Green currently serves as the task force’s cochair.

“There is increasing awareness and sensitivity toward issues of race and diversity,” he said. “Up and down the continuum of training, there have been efforts both at the national level and state levels and at institutions and colleges and medical schools to enhance and increase the number of underrepresented minorities going into medicine in general and specialty care in particular.”

References

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3. About the USPHS syphilis study. Tuskegee University. Accessed February 5, 2021. http://bit.ly/3tysh3P
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