Clinical Trial Participation Among Racial/Ethnic Minorities
An understanding of biology is crucial to any advance in oncology, and a proven way to improve this knowledge is through clinical trials. Clinical trials set the standard for oncologic practice and have the potential for narrowing gaps in cancer outcomes. However, participation in clinical trials among racial/ethnic minorities is disproportionately less, and there appears to be a general acceptance that minorities do not want to participate in clinical trials. This is belied by numbers from the Minority-Based Community Clinical Oncology Program (MB-CCOP), which had a 51% to 67% minority enrollment between 1995 to 2003—in marked contrast to an approximately 23% minority accrual to cooperative group trials. It would be important to find out the factors accounting for this discrepancy. This is especially important for racial/ethnic minorities in whom a cancer is known to have a higher-risk biology, higher-grade tumor, later-stage disease, and higher mortality rate.
Types of studies (eg, gene profiles/polymorphisms vs treatment trials) and ease of participation/adherence, cancer risks, and comorbid conditions all likely influence racial/ethnic minority clinical trial participation. Another barrier may be the lack of feedback to minority groups recruited for clinical trial participation regarding study results. In an open forum at the University of New Mexico with former NCI director Dr. Andrew von Eschenbach, Mr. Anslem Roanhorse, director of the Navajo Health Department, expressed the following sentiment shared by many Native American leaders and community members: Native Americans have been "overstudied," he noted, yet little to no change has come out of those studies to benefit their communities. More importantly, researchers have not come back to tell them what they have found. To publish clinical trial results in prestigious journals does little to inform research participants whether their participation led to anything that may have an impact on their own or their community's cancer risk, outcomes, and treatment decisions.
While many of the findings regarding treatment in women with breast cancer provide some general knowledge about disparities in cancer care among racial and ethnic minorities, a significant caveat is the great diversity within the minority group. For instance, the Hispanic ethnic group is loosely defined as people who share a common language in Spanish or a common ethnic origin in Latin, Central, or South America, or the Caribbean. It is easy to see how this creates great diversity within the group in terms of things as basic as race, less tangible belief systems, and social structures. Differing rates of acculturation, levels of education, and socioeconomic status also have a dramatic effect on an individual's or group's interaction with a physician, the health-care system, and attitudes about one's own health.
The challenge in addressing cancer disparities involves teasing out the differences from all confounding factors, including the possibility of a biologic difference. Until the contributions of each factor are better understood, our ability to truly make a difference will likely be limited. But the complexity of the problem should not be a deterrent. Eliminating cancer disparities—not only for racial/minority groups but for all underserved populations—must be a priority for those involved in cancer care. For individual practitioners, the first step in addressing disparities is accomplished through understanding the possibility that disparities exist in varying depth and complexity for each racial or ethnic minority patient.
Financial Disclosure: Dr. Royce is a member of the advisory board for Genentech and a member of the speakers bureau for Novartis.