By Crystal Seldon, MD; Awad Ahmed, MD; Anna M. Laucis, MD, MPhil; and Cristiane Takita, MD, MBA
Gender inequality is an ongoing problem among United States (U.S.) medical professionals.1-2 While there have been gains in diversifying the field of medicine, such as the number of women surpassing the number of men matriculating into U.S. medical schools,3 women continue to remain in the minority among faculty of academic institutions.4 Academic oncology is no exception.5 Women make up the minority of all faculty in the fields of medical oncology, radiation oncology (RO) and surgical oncology at U.S. academic institutions.6 This extends to leadership positions, specifically program director and department chair positions. In RO alone, women constitute 30.7% of the academic workforce and only 17.4% of the leadership roles.6 Women also make up the minority of positions on governing boards, such as the Board of Directors, as well as leadership positions for the national professional societies of the American Society of Clinical Oncology (ASCO) and the American Society for Radiation Oncology.7 There is some progress in this arena, as the current ASCO President is Lori J. Pierce, MD, FASCO, FASTRO, a female radiation oncologist and vice provost at the University of Michigan. And ASTRO currently has three women in Board leadership roles: ASTRO President Laura Dawson, MD, FASTRO, President-elect Geraldine Jacobson, MD, MPH, MBA, FASTRO, and Secretary/Treasurer Neha Vapiwala, MD.
Over the years, we have seen more women enter the field of medicine in the U.S., now representing a narrow majority of matriculating medical students, 50.5% as of 2019.8 However, as more women join the field of medicine, the number of female RO residents appears to have plateaued at 30.2% as of 2019.9 This plateau is also seen in leadership roles in RO residency programs. In 2012, the percentage of female program directors and department chairs was 24% and 9% respectively10 as compared to 23.8% and 11.7% in 2020.6 Studies have shown that female trainees are more likely to practice in programs with women in leadership positions.11-13 The lack of gender equity in leadership positions also likely contributes to the low number of female trainees who matriculate into the field each year, creating a self-perpetuating cycle with a limited supply in the workforce to become leaders.
To address the lack of gender equity in radiation oncology, barriers to equality must be addressed. These barriers include but are not limited to gender specific expectations, barriers to mentorship, disparities in research funding and biases in tenure and academic tracks.14 The lack of predefined finite time limits to leadership positions in academic radiation oncology may contribute to the lack of inclusion in the U.S. academic RO community. Policies introducing term limits for leadership positions in academic medicine have been proposed as a potential solution.15 Work by Odie et al. has showed that gender disparities among chairs exist and are widespread, even in fields where women make up the majority of the workforce, such as obstetrics and gynecology.16 This suggests that the pipeline may not be the heart of the matter. The current disparities seen in leadership, both gender and racial, represent a relic of the past and are unlikely to change without motivational policy; social and institutional guidelines will likely be needed to create gender parity in these leadership roles.
Within recent years, movements geared toward promoting gender equity, such as the #MeTooSTEM, #WomeninMedicine and #HeforShe online platforms, have identified the need for addressing this issue, especially in academia. With more women entering into the field of medicine, it is important to close the gap between men and women faculty members, especially those in leadership positions. Observing other women in leadership roles can inspire and motivate a bright message to students and the public that the field of RO is not only diverse but inclusive as well. An honest assessment of these barriers will be integral as the specialty seeks to attract future radiation oncologists and create a diverse workforce, such that the ideas and opinions representing those from diverse gender, racial and socioeconomic backgrounds can be better represented to ultimately help guide and inform the very best oncologic care for our patients.
Join us in the Gender Equity Community on the ROhub to continue the discussion. What are your suggestions to improve gender equity in radiation oncology?
Crystal Seldon, MD, is a PGY-3 radiation oncology resident at the University of Miami/Sylvester Comprehensive Cancer Center.
Awad Ahmed, MD, is a radiation oncologist practicing at Multicare Tacoma Washington and ASTRO CHEDI member.
Anna M. Laucis, MD, MPhil, is a chief resident physician in radiation oncology at the University of Michigan and an ASTRO CHEDI member.
Cristiane Takita, MD, MBA, is a professor and residency program director at the University of Miami/Sylvester Comprehensive Cancer Center and ASTRO CHEDI member.
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2. Mandel H. The role of occupational attributes in gender earnings inequality, 1970-2010. Soc Sci Res
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3. More women than men enrolled in U.S. medical schools in 2017 [press release
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4. Jagsi R, Guancial EA, Worobey CC, et al. The “Gender Gap” in Authorship of Academic Medical Literature — A 35-Year Perspective. N Engl J Med
. 2006;355(3):281-287. doi:10.1056/nejmsa053910
5. Ahmed AA, Hwang WT, Holliday EB, et al. Female Representation in the Academic Oncology Physician Workforce: Radiation Oncology Losing Ground to Hematology Oncology. Int J Radiat Oncol Biol Phys
. 2017;98(1):31-33. doi:10.1016/j.ijrobp.2017.01.240
6. Chowdhary M, Chowdhary A, Royce TJ, et al. Women’s Representation in Leadership Positions in Academic Medical Oncology, Radiation Oncology, and Surgical Oncology Programs. JAMA Netw Open
. 2020;3(3):e200708. doi:10.1001/jamanetworkopen.2020.0708
Jagsi R, Means O, Lautenberger D, Jones RD, Griffith KA, Flotte TR, Gordon LK, Rexrode KM, Wagner LW, Chatterjee A. Women's Representation Among Members and Leaders of National Medical Specialty Societies. Acad Med
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AAMC, 2019 Fall Applicant, Matriculant, and Enrollment Data Tables. Accessed April 22, 2021. https://www.aamc.org/system/files/2019-12/2019%20AAMC%20Fall%20Applicant%2C%20Matriculant%2C%20and%20Enrollment%20Data%20Tables_0.pdf
9. Boyle P. More women than men are enrolled in medical school. AAMC. Published online December 9, 2019. Accessed January 22, 2021. https://www.aamc.org/news-insights/more-women-men-are-enrolled-medical-school
10. Wilson LD, Haffty BG, Smith BD. A Profile of Academic Training Program Directors and Chairs in Radiation Oncology. Int J Radiat Oncol
. 2013;85(5):1168-1171. doi:10.1016/j.ijrobp.2012.10.035
11. Vengaloor Thomas T, Perekattu Kuruvilla T, Holliday E, et al. Cross-Sectional Gender Analysis of US Radiation Oncology Residency Programs in 2019: More Than a Pipeline Issue? Adv Radiat Oncol
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12. Sethi S, Edwards J, Webb A, Mendoza S, Kumar A, Chae S. Addressing Gender Disparity: Increase in Female Leadership Increases Gender Equality in Program Director and Fellow Ranks. Dig Dis Sci
. Published online January 6, 2021. doi:10.1007/s10620-020-06686-5
13. Hill E, Vaughan S. The only girl in the room: how paradigmatic trajectories deter female students from surgical careers. Med Educ
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14. Woitowich NC, Jain S, Arora VM, Joffe H. COVID-19 Threatens Progress Toward Gender Equity Within Academic Medicine. Acad Med
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15. Beeler WH, Mangurian C, Jagsi R. Unplugging the Pipeline — A Call for Term Limits in Academic Medicine. N Engl J Med
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16. Odei BC, Gawu P, Bae S, Fabian D, Odei J, Lee C, Mitchell D. Evaluation of Progress Toward Gender Equity Among Departmental Chairs in Academic Medicine. 2021;181(4):548-550. doi:10.1001/jamainternmed.2020.6267
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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.
By Malika Siker, MD, Ross Zeitlin, MD, and Danielle Bitterman, MD
In June 2017, the ASTRO Board of Directors named diversity and inclusion a core value in its Strategic Plan. As diversity, equity and inclusion advocates, we are thrilled to see reaffirmation of these values and eager to participate in expanded initiatives. To highlight ASTRO work in this area, ASTRONews featured stories on diversity and inclusion in its 2018 issues. Margaret Barnes, MD, penned a thoughtful Letter to the Editor that expressed disappointment in the lack of inclusion of the lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ+) community in these efforts and discussed a need for ASTRO to be intentional about considering LGBTQ+ voices as we advocate for diversity and inclusion. To Dr. Barnes and anyone else who has felt excluded by this omission, we emphatically agree with this suggestion and believe that addressing this issue will strengthen our field.
In 2017, the American Society of Clinical Oncology (ASCO) issued recommendations for reducing cancer disparities among sexual and gender minority (SGM) populations. This article defined known SGM cancer disparities and suggested ways to address these challenges. In addition to focusing on our SGM patients, we see a need to ensure that our SGM colleagues feel safe and included in our field. ASTRO’s Committee for Health Equity, Diversity and Inclusion (CHEDI) has been working behind the scenes on initiatives to advocate for SGM health equity from both a patient and provider perspective.
The 2019 ASTRO Annual Meeting showcased the results of collaborative efforts focused on elevating SGM equity in the field of radiation oncology during three educational sessions. All of these sessions were held on Tuesday, September 17, and were well attended with engaged audiences eager to learn more.
- The NCI/ASTRO Diversity Breakfast, held from 6:45 a.m. to 8:00 a.m., highlighted a panel on recruitment and retention of women and minorities in the radiation oncology workforce. Dr. Raymond Mailhot of the University of Florida was featured on this panel and discussed the additional obstacles he faced as a gay Latino man navigating medical education, the residency application trail and beyond. His story illustrated the courage and resiliency our SGM colleagues need to develop as they navigate their careers in an environment that has traditionally not been inclusive of SGM population issues. Our field and the care we provide to patients will be enriched by addressing barriers faced by LGBTQ+ individuals throughout their career to ensure they are supported in achieving their personal and professional aims.
- CHEDI sponsored a panel on the treatment of vulnerable communities in radiation oncology from 2:45 p.m. to 4:00 p.m. Dr. Ross Zeitlin of the Medical College of Wisconsin was included on this panel and examined cancer disparities in the SGM community with a specific focus on the impact these have in radiation oncology. His presentation included an evidence-based review of the current data, clinical challenges and future directions. Raising awareness and educating health care providers about SGM community cancer disparities is essential so we can improve health equity in this vulnerable community.
- From 4:45 p.m. to 6:00 p.m., a multi-institutional and multidisciplinary panel entitled “Is there a Standard of Practice in Oncologic Care for Transgender Patients?” featured Dr. Daphne Haas-Kogan, Dr. Anthony Zietman, Dr. Stephanie Terezakis, Paula Neira, MSN, RN, JD, Dr. Danielle Bitterman and Dr. Zackory Burns. During this session, they discussed fundamentals of transgender care, the need for workforce education, cultural sensitivity and legal issues in an engaging format. As radiation oncologists, we need to understand the best practices in caring for transgender patients to ensure we are meeting the needs of this population.
As a reminder, these sessions are available on the ASTRO Annual Meeting Virtual Meeting platform. If you attended the Annual Meeting, you have access to the Virtual Meeting; if not, the Virtual Meeting is available for purchase through the catalogue.
We are pleased to see that ASTRO and its members are interested in advocating for SGM health equity and inclusion through the events featured at the 2019 Annual Meeting and see a need to continue to build on these efforts. Recently, a new initiative for radiation oncology residents identifying as or allied with LGBTQ+ individuals was announced within the ARRO network. This initiative is in the building stages, and we are eager to extend an invitation to the radiation oncology community at large as we build this idea from the ground up. For further details, please email Dr. Ross Zeitlin.
With diversity and inclusion listed as a core value in ASTRO’s Strategic Plan, we know that these values remain part of the DNA of our organization, even starting with the first interaction one may have with ASTRO: the membership application. ASTRO recently updated the gender options on the membership application form to now include non-binary.
We must remain vigilant, transparent and responsive to the needs of our diverse members to ensure that all our colleagues feel included. Through CHEDI, ARRO and other collaborating groups, we must continue to work together to make sure we embody these values as an organization. Having a diverse and inclusive workforce ready to care for our diverse society will translate to improved health equity. We value our SGM patients and colleagues and will continue to advocate to ensure all voices are heard.
Malika Siker, MD, is an associate professor of radiation oncology and associate dean for Student Inclusion and Diversity at Medical College of Wisconsin in Milwaukee, Wisconsin. Her professional areas of interest include health equity, diversity and inclusion as well as hematologic and CNS malignancies.
Ross Zeitlin, MD, is a radiation oncology resident at the Medical College of Wisconsin. His academic interests include gynecologic malignancies and oncologic health disparities in the sexual and gender minorities.
Danielle Bitterman, MD, is a PGY-4 resident at the Harvard Radiation Oncology Program.
By Fumiko Chino, MD
ASTRO's Committee on Health Equity, Diversity and Inclusion (CHEDI) has made recruitment and inclusion of underrepresented minorities into cancer clinical trials a top priority for the upcoming year.
Clinical trials are the mainstay in the development and validation of new cancer therapies and treatment options. Despite the potential for access to novel new treatments and technologies, less than one in 20 adult patients with cancer participate in a clinical trial.1 This disparity is even starker for racial and ethnic minorities1 with data showing that the clinical trial enrollment of racial/ethnic minorities has actually decreased over the past 14 years.2 In 2012, only 17% of patients enrolled in industry-sponsored clinical trials were of a racial or ethnic minority, despite these groups making up about one-third of the population.3 One evaluation found that black participation reached 10% for only two of the 31 cancer drugs studied.4 Clinical trial participants are disproportionately non-Hispanic white men with higher education levels and household incomes.1,5
With skewed enrollment and participation, conclusions of clinical trials may be questioned for how generalizable they may be to patients not fully represented in the trial cohort.6 As racial/ethnic minorities carry some of the highest cancer burdens in the United States, equitable participation in clinical trials becomes an important tool in the fight against health care disparities. Adequate representation in cancer research is essential in the development of therapies that are both effective and tolerable to patients from diverse backgrounds. Recurring themes in the assessment of barriers to clinical trial enrollment for racial/ethnic minorities include trust, costs and access/knowledge:
- Trust in medical providers and the health care establishment is a known obstacle for minority engagement. From infamous historical outrages like the Tuskegee Syphilis Study and forced sterilization in segregated hospitals, distrust has been a valid protective measure for many patients for centuries. One study looking at barriers to cancer research found that almost one-third of the black women surveyed agreed that scientists “cannot be trusted” (compared to 4% of white women).7 Trust concerns can be exacerbated by the lack of minority investigators,8 making workforce diversity9,10 an essential target action to improve trust.
- Costs remain a consistent barrier to clinical trial participation, particularly among racial/ethnic minorities.12 Lower income patients are much less likely to participate across all subgroups5 and increased out-of-pocket costs were consistently stated as a concern limiting enrollment.13 Although the costs of study drugs, tests and procedures are typically covered under protocol, there are many “hidden costs” including gas, hotels and missed work.14 Extra costs are in part due to more frequent clinic visits and travel as most comprehensive cancer centers leading clinical trials are in major metropolitan centers. Although there are fears that financial incentives may create a type of economic pressure for patients with lower socioeconomic status to participate, the additive costs of participation are often exclusionary for those with fewer resources.
- Access/knowledge continues to limit many patients who may be otherwise willing and eligible for clinical trial participation. Black/African American patients are less likely to be aware of clinical trials17 and provider referral may also be limited. In one study of black women, almost all participants stated their doctor had “never talked to them” about participating in a clinical trial.18
- Workforce: In addition to improving diversity in physician workforce, which is a long-term process, greater community involvement and use of culturally concordant staff (for example, Hispanic staff and Spanish language-based education materials) have led to improved enrollment in certain target populations.11
- Cost: One intervention of graded financial assistance demonstrated the ability to improve clinical trial equity with successful increased enrollment for those patients typically underrepresented in trials.15 Expanding trials into community cancer centers may also decrease travel costs and increase participation.16
- Access/Knowledge: Targeting enrollment toward specific cultural background and literacy levels may improve recruitment of underrepresented populations.12 Patient navigation programs also hold unique promise to help recruit and retain racial and ethnic minority populations in clinical trials. One study found that black/African American enrollment increased from 9% to 16% after initiating an education and tailored support program.19
CHEDI has highlighted ways that equity, diversity and inclusion can be improved within radiation oncology since its creation as a committee. By focusing this year on underrepresented minority clinical trial enrollment, we hope to raise awareness of this crucial issue and ultimately increase access and outcomes for our patients. Share your suggestions for how to encourage minorities to enroll in clinical trials in the comments below.
Fumiko Chino is transitioning from chief resident in Radiation Oncology at Duke Cancer Institute and the Teaching Value in Health Care Learning Network Fellow for the Costs of Care, a global NGO. She will join the faculty at Memorial Sloan Kettering Cancer Center in August 2019.
- Murthy VH, Krumholz HM, Gross CP: Participation in cancer clinical trials: race-, sex-, and age-based disparities. JAMA. 291:2720-6,2004.
- Duma N, Vera Aguilera J, Paludo J, et al: Representation of Minorities and Women in Oncology Clinical Trials: Review of the Past 14 Years. J Oncol Pract. 14:e1-e10,2018.
- Proportion of Study Volunteers by Race and Ethnicity in Clinical Research Studies, 2012. JNCI: Journal of the National Cancer Institute. 109, 2017.
- Propublica. "Black Patients Miss Out On Promising Cancer Drugs" Published September 19, 2018, accessed June 23, 2019 at https://www.propublica.org/article/black-patients-miss-out-on-promising-cancer-drugs.
- Unger JM, Gralow JR, Albain KS, et al: Patient Income Level and Cancer Clinical Trial Participation: A Prospective Survey Study. JAMA Oncol. 2:137-9, 2016.
- Rothwell PM: External validity of randomised controlled trials: "to whom do the results of this trial apply?". Lancet. 365:82-93, 2005.
- Mouton CP, Harris S, Rovi S, et al: Barriers to black women's participation in cancer clinical trials. J Natl Med Assoc. 89:721-7, 1997.
- McCaskill-Stevens W, Pinto H, Marcus AC, et al: Recruiting minority cancer patients into cancer clinical trials: a pilot project involving the Eastern Cooperative Oncology Group and the National Medical Association. J Clin Oncol. 17:1029-39, 1999.
- Winkfield KM, Flowers CR, Patel JD, et al: American Society of Clinical Oncology Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce. J Clin Oncol. 35:2576-2579, 2017.
- Winkfield KM, Gabeau D: Why workforce diversity in oncology matters. Int J Radiat Oncol Biol Phys. 85:900-1, 2013.
- Symonds RP, Lord K, Mitchell AJ, et al: Recruitment of ethnic minorities into cancer clinical trials: experience from the front lines. Br J Cancer. 107:1017-21, 2012.
- Ford JG, Howerton MW, Lai GY, et al: Barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review. Cancer. 112:228-42, 2008.
- Unger JM, Hershman DL, Albain KS, et al: Patient income level and cancer clinical trial participation. J Clin Oncol. 31:536-42, 2013.
- Chino F, Zafar SY: Financial Toxicity and Equitable Access to Clinical Trials. Am Soc Clin Oncol Educ Book. 39:11-18, 2019.
- Nipp RD, Lee H, Powell E, et al: Financial Burden of Cancer Clinical Trial Participation and the Impact of a Cancer Care Equity Program. Oncologist. 21:467-74, 2016.
- Copur MS, Ramaekers R, Gonen M, et al: Impact of the National Cancer Institute Community Cancer Centers Program on Clinical Trial and Related Activities at a Community Cancer Center in Rural Nebraska. J Oncol Pract. 12:67-8, e44-51, 2016.
- Lara PN, Jr., Paterniti DA, Chiechi C, et al: Evaluation of factors affecting awareness of and willingness to participate in cancer clinical trials. J Clin Oncol. 23:9282-9, 2005.
- Trauth JM, Jernigan JC, Siminoff LA, et al: Factors affecting older African American women's decisions to join the PLCO Cancer Screening Trial. J Clin Oncol. 23:8730-8, 2005.
- Fouad MN, Acemgil A, Bae S, et al: Patient Navigation As a Model to Increase Participation of African Americans in Cancer Clinical Trials. J Oncol Pract. 12:556-63, 2016.