The Race toward Equity: Increasing Racial Diversity in Cancer Research and Cancer Care

The horrific murders of George Floyd, Breonna Taylor, and countless others have had a profound effect on the collective conscience of our society, prompting us to reexamine our own bias and survey for race-based discrimination to begin to acknowledge and combat the existing racism within our own ivory towers. This introspection has opened the eyes of many to the overt and implicit biases Black scientists face. Essential discussions stemming from this new awakening have been uncomfortable and eye-opening, and have resulted in many important conversations on social media and in person on our campuses. Although people of color face similar micro- and macroaggressions, most have not been harassed as they came to and from campus like our Black colleagues, especially many of the men, or feared navigating their own neighborhoods or sleeping in their own homes. Respected leaders in our cancer research field such as Robert Winn, Cancer Center Director at Virginia Commonwealth University, or Otis Brawley, former Chief Medical and Scientific Officer and Executive Vice President for the American Cancer Society and currently a Bloomberg Distinguished Professor and Associate Director for Community Outreach at the Johns Hopkins Kimmel Comprehensive Cancer Center, have recently described being held at gunpoint while walking to their cars, or in front of their own homes (https://cancerletter.com/articles/20200605_1/). This ever-present reality permeates the minds and informs the actions of our Black colleagues, and, as a result, sets them on a different footing from the start no matter their socioeconomic status or level of education. Transformative, intentional initiatives at our institutions and funding agencies aimed at the retention and recruitment of Black trainees and professors within the cancer research enterprise are therefore critical to creating preeminent academic research environments (1). Furthermore, many cancers such as breast, lung, and prostate cancers disproportionately affect people of color, and those health disparities need to be addressed. To do this, community outreach is critical to increase screening and encourage participation in clinical trials and laboratory-based studies. However, that cannot be done without building trust between underrepresented communities and the medical institutions that have historically betrayed them. Here, we attempt to succinctly identify these challenges for cancer research and care, consider solutions to begin effecting actual change in academia, and provide antiracism resources. Cancer research and cancer care require deliberate attention to racial diversity.

The first and overriding problem, not just in cancer research but in all biomedical research, is the vast underrepresentation of minorities. The NIH defines underrepresented minorities (URM) very specifically as “US citizens or lawful permanent residents who are African American/Black, Hispanic/Latinx, American Indian, and Alaskan Native.” Although many institutions have focused on increasing the input into the pipeline, beginning with efforts as early as middle school, the real problem comes at that transition from training to career. Gibbs and colleagues (2, 3) have shown that the number of URM receiving PhDs between 1980 and 2013 increased by a factor of 9.3, as compared with a 2.6-factor increase in non-URM groups. Despite this, there was no similar increase in the number of URM faculty recruited into assistant professor positions, whereas non-URM scientists transitioned into faculty positions at rates reflective of their entry into academia. Using a model that took all of these factors into account, the authors came to the depressing conclusion that with no intervention, and even in the face of exponential growth in the URM student population, faculty diversity would remain static well into the next 50 years. These models highlight the problem with focusing large amounts of effort on increasing the pipeline without similar efforts to increase retention. Diversity, equity, and inclusion (DEI) efforts have long been focused on students, and not only are URM faculty not included as targets of these efforts, they are asked to lead them, resulting in an increased workload that often goes uncompensated. Finally, URM faculty are also subjected to a lot of bias, both conscious and unconscious. As with all academics who are URM, be they Black, Indigenous, or immigrant, there are multiple micro- and macroaggressions that plague us. For an eye-opening list of these, search under the hashtag #BlackInTheIvory or explore the Twitter account of the same name. This “death by a thousand cuts” is a recipe for ensuring an absence of URM populations in academia.

First and foremost, it is critical to maintain investment into the pipeline. Bringing URM students into the pipeline early and finding ways to effectively retain them through their medical or scientific training is critical to creating and increasing the pool of candidates from which to draw at later stages. Beyond the increases in the pipeline, more effective partnerships between minority-serving institutions and cancer centers could provide increased opportunities for recruitment and knowledge exchange. Programs should be established for our URM students that address transitioning to graduate school (in the form of “boot camps” prior to their matriculation), provide check-ins throughout their training with dedicated, effective mentoring circles that go beyond professional development, and create safe spaces within our communities, such as an “Office of Diverse Research Training.” For the promising URM postdocs at our institutions who aspire to faculty track, “Pathway to Professorship” programs that include tailored mentoring, lab incubator space, and financial support should be developed. Akin to the successful NIH Stadtman Tenure-Track Investigators, institutions and cancer centers should initiate recruitment symposia that provide an opportunity for cancer research–focused URM postdocs to be exposed to them. Targeted funds for the recruitment of URM faculty such as “Target of Opportunity” programs should be made available. Faculty searches should include a committee member dedicated to increasing URM applications through outreach and solicitation. Universities should keep on hand a list of their talented minority alumni, tracking them through their graduate training and helping to promote them as faculty candidates. All of these are easy initiatives that can help to increase URM faculty hires. From there, efforts to increase the retention of these candidates need to be made. Above all these is the training of non-URM faculty in what implicit or unconscious bias is and how to recognize and mitigate it in dealings with fellow faculty and with trainees. As with everything, however, it is critical to note that although training and discussion work, the effects are not self-sustaining, and institutions will need to commit to gauging the effectiveness of the implicit bias training with clear metrics, continued implicit bias training as the research evolves, and systems for accountability, among other initiatives. Diversity initiatives should be rewarded rather than viewed as distractions, and leadership in cancer centers can do this by including DEI efforts as “credits” toward promotion and remunerating them where appropriate. Requiring statements of commitment to these activities at different stages of promotion is also one way to increase the incentive to partake in DEI efforts. The goal is to include non-URM faculty in these initiatives as well, and to provide them with resources on combating racism and on impactful responses to criticisms of antiracism programs (e.g., those listed in Table 1). Further resources, supporting data, and actions are also beautifully outlined in a 2015 article by Whittaker and colleagues (4) that we strongly recommend reading.

In addition to institutions and cancer centers taking a stand, funding agencies can do the same. Although organizations such as the American Association for Cancer Research (AACR), the American Society of Clinical Oncology (ASCO), and the American Cancer Society fund travel fellowships and trainee grants for URM scholars, we need to increase funding avenues for cancer research for URM as well. For example, five years ago The V Foundation established the Stuart Scott Memorial Cancer Research Fund to provide financial support for cancer research conducted by URM faculty as well as research that is dedicated to the aggressiveness, therapeutic responsiveness, and ultimate outcomes for Black and other minority population patients with cancer. In 2011, a seminal study by Ginther and colleagues indicated that URM scientists receive grant funding at lower rates than their non-URM peers (5). To address this, the NIH instituted a Scientific Workforce Diversity Taskforce in 2014 (https://diversity.nih.gov/building-evidence/racial-disparities-nih-funding). Amazingly, in that short time the gap in grant funding, especially at the R01 equivalent level, decreased significantly, although not totally, and represented an 117% increase in awards granted to Black scientists. Intentional diversity programs such as Build and the National Research Mentoring Network that equipped trainees with grant-writing tools, paired them with mentors with similar life experiences and academic interests, and taught students about implicit biases they may face, have significantly contributed to this success. Other such programs, including the Research Training Opportunities for Outstanding Leaders (ReTOOL) program, have shown similar success. This program was designed to increase the capacity for scientific research in underserved areas and to increase URM representation in biomedical research. Between 2012 and 2019, 40 URM scientists were identified and followed, and ReTOOL drove both the initial interest and ultimate retention of these URMs in science (6). With these types of initiatives showing success and setting the stage, cancer centers nationwide have strong examples to follow. Indeed, many are rising to the challenge.

From the Tuskegee experiments to the exploitation of Henrietta Lacks, beautifully documented in the book Medical Apartheid by Harriet Washington (7), the participation of Black people in clinical trials has a checkered history rightfully rooted in fear and mistrust. As a result, less than 4% of patients enrolled in clinical trials are Black and less than 4% are Latinx, and less than 10% of biobanked samples in cancer clinical trials come from URM patients (8). The numbers for American Indians are so low that they are hard to even factor into these statistics. In the words of The Cancer Atlas (https://canceratlas.cancer.org/the-burden/indigenous-populations), “Data related to cancer in these populations tend to be absent or of poor quality making many Indigenous peoples statistically invisible, with the majority of data that exist coming from a few high-income countries.” This is a huge issue, affecting everything from understanding and appreciating the impact of environmental and comorbidity biases on cancer progression to appreciating the impact of data input from racially biased studies into newer technologies such as artificial intelligence. The import of this issue is compounded by the fact that some cancers such as breast and prostate cancers disproportionately affect URM populations, in whom the disease is far more aggressive (https://www.cancer.org/research/cancer-facts-statistics/cancer-facts-figures-for-african-americans.html). Community outreach efforts to increase screening in URM populations face the challenge of mistrust. In addition to this mistrust, the lack of education and resources in underserved communities also leads to reduced screening and to long waits before finally seeing a physician. It is also no secret that the complaints of URM patients, specifically Black women, often fall on unsympathetic ears (https://www.oprahmag.com/life/health/a23100351/racial-bias-in-healthcare-black-women/). Even palliative care for oncology patients is inequitable: fewer URM patients are referred to palliative care, and those who are have inferior experiences (9). All these issues can be further compounded by the chronic stress URM populations experience due to less favorable socioeconomic status and simply trying to survive in a culture that does not favor them. Furthermore, many of our cancer centers find themselves at the heart of predominantly minority cities; thus, it is imperative to be creative about investing in those communities.

First and foremost, we need to increase the number of URM physicians in the cancer field. Of all medical disciplines, hematology and oncology are well behind other fields in their makeup of URM doctors. When compared to the US population, where 13% of the population is Black and 18% is Latinx, the numbers are dire: 2.3% of oncologists are Black and 5.8% are Latinx. The numbers for Indigenous people are even smaller. This stems from a pipeline issue, as only 11% of medical students are URM. What makes this issue even more urgent is that URM students are willing to work in underserved communities and are arguably better equipped to do so. Organizations such as the AACR and ASCO are taking important steps to increase diversity in their own leadership and membership to provide crucial representation. These initiatives include the expansion of mentoring opportunities for URM oncologists, the assessment of policies that could increase the diversity pipeline, and building upon ongoing diversity initiatives, such as awards for medical students. In an effort initiated in 2011, the NCI created a program through their Community Networks Program Centers that provided community-based training to prepare students and early-stage investigators and physicians for careers in oncology. Specifically, participants in the program were trained in disparities research and strategies for reduction of cancer health disparities. This remains a critical point for all physicians—once in training, oncologists need to undergo bias training so that they can create a productive environment for URM students and doctors. An important part of this training also needs to extend to the patients and focus on how to treat patients with respect and a lack of racial bias, however implicit it may be.

Next, we need to improve the representation of URM patients in clinical trials. The Cancer Disparities Research Network, for example, undertook an evaluation of biobanks among ten representative facilities. They found that only 10% of samples came from non-White patients, and only a handful of centers targeted URM populations, citing a lack of funding and other resources with which to pursue these initiatives. Increasing funding so that different centers can participate in these initiatives will be an important step. However, perhaps the most important step for improving cancer care for URM patients is rebuilding trust with the hospitals. Some centers are taking innovative approaches to this, pairing with the NAACP, for example, to learn how to better reach out to underserved communities. Some have instituted community outreach programs as critical steps toward tenure and promotion to better engage their physicians and overcome historically adverse relationships. Strategic partnerships with key community leaders are also an important avenue for increasing screening in URM patients and their participation in clinical trials.

Let us end with this call to action. It is no longer enough not to be racist—it is time to all come to the table and be actively antiracist. What does that mean? It means not being a silent ally, and it means standing up for someone who is being treated badly. It means being a “disruptor,” in the words of Dr. Russell J. Ledet, or making “good trouble,” in the words of the deeply mourned, recently departed Rep. John Lewis. It means going out of your way to invite, amplify, celebrate, and support your URM colleagues. It means approaching your URM patients with respect and really listening to their complaints. As a community, we need to increase URM representation at all levels of faculty and leadership. We need to appreciate and embrace the diversity that can bring important insights into everything from basic cancer research to the clinical practice of oncology. We provide a list of antiracism resources in Table 1, and we look forward to working with our colleagues to foster a more inclusive environment for our students, our faculty, and our patients.

D.C. Brady reports funding from Merlon, Inc. (co-owner) outside the submitted work. A.T. Weeraratna is on the scientific advisory board of Healthe Lighting Sciences and has received grants from Melanoma Research Foundation (scientific advisory board) outside the submitted work. No other potential conflicts of interest were disclosed.