Oct 26, 2022
By Aaron Tallent
When Brandon Blue, MD, first stepped onto the campus of Meharry Medical College, a historically Black medical school in Nashville, TN, becoming an oncologist was not on his mind. As the first person in his family to ever attend medical school, he was focused on getting through the next four years of schooling.
“At that point, I was just happy to get into medical school, but then people ask you what type of doctor you want to be and there are literally a hundred types of different specialties,” said Dr. Blue.
Fortunately, Dr. Blue received an ASCO Resident Travel Award, now called the Annual Meeting Research Award (AMRA). Funded by Conquer Cancer, the ASCO Foundation, the AMRA offers a $1,500 monetary award and complimentary ASCO Annual Meeting registration to non-oncology medical residents from populations underrepresented in medicine. The award enables them to meet with oncologists and to learn firsthand about a career in oncology.
“I’m literally a product of ASCO and its workforce initiatives. This one experience exposed me to the field of oncology, connected me with leaders in the field, and helped me get into a fellowship program that put me on the path to becoming an oncologist,” said Dr. Blue, who is now a medical oncologist at the Moffitt Cancer Center in Tampa, FL, and a past member of the ASCO Cancer Survivorship Committee.
ASCO is committed to reaching out to aspiring physicians, as Dr. Blue once was, to create an oncology workforce that is representative of the populations that it treats. For more than two decades, health equity has been woven into every facet of the Society’s work to reduce longstanding disparities in cancer care; increasing workforce diversity has been a focal point in that effort. While it will take years—perhaps generations—to fully reach a truly representative workforce, the goal is essential to addressing equity, improving patient care, and ultimately improving patient outcomes.
“Every field benefits from diversity. The more representation you have at the table, the more profitable, more expansive, and more innovative you can be. Unfortunately, the oncology workforce is behind, and it’s holding us back,” said Karen Winkfield, MD, PhD, ASCO Board of Directors member, past chair of ASCO’s Diversity and Inclusion Task Force, and a professor in the Department of Radiation Oncology at Vanderbilt University Medical Center and Ingram Professor of Cancer Research at Vanderbilt Ingram Cancer Center.
As Dr. Winkfield pointed out, the entire health care workforce is facing this same, persistent challenge. A 2021 study that found that, across six health care occupations, from 2000 to 2019, there was little to no increase in Black or Hispanic male physicians and surgeons, pharmacists, and dentists. While women have increased their representation in the workforce, those gains were mostly among white and Asian women; increases among Black and Hispanic women were more modest.1
Even as the population of medical school graduates becomes more diverse, research shows that a large percentage of those graduates go on to practice in primary care rather than medical specialties. For example, a 2012 study published in the Journal of the National Medical Association (JNMA) found that underrepresented physicians, including those identifying as African American, Latino, and Pacific Islander, were more likely to practice in primary care health professional shortage areas than white physicians.2
For oncology, this is a greatly missed opportunity. As Dr. Winkfield noted, diverse teams perform better than homogenous ones. By having a care team that is representative of the patients they treat and that understands their cultural sensitivities, practices can build greater trust with patients and their families, which leads to a better understanding of their patients’ goals, greater patient follow-through on recommendations, and improved conversations around end-of-life care. Physicians from underrepresented racial and ethnic backgrounds are also more likely than white physicians to work in medically underserved areas, according to the same JNMA study, which analyzed California Medical Board Physician Licensure Survey data of 48,388 physicians.2
“Ultimately, it’s about improving patient care. Regardless of which population you’re talking about, whether it’s race and ethnicity, gender, or age, this whole idea of being able to reach the milestones for health care outcomes requires someone who is in tune with the patients that they are seeing,” said Sybil Green, JD, RPh, MHA, ASCO’s chief Equity, Diversity, and Inclusion officer. “So, focusing solely on concordance (patients only seeing physicians whose identity is the same as their own) will not result in equitable care for cancer populations. All physicians must do the work.”
This lack of workforce diversity can lead to real-life issues that hinder care. This includes unconscious bias. For example, a 2018 study found that women of color who missed a mammogram appointment only received two follow-up calls, while white women received at least three times as many.3
“They were reaching out to white women more frequently, even though Black women have worse outcomes and mortality in breast cancer. This is just one example of unconscious bias. It’s likely that there was a wrong belief that Black women are simply not compliant,” said Narjust Florez, MD, a member of ASCO’s Health Equity and Outcomes Committee and associate director of the Cancer Care Equity Program, and a thoracic medical oncologist at the Dana-Farber Brigham Cancer Center. “Having a diverse workforce assures that the patients get culturally sensitive and culturally appropriate care. We need to make sure that we look back 20 years from now and see that we are not where we are today.”
The Oncology Workforce Today
According to the most recent U.S. Census, 13% of the U.S. population is Black or African American and 18% is Hispanic. When compared to cancer care, only 3% of practicing oncologists self-identified as Black or African American and 4.7% of practicing oncologists self-identified as Hispanic. In addition, 2.9% of Americans identify as Native American and Alaska Native (AIAN), but they comprise only 0.1% of the oncology workforce. When broken down by gender, women make up 51.1% of the U.S. population, but only 35.2% of the oncology workforce.4
“We’re not where we should be and where we need to be. By not having a diverse workforce, we’re limiting the talent that we have in the workforce, and we’re cutting out a large part of the population who can really contribute to advancements in oncology and better outcomes,” said 2022-2023 ASCO president Eric P. Winer, MD, FASCO, director of Yale Cancer Center and physician-in-chief at Smilow Cancer Network.
There have been some modest gains to increase the diversity of the oncology workforce. For example, women currently outnumber men in applications to medical schools, and broadly speaking, there is more diversity at the early stages of the medical school pipeline.5
“If you look at the trainees, the residents and fellows that are coming up in oncology subspecialties for the Hispanic population, the numbers are actually really good. We’re looking at closer to 7% to 8% of the trainees being from an Hispanic background. But for Black trainees, the number has really flatlined for the past 30 years or more,” said Dr. Winkfield.
Dr. Florez participated in an analysis of publicly available registries that were used to assess differences among women and underrepresented minority hematology and oncology fellows over the last 10 years. The data presented at the 2020 ASCO Annual Meeting showed that fellows who identify as women, Black or African American, or Hispanic continue to be underrepresented. The study authors called for fellowship programs and national societies to take action to increase the engagement and recruitment of people from backgrounds underrepresented in medicine.6
As a house is built brick by brick, the oncology workforce will have to be diversified one oncologist at a time. In addition, making sure it remains representative of the population will require continued vigilance.
ASCO’s Initiatives to Increase Workforce Diversity
ASCO was founded in 1964 with the goal of exploring and expanding the field of medical oncology, and has been focused on the oncology workforce ever since. As the Society has woven equity, diversity, and inclusion into every aspect of its mission, ASCO’s workforce efforts have expanded from addressing oncology workforce shortages to undertaking efforts to achieve an oncology workforce that reflects the demographics of the population it serves. This is a challenge that cannot be solved overnight, and the Society is committed to this effort for the foreseeable future.
“I think the single most important step we have taken is to shine a bright light on the problem. We’ve identified diversity in the workforce as a major goal for ASCO and are considering this challenge in almost everything we do,” said Dr. Winer.
ASCO released its Strategic Plan for Increasing the Racial and Ethnic Diversity of the Oncology Workforce in 2017, which established short-term goals to enhance existing programs and create new opportunities to move the oncology community closer to the vision of achieving a representative workforce. Specifically, the plan established a longitudinal pathway for increasing workforce diversity, enhanced ASCO leadership diversity, and integrated a focus on diversity across ASCO programs and policies.7
Continuing its commitment, and on the recommendation of the ASCO Board of Directors, ASCO established the Diversity and Inclusion (D&I) Task Force in 2019. This D&I Task Force worked from 2019 to 2021 specifically to devise new strategies to enhance and expand ASCO’s effort to support and engage members underrepresented in medicine across the oncology career spectrum, recognizing the continued efforts required to advance diversity and inclusion in the field. The task force developed a strategic plan focused on:
- Workforce Diversity: ASCO’s efforts to create a diverse workforce through pipeline and professional development programs
- Workplace Equity and Inclusion: ASCO’s role in advocating for change in the workplace
- Diversity Within ASCO: ASCO’s efforts to increase diversity within its membership, committees, and leadership
In December 2021, ASCO built on this strategy by releasing its Equity, Diversion, and Inclusion Action Plan, which recommitted the Society to increasing the diversity of the oncology workforce and set a strategy and metrics for success.8 The Society is making workforce data visible through infographics, reports, and articles like this one to ensure that every member of the oncology community is aware of this issue, and working to inspire people by building up role models to guide future leaders and encouraging its members to take action where they can. In addition, ASCO will continue to build connections with the populations it is trying to help grow and work with other stakeholders to increase the diversity of oncology workforce, at all stages of the pipeline.
“Building on the 2017 strategic plan, which focused largely on race and ethnicity, we’re now moving to a place where we are including women, gender identity, and sexual orientation in our efforts. It is making sure that they have all the same opportunities in terms of training, career development, and advancement that men have,” said Ms. Green.
ASCO has a number of initiatives underway that are intended to create more diverse oncology practices across the country, but there are other efforts that individual oncologists can take at each stage of an aspiring physician’s journey:
How You Can Increase Workforce Diversity in Oncology
While most of the work discussed in this article is happening at the organizational level, individuals in the oncology workforce can do their part as well. Every oncologist has a role to play in creating an inclusive work environment and can offer mentorship to colleagues and students from underrepresented minority backgrounds. Efforts oncologists can undertake include:
- Create an inclusive work environment: This can include conducting implicit bias trainings, gathering and valuing input from all team members, and ensuring that hiring and workplace policies reinforce equitable practices at all levels of the organization.
- Seek out and make available professional opportunities for people in underrepresented groups: Several places to start are with mentorship programs and potential grants and awards, and encouraging early-career physicians to submit manuscripts to scientific publications and abstracts to national medical conferences. It’s also important to step aside at times to provide opportunities for your colleagues to present data, lead research, and more. Their success is your success.
- Make data visible: Transparency is key to achieving diversity. Highlight who is serving on key committees, chairing departments, or leading the practice, as well as who has left the practice. Making this data visible will allow everyone to see disparities, understand trends, and take interventions to address inequities.
- Conduct outreach in your community: Visit schools, colleges, and other organizations to share why a career in oncology is meaningful, how oncologists help patients and their families, and encourage students to consider a job in oncology.
Do you have other ideas for supporting equity, diversity, and inclusion in the oncology workforce? Please share at firstname.lastname@example.org.
Before Medical School
The pipeline to becoming an oncologist doesn’t start at fellowship; it can start 10 to 20 years earlier, with early opportunities and exposure to science and medicine. However, a lack of educational investment in lower socioeconomic communities has played a major role in the dearth of educational opportunities for underrepresented minority students.9
“We know that once a child gets to high school or even college oftentimes it’s too late to recruit them to oncology. Children who attend an under-resourced school that can only spend $1,000 a year on their education may not have the necessary skillsets and background needed for medical school as compared to a child who attends a school that spends $30,000 a year per student,” said Dr. Winkfield.
Decades of longstanding discriminatory, albeit legal, practices have put underrepresented minority populations at a greater educational and financial disadvantage to pursue a career in oncology. For instance, redlining—now prohibited by federal law—allowed banks to refuse loans or insurance companies homeowners’ policies to potential customers who lived in neighborhoods classified as “hazardous” to investment. This practice historically excluded many minorities from living in more affluent areas, steering children away from high-performing schools and making it nearly impossible to access high-quality early childhood education, which is where science education really needs to begin.
For many students from historically marginalized communities, undergraduate education is too costly. When students are priced out of undergraduate education, they are cut off from the schooling needed to become an oncologist.
“Increasing the diversity of the oncology workforce is a pipeline issue. Until something changes in the early stages of the pipeline, it will be hard to see a big impact,” said Jamie H. Von Roenn, MD, FASCO, ASCO vice president of Education, Science, and Professional Development.
While ASCO does not yet have specific programs in place to reach students in elementary, middle, or high schools, individual oncologists and practices can make a difference in their own—or neighboring—communities.
“One of the things that we can do individually as cancer care providers is make sure that we are out in the community and being seen. It can be just showing up at a church or another local venue and talking about what it means to be an oncologist, or the need for diversity in the oncology workforce,” said Dr. Winkfield.
Dr. Blue grew up in Tampa Bay, where he currently practices. Having already known many of the kids in his community, as well as their experiences, he takes time to talk with them about his role as a cancer doctor and to try to direct them toward a career in medicine. “I’m trying to reach out to middle schoolers and high schoolers to get them into college. If they get into college and have an interest in science, engineering, or math, then they’re more likely to pick medicine-based careers,” he said.
The Medical School Pipeline
Once a student goes to medical school, they are embarking on arguably the most rigorous journey in academia and will need support. In fact, they will need advice and guidance at every rung of their career ladder, especially from someone who has had a similar experience or background—or looks like them. Unfortunately, as with the health care workforce, medical schools may be missing an important opportunity to provide physician mentors and role models to students from underrepresented populations:
Underrepresentation in Medical School Faculty
Research on medical school faculty found:
- Women’s representation among clinical faculty grew from 14.8% in 1977 to 43.3% in 2019*
- Women serving as deans went from 0 to 18.3% in the same period*
- Additional research found only 4% of medical school faculty identify as racial or ethnic minorities†
Michael Martinez, a physician-scientist in an MD/PhD program at Stony Brook University who has the goal of becoming an oncologist, is experiencing this firsthand. The son of two parents who immigrated to the United States from South America, Mr. Martinez grew up in low-income housing and was the first in his family to graduate from college. He went to college on a soccer scholarship with the hope of becoming a nutritionist, but a biology professor was impressed with his ability and suggested he explore a career in medicine.
In medical school, however, he has yet to meet or learn from anyone who looks like him. In a recent JCO Oncology Practice editorial, “Do I Belong,” Mr. Martinez described seeking professional guidance, but found that many did not have the same experiences that he did, so he had to tailor their advice to succeed. As he said in a separate interview, this makes the proverbial white coat feel a bit heavier.10
“There are two things that make the white coat feel heavy: how I view myself compared to my colleagues, and how I think my patients view me because I don’t look like my colleagues. More Latino representation is needed to change that,” said Mr. Martinez.
Even though he has not yet received his medical degree, Mr. Martinez is already taking steps to address the lack of diversity in medicine.
“The first thing I did was establish my school’s first chapter of the Latino Medical Student Association. I’m also seeking mentorship opportunities where I can inspire students like me to pursue medicine and/or science,” he said.
In carrying out its workforce diversity plan, ASCO has expanded and restructured its professional development opportunities to incorporate a focus on bringing people from underrepresented minority backgrounds into oncology. These programs and offerings aim to point medical students towards the oncology pipeline, or at the very least, make sure they know it exists. The programs include a diversity mentoring program, an ASCO Annual Meeting Research Award, and an Oncology Summer Internship program, which offers medical students from populations underrepresented in medicine an intensive oncology-immersion experience.
Even if participants don’t become oncologists, participation in these programs could help them understand the needs of patients with cancer and cancer survivors in other medical settings. For example, a primary care physician’s work will include cancer prevention, while an orthopedist will treat survivors who experience skeletal-related events associated with chemotherapy.
“The Oncology Summer Internship is a great program that provides students with access and exposure to oncology early in their medical training, and allows them to interact with people with similar backgrounds. For many of these students, this is the first time they have ever seen the inner workings of cancer care,” said Dr. Florez. “Our hope is that this and other programs will inspire them so they seriously consider a career in oncology.”
Creating and Maintaining Diversity at the Top: Retention and Career Growth
When a medical student completes their training and enters the oncology workforce, they will find a workforce that has become aware of its lack of diversity and is taking steps, some facilitated by organizations like ASCO, to change. Nevertheless, the majority of oncology practices and cancer centers are still led primarily by white men.
A 2021 retrospective cross-sectional study on representation in leadership positions at 63 National Cancer Institute (NCI)-designated cancer centers found that non-Hispanic white men were disproportionately represented in leadership positions compared to the U.S. population and 82.2% of all leaders were non-Hispanic white individuals. In addition, 23 NCI-designated cancer centers did not have a single Black or Hispanic member of their leadership team and eight had an entirely non-Hispanic white leadership team.11
“The lack of representation compounds the lack of equity in the oncology workforce. Men and people who are not from underrepresented minority backgrounds don’t automatically see inequities in the workforce. They don’t experience it, so it’s harder for them to see,” said Dr. Von Roenn.
ASCO has made a concerted effort within its own ranks to enhance leadership diversity. For example, the Nominating Committee has and is continuing to identify leadership from underrepresented backgrounds, an effort that has resulted in the Society currently having the most diverse Board of Directors in its nearly 60-year history. This has led to better and more productive discussions among leaders of the organization.
“When ASCO says it wants guidance, it is sincere and follows through. In 2017, we called for oncology organizations to lead by example in having diversity at the leadership level and ASCO came out responding like gangbusters,” said Dr. Winkfield, who is also an ASCO Board member.
Even with efforts to diversify, employee retention remains a challenge in medicine. A recent survey found that 20% of women in academic careers are likely to leave the field in the next five years, most likely because they feel that they are less likely to be promoted.12 These figures are even worse for people from underrepresented minority populations where barriers to staying in the health workforce include lack of mentorship, promotion denial, and work environments and infrastructures that have not overcome racism and sexism.13
Dr. Florez said she is aware that her Venezuelan accent—not her record or experience—is the first thing her patients notice. She has also had to deal with patients who question her understanding of cancer or assume she is part of the cancer center’s custodial crew. She said other colleagues who face these same issues may leave patient care to improve their own quality of life and minimize the number of microaggressions they face.
“Would you stay in an environment that continues to remember that you are an outsider or different?” she asked. “If you face that every day in clinic and you don’t have enough resilience, then a private pharmaceutical company comes and says they are going to increase salary and potentially your daily struggles with discrimination will decrease, which route will you take? The decision often boils down to self-preservation.”
To give newer Latina oncologists the additional support needed to help them stay in the workforce, Dr. Florez and Gladys I. Rodriguez, MD, a medical oncologist with the START Center for Cancer Care and ASCO Board member, started The Women Who Conquer Cancer Young Investigator Award (YIA) for an outstanding Latina researcher. They conducted a grassroots effort to award one YIA in 2021 and have raised enough money to give out two YIAs in 2022.
“ASCO and Conquer Cancer have worked with us to fund these awards. These are the types of interventions that will support Latina oncologists and encourage them to stay in the workforce,” said Dr. Florez.
Building Cultural Humility for All Oncologists
Even if the oncology community is successful in creating a workforce that looks like the patients it serves, not every patient will see an oncologist who is the same gender, race, or ethnicity, or has the same sexual orientation or gender identity. It is imperative that all members of the cancer care delivery team understand and address the social determinants of health, and other factors that directly impact treatment outcomes, including factors such as socioeconomic status, transportation needs, employment challenges, and caregiving concerns. Becoming culturally humble—which involves working to understand the values and challenges different populations face, as well as one’s limitations in cultural competency—is also key.
ASCO is taking steps to ensure that every oncologist, regardless of background, has the ability to provide high-quality, equitable, and culturally sensitive cancer care for each and every patient. It has developed resources to help build a workforce that is equipped to care for all patients, including a podcast series on social determinants of health and a modular digital edition course on cultural humility. ASCO, in collaboration with the Association of Community Cancer Centers (ACCC), also recently released a research site assessment tool and implicit bias training focused on addressing the systemic areas and implicit bias that limit equity, diversity, and inclusion in clinical trials participation.
Long term, diversifying the oncology workforce will also elevate the field and improve the understanding of disparities in cancer. In addition to inspiring children, adolescents, and young adults to consider a career in medicine or oncology, underrepresented health professionals have consistently been more likely to deliver health care to the underserved,2 and many conduct research on disparities and equity.
This is true of Dr. Blue, who recently presented a study on socioeconomic and racial disparities in chimeric antigen receptor T cell (CAR-T) therapy at the 2022 American Society for Transplantation and Cellular Therapy Conference.14 He is continuing to explore causes and interventions, and he said that none of this would have been possible if ASCO had not reached out to him when he was a resident.
“For someone like me who was the first doctor in the family, who is a minority, and who really wanted to just help people, ASCO gave me the assistance I needed to not only be an oncologist, but to be active in research too. These were things that I didn’t have exposure to, and I will be grateful and thankful to ASCO forever,” Dr. Blue said.
- Ly DP, Jena AB. Trends in Diversity and Representativeness of Health Care Workers in the United States, 2000 to 2019. JAMA Netw Open. 2021;4:e2117086.
- Walker KO, Moreno G, Grumbach K. The association among specialty, race, ethnicity, and practice location among California physicians in diverse specialties. J Natl Med Assoc. 2012;104:46-52.
- Ruddy KJ, Sangaralingham L, Freedman RA, et al. Adherence to Guidelines for Breast Surveillance in Breast Cancer Survivors. J Natl Compr Canc Netw. 2018;16:526-34.
- 2021 Snapshot: State of the Oncology Workforce in America. JCO Oncol Pract. 2021;17:249.
- American Association of Medical Colleges. 2021 Report on Residents. Available at: https://www.aamc.org/data-reports/students-residents/data/report-residents/2021/executive-summary.
- Velazquez Manana AI, Leibrandt R, Duma N. Trainee and workforce diversity in hematology and oncology: Ten years later what has changed? J Clin Oncol. 2020;38:15s (suppl; abstr 11000).
- Winkfield KM, Flowers CR, Patel JD, et al. American Society of Clinical Oncology Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce. J Clin Oncol. 2017;35:2576-9.
- American Society of Clinical Oncology. ASCO’s Equity, Diversity, and Inclusion Action Plan: A Legacy of Commitment, A Future of Promise for All Individuals with Cancer. Dec 14, 2021. Available at: https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy/documents/2021-ASCO-EDI-Action-Plan.pdf.
- Baker BD, Weber M, Srikanth A, et al. The real shame of the nation: Causes and consequences of interstate inequity in public school investment. 2018. Newark, NJ: Education Law Center of New Jersey & Rutgers University. Available at: https://www.shankerinstitute.org/sites/default/files/The%20Real%20Shame%20of%20the%20Nation.pdf.
- Martinez MA. Do I Belong? JCO Oncol Pract. 2022;18:378-9.
- Morgan A, Shah K, Tran K, et al. Racial, Ethnic, and Gender Representation in Leadership Positions at National Cancer Institute-Designated Cancer Centers. JAMA Netw Open. 2021;4:e2112807.
- Merfeld EC, Blitzer GC, Kuczmarska-Haas A, et al. Women Oncologists’ Perceptions and Factors Associated With Decisions to Pursue Academic vs Nonacademic Careers in Oncology. JAMA Netw Open. 2021;4:e2141344.
- Garran AM, Rasmussen BM. How Should Organizations Respond to Racism Against Health Care Workers? AMA J Ethics. 2019;21:E499-504.
- Blue B. Socioeconomic and Racial Disparity in Chimeric Antigen Receptor T Cell (CART) Therapy Access. Transplant Cell Ther. 2022;28:345-6.
* Kamran SC, Winkfield KM, Reede JY, et al. Intersectional Analysis of U.S. Medical Faculty Diversity over Four Decades. N Engl J Med. 2022;386:1363-71.
† Wilbur K, Snyder C, Essary AC, et al. Developing Workforce Diversity in the Health Professions: A Social Justice Perspective. Health Professions Education. 2020;6:222-9.