Will cancer centers remain committed to improving equity in the long term?

Matthew Ong: What best practices in hiring and recruitment—or in pipeline programs—do you use at your institution to elevate potential diverse leaders? How effective are these strategies?

Christopher Lathan: I think, first, as I answer that question, I want to put it in context, because I think that this conversation is quantitatively different from a conversation that could have been had a couple of years ago. 

So, 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. The focus on structural inequity throughout our system has really made the medical leadership rethink their approach. There’s always been good intentions, there’s always been good thoughts, but I think that some of this was not seen as the priority.

To answer your question now, I would say our institution has always focused on some of the standard efforts that you’ve seen. We have focused on the usual approaches in the past. Pipeline issues, trying to support underrepresented leaders on multiple levels. 

So, one new approach is supporting young aspiring leaders with continuous mentorship, especially folks who are coming from underrepresented-in-medicine backgrounds. In addition to that, creating relationships with, whether it’s medical schools and community leaders, where you can try to build those new diverse leaders. So, I think the first part is your pipeline.

The second part is prospectively thinking about support group situations. So, if you have underrepresented minority faculty, then, again, putting folks in groups and efforts to try to give them support through. I think those have kind of been the standard approaches. And I would say our institution has utilized those. 

What I would say is that those approaches work somewhat. I think one of the things that we haven’t seen until fairly recently is really putting leadership in the executive suite, because that’s where the difference comes in.

I would also say there isn’t enough time yet to see. For example, my position is relatively new just within the last few months. And I think there’s a lot of folks in the country who are in a similar situation. 

So, let’s see, I think these efforts will pay off, but I think the pipeline and the fermenting of young dynamic leaders and reaching out to try and pull established leaders from other institutions is another thing that, I think, institutions have tried to utilize, and my institution has done that as well—kind of thinking outside the box and maybe really thinking about leadership tracks and looking at folks who don’t fit the same mold, I think, and maybe having people really broaden what they think a leader can do as well as what a leader looks like would be really helpful.

In your experience as a member of your center’s executive leadership, how has increased diversity among your faculty improved patient outcomes, as well as your ability to reach and engage underserved communities in your catchment area? Could you provide a few examples?

CL: I would say the short answer to your question is, again, in the executive suite, looking at representation there, it’s relatively recent at our institution. So, we’re going to have to see those outcomes; we’ll look at that going forward. 

I would say we have seen other institutions, though, where this has paid off. At ASCO this year, Dr. [Carmen] Guerra and Dr. [Robert] Vonderheide [from Penn’s Abramson Cancer Center] actually presented some data that showed how their intervention—it was an intervention, but it was really supported by the cancer center director—to really diversify their patient population and have it match up with Philadelphia’s catchment area . 

And they showed, how these kinds of initiatives are actually supported from the top throughout the institute—integrating the whole institute’s mechanism to really think about clinical trials and improving clinical trials for marginalized populations, African Americans for the most part—really made a huge difference in recruitment of folks to clinical trials, and greater representation of the marginalized catchment area. 

I think that that is a good example of how Dr. Guerra’s work where she is, in a leadership-level job, with the support of the cancer center director, has shown that if you put people who are interested in outreach, who are dedicated to outreach, and I think looking for leaders who are from different and diverse backgrounds, gives you folks who might have slightly different emphasis in their career. If you give them the support, they will build the initiatives and put the folks together and really make things work.

I do think that there are other examples out there. Derek Raghavan’s efforts at the Levine Cancer Center, and what they’ve been doing, I think, is another example of how you find the people who want to do this kind of work. You support that from the cancer center leadership on down. 

You pick executives who want to do this work, medical leaders who want to do this work, and you can make incredible gains and get the outcomes that you’re looking for.

The trap for me in the question that you asked is, “Hey, so you’re going to do this. You’re going to diversify your leadership. Well, where’s the money? When are we going to see the outcomes that we want?” 

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.” 

That’s the one thing about having it so black and white, you’ve got to have a longer term view and plant the seeds so that the leaders can grow strong and can integrate their ideas throughout your institution.

CL: Right. That’s exactly right.

What programs have you led or are leading that are directly contributing to greater equity i.e. a reduction in disparity of outcomes or disparity of access in your catchment area? What is the nature of those disparities and what have you learned?

CL: We’ve been fortunate. Even though my particular role is relatively new, there have been some efforts that we’ve been working on at our institution for some time that we have some data on. 

I’ll talk about two things, and they’re related. One is one of the efforts I’ve been involved in for about 10 years. It’s our Cancer Care Equity Program where we’ve actually set up outreach clinics in Federally Qualified Health Centers. And the idea is that we would help the primary care docs with any cancer-related questions. 

So, we do expedited workups, survivorship, lung cancer screening visits, all in their health center under their license. For people who actually need to get biopsies or other things, they come into the cancer center. And that’s a navigated process. It’s built around a nurse navigator.

We put that program together about 2011. And so, over the nearly 10 years, we’ve collected data that shows that, not only do we help people, we decrease the time to evaluation for cancer-related questions, and we’ve got a manuscript that we’ll be sending out, but there’s some other published work that we’ve done. 

Also, we found that the folks who did get diagnosed with cancer who were sent to our program were more likely to go on clinical trials. And this is a majority diverse population, about 40% of the patients speak Spanish and 70% identify as African American.

So, I think we have some preliminary data that shows that this kind of prolonged, determined, navigation, clinical access program not only helps the patient, but it also gives what we’re looking for in the long term, which is more access and higher representation in clinical trials. 

Now, the actual total N is small, because this is a small pilot program, but we’re expanding this program and we’re trying to make a bigger impact.

The other thing is our Community Benefits Office and our research programs have long been working hand in hand to really innovate and try to come up with different types of interventions that can have impact. 

So, besides some of the work that we’ve been doing, there’s some work on prostate cancer, there’s work on liver cancer, where they’re really trying to integrate the research process much more in addition to the clinical process. 

And in our breast cancer group, there is a Boston-wide navigation program where all the different institutions, different academic institutions are coming together. 

And the data isn’t quite published yet, but that’s another, probably seven or eight year program that we have some good data showing the impact of navigation for breast cancer patients, specifically, for comparing what happens to folks who are coming from underserved neighborhoods from marginalized communities. 

So, these programs have been going on for a while. I think it’s just we need to ramp them up a little bit more.

Speaking of next steps, are you working on any new initiatives or new priorities, on a very high level, at your institution?

CL: We are working on, like many institutions, rethinking the integration of our approach to clinical access throughout the institution. 

One specific example is integrating navigation into the disease center in a much more prospective way for vulnerable and underserved patient populations. 

So, as opposed to having a navigator that’s supported by a philanthropic program, we’re talking about in the center, integrating the navigator, the community-focused navigator, to really assist all the way through their process on a disease center level throughout the cancer center.

That’s something that I really haven’t seen often, even in programs that have navigators in clinical operation systems. So, we’ve started that program where we’re going to integrate, we’re going to look at some metrics, and we’re going to try to demonstrate that approach over time. 

And in addition to that, I think really building up some of our outreach programs, some of the interventions from the ground up, removing structural barriers and actually focusing on some socioeconomic and other barriers it takes for folks to get on clinical trials.

Lastly, our institution has been able to renegotiate some of the insurance contracts. So, before there was a big gap. Many patients who were in Boston who had a specific managed Medicaid product that excluded our institution, or the health insurance program at our institution was too expensive. 

They renegotiated that, so that these patients can, just like everybody else, come into the institution and get a second opinion or get their transplant or specialty care, if need be. 

And I think that’s also going to allow us to have a positive impact on the patients.

Did we miss anything?

CL: I will say that I’m happy that there’s a majority of institutions that are thinking about this in a prospective way. 

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? Where is their commitment and how strong is their will for change?

That is where I think we will really see where we’re going with this and whether this is representation that is weaved in, or if this is a reflexive response to the moment, because many of us who’ve been doing this work for 15, 20 years have been pushing these things. 

Go back and look at the guidelines that ASCO’s done, that any of the groups have talked about, and you’ll see the same thing. 

Even NCI, when they changed the core grant, the CCSG grants include more about community engagement. People have been trying to push this for a while. 

So, these aren’t new concepts. What we want to see, in all of this, is as we go forward, is it going to be sustained? And that’s, to me, where we’re going to see the difference in communities, and communities will know the difference then, too.

Right; a friend described it very succinctly to me in a conversation about equity initiatives now popping up everywhere: “Y’all, we’ve been seeing it for a long time before COVID and before BLM, but thank you, better late than never.”

CL: Exactly. That’s very true. I think that’s very true. So, I think, good, if you’re late to the party and you want to help, that’s great, but let’s see what it’s going to look like going forward.

Matthew Ong: What best practices in hiring and recruitment—or in pipeline programs—do you use at your institution to elevate potential diverse leaders? How effective are these strategies?

Karriem Watson: 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. 

This is clearly seen in our office of Community Engagement and Health Equity (CEHE) of the UI Cancer Center, which is affiliated with the Community Outreach and Engagement (COE) and health equity program of the UI Cancer Center—where the majority of the leadership and team members of CEHE and the COE program are from diverse racial/ethnic backgrounds that reflects the UI Cancer Center catchment area. 

One of the strategies that we deploy is ensuring that new researchers and public health professionals are recruited from our UIC School of Public Health.

In your experience as members of your center’s executive leadership, how has increased diversity among your faculty improved patient outcomes, as well as your ability to reach and engage underserved communities in your catchment area? Could you provide a few examples? 

KW: It is well documented in the literature, as well as in my professional experience as associate director of Community Outreach and Engagement of the UI Cancer Center, that having research faculty and staff that reflect a cancer center’s catchment area improves the ability of cancer centers to reach and engage with communities in which they share similar lived experiences. 

One example of this is how the UI Cancer Center has been able to increase its workforce diversity by creating intentional pipelines from health equity research and engagement efforts such as the NCI funded U54 Chicago Cancer Health Equity Collaborative (Chicago CHEC). Chicago CHEC has served as a major asset in advancing the careers of early stage investigators from underrepresented groups as well as creating workforce opportunities for students who matriculate in the Chicago CHEC fellows research program. 

I currently lead a R01-level research project supported by Chicago CHEC engaging African American men in lung cancer screening and two members of our research team are former students from the Chicago CHEC program including the lead study coordinator for the project.

What programs have you led that are directly contributing to greater equity i.e. a reduction in disparity of outcomes or disparity of access in your catchment area? What is the nature of those disparities and what have you learned?

KW: In addition to the NCI funded U54 Chicago CHEC program, the director of CEHE, Dr. Vida Henderson and I have led a community-engaged research and service project to improve colorectal and cervical cancer outcomes among underserved populations in the UI Cancer Center catchment area. 

The project is funded by the Bristol Myer Squibb Foundation (BMSF) and engages barbers, beauticians and safety net hospitals in the UI cancer Center catchment area. Data from our catchment area showed colorectal cancer disparities on Chicago’s Southside were greater than many state and national averages. 

The catchment area data also showed inequities in access and screening uptake for cervical cancer among African American and Latina/Hispanic women on Chicago’s west side area. 

We have learned from this project that it is both feasible and effective to implement community based colorectal cancer screening within community settings including barbershops, beauty salons and Federally Qualified health centers. 

We also learned that embedded patient navigators in safety net hospitals in collaboration with cancer centers is an effective way to increase cervical cancer screening and identify system level barriers that can prevent timely cervical cancer screening.

What are your next steps?

KW: Our next steps are to continue to leverage NCI funded centers for health equity like Chicago CHEC to support early stage investigators and to grow the pipeline of students from underrepresented groups engaged in health disparities research. 

We will also work with the seven health science colleges at UIC to ensure opportunities for research and student and faculty engagement to support researchers from underrepresented groups. 

We are also actively seeking funding that can examine the impact of systemic racism on both cancer screening and uptake as well as its impact on the cancer research workforce.

Matthew Ong: What best practices in hiring and recruitment—or in pipeline programs—do you use at your institution to elevate potential diverse leaders? How effective are these strategies?

Ruben Mesa: The Mays Cancer Center at UT Health San Antonio is based in a catchment area of San Antonio and South Texas, a 38-county region of 4.9 million people of which 69% are Latino, so a diverse team and leadership team is crucial. 

Working closely with our wonderful vice dean for diversity—Dr. Chiquita Collins of the Long School of Medicine—the Mays Cancer Center is dedicated to first developing diverse faculty. 

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. 

We deeply value diversity in new faculty hires, and work to have a diverse pool of candidates before offers are extended. We actively focus on retention, looking at mentorship, career development, and competitive hiring and retention efforts. 

Our university, Long School of Medicine, and Mays Cancer Center have a robust leadership development program, which enriches the career development of potential diverse leaders. 

New leadership searches begin with a discussion on diversity, intentional efforts to reach out to diverse candidates and seek their recruitment. We have a very diverse faculty, staff, and leadership structure. 

In your experience as members of your center’s executive leadership, how has increased diversity among your faculty improved patient outcomes, as well as your ability to reach and engage underserved communities in your catchment area? Could you provide a few examples?

RM: We have a diverse faculty who is focused on conducting research in our very diverse catchment area. South Texas is diverse with both rural and urban areas, with 4.9 million people, mostly Latinos (69%). Nearly half speak Spanish as their primary language, and many face barriers like poverty and low educational attainment.

Amelie Ramirez: Many people in our community fear getting cancer. Cancer has become the leading cause of death for Latinos. I have lost a family member to cancer, and it is not something we want anyone to have to go through. 

This is why I am leading studies that are focused on Latinos, engaging them in research and delivering interventions and communications to help them. 

And this is why every researcher, clinician, education specialist, and health care worker at the Mays Cancer Center is working hard to make a difference in preventing, reducing, and eliminating cancer for all people. 

What programs have you led that are directly contributing to greater equity i.e. a reduction in disparity of outcomes or disparity of access in your catchment area? What is the nature of those disparities and what have you learned?

RM: We know Latinos are getting vaccinated for COVID-19 at much lower rates than their peers. Dr. Ramirez and her Salud America! program created the “Juntos, We Can Stop COVID-19” bilingual digital communication campaign to inform and urge Latino families to take action to slow the spread of coronavirus, including getting the vaccine when it’s available. 

The #JuntosStopCovid campaign features Latino culturally relevant fact sheets, infographics, and video role model stories in English and Spanish. Dr. Ramirez and her Salud America! program also created the Latino COVID-19 Vaccine “Change of Heart” Bilingual Storytelling Campaign to move Latinos from vaccine hesitancy to vaccine confidence. 

The campaign uplifts the stories of real Latinos from South Texas and beyond who overcame misinformation, got the vaccine, reconnected with family, and are helping end the pandemic. We want our families to be able to get back together. We want to visit our sisters and brothers, parents, and abuelos and abuelas.

 And we want to be able to do our jobs and go to school safely. The best way to achieve what we want is to get the vaccine right when it is available. Vaccines help our bodies become immune to a virus without becoming ill from it.

AR: We are continuing to build the pipeline for a diverse healthcare and cancer research workforce. My NCI-funded program, Éxito! Latino Cancer Research Leadership Training, annually recruits 25 Latino students and health professionals annually for a culturally tailored curriculum to promote pursuit of a doctoral degree and cancer research career. 

The program also offers internships and ongoing support. Of 101 program participants from 2011-2015, 43% applied to a doctoral program and 29.7% were currently enrolled. 

We proved that Éxito! is a strong model pipeline program that equips Latinos for applying to and thriving in doctoral programs, with added potential to boost the pool of cancer health disparities researchers.

What are your next steps?

RM: We are working to engage more Latinos in clinical trials. Latinos represent 18.5% of the U.S. population, but are less than 10% of those in federal cancer and drug studies. 

Dr. Ramirez has received a three-year, $650,000 grant from Genentech, a member of the Roche Group, to create Latino-focused recruitment strategies and systems for clinical trials in cancer treatment and Alzheimer’s disease. 

The new funding, part of Genentech and The Genentech Foundation’s $16 million initiative to promote health equity and diversity in STEM, will help her team expand its work into inclusive clinical trial promotion and recruitment. 

This includes using culturally relevant digital health communications, advocacy networks, and clinical partnerships to promote health equity and advance clinical trials for cancer treatment and Alzheimer’s disease among Latinos.

AR: Ever-changing technologies motivate us to find new, culturally relevant ways to reach our Latino population with cancer prevention and healthy lifestyle messages. 

My team helped create Quitxt, a quit-smoking coach that utilizes text messages or Facebook Messenger to help young adult Latinos kick the habit in South Texas. Quitxt is being expanded to include messaging to quit vaping, too. 

My team also is pioneering a culturally tailored app to help Latinas with breast cancer adhere to their endocrine hormonal therapy. 

There are fewer and fewer limits on technology, creating an opportunity for health communicators to innovatively help people increase their healthy behaviors.

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.