Commentary: One Small Step.

Abstract

Over the last 20 years, the oncology community has seen the publication of mountains of descriptive work from health service researchers, epidemiologists, and clinical trialists, detailing the enormous problem of disparities by class and race/ethnicity in oncology outcomes. The fact that there are disparities in treatment among ethnic minorities and the poor is not new. Social scientists have been documenting this for decades, but unfortunately, medicine has been slow to recognize this as a major issue. However, since the publication of the Institute of Medicine report Unequal Treatment,1 in which racial and ethnic disparities in health care are described as systemic and multifactorial, the elimination of racial disparities in health care has become a major focus in health services. The National Institutes of Health has made this a major goal, and many health policy leaders have also discussed the eradication of racial disparities in care as a priority. Not surprisingly, cancer centers have begun to examine the impact of racial disparities on the delivery of cancer care. The National Cancer Institute has promoted its own initiatives to eliminate racial disparities in care. It has become acutely apparent that advances in cancer care must be accompanied by the equitable distribution of cancer treatment. All of this has led to an avalanche of studies describing the landscape of health care disparities. Researchers and policymakers often focus on just one aspect of the problem when seeking solutions. In truth, racial disparities in care often have multiple causes, including access to care, cultural differences, communication issues with providers leading to refusal of care, biologic differences, and the systemic and structural effects of race and class. This combination of factors does not allow for simple solutions. Therefore, descriptive research is still important to root out the myriad of interactions that will lead to an informed process in dealing with disparities. For this reason, there has been a lack of interventions in the push to change the landscape of health care disparities. Although the research approach has been large and well supported, interventions have been of a small scale and initiated at the local level. Professional organizations of physicians have only just begun to attempt to address the issue in a targeted manner. Although there is now some movement in plans to address disparities in care, with increased research funding and disparities programs in every cancer center, we are still falling short of our goals on workforce diversity as a profession. Oncology in particular has few physicians from underrepresented backgrounds. Fewer than 6% of practicing physicians, and fewer than 4% of oncology fellows, are African American.2 The percentage of Hispanic/Latino fellows in oncology is less than 10. Physicians from underrepresented groups have a tendency to work in underserved areas, and given the challenges among these groups with poor outcomes in breast, colon, head and neck, and lung cancers, it is imperative that we as a profession move to address this issue. The formation of the ASCO Health Disparities Advisory Group marked the beginning of such a process. This has led to the ASCO Diversity in Oncology Initiative funded by Susan G. Komen for the Cure. The ASCO policy statement on disparities in cancer care3 has encouraged a multilevel approach. The new ASCO initiative focuses on encouraging workforce diversity in medical oncology by exposing underrepresented medical students and residents to the practice of oncology and supporting oncologists who serve the underserved with loan repayments. These efforts are realized with support from Susan G. Komen for the Cure, an organization that has long recognized the importance of funding initiatives to address disparities. It has been pointed out that the ASCO initiative is limited in scope. This is true. However, it is a positive step by an organization interested in improving outcomes for all patients with cancer. It is important that medical professional societies show more than just platitudes regarding issues of disparity. The ASCO programs represent a small step in the right direction. As we continue to elevate the quality of cancer care, we cannot overlook the fact that targeted therapy and personalized medicine add importance to the task of providing appropriate treatment for all racial, ethnic, and socioeconomic groups. We should continue to support ASCO and philanthropic groups like Susan G. Komen for the Cure as they attempt to ensure that all of our patients have effective and equitable treatment opportunities.