By Curtiland Deville Jr., MD, Deputy Editor, International Journal of Radiation Oncology • Biology • Physics
The following includes excerpts from Dr. Deville’s editorials in the two special HEDI issues of the Red Journal. Read the full editorials and explore each special issue at www.redjournal.org.
It’s been said that we often overestimate what can be accomplished in a year and underestimate what can be accomplished in a decade. It’s been over a decade since Christina Chapman, MD, MS, and I published the first physician workforce diversity analysis in our specialty.1 At the time, I found only a single publication discussing concepts of diversity, underrepresentation and exclusion in our field — an editorial by Reshma Jagsi, MD, PhD, FASTRO, and Nancy Tarbell, MD, FASTRO, discussing the lack of gender representation and the need to address the proverbial “glass ceiling.”2
Over a decade later, hundreds of manuscripts exploring health equity, diversity and inclusion (HEDI) across a range of topics in radiation oncology, biology and physics have since been published, and we arrive today at the Red Journal’s HEDI special editions with dozens more contributions carrying the potential to inform and shape the field. But progress does not occur simply with the passing of time. Tireless, restless, persistent and courageous efforts by early, mid-, and advanced-level trainees, physicians, physicists, scientists, administrators and leaders have facilitated the awakening and commitment to diversity, equity and inclusion in our field, ultimately to the benefit of our future patients, colleagues and staff. Below, I give a brief overview of several studies included in each issue, but I strongly encourage all readers of this blog to study both special issues carefully.
The first HEDI special issue includes a number of analyses and interventions to address health equity in radiation oncology, medical physics and radiation biology. In their manuscript, Radiotherapy Deserts: The Impact of Race, Poverty and the Rural-Urban Continuum on Density of Providers and Use of Radiation Therapy in the United States, Alcorn et al. characterize so-called radiation deserts — areas with the greatest mismatch of oncologic need and radiation resources — and provide an online tool to drive targeted investigation of underlying barriers to care in areas of highest need, with the goal of reducing health inequities in this context.
Kronfli et al. report on a psychosocial needs assessment implemented for patients with cancer undergoing curative radiation therapy in an inner-city, academic center to address radiation disparities. In their companion editorial, Suneja et al. laud the efforts of this group’s targeted intervention to address social determinants of health such as socioeconomic and transportation barriers, delve further into fundamental concepts in health equity, and provide cautionary guidance for investigators to ensure that their analyses and author teams do not themselves perpetuate inequities, exclusion and bias and moreover risk engaging in health equity tourism.3
Regarding progress toward inclusive clinical trial enrollment, Roy et al. provide a framework in their critical review Increasing Diversity of Patients in Radiation Oncology Clinical Trials, while Chen et al. discuss why the Inclusion of Sexual Orientation and Gender Identity in Clinical Trials is Necessary for Health Equity, and Patel et al. discuss the role of industry partners in Carrots or Sticks: An Industry Perspective on the Significance of Regulatory Guidance in Promoting Participant Diversity in Clinical Trials.
The second volume of the HEDI special issue highlights needs and innovations across a variety of domains: the physician, physics and basic scientist workforce, education, technology access and global health. With respect to workforce diversity and inclusion, analyses of demographic representation trends reveal that women and historically underrepresented racial and ethnic groups in medicine (URiM) remain excluded, likely along with a host of other marginalized groups for whom data is largely unavailable.
The review by Jimenez et al. entitled Using Holistic Residency Applicant Review and Selection in Radiation Oncology to Enhance Diversity and Inclusion, an ASTRO SCAROP-ADROP-ARRO Collaboration, opens with a detailed review of current representation trends and the lack of significant changes in representation for women and URiM trainees in radiation oncology over the past decade, despite gains in the overall U.S. graduate medical education trainee pool. Broadening the scope of diversity with additional dimensions is increasingly needed to assure equity, inclusion and belonging. Such historically marginalized dimensions include deaf and disabled status, veteran status, sexual orientation and gender identification (SOGI), first generation and low income (FGLI), religion, geography (e.g., urban versus rural) and disadvantaged background. Limited data exist regarding representation of many of these groups within medicine and radiation oncology specifically, but several data collection initiatives are underway and included in this edition.
Marginalized demographic groups remain disproportionately underrepresented and ultimately excluded in radiation oncology relative to the available pool. This indicates that simply increasing the pipeline is not enough without thoughtful recruitment, applicant review and selection, and retention and advancement strategies as reviewed in the HEDI focus issues.
Our charge is that the next decade and beyond bring scaled, sustained, strategic departmental, organizational and societal policies and interventions that address the long-standing disparate representation in the radiation oncology physician, medical physics and radiation biology scientist workforce. These efforts are requisite if we wish to dismantle structural bias and systemic inequities in the specialty and ensure that our workforce is reflective of the ever-diversifying domestic and global patient populations and communities we serve.
- Chapman CH, Hwang WT, Deville C. Diversity based on race, ethnicity, and sex, of the US radiation oncology physician workforce. Int J Radiat Oncol Biol Phys. 2013 Mar 15;85(4):912-8.
- Jagsi R, Tarbell NJ. Women in radiation oncology: time to break through the glass ceiling. J Am Coll Radiol. 2006 Dec;3(12):901-3.
- Lett E, Adekunle D, McMurray P, et al. Health Equity Tourism: Ravaging the Justice Landscape. J Med Syst. 2022 Feb 12;46(3):17.
By Yun Rose Li, MD, PhD, Parul Barry, MD, and Adrianna Masters, MD, PhD
While many women scientists and physicians made critical contributions that paved the path to modern day advances in radiation oncology, few were recognized for their work. Perhaps one of the most well-known pioneers in the field of radiation oncology is a woman: Marie Curie, recipient of two Nobel Prizes for her extensive work on radioactivity and the discovery of radium.
But aside from Marie Curie, most of her contemporaries received little acknowledgment. For example, Lise Meitner, an Austrian-Swedish physicist, helped discover the element protactinium-231 and described the process of nuclear fission (Sime, 1996). Her work demonstrating that uranium atoms split when bombarded with neutrons allowed for the later development of nuclear energy and nuclear bombs. For her contributions, she was nominated for the Nobel Prize in chemistry and physics 48 times, though she never received the award.
Another example is Margaret Cleaves, who in the early 1900s was one of an estimated 20 physicians (the only female) to have access to radium for clinical purposes and ultimately became the first to use radium in gynecology to treat cervical cancer (Aronowitz, Aronowitz, & Robison, 2007). She was heavily criticized and was largely dismissed by other physician colleagues. At that time, not only were educational opportunities and access to postgraduate training for women extremely limited, but society placed strict limitations on the role of women as physicians and leaders in medicine.
It was not until the demands created by WWI and WWII that broader access to medical/graduate education and career opportunities, aside from those that were traditionally seen as “feminine” roles, were made available to women. Often considered to be a founder of nuclear medicine, Edith Quimby studied the medical effects of radiation and dose limiting side effects with the application of radioactive isotopes in the treatment of thyroid disease, brain tumors and other cancers during her time at Memorial Hospital for Cancer and Allied Disease in New York (Linton, 2012). In 1954, she became the first female president of the American Radium Society and was the recipient of the Janeway Medal of the American Radium Society, the Gold Medal of the Radiological Society of North America and the Gold Medal from the American College of Radiology.
Other important women who made contributions to radiation oncology include Chien-Shiung Wu, also known as the First Lady of Physics. Wu, a Chinese American particle and experimental physicist, worked on the Manhattan Project and played an important role in the advancement of nuclear and particle physics. Despite their successes, very few women obtained faculty positions and even fewer chaired departments during the mid-1900s. One example was Ruth Guttman, who became the director of the Department of Radiotherapy at Columbia University from 1955 to 1976. Other notable examples include Florence Chu, who was the chair of Radiotherapy at Memorial hospital 1976-1984, and Anna Hamann, who at the end of a long career, became the director of radiation therapy at Evanston Hospital, although she never attained a full professorship. These women and many other women physicians and scientists overcame tremendous challenges and faced persecution and hostility in order to pursue their dreams to advance the field of radiation oncology and radiation physics.
Though many would like to believe that efforts made to address challenges faced by women in science and medicine have allowed women to break the glass ceiling in radiation oncology, there is still a lot left to do. In fact, the lack of gender diversity among radiation oncologists begins with medical school applicants and continues to widen throughout career development. Currently, women represent at least half of all medical school students but make up only 30% of applicants to radiation oncology training programs. The gender disparity widens as women progress in their careers, with leadership positions and chair positions further widening the gap: academic positions 17.4% and female chairs 11.7% (Gharzai and Jagsi 2020).
Leadership roles on editorial boards of oncology journals are another area of noticeable disparities in representation of underrepresented minorities and women. A recent abstract presented by Patel et al. reviewed 54 oncology journals and 793 board members, and there was not a single editor-in-chief position held by a minority female. At a time when COVID-19 has disproportionately affected the career development of women, who often serve as primary caretakers at home, how do we create an even ground for achieving career success? This is a pivotal time to reevaluate our measures of productivity and the metrics we use to decide on tenure or promotion. Recognizing that women in STEM in general have shown much larger interruptions in submissions to journals during this time than their male counterparts, even those with young children, the charge is with institutions and national organizations within our field to make a change to do better for women in radiation oncology.
We would argue that we need to promote diversity of not just representation and service on committees, but chairing committees, successfully applying for FASTRO status and even the Gold medalists. We reviewed the listed ASTRO Gold medalists on the website and found that since 1977 only 12% of honorees were female. The majority of the current ASTRO executive committee is female. In reviewing the chair and vice-chair positions of the councils, two of five council vice-chairs are women. Because portions of the application process for FASTRO focus on recommendations of existing recipients, leadership roles and other metrics of academic success, is this placing an undue burden on persons from underrepresented groups? We are curious to know what the success rates are for applications and if there is a way to blind applications to reduce bias.
It is important to recognize that, even though much remains to be done to level the playing ground for women in radiation oncology, our field has seen enormous contributions made by women, and more and more women are being recognized for their work. The 2021 ASTRO Gold medalists were notably both women (Colleen Lawton, MD, FASTRO, and Lori Pierce, MD, FASTRO). Moreover, Sue Yom, MD, PhD, FASTRO, who has made tremendous contributions to major societies in our field including ASTRO and American Radium Society where she is the immediate past chair, is the incoming editor-in-chief of the Red Journal.
What are some of our thoughts on increasing representation of diverse groups of people in leadership?
- Recognize the accomplishments of others and go out of your way to highlight those who may not be in a position to do it for themselves.
- Do not assume that someone doesn’t want to serve in a leadership role, is too busy or wouldn’t want to take time away from a specific activity (raising young children, for example). Why not simply ask?
- Offer support in a positive way that sponsors the success of others and specifically think about multiple candidates for a task or role in leadership.
- Be thoughtful with your word choices and their impact on those around you.
- Acknowledge the additional burden of unpaid domestic work, specifically during global pandemics, and think about ways to provide resources: Adapt to a changing environment to allow diversity of experience to enrich our culture as radiation oncologists!
- Be aware of biases, speak up when you recognize them and acknowledge when you recognize your own. Positive change cannot happen unless we do.
Join us on the ROhub to share your thoughts and discuss: What other ways can we support diversity of leadership and diversity of thought?
And be sure to acknowledge Marie Curie on Sunday, November 7 with #WeWhoCurie day!
Aronowitz JN, Aronowitz SV, Robison RF. Classics in brachytherapy; 2007.
Gharzai LA, Jagsi R. Ongoing Gender Inequity in Leadership Positions of Academic Oncology Programs: The Broken Pipeline. JAMA Network Open 3 (3): e200691–e200691. 2020. doi:10.1001/jamanetworkopen.2020.0691
Linton O. Edith H. Quimby. Journal of the American College of Radiology, 9(6), 449. 2012. https://doi.org/10.1016/j.jacr.2011.11.020
Sime RL. Lise Meitner: A Life in Physics. University of California Press. 1996.
By Rehema Thomas, MD candidate, Class of 2022
Going into medical school, I knew that treating cancer was what I was called to do. With my eyes set on oncology, I was aware that there were still options when it came to choosing a specialty. There was surgical oncology, medical oncology and radiation oncology. What road would I choose in the end? As my first year of medical school went along, our preclinical curriculum covered aspects of medical oncology, chemotherapies and surgical techniques. However, I realized I was not getting much exposure to radiation oncology, and I wanted to know more. With that and a growing love for imaging, I knew I wanted more experience in “rad onc” and decided to find out how I could secure it. With a simple internet search for summer research opportunities in radiation oncology, the ASTRO Minority Summer Fellowship (MSF) was the first result I saw. It was perfect! I reached out to my mentor, Curtiland Deville, MD, via email, scheduled a meeting with him, completed the application and ― the rest is history.
Being a recipient of the ASTRO MSF Award provided me with one of the most rewarding experiences in my medical training that I have had to date. My summer experience truly cemented my choice to pursue radiation oncology as a specialty. Throughout my summer working at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center with Dr. Deville, I was exposed to many different facets of radiation oncology. I was able to witness firsthand what goes into a complete course of treatment ― from the consultation to treatment planning, to treatment delivery. I had the opportunity to spend time with nurses, dosimetrists, physicists, therapists and physicians and see just how much each member of the team contributes to patient care. I sat in on several consultations with Dr. Deville for his prostate and sarcoma patients. I really appreciated how much patient education goes into consultations and how there is a visible alleviation in the uncertainty patients feel after having a conversation with the physician and getting a better understanding of their options.
Not only did I get to observe prostate and sarcoma consultations, but I was able to sit in on breast, lung and gynecologic consultations with other radiation oncologists in clinic. In my observation of on-treatment visits, I was able to gain more insight into the radiation-associated side effects that patients experience throughout treatment and how they are managed. Patient simulations, treatment set-up and treatment delivery were also exciting elements of my clinical exposure. Although the majority of my experience was in Washington, D.C., I did get the chance to travel to Baltimore and participate in Johns Hopkins’ Prostate Cancer Multidisciplinary Clinic. I thoroughly enjoyed that experience, as I value the shift medicine is taking toward multidisciplinary individualized care. Outside of the clinical visits and research, I had the opportunity to contour volumes for patient organs at risk and through that, gain familiarity with treatment planning systems used by the team.
Most importantly, I was able to foster a meaningful mentorship and complete significant research throughout the eight weeks of the fellowship. Dr. Deville was and continues to be an excellent mentor. I am very proud of how much I was able to learn and what we produced in the eight weeks. My poster, “Comparative in Silico Analysis of Pre-operative Scanning Beam Proton Therapy, Intensity-Modulated Photon Radiation Therapy, and 3-D Conformal Photon Radiation Therapy in Adult Soft Tissue Sarcoma,” was presented at the 2020 ASTRO Annual Meeting.
I enjoyed all aspects of the fellowship, and it confirmed my choice to pursue radiation oncology as a specialty. I extend my sincerest thanks to the ASTRO Committee on Health Equity, Diversity and Inclusion for the invaluable opportunity.
Share this opportunity with medical students and colleagues. See the eligibility requirements and access the application for the ASTRO 2021 Minority Summer Fellowship.
Rehema Thomas is an MD candidate in the Class of 2022 at the George Washington University School of Medicine and Health Sciences. She is a METEOR Research Fellow and president of the GW SMHS Women in Radiology.