Racial, ethnic minorities are systemically underrepresented in leadership teams across NCI cancer centers

Racial and ethnic minorities that are underrepresented in medicine have even lower representation in leadership of NCI-designated cancer centers, a study by Memorial Sloan Kettering Cancer Center researchers found. 

In an analysis of the diversity in leadership across all 63 NCI-designated cancer centers, the researchers identified 856 members in leadership teams, finding that 82.2% of cancer center leaders—or 688 individuals— were non-Hispanic white.

The study, published June 7 in JAMA Network Open, noted that non-Hispanic white individuals make up 60.6% of the U.S. population and 56.2% of active physicians. 

“Our findings are similar to a recent director survey from the Association of American Cancer Institutes and The Cancer Letter, which found a high percentage of White men in director roles,”   study authors wrote (The Cancer Letter, Oct. 9, 2020).

Twenty-three institutions—more than a third of NCI-designated cancer centers—“did not have a single Black or Hispanic member” on their leadership teams, and eight cancer centers had all non-Hispanic white leadership teams, the MSK study found.

These results (Figure 1) demonstrate that workforce diversity, equity, and inclusion is critical for improving health care equity in oncology, senior author Fumiko Chino said to The Cancer Letter.

“In terms of actual patient care, we know that patients are more likely to trust providers that look like them,” said Chino, a radiation oncologist at MSK, who specializes in the treatment of gynecological and breast cancers. “I think dive-bombing into a community outside of your own and to try to say, ‘Well, this is what you should do to fix this problem,’ is probably one of the most harmful things that we can do within clinical research.”

The authors of the study—a diverse team that includes student researchers from Arkansas—also found:

• Leadership teams with more women and institutions in the South were more likely to have at least one Black or Hispanic leader;
• A weak to moderate correlation between city Hispanic population and Hispanic representation on leadership teams, but no significant association between Black population and Black leadership was found;
• Both Black and Hispanic physicians were underrepresented (Black: 12.7% of US population, 5.0% of active physicians; Hispanic: 18.1% of U.S. population, 5.8% of active physicians); however, they were even more scarce in leadership positions (Black leaders, 3.5%; Hispanic leaders, 3.8%);
• Asian physicians were overrepresented, compared with their census population (17.1% of active physicians, 5.6% of U.S. population); however, Asian individuals were underrepresented in leadership positions (11.0%) when compared with their percentage of active physicians.

“We already know that, for example, within medical school, Black students are more likely to be scored poorly when performing at the same level,” Chino said. “They’re more likely to be judged based on physical appearances … that element of systemic racism is downgrading them.

“‘Professional,’ it’s almost like a code word at this point for, ‘They were too different. They didn’t go to the same school that I did. They don’t meet my expectations of what a leader looks like.’ This goes beyond even looks.

“There’s this sharp decrease when we think about [Asians] in leadership. And so again, Asians are allowed to be physicians, but somehow no one trusts us to be leaders,” Chino said. “This is backed up by other research, again, showing that it’s okay to think of Asians as a physician, but you don’t want an Asian American president or you don’t want an Asian American CEO of a company. 

“And in that, itself, again, another manifestation of systemic racism.”

The study’s findings mirror many trends and demographic patterns identified via a leadership pipeline survey conducted by this reporter and AACI last year.

“When The Cancer Letter published your survey data, which is remarkably similar to the study that was just published, there was some consternation, but there wasn’t as much focus,” said Christopher Lathan, chief clinical access and access officer at Dana-Farber Cancer Institute, faculty director for cancer care equity, and assistant professor of medicine at Harvard Medical School. 

“The focus on structural inequity throughout our system has really made the medical leadership rethink their approach,” Lathan, who wasn’t involved in Chino’s study, said to The Cancer Letter. “What I want to see, though—what I really want to see—is in three, four, or five years, do they remain as committed? And where are they when some of these initiatives start off a little rocky and they don’t necessarily give fruit early?”

This begs the question: What, then, are academic cancer centers doing, right now, to improve health care equity?

“I think one of the easiest ways—this is something that can only come from leadership—is to just say, ‘Hey, this is a priority of our cancer center,’” Chino said. “And it’s amazing how much things can happen if leadership has said X is a priority.

“In terms of even getting people into the pipeline, we’re kind of at a standstill. We’re not making improvements over what we have historically, if anything, we’re backsliding. Providing more logistical support—for example,  fee waivers, MCAT preparation classes—more mentorship, I feel is just so essential.”

To answer that question, The Cancer Letter asked executive leaders at several cancer centers across the United States to describe their hiring processes, pipeline programs, and initiatives aimed at mitigating disparities in access and cancer outcomes; and to comment on the state of diversity in oncology:

• “This sort of thing takes time and effort and commitment. And the trap is, if these physicians are not in the position to succeed, then leadership gets to say, ‘Oh, we’re going to go back to what we’re doing,’” Dana-Farber’s Lathan said.
• “One of the best practices that we have in our cancer center is to ensure that our research faculty and research team members reflect our diverse patient population,” said Karriem Watson, associate director of community outreach and engagement at University of Illinois Cancer Center.
• “We have designed a portfolio of training programs emphasizing opportunities for diverse students to develop careers as cancer investigators and physicians that begin at the high school level through the junior faculty level,” said Ruben Mesa, executive director of Mays Cancer Center at UT Health San Antonio MD Anderson.

The responses from Lathan, Watson, and Mesa appear here.

Sustained, committed efforts to improve equity and access, for instance, in clinical trials, have proven to be effective. Over a five-year period, researchers at the Abramson Cancer Center at the University of Pennsylvania doubled clinical trial enrollment of Black patients with cancer from 12% to 24%, according to data presented at the most recent annual meeting of the American Society for Clinical Oncology. 

This is also possible on a national scale. NCI, too, has made progress, albeit over 20 years. Last year, NCI announced that it has nearly doubled the proportion of racial and ethnic minority patients in institute-funded trials over two decades—from 14% in 1999 to 25% in 2019 (The Cancer Letter, June 26, 2020).

Dive-bombing into a community outside of your own and to try to say, ‘Well, this is what you should do to fix this problem,’ is probably one of the most harmful things that we can do within clinical research.

“The onus is on us as members of these leading cancer centers to really think about, how do we work from within to make this a priority, to make meaningful change not just for our patients, but also for our fellow providers, for our staff members—so that we can really, again, lead the charge to a better and more equitable future,” Chino said.

Chino spoke with Matthew Ong, associate editor of The Cancer Letter.

Matthew Ong: I’m so glad we’re able to discuss your study, now published in JAMA Network Open. What’s the most important takeaway?

Fumiko Chino: I think what this study shows is that there’s a real pipeline issue within cancer leadership. 

We know that as the population in the United States gets distilled down to those attending medical school, we lose a lot of passionate and qualified Black or Hispanic potential leaders that don’t even make it into medical school. 

Then, once you’re an active physician, and you progress through your career, we lose more and more underrepresented in medicine Black and Hispanic physicians that don’t make it into a leadership position. 

And ultimately, this leads to a leadership group which is not reflective of the population of the United States, the population of cancer patients who are receiving care, and I think it really highlights that we could be serving our patients better.

FC: Thankfully there’s a number of different potential diversity inclusion efforts out there. I think that a dedicated effort to have broad search criteria—highlighting how different voices can really bring important perspectives into a leadership team—having things like blinded searches, and having specific bias training before you even start the process can really help improve the leadership hiring process. 

Thinking about how to eliminate the obstacles that some potential leaders have on their way to success is also important, so thinking about how to improve and support mentorship opportunities that may not come as easily to certain populations. 

Along the process from undergraduate to medical school to residency to first faculty position to becoming chair of your department, there are certain things that can give you a lift, and there are certain weights that can pull you down. We need to be working to remove weights from some of our faculty so that they can achieve their leadership potential.

I think what the study highlights is that we are potentially not elevating the full range of our potential leaders to the top, and that there really is this overrepresentation of non-Hispanic white men in leadership, which is not indicative of their ratio as part of the United States and is an overrepresentation of their population, even as active physicians.

Speaking of pipeline issues, a common response to underrepresentation often sounds like “it’s not us, it’s them”—characterizing those populations as not “making it” into the pipeline to begin with, thereby contributing to a limited pool of diverse “qualified candidates” for leadership. How do you frame that conversation?

FC: I think that we could be doing better in terms of giving people the support they need and encouraging them to become leaders. 

And it’s not just imposter syndrome, which is real, but I think imposter syndrome exists because there are so few, for me, women of color in leadership positions. So—even without someone saying a word—I know that my place at a leadership table may be limited.

If we want to improve the diversity of the leaders, we have to start thinking: how do we provide opportunities for our junior faculty, and how do we pay back time spent on mentoring, committees, and diversity-related activities? Dr. Theresa Williamson wrote an excellent piece recently on how to “pay back” the taxes placed on minority faculty members.

For example, I have three undergraduate/early medical school mentees this summer that I am trying to help design and implement research projects. This takes time away from my research and what I would be doing normally, so that‘s sort of a tax on me. 

Please do not mistake, I’m honored to play this role, and Memorial Sloan Kettering has so many amazing programs, including the SCORE program and the NIH-funded Medical Student Summer Fellowship program to help introduce cancer research early to young minds from diverse backgrounds.

But I feel that if we actually compensated people for the time that they spend helping lift up those behind them and then supported junior faculty mentoring programs to help advance new faculty, I feel it could create a chain reaction. 

A rising tide lifts all boats in terms of acknowledging that the education that I put in helps the next generation, but it also weirdly punishes me by taking time away from writing grants to fund comprehensive investigator-led research. 

Although, [laughs] actually, I guess this study itself is sort of the negative example of that, because this was with an Memorial Sloan Kettering Summer Pipeline student Austin Morgan that I worked with last year and it’s in a JAMA journal, so I think we’ve done well with it. 

The Pipeline program was specifically designed to foster the next oncology leaders in those students who are under-represented in medicine  (The Cancer Letter, Oct. 23, 2020). 

Right; quite the juxtaposition. This is probably DEI 101, but could you briefly provide examples for how a diverse workforce in oncology can improve patient outcomes, specifically on three points—basic research, translational research, and clinical care?

FC: I think that a diverse workforce can really improve basic research in that we’re talking about different perspectives and a different approach to potentially complex problems within the communities that are the least served by basic science. 

And so, when we’re thinking about healthcare disparities and poor cancer outcomes, it really is patients who are in certain groups—for example Black patients—that have some of the worst outcomes. 

When we’re thinking about how to fundamentally improve their care, investigators coming from within those groups are likely to have the best, most intuitive ideas in terms of providing even the research questions that should be asked.

For example, think about disparities in triple-negative breast cancer. We know that Black women have some of the worst oncological outcomes, they also have some of the highest rates of triple-negative breast cancer at diagnosis, and so if there’s a genetic component that’s driving some of the worse prognosis, someone within the community, within that background could maybe ask the better question of how to address that unique biology.

I think within clinical research, again, the access concerns that patients have receiving cancer screening, cancer diagnosis, cancer treatment, and then survivorship care—we are losing patients all along the cancer cascade, in terms of patients not being able to get a mammogram or not being able to get in the door to actually start their cancer treatment or having delays to care.

And again, active, engaged physicians within those communities are most likely the ones who will have the most insight in terms of overcoming those obstacles. 

Using a different example, thinking about Asian American patients who have significant cultural barriers to receiving mental health care. 

Given all of the potential downstream effects of a cancer diagnosis, including anxiety, depression—again, the providers within those communities are most likely going to have unique insights which can help really tap into potential engaged solutions, and they’re also more likely to have connections within those communities to do the best type of research. 

I think dive-bombing into a community outside of your own and to try to say, “Well, this is what you should do to fix this problem,” is probably one of the most harmful things that we can do within clinical research.

Right; that breaks trust.

FC: And then in terms of actual patient care, we know that patients are more likely to trust providers that look like them. They’re more likely to have better communication. They’re more likely to adhere to therapies from providers that look like them. 

And I think, again, it’s a cycle of, if someone has never had a Black physician and they walk in the door and they see that their physician is Black, they realize that they may have more trust in their counsel —even though historically and presently, Black patients are really underserved by the medical community. 

It may foster more of a trust connection there, and they may be more likely to trust their diagnosis, come in for their cancer treatment, take their medications as planned, and potentially avoid some downstream effects that could ultimately affect the fidelity of their cancer treatment.

I like your description of the cancer care pathway as a cascade. You’ve done a lot of work on patient access, or rather, lack of access to health care. Would you say that’s the primary barrier in this country to better outcomes?

FC: It’s so hard, because I think what I consider difficulties in access for many of our patients is really just a manifestation of the social determinants of health and, for some, structural racism.

For example, I’m a radiation doctor, and I can design the very best radiation plan for someone who may even have access to see me in consult, but ultimately is not able to actually receive that radiation treatment, because they’re not able to take the time off work because they work an hourly job and they’re too afraid of losing their work, or they may not be able to arrange child care for their kids and so, they no-show to their actual treatment appointments. 

So, it is such an interwoven mixture of access and structure in terms of the tangled web of the U.S. healthcare system.

And not to mention the coverage options that are available—or more often than desired, not available—to these patients as well; right?

FC: Exactly. At Memorial Sloan Kettering, we have a lot of resources including copay assistance, quality of life funds, financial navigation through the patient financial services team, but even here we sometimes struggle to get the right resources into the right people’s hands. It can be almost like a missed connection. 

The challenge continues to be: how do we provide not just the best quality of care, but actually allow someone who could be cured of their cancer to be cured of their cancer each and every time, instead of being sidelined and delayed because some of the barriers are outside of the cancer center—their parking or their potential time off work, or sick leave. 

Take parking for example. In July 2020, I published research in JAMA Oncology where we found that some cancer patients pay $1,680 over the course of treatment. 

These parking fees can be a huge barrier when it comes to financial toxicity in cancer treatment. At Memorial Sloan Kettering, patients can apply for aid to cover parking costs, but this aid is only helpful if patients know about it and are encouraged to apply. 

In what ways can a diverse leadership improve access, however kaleidoscopically, to historically underserved and underrepresented communities?

FC: I think one of the easiest ways—this is something that can only come from leadership—is to just say, “Hey, this is a priority of our cancer center.” And it’s amazing how much things can happen if leadership has said X is a priority. 

I know, again, speaking from my own experience at Memorial Sloan Kettering, within strategy and innovation, it has become a priority for us to usher some people in the door who have been historically excluded, and so, specifically trying to do targeted outreach to certain populations. 

For example, New York has an incredible, huge immigrant population. So, how do we provide the resources for non-English speaking patients to come in the door to get over those barriers, and so, many of our educational materials are available in multiple, multiple languages. Last time I checked, we had over 4,000 educational resources in Spanish, for example. 

But that’s not something that happened organically.

It had to be made a priority to invest in translating the educational resources to other languages. How do we make it a priority for our staff to have cultural competency and implicit bias training? Because I think there is a lot of lip service to this idea of like, “Oh, we have equal care.” 

But ultimately, you still need to have training. There are very few individual people who are wholly racist, but many more who have implicit bias and therefore have racist or biased actions. Part of improving the standard of care—the quality of care for diverse populations— is acknowledging our own biases.

It goes beyond just being required to do a module. But even within the institution level, within each department, how do we engage at every aspect of the healthcare system from the front desk person to the person who does the lab draws, all the way—physicians, nurses, techs—to think about really the whole person as opposed to just their diagnosis and what they look like. 

I think that the leadership team really has a lot of power in terms of pushing the entire institution. Again, just to use an example from my own institution, we have now a stated research priority of trying to actively engage certain underrepresented populations in clinical trials. 

So, we are designing programs around the idea of: How do we provide navigation for certain patients to try to get them to the clinical trials that they would potentially qualify for but they were not getting offered now? 

There are many, many ways that we can improve access from patient facing to provider facing interventions. I think, again, there’s a ground up and then there’s a top down, and I think we can do both those.

FC: There are just so few Black leaders, and I think there are so many potential obstacles to rise to a position of leadership for Black physicians. 

I would have loved to have seen diverse cities have more diverse leadership in that respect, but I just think that there are so many, even maybe potential additional barriers than some other racial or ethnic groups with our Black physicians. 

In terms of even getting people into the pipeline, we’re kind of at a standstill. We’re not making improvements over what we have historically, if anything, we’re backsliding. Providing more logistical support—for example,  fee waivers, MCAT preparation classes—more mentorship, I feel is just so essential. 

And of course, I’ve seen it manifest from the other side for some friends: If you are a Black physician, students and trainees and junior faculty approach you constantly like, “Mentor me. Mentor me.” 

You’re one of the few. And that can be itself also very overwhelming to be one of the few people who, again, feels the onus of the obligation to provide mentorship for the next generation while you’re also just trying to do your own work.

FC: I think that there’s so many potential ways that the pipeline is leaking all the way from education within certain neighborhoods, to potential restrictions in terms of what universities people can even afford to go to, to then again barriers to even getting into medical school and so on. 

We already know that, for example, within medical school, Black students are more likely to be scored poorly when performing at the same level. They’re more likely to be judged based on physical appearances. 

There was a really great study evaluating how women were judged by their hairstyle—and so, things that were essentially superficial or not related to their performance as a physician or their potential as a future leader. But that element of systemic racism is downgrading them.

In terms of even getting people into the pipeline, we’re kind of at a standstill. We’re not making improvements over what we have historically, if anything, we’re backsliding.

When you get to the point in which you are saying, “Well, who are the qualified candidates for a leadership position,” you’re seeing a discrete lack of certain types of individuals, because along the way, their path has been stymied. And again, I don’t think that anyone within the hiring committees is specifically saying, “Well, I don’t want a Black physician.” 

But this idea of, for example, “This person didn’t have as many achievements.” or “Well, this person wasn’t professional.”

“Professional,” it’s almost like a code word at this point for, “They were too different. They didn’t go to the same school that I did. They don’t meet my expectations of what a leader looks like.” This goes beyond even looks. 

Even for me, if I see this physician went to Duke, I’m going to give them a leg up, because, hey, they went to my alma mater; whereas this person went to Morehouse, and I don’t know anyone who went to an HBCU [Historically Black Colleges and Universities].

FC: Absolutely. You get downgraded all the time. 

Our unconscious bias is to elevate people who are like us. It is a forward feeding problem with, for example, an overrepresentation of non-Hispanic white men in leadership positions in that it reinforces the next generation, the next wave of non-Hispanic white men. 

And I think even if we get to the point of diversifying the search committee, that itself will help. And then of course ironically being in the search committee is a lot of work and it’s, you’re behind the scenes elevating, but you are yourself still doing a lot of unpaid labor.

And so, ironically, by getting a more diverse search committee, we’re adding to the burdens of our limited faculty who are already overburdened, and so, even the solution has its own potential problems.

FC: I just wanted to highlight one thing that we found which I think hearkens back to something I think you had mentioned, again, last year, which is that there’s a real problem in terms of seeing Asian physicians as leaders. 

I think outside of the discrete finding that those who are underrepresented in medicine are even less represented in leadership, we also found that although Asians are way overrepresented as physicians, according to our percentage in the population, there’s this sharp decrease when we think about them in leadership. 

And so, again, Asians are allowed to be physicians, but somehow no one trusts us to be leaders. 

This is backed up by other research, again, showing that it’s okay to think of Asians as a physician, but you don’t want an Asian American president, or you don’t want an Asian American CEO of a company. And in that, itself, again, another manifestation of systemic racism.

And that’s a whole other conversation as well—the unique challenges for each community. For Asian Americans, it’s “Well, what’s the bamboo ceiling?”

FC: Yes. We finally have representation, we have Crazy Rich Asians, “Okay, we had a Hollywood blockbuster movie, so we can move forward.” 

But, I think again, there was a racial reawakening last year with both Black Lives Matter and the increased percentage of violence against the AAPI community.

I think, in that respect, I’m glad that this study comes out now, because I think it really highlights the fact that each population has its burdens.

FC: According to our study, in terms of percentages of women who are active physicians, and percentages in leadership, we’re doing okay. 

I think this may be a manifestation of some discrete efforts, in terms of trying to think about gender equity within medicine. 

But ultimately, we know that women are still paid less than men, even in medicine, for the same position. 

We know that women are more likely to have other taxes of their time, so for example, child care or home duties. Specifically during COVID, we know that we were more likely to sacrifice our time.

 So, we had less time for research due to, for example, having to monitor children doing homeschooling online classes.

And so, there’s a lot of additional potential burdens that women in medicine face. 

My mother raised seven kids and was an active physician, so I have a 1000% respect for her, because I really did see how much she did have to sacrifice in order to have a successful career and to have a family. And I think again, it’s baby steps, sometimes literally. 

But I was at least encouraged to see that we’re doing okay in terms of leadership.

Got it. Did we miss anything?

FC: This is the baseline, and then, what’s next is really the most important, because I think a lot of large corporations last year, again, during the Black Lives Matter protests, announced all of these. 

They had plans to make donations, support equity efforts, and I think a lot of people—appropriately—are calling them out now for not following through.

Same timely conversation, now that it’s Pride Month; right? One could almost hear our LGBTQ+ friends lamenting, “Look at all these rainbow versions of the apps popping up on our phones now! Here comes the rainbow tornado, but where’s the money?”

FC: Exactly. This idea of “rainbow capitalism,” which is, you stick a rainbow on it and suddenly you’re like, “I’m gay-friendly or I’m an ally.” 

Asians are allowed to be physicians, but somehow no one trusts us to be leaders. But, I think again, there was a racial reawakening last year with both Black Lives Matter and the increased percentage of violence against the AAPI community.

And so, the onus is on us as members of these leading cancer centers to really think about, how do we work from within to make this a priority, to make meaningful change not just for our patients, but also for our fellow providers, for our staff members—so that we can really, again, lead the charge to a better and more equitable future.

I will say it’s important to think about the next generation. And so, for example, when I was picking a student to work with me through the Summer Pipeline Program, I specifically picked someone from the University of Arkansas, because I thought the likelihood that he would have a similar opportunity would be small. 

That is another way to think about outreach and to try to actually get new and engaged people into our field. So, a Black man from a state medical school in Arkansas—that is exactly the person that I want to try to work with. And we really developed this project together, and I couldn’t be prouder of the incredible work he put into it.

Thanks for speaking with me, and for your work on this study.

FC: Thank you.

This story is part of a reporting fellowship on health care performance sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.