Health Disparities and Cancer Clinical Trials, with Petros Grivas, MD, and Edith P. Mitchell, MD, FACP

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors who care for people with cancer. The purpose of this podcast is to educate and to inform. This is not a substitute for professional 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. Cancer research discussed in this podcast is ongoing, so the data described here may change as research progresses. Cancer does not affect all people equally. Some groups of people, including racial and ethnic minorities, poor people, sexual and gender minorities (LGBT+ people), adolescent and young adult populations, and older adults, are more likely to be diagnosed with cancer, or have poorer outcomes. This is known as “health disparities.” In today’s podcast, Dr. Petros Grivas and Dr. Edith Mitchell discuss health disparities in cancer clinical trials, why it is important for clinical trials to be inclusive, and resources for people with cancer who face barriers to care. Dr. Grivas is the clinical director of the Genitourinary Cancers Program at University of Washington Medicine, and an associate member of the clinical research division at the Fred Hutchinson Cancer Research Center. He is also a Cancer.Net Specialty Editor. Dr. Mitchell is Clinical Professor of Medicine and Medical Oncology at Jefferson Medical College of Thomas Jefferson University, and the Director of the Center to Eliminate Cancer Disparities at the Sidney Kimmel Cancer Center at Thomas Jefferson University. View disclosures for Dr. Grivas and Dr. Mitchell at Cancer.Net. ASCO would like to thank Dr. Grivas and Dr. Mitchell for discussing this topic. Dr. Grivas: Hello. This is Petros Grivas. I'm a medical oncologist at Seattle Cancer Care Alliance. I'm an associate professor at University of Washington and associate member of the Fred Hutchinson Cancer Research Center. I'm real delighted today to be able to discuss with a legend in the field, Prof. Dr. Edith Mitchell. Dr. Mitchell is well-known internationally for her work in oncology as well as health care disparities. Dr. Mitchell is directing the Diversity Services features of the Sidney Kimmel Comprehensive Cancer Center, and is a full Professor there, she is a medical oncologist, as I mentioned. And in addition to many achievements that she has over the years, and her international role in cancer research education and patient care, a few examples of her achievements include that she has been selected to be a member of the President's Cancer Panel and also in the NIH Council of Councils, which speaks highly of her contributions in the field. And I was impressed to find out recently that she was the first woman physician that was promoted to the rank of general in the U.S. Air Force. And again, there're many other accomplishments. Dr. Mitchell and myself have no relevant disclosures in relation to this particular topic that we're discussing today.  Dr. Mitchell, thanks for joining us today. Dr. Mitchell: Well, thank you so much, Dr. Grivas. It's really good to speak with you again, Dr. Grivas.  And thank you so much for the opportunity to discuss disparities with you today. Dr. Grivas: Absolutely. And thank you so much, Dr. Mitchell, for your nice words. We talked a bit about health care disparities. And your work in the field is really, really important. Could you comment a little bit about health care disparities—the definition—and what we mean when we talk about that? Dr. Mitchell: Sure. So when we speak about disparities, it's very important that we understand that for any disease process, whether it's a cancer disease or some other disease, if there are differences among communities, either in the incidence rates, that is, how often the disease or the problem occurs, as well as how often there are deaths. So mortality rates being different in different individuals. Could be men versus women, or Blacks versus Caucasians, or Latinx or other racial or ethnic, or differences even between the South and the North. There are a number of disparities that are different and occur more frequently in individuals who live in the southern part of the country. So disparities meaning that there are differences either in the number of occurrences or incidence rates or in the number of deaths, mortality rates, in different communities and among either a racial or ethnic groups or among people. For example, young patients versus older patients. So evaluating differences that occur among people because of their community. Dr. Grivas: Thank you, Dr. Mitchell. This is very, very helpful to understand. You mentioned some very good examples. Can you elaborate a little bit further about who are the most negatively affected by this, in your opinion? Dr. Mitchell: So it's well-recognized that men have higher death rates from certain cancers. It's also recognized that for the number of individuals that we've collected information about over the years, that African Americans have higher incidence rates of certain cancers and higher mortality rates of others. It's also recognized that African American men have the highest death rates and highest cancer occurrence rates or incidence rates of any group in the United States. So there are a lot of research ongoing now, evaluating men, and particularly African American men, to find out why there is a higher incidence rate and a higher death or mortality rate in this country. So lots of research. There is also a lot of information that over many years, cancer incidence rates have been higher in Blacks compared to whites among males and in whites compared to Blacks among females. So while Caucasian women have higher incidence rates, the African American women have higher death or mortality rates. Also, we have evaluated cancer mortality rates in many different populations and it's still the fact that African American men as well as African American women have higher mortality rates compared to whites. So very important that research continues with those. And for a few cancers, for example, prostate cancer in men, African American men have higher incidence rates of prostate cancer as well as higher death rates. Breast cancer, another area. African American women have higher death rates from breast cancer, although the incidence rates are approximately equal. African American women have more aggressive tumors and more of triple-negative tumors. And triple-negative breast cancer tumors are more aggressive tumors. They spread more rapidly, there are fewer medications to treat the cancers with, and consequently, overall death rate's higher in Black women compared to Caucasian women. Colorectal cancer, another where there are higher incidence rates, with African Americans having a 20% higher incidence rate of colorectal cancer in this country and African Americans having a 40% higher mortality or death rate in this country from colorectal cancer. And then the last that I will mention-- now, I could go on and on with different cancers, but multiple myeloma. Multiple myeloma is probably the most disparate cancer of all of those in the United States. The incidence rate of myeloma in African Americans is twice that of Caucasian patients, and the death rate being even higher than twice as many. So there are so many different-- and consequently, it's important for clinical trials for us to-- understand everything from the preventive strategies and trying to prevent cancer in various populations through early detection and trying to find the cancers at an earlier stage. And the earlier we find the cancer, the better the treatment outcomes and better opportunities for a cancer cure. So really important. And then, of course, there're the diagnostic studies. Treatments can be different in patients and consequently, finding the right treatment for the right patient at the right time being important. Also, we do research and clinical trials regarding posttreatment, quality of care, and survivorship. So really important for individuals to participate in clinical trials so that the patient can have access to and the opportunity to receive the latest information on treatment for this specific cancer as well as follow-up diagnostic studies, the specific scans, or other markers.  There, actually, Dr. Grivas, is a study ongoing where individuals may participate in a study even before they develop cancers or chronic diseases. And that's called the All of Us study. With All of Us, it is planned that approximately 1 million participants will be invited to participate in this trial, and information regarding a specific participant or a specific individual can be given back to the patient or the individual. Like I said, many individuals will not have developed a cancer or a chronic disease. And this might help individuals determine what the risk factors are for developing certain tumors over a period of time. So All of Us is another study by the NIH that will help determine risk factors for patients. So I think for every patient to try and find out information, 1, regarding the tumor if they have developed a cancer but, 2, determine screening strategies to try and find the tumor at an earlier stage and then opportunities for participation in prevention trials to try and prevent cancers from forming. So lots of different clinical trials ongoing and very important for specific populations. It's well-recognized that African Americans have higher incidence and mortality rates. Latinx or Hispanic patients, there are some tumors that have higher incidence or higher death rates. And the Native Americans also, for certain tumors, have higher incidence rates and higher death rates. So so much in terms of clinical trials ongoing and especially for minority populations. Finding out information about a clinical trial and the opportunity for participating in a clinical trial, very important. Dr. Grivas: These are excellent points, Dr. Mitchell. I want to ask you to comment a little bit on the efforts overall and your role in National Cancer Institute and other forums. What is the oncology community's trying to do to reduce these disparities? You mentioned clinical trials as a main important topic. But what resources are available to the patients in order to try to avoid those barriers and enroll in clinical trials and eliminate disparities in patient care? Dr. Mitchell: Certainly. And that's a great question because individuals can, if there is access to the internet, go into clinicaltrials.gov. One can find information about trials as well as potentials for treatment trials and just basic information about the disease process. So if there is breast cancer, you can type in "breast cancer," and you'll get the information on breast cancer or any specific cancer. And I urge patients not to just go to the internet and look for things but go to the NIH or the NCI websites. Those are the areas where the greatest research has occurred, and this is research that is specifically targeted for the United States population. So we do provide that information. We also provide information that patients can give to their physicians and ask questions. Always ask questions to your physicians or other clinical staff. The nurses are great resources of clinical information. It's always good to ask those questions. And if you use the internet, go to clinicaltrials.gov, and you will get the latest in terms of the National Cancer Institute studies. But you can also get information regarding the disease processes. And another good site is that of the American Cancer Society, which also has outstanding patient information that is reliable and trustworthy. So I usually recommend those 2 sites, but there are others. And especially if there is a National Cancer Institute-designated cancer center in the area. These are funded by the Congress and therefore are excellent areas for information as well as treatment. So I do recommend that patients utilize these resources instead of routinely just clicking on the disease process and seeing whatever comes up on the internet. There are some resources on the internet that are not reliable, that are not clinical trials, and I advise patients to be careful about obtaining information on the internet, and make sure it's from a trustworthy resource. Dr. Grivas: These are great points, Dr. Mitchell. I appreciate all your work you have done in the field. That's one of the very valuable points for our audience today. I think the take-home message is for our patients and audience participants to ask questions, seek opportunities, make sure they discuss with their treatment providers about clinical trial opportunities for them to be involved in the research and clinical trials. As you mentioned, that's the way to move forward as well as to eliminate disparities in health care. So thank you so much again for your time today and your so-important insights for our audience. Thank you, Dr. Mitchell. Dr. Mitchell: Oh, thank you so much, Dr. Grivas, and we look forward to working with you on the various projects that we have. And the last thing I'd like to say for patients, that despite the COVID-19 pandemic and the number of patients affected, if 1 has symptoms, then they should still discuss this with their clinicians and go in for cancer screenings, go in for cancer treatment. And if there are questions, talk with your physicians about it. Because although the coronavirus is here, cancer doesn't go away. So we still have to address cancer despite the COVID-19 pandemic, which affects so many Americans. But cancer is not going away. So still talk with your doctors about cancer screening and cancer treatment. Thank you. Dr. Grivas: Fully agree with you. Great point. Absolutely. And thank you for pointing this out to avoid delays in cancer diagnosis, avoid delays in screening and proper workup. Thank you so much, Dr. Mitchell, for your time today. ASCO: Thank you, Dr. Grivas and Dr. Mitchell. Learn more about cancer disparities at www.cancer.net/disparities. 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