Social Determinants of Health - Living Our Values

Social Determinants of Health in Cancer Care

This episode was originally released December 9, 2020

In this episode of ASCO eLearning's Social Determinants of Health (SDOH) series, Narjust Duma, MD, moderates a discussion with ASCO CEO, Clifford A. Hudis, MD, FACP, FASCO and Sybil R. Green, JD, RPh, MHA, Director of Strategic Initiatives in ASCO’s Policy and Advocacy Department, on what ASCO is doing as a professional society to address equity as part of its mission.

TRANSCRIPT

PRESENTER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

NARJUST DUMA: Welcome, everybody, to the second episode of ASCO's Social Determinants of Health series. My name is Dr. Narjust Duma. I am an assistant professor at the University of Wisconsin and also a thoracic oncologist. Today I'm joined by ASCO's CEO, Dr. Cliff Hudis, and Sybil Green, Director of Strategic Initiatives in the policy and advocacy department for ASCO. This series is a new initiative proposed by ASCO president, Dr. Lori Pierce. It focuses on increasing oncologists' awareness about the social determinants of health through the cancer care and how impacts our patients' outcome, including modifiable risk factors. This series is inspired by Dr. Pierce's presidential team of equity, every day, every patient, everywhere. In this episode, we look at what ASCO is doing as a professional society to improve health equity and cancer care.

Welcome, Dr. Hudis. Welcome, Mrs. Green. First I would like to us what is ASCO doing as an organization in the matter of health equity and cancer care?

CLIFF HUDIS: So I guess I'll start here. Thank you very much for spending some time with us on this. If you look at ASCO's mission, it is conquering cancer through research, education, and the promotion of the highest quality and equitable cancer care. So the idea of equity and our responsibility to address disparities is really in our organizational DNA.

I have to point out something that many people may not realize. But when ASCO was founded in 1964, one of the seven founders was a black woman, Jane C. Wright. Dr. Wright died in February of 2013. But her father was among the first African-American graduates of the Harvard Medical School. His father was also a physician. And he was educated at what became Meharry. So I remind everybody of this as often as I can, to make the point that not only do we have an opportunity to advance equity and to deal with disparities in health care, but it's my perspective as a leader of ASCO that we have a special obligation and responsibility to do all of that.

So we can talk more about it. But I'll just introduce maybe the answer by saying there are really two broad themes at work for us at ASCO. One is externally facing. And one is internally facing. The externally-facing work includes a range of projects and output that we can talk about a little more, but for example our position papers describing disparities and then identifying potential steps to take to address and solve them. But it also includes support for targeted research that is meant to narrow those gaps. It includes our educational efforts, both for our members and for legislators, advocacy for policy, and so on.

And then on the internal side-- and here I'll ask Sybil to talk a little bit-- I think we've recently recognized our opportunity, and again responsibility, to think about the workplace itself and to think about our staff and to think about the activities and actions we can take and the roles we can model to create a better world. So I know I've been high level in my initial answer here. But the two domains again are external and internal. And then we can talk about some of the specific projects as we go on.

NARJUST DUMA: Mrs. Green, I think it's very important to share about these internal aspects of ASCO because many of us are now aware as members, we see the surface. But ASCO is a large organization with many staff and members. So it would be great that you can share that with us.

SYBIL GREEN: Absolutely. And thank you for allowing us to share that. I think Dr. Hudis pointed out some of what we've done since ASCO's establishments and really charging everyone on staff to really live out that obligation of equity, diversity, and inclusion. And so through our programs, our staff have to do their work, make sure that we are creating equitable opportunities for patients and physicians, but it starts at home.

And so we have to make sure that internally, we are offering those same opportunities for our staff to engage because what we know is that when staff are engaged, and they have the opportunity to bring their true selves to work every day, they bring their personalities. They bring their lived experiences. And that all plays out in the work that we're doing on behalf of members, in their patients, but also for staff.

I think if I were sum up where our program is going, similar to what Dr. Hudis has done, the three components are really enabling staff success. We ought to be able to do that for our staff internally. Every day we ought to provide opportunities for them to succeed. And then making sure that our partnerships-- those that we work with, whether it's in our publications, our meetings-- making sure that our partners goals and ideals align with ASCO's values and ideals. And all of this, of course, is in support of the greater ASCO enterprise, which is our members and the patients and of course, ASCO staff.

NARJUST DUMA: And I think that it's really important-- I had the pleasure of interacting with several staff members with diverse backgrounds. And I think as we develop the mentorship program and other things, their input is diverse. It means we also are able to cover the trainees needs because every trainee's needs are different. And because I cannot give a talk or do a podcast without mentioning my grandma, [INAUDIBLE], I have to say that it's important to clean your house first before you go and try to clean other people's houses. I do promise it's beautiful in a Spanish. But I think it's important that everybody knows that internally ASCO is doing a lot of work.

And I think it's important to talk about the grants in health equity. And I'm mentioning this because I haven't been doing health equity since I was a med student. And sometimes you find yourself not having enough grant opportunities. Now there is an increase. But when you compare it to other areas of oncology, you may be more competitive because there are less grants. And I think it would be great to hear from the both of you about the new health equity grants, the breast cancer disparity grant, and beyond.

CLIFF HUDIS: Well I would just point out something to build on your comment, first of all. Since we were founded in 1964 til now-- so just over 55 years-- we've made unbelievable advances, I think, in oncology in general. Indeed the reason I as an old man chose to go into an oncology in the 1970s was that the vision ahead was that this was going to be an exciting field. And it has not disappointed.

However there's a dark that I think we should acknowledge. The advances have not been fairly or evenly distributed. And indeed in some cases when we make massive improvements in outcomes in terms of what's possible with state-of-the-art care, we increase disparities because not every group catches up. And I say all that because it's important to understand that this is not about abstraction. These grants that address that gap are as or more important than the basic science grants that actually advance the biology and understanding in the first place. One without the other is incomplete.

So I can't agree more that this is important. And actually from an investment or return on investment point of view, in some ways, these grants are an even better deal because we can rest many of these gaps in care delivery and in knowledge pretty quickly and narrow the gap. And we've seen it. I'm going to give you some examples in a moment. Whereas funding basic science, honestly, is a much higher risk proposition, if you think about it. So I don't mean to set up a false competition here. But I want to point out that there's a big reward.

So here's an example. The plenary session abstract at ASCO two years ago now-- abstract number one, if you recall, was no moral less than an analysis of the impact of Medicaid expansion. And what did it show? It showed that with Medicaid expansion, those states that implemented it quickly narrowed the gap in time to initiation of therapy for curable colon cancer. It's a simple take-home point. I care passionately about this personally because these are differences in outcome that have been labeled as associated with race for many years or other specific ethnic facts. But really what they're about is nothing except unfair, uneven access to care in the first place on the basis of race. And it's something that we can address.

So we are building out programs to address this through a number of granting mechanisms. For 2020 alone, there are going to be two Young investigator awards that are earmarked for underrepresented populations. And there's a career development award and another YIA, Young Investigator Award, in health disparities specifically. But this is just, I think, part of the issue.

The other issue for us-- and actually a commitment going back for years-- is to do something about the workforce itself. And I don't have to tell you, but of course, there is a huge disparity playing out when we look at makeup of medical students in America. And it gets accentuated to the extreme when we look at black men. They are the most disproportionately underrepresented group right now.

So how are we going to address that? And we're really proud this year to be launching a program that is aimed at newly-matriculating medical students building on a successful program in Boston that's been running for a couple of years already with Bob Mayer is the founder. And our goal is to the interest of specifically targeted populations, not just in medicine but specifically in oncology.

NARJUST DUMA: Mrs. Green, you would like to add something about the grant and what is happening to support health disparities various research at ASCO?

SYBIL GREEN: I'll just add the importance of any grant opportunity in any program being one to two. So it's one thing to be able to address bringing in the right medical students to be able to mirror the populations that they serve. It's something else to continue to support them along the way, and so not just stopping at the students, not just stopping at the research, but also making sure that was they're in practice they're supported.

And a couple of grants that we've had for some time focus on quality, not just in ensuring that quality services are delivered, but actually helping practices to determine how to identify gaps in [INAUDIBLE] populations that are underserved because we may not be able to identify those same gaps that we would identify in majority populations. And so by giving them the tools to some of the other programs that ASCO has to be able to identify those gaps and then to support them along the way is really important.

NARJUST DUMA: And I want to add to what Dr. Hudis mentioned about workforce diversity because this is one of my areas of research and passion. And it's extremely important to have a diverse workforce to represent the patients we're caring for. It's not only having a diverse workforce, but having a workforce that practices cultural humility. We cannot assume that we are proficient or we are competent in somebody's culture.

I'm a Latina. And there are so many Latinos in so many different backgrounds that I cannot learn them all. And I think it's important that early interventions are-- because when you get exposed to a specialty early on during the training, that would change your pathway. I'm the daughter of two surgeons. I'm supposed to be a plastic surgeon. But a patient with cancer changed my life and my pathway. So we're able to support those students that have less resources and less access-- and that also includes rural students-- they may don't be black or Latino, they may be white, but they come from rural areas with limited resources-- we are sure that we meet the patient needs because there are aspects I don't understand.

Like I'm in Wisconsin, and there are some aspects to farming I didn't know. Now I know when harvest is. And all of that allows us to plan appropriately. So I can see how important it is. And there's a task force that is run by Dr. Winfield, which I'm lucky to be part, that focuses on the workforce diversity.

Along those lines, as a minority in medicine, I have seen up and downs of the interest in workforce diversity and health equity. I think many events in 2020 helped a lot of people open their eyes or be more conscious like, oh, that's not isolated. That happens in my back yard. It happened in Kenosha, Wisconsin. But we want to hear how is ASCO making these things long term, how the internal and external changes are going to be long term? And I will start with Mrs. Green and then go to Dr. Hudis.

SYBIL GREEN: So in terms of making it long term, it can't be one and done. I think quite often when we focus on equity and diversity issues, we always look at diversity first. And so whether it's workforce or whether it's increasing opportunities for access, you can't just look at the numbers. You have to also think a little bit deeper. You have to think about culture. And so culture with humility, like you mentioned, Dr. Duma, is important, but making sure that attitudes are changing along the way.

And that happens through self-awareness. That happens through understanding. And I think that ASCO plays a real role in making sure that our members understand what the issues are and how to dig past those things and provide them with the tools to be able to [INAUDIBLE]. ASCO I think, is not unique. And the idea that this is all new to us has gotten a lot of attention because of some of the social and racial injustice. But what that means is that our members now are probably more interested in ensuring equity than ever before.

But we have to teach them how to do it. We have to teach them how to speak the language. We have to teach them how to be more aware, both in their own organizations, at ASCO internally, and for their patients. And so it's a cultural change. It's not going to happen overnight. It's gradual understanding of the dynamics, gradual understanding of different peoples goals, and meeting them where they are, so that we can help them to move along, so that we can come to a more equitable and just [INAUDIBLE].

CLIFF HUDIS: I think one of the things Sybil and I spoke about this summer is we launched our internal EDI effort-- relates to this. And that is this is not about identifying a leaky pipe and patching it and saying, well, we're done now. This is actually, in my view, a permanent change in the way we see work and the way we see our growth. So the goal is to reach a specific landmark. The goal is to change how we think about our work and how we think about our role in the world, so that we're constantly improving.

And it's a journey, not a destination, I think, which sounds trite. But that's the spirit of it. And it gets to your question about how we make sure that the commitment is continuous and not just while it's [INAUDIBLE] and exciting. And I think we are committed and dedicated to that.

I do want to present a related challenge because it's something you said really sparked this thought for me. As a physician, when did you know that you wanted to be a physician? How old were you?

NARJUST DUMA: I was 5.

CLIFF HUDIS: And, Sybil, when did you know what your career path was going to be?

SYBIL GREEN: I was 9.

CLIFF HUDIS: That doesn't support my thesis [LAUGHS] [INAUDIBLE]. So here's the issue. The issue of burnout in medicine right now is getting a lot of attention. And one of the reasons for it, frequently given, is that doctors on average decide to commit to their careers a decade younger than most people on average commit to other careers. You're an exception, Sybil, so I should have pretested the question.

But the issue is we're not here to talk about burnout today, even though that's really important. The issue is this. In order to ultimately address the makeup of the population of physicians, we need to reach deeper and further into precollege communities. And we need to show people that they could have lives in science and health care and in medicine and maybe specifically oncology.

And I'm just pointing out to you that that's a daunting challenge for a professional society like ASCO. That's not our audience. We don't have a natural connection there. And one of the things that we're working on right now is identifying programs that have worked, that exposed high school students from previously excluded populations or communities to medicine, so that we can spark that passion before college, not during college, and therefore have the commitment that it takes to go far into medicine.

And I'll just close by saying something that you hinted at but needs to be said. The reason to have diversity in our workforce is not that an Asian patient needs an Asian doctor. It's that an Asian patient needs a practice that has Asian doctors in it, so that the practice as a whole is able to be culturally sensitive and able to relate and communicate and support them because I think sometimes this issue gets oversimplified as well.

SYBIL GREEN: So Dr. Hudis, your theory is not completely [INAUDIBLE] I think it's relevant to this conversation because while I knew what I wanted to do at 9, what I didn't have was the representatives in the community. I didn't have the mentor. Interestingly enough, I had more mentors in pharmacy than I had in law because I saw pharmacists who looked like me. I happened to live in a town where there was a historically black college with [INAUDIBLE]. And so I saw people look like me. And it made it a lot easier for me to reach out to them, for them to mentor me, for them to start talking to me about what equity in health care looked like. That really wasn't until I was in college.

But the truth of the matter is for most diverse students, most minority students, that doesn't exist. And I think that that's where ASCO's mentoring programs are really rich. You have the opportunity to do that.

NARJUST DUMA: And I think this is important because you can do what you can see. And that has been proven over and over again. We unfortunately are running out of time. But I want to ask the final question. Like a manuscript, like a study, everything has limitations. And I think it's important that we talk about the limitations of ASCO doing this work because realistic expectations are helpful so we don't get disappointed when we have big expectations that may not be met. So Dr. Hudis, what are some of the limitations of ASCO to help equity work now?

CLIFF HUDIS: You're right, it's a huge issue. If you think about where our scientific focus is, we can measure the disparities or the difference in outcomes. And we can write a paper about that but when you really get to addressing the reasons for it, it extends far beyond what we can do. So I guess our limit is we can call attention and rally colleagues and collaborate across the House of Medicine and broadly into Congress, where we can make a difference-- or to the United Nations and World Health Organization. But we can't do this heavy lift alone. We need other colleagues who agree who are willing to invest time and money to make the change.

SYBIL GREEN: And I would add partnerships because as much as we're talking about social determinants of health, we recognize that all social determinants of health are not health related. They're not [INAUDIBLE]. And many of them live and operate outside of the realm of health care. But what we can do is bring our expertise to the table about the impact of those things, so that our partners stand in their own world, in education, in criminal justice, in financial assistance, how that can help really change the outcomes for patients. I think at ASCO, we've got that expertise. And we can do that.

NARJUST DUMA: Thank both of you for your time. Thank you, everybody, for joining us for the second episode of ASCO Social Determinants of Health series. Please keep up with us. You can subscribe. You can see this on Facebook, YouTube-- when it becomes available. We'll continue to explore the social determinants of health and cancer care. You can leave feedback or emails, any questions to the professional development, at asco.org. And I thank you for your time. And have a wonderful week.

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