Stunning progress in the development of novel treatment options for patients with cancer and hematological malignancies, made over the last decade, leading to nearly 17 million cancer survivors, is a testament to the success of collaborative research and an improved understanding of cancer and cancer biology. However, these advances are, unfortunately,  out of reach for many Americans.[1][2]

Now, new recommendations issued by the American Society of Clinical Oncology (ASCO) may help reduce cancer disparities and improve equitable access for patients. The recommendations specifically call for new actions designed to reduce disparities in cancer outcomes affecting racial and ethnic minorities, rural populations, sexual and gender minorities, people without insurance, and other disadvantaged populations. [1]

Lori J. Pierce, MD, FASTRO, FASCO, the current president of the American Society of Clinical Oncology (ASCO), is a radiation oncologist, professor, and Vice Provost for Academic and Faculty Affairs at the University of Michigan. Pierce is also director of the Michigan Radiation Oncology Quality Consortium. A national leader in breast cancer research, Pierce was previously a Senior Investigator at the National Cancer Institute, National Institutes of Health, and in 1992, joined the faculty at the University of Michigan where she has focused her career primarily on the treatment of breast cancer. An active ASCO member since 1992, Pierce is a past member of multiple ASCO committees including the Government Relations Committee, Annual Meeting Scientific Program Committee, and the Conquer Cancer Foundation Nominating Committee, and she served as a mentor for the Leadership Development Program from 2015 to 2018. She previously served on the ASCO Board of Directors from 2010 – 2014 and was named a Fellow of ASCO (FASCO) in 2015. Photo courtesy: 2020 ASCO. Used with permission.

In a policy statement, the result of a year-long consultation process among the members and staff of ASCO, was published in the Journal of Clinical Oncology (JCO). In the article, ASCO argues that while progress has been made in raising awareness of disparities and driving research, to really solve the problem, the cancer community needs to take bolder, more aggressive steps to achieve equity for all patients.[1][2]

Ensure equitable access to care and research
ASCO recommends a series of steps to ensure equitable access to care and research, to guide both ASCO’s own programs and the work of the broader oncology community. The statement was developed by ASCO’s Health Equity Committee, which is made up of members with specific expertise in cancer care disparities and approved by the organization’s board.

“To do right by the patients we serve, we have to confront the complex forces and systems that have created disparities in cancer prevention, treatment, and research participation,” noted Lori J. Pierce, MD, FASTRO, FASCO, president of the American Society of Clinical Oncology and author of an accompanying editorial in Journal of Clinical Oncology.[2]

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“Our field has taken important steps in recent years. Now it’s time to dig deeper, take new risks, and do everything we can to ensure that every patient benefits from decades of advances in cancer care,” Pierce said.

“Everyone should have equitable access to timely, high-quality cancer care, no matter their race or ethnicity, where they live or were born, or how they identify,” said Manali Patel, MD, MPH, Immediate-Past Chair of ASCO’s Health Equity Committee and lead author of the policy statement.

“Like all health care in America, cancer care remains far from that goal. But there is a path to achieving equity, and it’s what we’ve begun to lay out here.”

Emerging challenges
The recommendations and editorial briefly examine developments since ASCO issued its last policy statement on cancer disparities in 2009. The organization, as well as others in the oncology community, has worked to expand awareness of disparities across the field, increase diversity in the oncology workforce, and conduct research to identify specific changes in medical practice or policy that can reduce or eliminate disparities.

And while progress in cancer prevention, detection, and treatment has, over the past decade, reduced overall mortality, this progress has not been equitably distributed. For example, Black men and women, people in rural areas, and those with lower income and education status experience worse survival for a number of cancers, regardless of stage at diagnosis. In addition, a lack of reliable data makes it hard to even measure access to care or outcomes in some populations, especially sexual and gender minorities.

However, ASCO and other organizations are sounding the alarm bell and warn that several recent developments could worsen existing disparities if not aggressively addressed. For example, continuity of care is especially important for patients with cancer in the midst of treatment. Such treatment often requires frequent and repeated outpatient visits.

According to the University of North Carolina at Chapel Hill Nationwide, 172 rural hospitals have closed since 2005 (130 since 2010). And with the closure of these facilities, rural residents lose health care services when wards are shut down and doctors and nurses move away. The closures of rural hospitals and oncology practices, there is a risk leading to further limiting access to care for cancer patients.

And as a result of COVID-19, and the economic impact of the pandemic, many Americans have lost their jobs, leading to the loss of their employer-sponsored health insurance coverage. In addition to the loss of insurance, cancer screening and care have also been interrupted by COVID-19.  This interruption has disproportionally affecting Black and Hispanic communities across the country.

The statement describes a set of principles and recommendations designed to guide ASCO’s efforts into the future.

“Our patients need us, today more than ever, to be champions for equity in cancer care,” Pierce said.

“Whether barriers result from our geography, race/ethnicity, age, sexual orientation, and gender identity, health insurance, culture, or trust—or all of these—we have a responsibility to meet them head-on,” she added.

“We have to be willing to take bold steps to overcome the barriers to progress against this disease,” Pierce said.

Policy Recommendations
The ASCO policy recommendations are intended to guide the work of both ASCO and other stakeholders, including medical training programs, health systems, payers, policymakers, and researchers.

Following the development of the statements, ASCO is committed to advancing the recommendations in all areas of its work. To that end, the ASCO’s Health Equity Committee is developing a concrete action plan that the organization, in the coming years. will pursue. As part of this approach, ASCO is expected to emphasize increasing workforce diversity, building partnerships with communities affected by disparities, and addressing institutional discrimination in the oncology field.

In her accompanying editorial, Pierce concludes: “We should not accept a world in which racial and ethnic minorities face poorer health outcomes and geography affects treatment outcomes. We should not rest until the opportunity to participate in clinical trials is available to—and represents—all patients with cancer, not just the 5% who enroll today. And we should lead the change toward a system of cancer care that serves the whole person, not just their disease.” [2]

[1] Patel MI, Lopez AM, Blackstock W, Reeder-Hayes K, Moushey A, Phillips J, Tap W. Cancer Disparities and Health Equity: A Policy Statement From the American Society of Clinical Oncology Journal of Clinical Oncology Published online August 12, 2020. DOI: 10.1200/JCO.20.00642
[2] Pierce LJ. A Time to Dig Deeper and Take Meaningful Action. Journal of Clinical Oncology Published online August 12, 2020. DOI: 10.1200/JCO.20.02158 Journal of Clinical Oncology

Featured image: General views of the 55th Annual Meeting of the American Association of Clinical Oncology (ASCO) – held in the McCormick Place in Chicago, Ill. Courtesy: © 2019 ASCO/Max Gersh. Used with permission.

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