Cancer patients need care, but they also need to feel represented — and not just by the folks parking their car, greeting them at the front desk or walking the halls on their security rounds.
Patients need to see themselves in the clinicians and nurses who treat them; the radiation technicians who conduct their scans and the phlebotomists who draw their blood. They also need to see themselves in the scientists who investigate their therapies and the leaders who guide them.
It’s not just personal preference; research consistently shows diversity in cancer providers actually improves access to care and satisfaction with care. Diversity among providers also improves health outcomes — especially, but not exclusively, for patients of color.
But diversity in a workforce doesn’t just happen. It takes planning and commitment, focus and funding. And that’s where the National Cancer Institute comes in.
“The NCI has recognized there is has been a persistent lack of diversity among scientists conducting research and in leadership positions in cancer centers,” said Fred Hutch Cancer Center’s Christopher Li, MD, PhD, holder of the Helen G. Edson Endowed Chair for Breast Cancer Research. “So in 2021 they added a requirement that all NCI cancers need to have a plan to enhance diversity.”
The nation’s principal agency for cancer research and training, the NCI regularly reviews and updates its policies and prerequisites.
In 2016, the NCI mandated its cancer centers fold in Cancer Research Training and Education Coordination (CRTEC) to build a pathway for researchers and clinicians; the same year, they asked centers to create offices of Community Outreach and Engagement, or COEs, to better connect with the communities each cancer center serves.
The agency uses carrots and sticks to ensure adherence and funding is tied to how well each center meets the various requirements. Every five years, the NCI organizes site visits of centers to evaluate — and grade — their progress and performance. Now, the higher the grade, the more infrastructure funding the cancer center receives.
The latest NCI requirement is the PED, or Plan to Enhance Diversity. Li was named associate director of Diversity, Equity and Inclusion for the Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium, and he and Consortium associate director for administration Wendy Law, PhD, immediately began brainstorming strategies to meet the new requirement.
One of their first actions was to reach out to their counterparts at other centers to connect and exchange ideas and best practices. They created the NCI Cancer Center DEI Network, and encouraged others to join in an interview in The Cancer Letter.
“We started with a dozen or so people at our first meeting but we’ve grown now to include full participation from all cancer centers,” Li said. “We have monthly virtual meetings that draw more than 100 people.”
Law, who has a long history with Fred Hutch, said creating the network was hard work, but definitely worthwhile.
“The DEI Network is an amazingly collegial group of people who are open to sharing their successes as well as their challenges in developing, implementing and measuring their respective plans to enhance diversity,” Law said, adding that she’s learned a great deal from other cancer centers.
“The level of wanting to connect with one another is evidenced by the two in-person DEI Summits for cancer center PED leaders in 2023,” she said. “Chris and I were approached by the Association for American Cancer Institutes and American Cancer Society. They wanted to support our efforts and co-sponsor the summits with us. Both sold out quickly and we’re planning the next one for this October.”
Li and Law also worked with network members to survey the group’s progress aligning with NCI’s appeal to increase diversity in the cancer workforce.
“The NCI put forward the goal that the different populations within the cancer centers should reflect the diversity of the nation — and that’s an ambitious goal,” Li said. “Nobody can do this overnight. And the centers are all far from doing that. That’s why the word ‘plan’ is in the name. We have to have a plan in place to do this.”
Their findings, published earlier this month in JNCI, the Journal of the National Cancer Institute, provide a snapshot in time of NCI cancer centers’ initial progress in diversifying their research and cancer care workforce.
The 87-item questionnaire, designed by Li, Law and others, assessed the domains, infrastructure, support and future plans of the centers. Li said response was overwhelming with more than 80% of designated NCI cancer centers providing feedback.
The responses, he added, were also quite mixed.
“One of the things the survey revealed is that there’s incredible heterogeneity among the cancer centers,” he said. “For example, the FTE support for PED leaders like myself ranges from 2% to 80% and in terms of PED staff, this ranges from zero to as many as five. Thus, there is a considerable variability in how much centers are investing in their PED efforts.”
The majority of cancer centers (68%) said the most common challenge to enhancing diversity was recruiting; the most common strategy to fix this was to review and revise faculty recruitment practices.
Other challenges included:
Most of the centers (88%) had an appointed PED leader — Li is leading the Cancer Consortium team — and 91% of those leaders were part of their cancer center’s senior leadership team. The survey also found PED leaders were “considerably more diverse than cancer centers leaders and directors” who are primarily white and male.
“Particularly stark,” the authors wrote, “is the substantial underrepresentation of American Indian/Alaska Native, Black and Hispanic people — from medical students up to cancer center directors — and the low proportion of women who are cancer center directors.”
All in all, they concluded, “sharing best practices and exemplar programs had the potential to elevate the impact of [the NCI’s plans to enhance diversity] efforts nationally.”
— Fred Hutch's Drs. Christopher Li, Wendy Law, et al, JNCI — Journal of the National Cancer Institute
Fred Hutch has already revised many of its hiring practices to bring in more representative researchers, clinicians and leaders, Li said.
“We’ve made a number of changes to our faculty recruitment process and they’ve had a tremendous impact on the diversity in our faculty applicant pools,” he said. “In 2019, across all our faculty searches, 4% of applicants identified as underrepresented racial and/or ethnic minorities. Now, it’s 18%. You can’t recruit diverse faculty unless you have a diverse applicant pool.”
One strategy used by 28% of the cancer centers surveyed is faculty “cluster hiring,” where a diverse cohort of candidates is hired as a group.
“We’ve used cluster hiring to increase the diversity of our faculty,” Li said, “We’re also trying to better support our underrepresented faculty through mentorship and sponsorship. To diversify our leadership, we started a faculty leadership academy a few years ago which provides fairly intense training and education on leadership development. A number of people have gone through that program and then gone on to leadership roles.”
Despite the benefits of diversity, equity and inclusion, the practice is currently under attack in various parts of the country.
“It’s a difficult time, particularly for cancer centers in states where this work is under continuous assault,” Li said. “In states like Texas, Florida, Oklahoma, Iowa, Utah and elsewhere, words like ‘diversity’ can’t even be used.”
Fred Hutch is not backing away from its commitment to DEI, he said, but leaders here are very aware of the national landscape and “how it can be a threat to this work more broadly.”
The main point, he stressed, is the mission.
“We’re a very mission-driven organization,” he said. “We’re trying to eliminate cancer and infectious disease through research. Many, many studies show the value of diversity in the workplace in terms of increasing innovation, teamwork and productivity. It’s all about bringing in different ideas and perspectives to the question at hand. To achieve our mission, we really need a diverse workforce.”
Diane Mapes is a staff writer at Fred Hutchinson Cancer Center. She has written extensively about health issues for NBC News, TODAY, CNN, MSN, Seattle Magazine and other publications. A breast cancer survivor, she blogs at doublewhammied.com and tweets @double_whammied. Email her at dmapes@fredhutch.org. Just diagnosed and need information and resources? Visit our Patient Care page.
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