Key Steps to Reduce Racial Cancer Disparities Include Supporting Minority Scientists, Diversifying Medical Schools and Clinical Trials

July 15, 2020

Today, The American Journal of Managed Care® is speaking with 2 experts to discuss the root causes of racial inequities in cancer care. Dr John Carpten, professor at the University of Southern California Keck School of Medicine, outlines what needs to happen to improve cancer outcomes for minority populations and support minority scientists, and Dr Russell Ledet, president of The 15 White Coats and medical student at Tulane University School of Medicine, explains the steps to breaking down the barriers to medical school for those from marginalized communities.

Today, The American Journal of Managed Care® is speaking with 2 experts to discuss the root causes of racial inequities in cancer care. Dr John Carpten, professor at the University of Southern California Keck School of Medicine, outlines what needs to happen to improve cancer outcomes for minority populations and support minority scientists, and Dr Russell Ledet, president of The 15 White Coats and medical student at Tulane University School of Medicine, explains the steps to breaking down the barriers to medical school for those from marginalized communities.

AJMC®: Welcome. Can you introduce yourself and tell us about your work?

John Carpten, PhD: Hi, my name is John Carpten, professor and chair of the USC Department of Translational Genomics. I’m also program co-leader for the Norris Comprehensive Cancer Center, Translational and Clinical Sciences Program. My research interests primarily center around human genetics and genome science.

Throughout my career I’ve had a strong focus in the area of cancer research, including cancer genomics, cancer cell biology, precision oncology, and I’ve also spent a large portion of my career trying to understand what we tend to consider or call cancer disparities, which are cancers that disproportionately affect underrepresented minorities and the medically underserved.

AJMC®: What are some root causes of racial inequities in cancer care?

Carpten: Some of the root causes of inequities and cancer care, again when we look at underrepresented minorities or the medically underserved, tend to sort of center around socioeconomics and limitations in access to quality health care. A lot of this, of course, is due to systematic racism, which has sort of created this built environment, this environment that many individuals, particularly those from underrepresented communities, reside within, where there’s limited access to quality care, there’s no strong focus on actual health care itself, on being a healthy individual. When we think about access to detrimental environmental factors, you think about certain areas where you see a significant increase in signs for cigarette smoking, signs for alcohol, and so this built environment that many individuals live in contributes significantly to these inequities that we see in health care, particularly cancer care.

Of course, the financial issues, financial toxicities, when we think about something like cancer care, can be typically really expensive. And so when we think about access to the best diagnostic methods, the best treatment options, in many cases, those things are dictated by access to private insurance or access to specific types of insurance or access to significant financial resources, which we know in many cases are not in alignment with these communities and these population. So a lot of this is socioeconomics, financial issues, financial toxicities. And then I think, of course, a lot of this is brought about through just sort of overall systemic racism and social injustices in America. I think we should also consider additional issues, when we think about these sort of inequities that we see, that again are just related to aspects, just the overall systematic limitation in resources, right, overall resources in general, play a huge role. Now, I think we can also point to policy, and the lack of push towards policies that will sort of lead to improvements in these environments and in these communities, which could then perhaps turn the table and provide individuals with the type of health care that they deserve as citizens of this country.

AJMC®: How do racial inequities in research lead to disparities in outcomes and mortality?

Carpten: So racial inequities in cancer research, right, also contribute to some of the differences we see in incidence and outcomes. When we think about cancer and we think about cancer disparities, I think there are a number of things that we can point to. I think one is sort of this whole issue with a lack of diversity in clinical trials. I think that’s one place where we can start, where many of the therapies that are developed, whether they’re therapeutic modalities that are based on sort of improving standard of care in combination with chemotherapy, or whether they’re clinical trials to test some of the latest and greatest types of cancer therapies. In many cases, we know throughout the continuum of clinical development from the model systems that are used for early testing of these agents in animal systems, the actual tumors that are growing in the mice are typically not derived from a diverse collection of individuals. Most of the tumors are going to be derived from individuals of largely European descent, and then we move on to phase 1 clinical trials, which are small trials, typically, that are in most cases going to take place within cancer centers, academic medical centers, and in many cases, the patient populations there are just not diverse at all. And then of course, we move on to the phase 2 and phase 3, the larger trials, those trials that actually are going to be those definitive clinical trials that are going to lead to an FDA approval.

We know that particularly when we look in cancer, the overall number of underrepresented minorities in those trials is infinitesimal and this is even for cancers that have known disparities and incidence and outcomes: prostate cancer, triple negative breast cancer, colorectal cancer. We see typically numbers below 5% and sometimes below 3% in terms of the sort of the minority individuals that make up the clinical trial cohorts. So I think that that’s one of the big problems.

And just to expand on that just a little, I think we don’t necessarily have to look at it as “Oh, we, we want to diversify the trials just because we want more minorities.” I think we have to look at it from the standpoint that by diversifying the cohort, we learn more about the efficacy of the therapy, right, or perhaps the toxicity profile. We shouldn’t have to wait until the drug is approved and then used in practice to say, “Oh, we see a difference in sort of toxicity profile or we see a difference in the effect of this drug across different populations.” That should be built into the trials and from my perspective, by diversifying trials, we help everyone, right.

It’s not just diversifying trials just so that we can potentially help individuals from these underrepresented minority populations, but by studying a sort of broader group of patients from the standpoint of populations, communities, perhaps we gain a broader breadth and depth of the activity of that therapy when it’s being used to treat patients with cancer. So I think that whole concept of lack of diversity in clinical trials is one of the things that hampers our ability to really eliminate and deal with some of these disparities.

I think the same thing can be said for the tools and the reagents that we use in biomedical research to understand the biology of cancer. Again, going back to some of the comments I made about clinical trials, the model systems that we use, the cell lines that we use, in many cases, are cell lines that are not diverse. They weren’t derived from individuals from diverse backgrounds. So the understanding of the biology of cancer tends to be derived from a relatively homogeneous set of reagents. And so expanding the diversity in the biological reagents that we use for cancer research, again, could broaden our understanding of cancer and get us away from this concept of generalization if we, whatever we understand here is going to generalize over here, and that may not necessarily always be the case. I think we also see this in, for instance—I have a tremendous amount of interest in cancer genomics and genome science—and so one of the other things we know is that many of the large genetic and genomic studies that have been performed to try to understand the genomic alterations and changes that occur in cancer. Many of the tumors, again, were derived from largely European individuals. And we know that the diversity of those biomedical research cohorts is also significantly limited, again, even when we think about tumor types that disproportionately affect African Americans, Black and Brown people, Hispanic Latinos, and so on and so forth.

So, thinking about clinical trials, thinking about these research reagents, and then finally, the workforce, right. We know that there has been a significant limitation in the numbers of underrepresented minority faculty members at large academic medical centers, where a lot of the health care innovation occurs. And then we can continue to move back in the career path trajectory as we go back to the early stage scientists, the postdoctoral fellows, the graduate students, undergrads, and then even high school students, right, who have access to internships in STEM [science, technology, engineering, and math] related fields. We know that there are disparities there, and so if we don’t break down those barriers, we’ll continue to have this relatively homogeneous, relatively nondiverse workforce, and so that also plays a huge role in the disparities. I think that we can point to a number of areas where that can impact, but when we think about things like having access to, for instance, patient navigators or having access to individuals who work in the health care system, who can help provide and communicate most effectively with patients to educate them to help them better understand their particular medical issue, can better help them better understand their diagnosis or the various treatment options. So because we have this workforce that’s relatively homogeneous, and we really need to do a better job of diversifying our workforce. All of these things, I believe, play a significant role in cancer disparities.

AJMC®: Are there any other things that need to happen in order to improve cancer outcomes for minority populations?

Carpten: Well, I think one of the main things, and without a doubt, even though my focus is biology and trying to understand the biological factors that are driving these disparities, I think it all starts with policy. It all starts with sort of resources and access to resources, right, and equal access to resources. And, so, of course, you know, we have to get out and vote, we have to lobby our Congressmen, we have to work with patients, patient advocates, right, who have relationships with those individuals who actually can create and change policy. I think that that to me is first and foremost. Again, I think, going back to the whole concept of doing a better job of diversifying the workforce, I think that’s another huge issue. When we look back over time, we’ve made some progress, but the progress definitely hasn’t been substantial enough, where we can really say that we’ve made a significant difference. Policy is a big deal. I think one of the other things is bridging disciplines, so bringing together individuals from various disciplines and creating transdisciplinary and multidisciplinary research programs where we bring in individuals who study the environment or environmental factors, individuals who study social stressors in the built environment, and how the environment and the societal pressures can impact physiology in a negative way, such that it sort of breeds an internal host environment, that if a cancer manifests, it’s in the perfect environment to thrive. And so I think the whole concept of interdisciplinary and transdisciplinary research will probably be part of the answer. And we have to break down the barriers, break down the walls, and break down the silos, and begin to work together and come up with novel study designs that bring to bear various disciplines to address these issues.

AJMC®: What specifically can cancer research centers do to support the needs of minority scientists?

Carpten: So, one of the biggest issues in terms of cancer centers and minority scientists is that there just aren’t enough of us. I think we can look at this in 2 ways. We can look at it from the standpoint of the pipeline, right, and really working harder to increase the size of that pipeline—providing the types of educational programs for underrepresented minority students to get access to innovation, to be involved in innovation, to be a part of innovation.…And I think one of the problems is when we see many of these programs, in many cases, the students are separated, right? You may have a special program for underrepresented minority students, but you don’t have mainstream students involved, right, so we tend to see these siloed programs. I think we need to develop programs where the students are all working together and learning how to collaborate and how to communicate with each other, and how to come up with innovative and novel ideas on how to solve problems. So I think coming up with better ways to build a more robust and effective pipeline, so that we can feed the students into the process, but I think we also have to look at the back end of the pipeline when the students become graduate students, and then postdoctoral fellows or faculty members, that we provide the type of environment to support their career development, again at the fellowship level, as well as at the faculty level, that they have the appropriate mentoring in place, that they have the appropriate role models in place, that resources are available for them to support their careers. So, we have to work on building a more robust pipeline, but at the same time, we have to ensure that the appropriate environments are being created in those cancer centers to support retention of the faculty that we hope to recruit into these centers.

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AJMC®: Can you introduce yourself and tell us about your work?

Russell J. Ledet, PhD: Yes. So my name is Dr Russell Joseph Ledet. I’m currently the president and cofounder of The 15 White Coats. And I’m also a third-year MD/MBA student at Tulane University School of Medicine and Freeman School of Business, respectively. I live here in New Orleans with my wife and 2 children.

AJMC®: Great. Can you tell us about how The 15 White Coats evolved from a photo into an organization with a larger mission?

Ledet: Basically, The 15 White Coats was formed after a very unique experience happened between my daughter and I. So essentially last summer, my very best friend came down to visit me from New York. He was getting his PhD at the same lab as I, and so we both went to historically Black colleges and universities—he went to North Carolina A&T and I went to Southern University in Baton Rouge, Louisiana—and so Black history is important to us. And so when he came down to visit, and we decided to go to the Whitney Plantation, and I brought my daughter along, and it’s about 45 minutes outside of New Orleans, so on our ride back, about 15 minutes down the road, my daughter sort of interrupted me and asked this question, she was just like, “Dad, you know, it’s interesting that we just left a plantation, and, you know, I’m riding in the car with 2 Black doctors.” And I’m like, “Well, why is that such a big deal?” And she’s like, “Well, just think about it.” Like there was a time when we couldn’t do that. There was a time when we couldn’t be lawyers, accountants, firefighters, any of those things, right? So she really understood the moment and also the historical context. And so, essentially, from that, I looked over and I was like, Yeah, I got an idea….I think we should get together a couple of my Black classmates, and we should go and take a photo.

Obviously, there was more to it than just taking a photo. There was also the experience itself. And so, after we had this experience, and we took these photos, the idea behind the photos was for us to capture just how far we’ve come, and even more so our resilience with coming back from that. And so we released those photos, those photos got a ton of attention, and because of that, we realized that we had an opportunity to leverage that attention for good. And so, because of that, we formed the company and the idea behind the company was to promote cultural imagery and learning spaces, because we realized, it’s kind of hard to be something that you’ve never seen before. Right, that’s half the challenge. And the other part is too that it was kind of like, we’ll get past these issues anyway. Like, we’ll get past these circumstances, the systemic racism, institutional racism, systemic oppression, like we’ll get past it anyway, and we’ll still get to where we want to be, because, I mean, everyone’s knowledgeable of the esteem doctors are held to in the United States specifically. And so I think that’s what really captivates a lot of people’s attention is that they saw 15 budding, bright minded student physicians, and they just so also happened to be Black.

So that was really captivating for a lot of people, and because of that we formed the organization. We put the photo up in classrooms around the country. We sell the photos, and nobody earns any of money from the from the proceeds; we take all of that and put it towards scholarships for minorities applying to medical school, high schools, students graduating high school, medical students, and we also use the money obviously to buy more posters to send out to classrooms, so schools can go to our website, sign up for a poster, and we’ll mail it out to them for free.

AJMC®: What are your hopes for the organization?

Ledet: Yeah, so the hope for the organization is for us to eventually be able to pay for someone’s medical school, specifically someone from the minority community, to raise enough money to offset some of the costs that come with applying to medical school. You know, if you take into account the historical economic perspective for marginalized communities, we know that those communities are well behind in terms of opportunity to gain wealth, opportunity to maintain wealth, especially with things like the Tulsa, Oklahoma, massacre and things of that nature, we know of all the situations in which even when marginalized communities tried to gain wealth, it was stifled. So we have to do something to try to offset that economic barrier. People don’t even know how much it costs to apply to medical school; in general, costs between $3500 and $10,000. That’s a lot of money just to apply. So if you take that into account, right, and then you take into account a lot of your students are already in debt from undergrad, where you can come up with that kind of money from? And so we want to try to take some money that we have and alleviate some of those costs. Then the other part of it, too, is that once you get into medical school, there are a lot of costs that come with being in medical school, whether it be some of the learning platforms you need in order to learn the material you need for school, or having professional attire, living costs, all these things. And so that’s really our hope is to try to offset some of the economic burden, specifically for marginalized communities, when it comes down to the medical school process.

AJMC®: What’s the importance of representation in the media for young Black children and teens, especially in a field like medicine?

Ledet: Yeah, I think the importance of representation is multipronged, obviously. I think if you think about it, just from a visual perspective, the reason why a lot of people especially, you know, Black men can aspire to be great basketball players, is because we’ve had so many Black great basketball players. If we never saw them, it’d be kind of hard for us to imagine it, right. It’s the same thing in medicine. We need to see representation in order for us to see to this even possible. I’ll never forget, I had this one experience. I was shadowing a child psychiatrist. And he went to go get a patient, a young African American boy, and when the young boy walked into the room, his eyes just lit up. It’s like he, I don’t know, it’s like he saw Jesus or something. And he sat down, and I knew why he was looking at me like that. Because he probably had never seen, you know, a Black male who looks like me with the hair, beard, in a white coat or sitting in a room, you know, almost as if to say, like, do you belong here? Like, are you supposed to be here? Is it okay for you to be here? And I finally got an opportunity to talk to him, and he just poured out his life in front of me. And so I think that representation goes far, just from a visual perspective, but I think there’s an underlying experiential perspective. We know that representation matters in terms of how the doctor’s visit will go, and because of the cultural understanding that that is very possible in an environment where there is some sort of congruency in experiences as well as a culture. So, that's not a secret.

And then more so I think, you know, if you take into account the history of medicine and marginalized communities, it’s not pretty, right. I think her name was Harriet Washington, wrote the book, The Medical Apartheid, and she talked about the atrocities that have happened for a lot of medicine to progress. And now this was done on the backs of a lot of Black people, a lot of the experiments, a lot of these falsehoods that are out there that Black people experience less pain. The experimentation has been done on Black folks for eons of time have contributed to some mistrust, right, and so how do we try to overcome that, or at least to some degree, try to fix it? You got to have some people who understand the history, some people who understand the culture, but also some people who have come from those communities, providing care, because they know they know their people, they do, they genuinely do. And so accessibility in the medical school will help with that, and also accessibility when it comes to positions of influence and power within medical schools, within academia, within hospital systems. It’s not just medical school; it’s got to be institutional change at a lot of different levels. Obviously, with me being in med school, my interest right now is med school, but I’m certain that will change over time, and it will expand.

AJMC®: So what needs to happen in order to change to break down these barriers to medical school?

Ledet: Right, so I think there are a couple things that need to happen for accessibility to medical school. I think you need to get some different people selecting who goes to med school. I think you have to get some people in the room who value people from minority communities as people, and not just because they’re trying to fill a quota, but because they genuinely value their culture, their experiences, what they bring to the table, and they’re willing to institute antiracist policies that kind of go against has been done for a long time. And I always say this because we, as a human race, we have accomplished some very lofty feats. Some very lofty goals like sequencing the human genome, identifying PD-L, PD-L1 as therapeutic targets for cancer. We’ve done a number of things that were absolutely incredible and pushed humanity forward. I think we can achieve true diversity and inclusion, because we can’t forget about the inclusive piece, by relearning a lot of things, unlearning some things that we utilize the status quo for how we go about selecting people for medical school, but also learning new ways to value people as people. And I talk about this inclusive piece because, you know, it’s no point in you recruiting me if you’re not going to include me. So if you’re going to bring me to your building, but then it’s clear that I’m not welcome, but you’re kind of doing it to check a box, I mean, am I really gonna want to stay there? And even if I get through, am I really gonna want to contribute afterwards? Most likely not. And so, I think another big piece to changing the paradigm is changing the culture. I think it says something that a lot of faculties in general may have 1 or 2 Black people on the faculty. That’s not good. Like, that’s just fundamentally not good. If you’re graduating a lot of Black medical students, don’t you think you should have more Black faculty? I mean, you’re producing doctors, you should be getting them back, or you should be getting some from somewhere, and so that speaks to culture. I heard Roland Martin talk about something this morning with ABC, and one of the issues was it was a culture problem. And I will say that there are some cultural issues in medical school around there not being enough antiracism being taught.

So I think that that’ll help. Definitely the economic piece, definitely getting the right people in the room to choose who should who should be in a medical school class, and lastly, the culture. The culture needs to be overhauled, not just fixed, it needs to be overhauled. We need to be teaching about medical apartheid, and the history of how obstetrics and gynecology moved forward, how pain management moved forward, how all these different fields like surgery moved forward, and the ugly history behind it. Because if you aren’t teaching doctors that or if you aren’t teaching student physicians that, then when are they going to learn it? When they get into their specialty? No, they’ll be too busy. So you’ve got to teach it to them at the foundation of their medical school education.

AJMC®: Right. That’s the end of my questions. Was there anything else you wanted to add?

Ledet: If you want to check out The 15 White coats, you can check us out on Instagram, Twitter, or Facebook at The 15 White Coats, or you can check out our website, the15whitecoats.org. And we’ll always speak truth to power.

AJMC®: Great, thanks so much for taking the time to speak with us.

Ledet: No problem at all.