The Ethical Imperative of Equity in Oncology: Lessons Learned From 2020 and a Path Forward

A call to action to advance patient-focused and decentralized clinical trials

This commentary is a call to action for a concerted commitment and effort to transform clinical trials and enable people with cancer to participate in clinical trials closer to home. Three key strategies are identified to address major barriers: confront challenges with the interpretation of US Food and Drug Administration Form 1572 requirements (Statement of Investigator); broaden acceptance of local laboratories and imaging centers; and invest in the creation of effective, sustainable partnerships between research centers and local providers.

Characteristics and outcomes of pediatric oncology patients at risk for guardians declining transfusion of blood components

BACKGROUND

Transfusion of blood products is a necessary part of successful delivery of myelosuppressive regimens in pediatric cancer. There is a paucity of literature characterizing outcomes or management of pediatric patients with cancer when transfusion is declined.

AIMS

The objective of this paper is to describe the clinical characteristics, care, and outcomes of patients with cancer at risk for declining transfusion.

METHODS AND RESULTS

A retrospective cohort of patients aged 0-21 years with cancer managed at Children's Healthcare of Atlanta between 2006 and 2020 and with ICD-9 codes indicating risk of "transfusion refusal" or Jehovah's witness (JW) religion was identified. Demographics, disease, and management were abstracted. Descriptive statistics were performed to examine associations with transfusion receipt. Among 35 eligible patients identified as at risk for declining transfusion, 89% had primary guardians who identified as JW, and 45.7% identified as Black, non-Hispanic. Only 40% of guardians actively declined transfusion. Transfusion recipients had significantly lower hemoglobin (g/dl) and platelet counts (1000/μl) at initial presentation (9.6 vs. 11.9, p < .002 and 116.0 vs. 406.5, p = .001, respectively) and at nadir (5.9 vs. 8.7, p < .001 and ≤ 10 vs. 154, p < .001, respectively) than non-recipients. Legal intervention was required in 36.4% of those who ultimately received a transfusion.

CONCLUSION

Among pediatric cancer patients whose medical record initially indicated a preference for no transfusion, 60% of guardians accepted blood products when prescribed for oncology care. Guidelines for systematic management and transfusion sparing approaches are needed to honor guardian's preferences when possible yet while maintaining equitable cancer outcomes in this population.

Enrollment Matters: The Reality of Disparity and Pursuit of Equity in Clinical Trials

SUMMARY

Disparities in clinical trial enrollment persist, fortified by the foundation and historical ideologies undergirding clinical cancer research. The scientific community has an ethical responsibility to seize the current moment to deconstruct and reconstruct these paradigms for more equitable research.

Assessing the impact of the COVID-19 pandemic on breast cancer screening and diagnosis rates: A rapid review and meta-analysis

OBJECTIVE

The ongoing COVID-19 pandemic has caused an indefinite delay to cancer screening programs worldwide. This study aims to explore the impact on breast cancer screening outcomes such as mammography and diagnosis rates.

METHODS

We searched Ovid MEDLINE, Ovid Embase, medRxiv and bioRxiv between January 2020 to October 2021 to identify studies that reported on the rates of screening mammography and breast cancer diagnosis before and during the pandemic. The effects of 'lockdown' measures, age and ethnicity on outcomes were also examined. All studies were assessed for risk of bias using the Newcastle-Ottawa Scale (NOS). Rate ratios were calculated for all outcomes and pooled using standard inverse-variance random effects meta-analysis.

RESULTS

We identified 994 articles, of which 7 registry-based and 24 non-registry-based retrospective cohort studies, including data on 4,860,786 and 629,823 patients respectively across 18 different countries, were identified. Overall, breast cancer screening and diagnosis rates dropped by an estimated 41-53% and 18-29% respectively between 2019 and 2020. No differences in mammogram screening rates depending on patient age or ethnicity were observed. However, countries that implemented lockdown measures were associated with a significantly greater reduction in mammogram and diagnosis rates between 2019 and 2020 in comparison to those that did not.

CONCLUSION

The pandemic has caused a substantial reduction in the screening and diagnosis of breast cancer, with reductions more pronounced in countries under lockdown restrictions. It is early yet to know if delayed screening during the pandemic translates into higher breast cancer mortality.

Increasing Racial and Ethnic Diversity in Cancer Clinical Trials: An American Society of Clinical Oncology and Association of Community Cancer Centers Joint Research Statement

A concerted commitment across research stakeholders is necessary to increase equity, diversity, and inclusion (EDI) and address barriers to cancer clinical trial recruitment and participation. Racial and ethnic diversity among trial participants is key to understanding intrinsic and extrinsic factors that may affect patient response to cancer treatments. This ASCO and Association of Community Cancer Centers (ACCC) Research Statement presents specific recommendations and strategies for the research community to improve EDI in cancer clinical trials. There are six overarching recommendations: (1) clinical trials are an integral component of high-quality cancer care, and every person with cancer should have the opportunity to participate; (2) trial sponsors and investigators should design and implement trials with a focus on reducing barriers and enhancing EDI, and work with sites to conduct trials in ways that increase participation of under-represented populations; (3) trial sponsors, researchers, and sites should form long-standing partnerships with patients, patient advocacy groups, and community leaders and groups; (4) anyone designing or conducting trials should complete recurring education, training, and evaluation to demonstrate and maintain cross-cultural competencies, mitigation of bias, effective communication, and a commitment to achieving EDI; (5) research stakeholders should invest in programs and policies that increase EDI in trials and in the research workforce; and (6) research stakeholders should collect and publish aggregate data on racial and ethnic diversity of trial participants when reporting results of trials, programs, and interventions to increase EDI. The recommendations are intended to serve as a guide for the research community to improve participation rates among people from racial and ethnic minority populations historically under-represented in cancer clinical trials. ASCO and ACCC will work at all levels to advance the recommendations in this publication.

Virtual Cancer Care Equity in Canada: Lessons From COVID-19

The COVID-19 pandemic radically shifted healthcare delivery to patients with cancer. Virtual cancer care, or the remote delivery of health care, has become an important resource for patients in Canada to maintain access to cancer care during the pandemic. With an increased number of people regularly accessing the internet and smartphones being ubiquitous for nearly all ages, technology in health care has grown. Virtual cancer care has been referenced as the fourth pillar of cancer care and it appears it may be here to stay. This article explores the benefits and challenges associated with virtual cancer care and outlines the importance of ensuring it is safe and equitable. Oncology nurses can identify where virtual care can be used to mitigate inequities and call attention when these tools exacerbate inequities.

Mapping disadvantage: identifying inequities in functional outcomes for prostate cancer survivors based on geography

Background

Prostate cancer is the most common internal malignancy in Australian men, and although most patients have good survival outcomes, treatment toxicities can impair function, leading to diminished quality of life for prostate cancer survivors. Socioeconomic disadvantage and geographical remoteness have been shown to be related to worse oncologic outcomes, and it is expected that they would similarly influence functional outcomes in prostate cancer.

Methods

Using data from the Victorian Prostate Cancer Outcomes Registry (n = 10,924), we investigated functional outcomes as measured by the Expanded Prostate Cancer Index Composite-26 (EPIC-26) following prostate cancer treatment, focusing on associations with socioeconomic status and geographical remoteness and controlling for clinicopathologic characteristics. A single composite score was developed from the five separate EPIC-26 domains for use in geo-mapping.

Results

A total of 7690 patients had complete EPIC-26 data, allowing mapping hotspots of poor function using our composite score. These hotspots were observed to relate to areas of socioeconomic disadvantage. Significant heterogeneity in outcomes was seen in urban areas, with hotspots of good and poor function. Both socioeconomic disadvantage and geographical remoteness were found to predict for worse functional outcomes, although only the former is significant on multivariate analysis.

Conclusions

Geo-mapping of functional outcomes in prostate cancer has the potential to guide health care service provision and planning. A nuanced policy approach is required so as not to miss disadvantaged patients who live in urban areas. We have demonstrated the potential of geo-mapping to visualise population-level outcomes, potentially allowing targeted interventions to address inequities in quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09389-4.