By Richard L. Schilsky, MD, FACP, FSCT, FASCO
After a year like no other in living memory, we honor this 21st World Cancer Day with a continuing commitment to tackling challenges in cancer care together because, as exemplified by the SARS-CoV-2 pandemic, our collective actions matter in advancing science, delivering care, and protecting public health.
Working to provide high-quality care while protecting patients and care teams, physicians have faced both drug and equipment shortages at various points during the pandemic. Alarmingly, many newly diagnosed patients with cancer have had delays in beginning treatment, and those without cancer have delayed or skipped critical cancer screenings. Data from ASCO’s 2020 National Cancer Opinion Survey revealed that of Americans scheduled for a cancer screening test, two-thirds reported that it was delayed or cancelled.1 This means that down the road, we’re likely going to diagnose more late-stage cancers that are harder to treat.
Physicians, researchers, and patients also have witnessed interruptions in clinical trials. Although most patients already enrolled in clinical trials have been able to continue their participation, COVID-19 has caused massive disruptions to clinical trial enrollment and the launch of new trials. Many research sponsors observed a 40% to 50% decline in trial enrollment as many research institutions temporarily halted patient recruitment. As the cornerstone of progress against cancer, disruptions to the clinical trial enterprise will likely delay future advances while also preventing patients from receiving promising new therapies now.
As clinical trials begin enrolling again and as new ones are initiated, all members of the oncology community should work together to make trial participants reflect the population of patients with cancer. In the United States, although most patients express a willingness to participate in clinical research, only approximately 8% of adult patients with cancer enroll in cancer clinical trials,2 and the percentage of minorities participating is, overall, much lower than their representation in the general population. Racial and ethnic minorities, sexual and gender minorities, and older adults are all significantly underrepresented in clinical trials despite cancer incidence and mortality rates that are often equal to or higher than those of the general population.3
To change course and make clinical trials better reflect the population with cancer, we are encouraging research institutions, trial sponsors, and regulators to make the clinical trials system more resilient and more accessible to patients by: continuing remote and virtual approaches to consent and other procedures and better integrating trials into routine cancer care; streamlining and standardizing regulatory and training requirements and using central Institutional Review Boards and innovative trial designs; and cross-training research teams so that key functions can be led by various team members and sustaining pandemic-era flexibility for site selection, initiation, and data collection.4
The global pandemic also revealed and amplified inequities in all aspects of society, including health care, and highlighted them through disparate outcomes in patients from various subsets of the population.
Emerging data from the United States, the United Kingdom, and Nordic and Asian countries show that ethnic minorities have greater risk of infection with and death from COVID-19, exemplifying the global nature of the problem of health disparities.5
Here in the United States, ASCO reported on both perceptions of disparities—that six in 10 Americans (59%) believe racism can impact the care a person receives within the U.S. health care system, with differences in opinion along racial lines1—and research from its CancerLinQ database showed that Black and Hispanic patients with cancer were more likely to be infected with COVID-19 than white patients.6
This year’s Clinical Cancer Advances 2021 report, published February 2, focuses on disparities in cancer care and, for the first time, includes a chapter devoted to health equities, both the challenges that we face and the opportunities for improvement and greater inclusion. This chapter applies to all of the most important developments in cancer care in the past year, including progress in bringing targeted therapies to patients with earlier-stage disease; biomarker-driven treatment approaches that offer more personalized care for patients with lung, colorectal, and gastric cancers; using combinations of therapies to extend survival without increasing toxicity; and, the advance of the year, molecular profiling as a driver of progress in gastrointestinal cancers.
Post-pandemic, to get patient care back on track and continue our mission to improve the quality of care for all people with cancer, we must act together to make cancer care and research opportunities more accessible to and equitable for patients in every community.
To help guide this process, ASCO has developed recommendations that apply lessons learned during the pandemic, Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care, which were published in December 2020. The goal is to address longstanding obstacles to high-quality cancer care that have been highlighted by the pandemic so cancer care does not return to pre-pandemic practices but leverages the pandemic experience to implement something better: more accessible, efficient, and affordable care for every patient. The recommendations fall into two broad categories: clinical cancer research and cancer care delivery. For clinical cancer research, ASCO calls on research institutions, trial sponsors, and regulators to make the clinical trials system more resilient and flexible and more accessible to patients. For cancer care delivery, ASCO calls on policymakers, payers, clinicians, and others to build on strategies that have helped to meet patients’ most urgent needs in the worst of the pandemic.
If we can achieve an accurate representation of patients with cancer in research, we can unlock its full potential for the benefit of all patients, present and future.
Together, we can work for a better, more inclusive and diverse oncology care system than we had before the pandemic as we continually strive toward our vision of a world where cancer is prevented or cured and every survivor is healthy.
Dr. Schilsky is ASCO's chief medical officer and executive vice president. Follow him on Twitter @rschilsky. Disclosure.
- American Society of Clinical Oncology. 2020 National Cancer Opinion Survey. Oct 9, 2020.
- Unger JM, Vaidya R, Hershman DL, et al. Systematic Review and Meta-Analysis of the Magnitude of Structural, Clinical, and Physician and Patient Barriers to Cancer Clinical Trial Participation. J Natl Cancer Inst. 2019;111:245-55.
- American Society of Clinical Oncology. Improving Diversity in Clinical Trial Participation. Policy Brief. October 2020. Available at: https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2020-CTDiv-Brief.pdf. Accessed Jan 12, 2020.
- Pennell NA, Dillmon M, Levit LA, et al. American Society of Clinical Oncology Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care. J Clin Oncol. 2021;39:155-69. Epub Dec 8, 2020.
- Yaya S, Yeboah H, Charles CH, et al. Ethnic and racial disparities in COVID-19-related deaths: counting the trees, hiding the forest. BMJ Glob Health. 2020;5:e002913.
- Potter D, Riffon M, Kakamada S, et al. Disproportionate impact of COVID-19 disease among racial and ethnic minorities in the U.S. cancer population as seen in CancerLinQ Discovery data. J Clin Oncol. 2020;38 (suppl 29; abstr 84).
- American Society of Clinical Oncology Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care
- ASCO Policy Brief: Improving Diversity in Clinical Trial Participation
- Cancer Disparities and Health Equity: A Policy Statement From the American Society of Clinical Oncology
- Clinical Cancer Advances 2021
- For Your Patients: Progress in Treating GI Cancers Through Molecular Testing
- ASCO Equity in Cancer Care & Research Resources Page