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Diversity in the Academic/Research Setting A Comprehensive Cancer Center Perspective

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Title: Diversity in the Academic/Research Setting A Comprehensive Cancer Center Perspective


1
Diversity in the Academic/Research Setting A
Comprehensive Cancer Center Perspective
  • Carol L. Brown MD, FACS
  • Director, Office of Diversity Programs in
  • Clinical Care, Research, and Training
  • Memorial Sloan-Kettering Cancer Center
  • Academia Industry Symposium
  • Diversity Inclusion
  • October 6, 2006

2
Diversity in the Academic/Research Setting
  • Objectives
  • What groups do you work with in clinical
    research?
  • How do you involve diversity in your research?
  • In health care, what is the diversity challenge?
  • What population do you work with and what are the
    specific diversity issues with this population?

3
Memorial Hospital
4
Mortimer B. Zuckerman Research Center
5
MSK Network
In development
6
Memorial Sloan-Kettering Cancer Center
  • Oldest and largest private institution devoted to
    patient care, education and research in cancer
  • Consistently ranked one of top cancer centers by
    US News World Report and other surveys
  • 8700 employees 700 MDs and PhDs,
  • 19,000 new patient visits annually
  • Operating expenses 1.5 billion
  • 445 active clinical protocols and 117 million in
    new grants and contracts in 2005

7
Workforce (non-clinical) Diversity at MSKCCThe
Analysis
  • Diversity Task force formed to review issues
  • Analyzed employee data, industry trends,
    demographic data and diversity best practices.
  • Entire population is diverse
  • Less diversity at higher levels
  • Low turnover at senior levels
  • Low retention at lower levels

Dillon-Weed, MSKCC 2005
8
Workforce Diversity at MSKCC The Analysis
  • Partnered with diversity consultants for
    continued analysis and input
  • Analysis included additional data review, task
    force and employee interviews

Dillon-Weed, MSKCC 2005
9
Workforce Diversity at MSKCC Recommendations
  • Build cultural competency
  • Provide diversity training
  • Establish cultural diversity advisory board
  • Define linguistic capabilities needed to better
    service potential target communities

Dillon-Weed, MSKCC 2005
10
Workforce Diversity at MSKCC Recommendations
  • Recruitment and Retention Strategy
  • Identify high potential minorities to prepare for
    advancement
  • Implement a mentoring program focusing on
    mentoring across differences
  • Provide training programs to improve skills and
    build on existing training opportunities

Dillon-Weed, MSKCC 2005
11
Workforce Diversity at MSKCC Next Steps
  • Communicate diversity vision to employees
  • Provide training for all management in 2005
  • Ensure accountability

Dillon-Weed, MSKCC 2005
12
Adding Diversity to the Mission Statement
  • Mission (Memorial Hospital) revised 11/8/04
  • The mission of Memorial is to maintain its
    leadership role as a preeminent institution for
    the prevention, diagnosis, treatment, and cure of
    cancer and associated diseases through
    excellence, vision, and cost-effectiveness in
    patient care, research, education and outreach
    programs.
  • In fulfillment of its mission, the Hospital must
  • Foster an environment that supports diversity
    through the support and enhancement of
    initiatives in the areas of patient care,
    research, education and outreach.

13
Office of Diversity Programs Rationale
  • Disparities are found in measures of cancer
    incidence, treatment, and survival based on race,
    ethnicity, and socioeconomic status
  • Reduction of disparities remains a priority for
    the national cancer research agenda
  • MSKCC should be a leader in the effort to reduce
    and eliminate cancer-related health disparities

14
Branding Diversity at MSKCC
15
MSKCC Office of Diversity Programs Organization
and Staff
Office of the President
16
MSKCC Office of Diversity Programs Goals
  • Enhance institutional diversity through training,
    recruitment, and retention of underrepresented
    minority faculty and professional staff
  • Increase utilization of MSKCC prevention,
    screening, and treatment programs by
    racial/ethnic minorities and the underserved
  • Increase participation of racial/ethnic
    minorities and the underserved in the MSKCC
    clinical trials program
  • Develop a Research Program whose focus is the
    reduction and elimination of cancer health
    disparities

17
Castillo, L Diversity in the Physician Workforce
Facts and Figures 2006 AAMC www.aamc.org/factsan
dfigures
18
Castillo-Page Minorities in Medical Education
Facts and Figures 2005 AAMC www.aamc.org/factsandf
igures
19
Castillo-Page Minorities in Medical Education
Facts and Figures 2005 AAMC www.aamc.org/factsandf
igures
20
Castillo-Page Minorities in Medical Education
Facts and Figures 2005 AAMC www.aamc.org/factsandf
igures
21
Castillo-Page Minorities in Medical Education
Facts and Figures 2005 AAMC www.aamc.org/factsandf
igures
22
Castillo-Page Minorities in Medical Education
Facts and Figures 2005 AAMC www.aamc.org/factsandf
igures
23
Castillo, L Diversity in the Physician Workforce
Facts and Figures 2006 AAMC www.aamc.org/factsan
dfigures
24
Castillo, L Diversity in the Physician Workforce
Facts and Figures 2006 AAMC www.aamc.org/factsan
dfigures
25
Castillo, L Diversity in the Physician Workforce
Facts and Figures 2006 AAMC www.aamc.org/factsan
dfigures
26
Castillo, L Diversity in the Physician Workforce
Facts and Figures 2006 AAMC www.aamc.org/factsan
dfigures
27
Race/Ethnicity of Memorial Hospital Faculty
Data from Employee Personal Data Form MSKCC
Human Resources as of 12/25/05
28
Race/Ethnicity of Memorial Hospital Faculty vs.
U.S. Medical School Faculty 2004
Minorities in Medical Education Facts and
Figures 2005, Association of American Medical
Colleges 2005.
29
Minority Faculty Recruitment Strategies
  • Intramural
  • MSKCC fellows
  • Local/Regional
  • Medical School Office of Minority Affairs
  • Local chapters minority professional societies
  • National
  • National Medical Association, National Hispanic
    Medical Association, Association of American
    Indian Physicians, Association of Academic
    Minority Physicians, Association of Black
    Academic Surgeons
  • AACR-MICR, ASCO, ASH, SSO, American College of
    Surgeons, AMA
  • NCI, American Cancer Society, Foundations-RWJ
  • Faculty at other institutions

30
Fellowship Status MH Faculty Fellow Pool
2000-2005
Data from Employee Personal Data Form MSKCC
Human Resources as of 12/25/05,
31
Training Core Strategies
  • Survey minority MSKCC faculty regarding
    recruitment, retention, promotion, and
    institutional diversity climate
  • Communicate goal of faculty diversity to
    department chairs, service chiefs, program
    leaders and laboratory heads and develop best
    practices strategies based on discipline.
  • Fund clinical and laboratory research fellowships
    for minority physicians and scientists.

32
Training Core Strategies
  • Outreach to minority health professions and
    scientific societies, minority serving graduate
    and medical schools.
  • Expand and publicize existing pipeline programs
  • High school programs Summer Exposure
  • Summer Medical Student Fellowship Program
  • Summer undergraduate student program at SKI

33
Strategies to Increase Diversity in the Medical
Workforce Fueling the High School Pipeline
CCNY-MSKCC Partnership Inaugurates Program for
Inner City Students "Growing up, my basketball
coach was instrumental in my development," said
Raja Flores, Memorial Sloan-Kettering Cancer
Center thoracic surgeon and mentor to six high
school students who participated in Memorial
Sloan-Kettering Cancer Center's inaugural Summer
Exposure Program. "I've always wanted to go back
to the neighborhood to coach, but as a surgeon
I'm just too busy. However, what I've been able
to do through this program is help kids who
remind me of myself back then. I've been where
they are now and I'm here to say 'You can do
it.'" A component of the City College of New
York (CCNY) and Memorial Sloan-Kettering Cancer
Center partnership -- funded by a five-year grant
from the National Cancer Institute to promote
collaborations between minority-serving academic
institutions and comprehensive cancer centers --
the six-week summer program was designed to
expose minority and inner city students to
clinical and research opportunities in oncology.
Five students were recruited from the CCNY High
School of Mathematics, Science and Engineering,
and the sixth from the Greenwich Day School in
Connecticut.
Raja Flores (in green scrubs) demonstrates
laparoscopic surgical techniques to students
(from left) Julian Carrasquillo, Aleyah Soleyn,
Timon Ajlan, and Kristina Butron.
CCNY-MSKCC Partnership Inaugurates Program for
Inner City Students Center News October 2005
www.mskcc.org
34
Diversity in Cancer Clinical Trials
35
Health Disparities in Oncology.
  • ..exist based on
  • Race/ethnicity
  • Socioeconomic Status
  • Age
  • ..are found in measures of
  • Incidence
  • Treatment
  • Survival

36
Cancer Incidence Rates by Race and Ethnicity,
1998-2002
Rate Per 100,000
Age-adjusted to the 2000 US standard
population. Hispanic is not mutually exclusive
from whites, African Americans, Asian/Pacific
Islanders, and American Indians. Source
Surveillance, Epidemiology, and End Results
Program, 1975-2002, Division of Cancer Control
and Population Sciences, National Cancer
Institute, 2005.
37
Percent distribution of prior Pap test by
race/ethnicity
Benard et al. Cancer Causes and Control
1261-68,2001.
38
Cancer Death Rates by Sex and Race, US, 1975-2002
Rate Per 100,000
African American men
White men
African American women
White women
Age-adjusted to the 2000 US standard
population. Source Surveillance, Epidemiology,
and End Results Program, 1975-2002, Division of
Cancer Control and Population Sciences, National
Cancer Institute, 2005.
39
Cancer Survival() by Site and Race,1995-2001
Difference
African
Site
White
American
All Sites 66 56 10 Breast (female) 90 76
14 Colon 65 55 10 Esophagus 16 10
6 Leukemia 49 38 11 Non-Hodgkin
lymphoma 61 52 9 Oral cavity 62 40
22 Prostate 100 97 3 Rectum 65 56
9 Urinary bladder 83 64 19 Uterine
cervix 75 66 9 Uterine corpus 86 62 24
5-year relative survival rates based on cancer
patients diagnosed from 1995 to 2001 and followed
through 2002. Source Surveillance,
Epidemiology, and End Results Program, 1975-2002,
Division of Cancer Control and Population
Sciences, National Cancer Institute, 2005.
40
Racial and Ethnic Disparities Cancer Outcome
Contributing Factors
  • Age and Socioeconomic status
  • Access to screening and treatment services
  • Comorbid illness
  • Racial discrimination
  • Cultural beliefs
  • High Risk Behaviors
  • Compliance with treatment
  • Treatment Aggressiveness
  • Biologic Differences

41
Population Size and Diversity in NYC, 1900-2000
42
Population Diversity New York City
Interim Report of the GNYHA Advisory Task Force
on Diversity in Health Care Leadership October
2005 www.gnyha.com
43
Regulating Diversity in Cancer Clinical Trials
44
National Institutes of Health Policy on the
Inclusion of Women and Minorities as Subjects in
Clinical Research
  • NIH Revitalization Act of 1993( Public Law
    103-43)
  • effective September 1994
  • NIH ensure that women and minorities and their
    subpopulations be included in all clinical
    research
  • Women and minorities be included in Phase III
    trials in numbers adequate to allow for valid
    analyses of differences in intervention effect
  • Cost is not allowed as a reason for excluding
    these groups
  • NIH initiate programs and support for outreach
    efforts to recruit and retain women and
    minorities as participants in clinical studies.

Farley et al. SGO 2000
DHHS NIH Monitoring Adherence to the NIH policy
on the Inclusion of Women and Minorities as
Subjects in Clinical Research NIH
Tracking/Inclusion Committee 2005
45
NIH Definition of Clinical Research
  • Patient-oriented research.
  • Research conducted with human subjects (or on
    material of human origin such as tissues,
    specimens and cognitive phenomena) for which an
    investigator (or colleague) directly interacts
    with human subjects. Excluded from this
    definition are in vitro studies that utilize
    human tissues that cannot be linked to a living
    individual. Patient-oriented research includes
    (a) mechanisms of human disease, (b) therapeutic
    interventions, (c) clinical trials, and (d)
    development of new technologies

Sex, Gender and Minority Inclusion in NIH
Clinical Research What Investigators Need to
Know http//grants.nih.gov/grants/funding/women
_min/training/index.htm
46
NIH Definition of Clinical Research (continued)
  • (2)  Epidemiologic and behavioral studies
  • (3)  Outcomes research and health services
    research.

Sex, Gender and Minority Inclusion in NIH
Clinical Research What Investigators Need to
Know http//grants.nih.gov/grants/funding/women
_min/training/index.htm
47
Decision Tree for Inclusion of Minorities In
NIH-Defined Phase III Clinical Trials
Is a NIH-Defined Phase III Clinical Trial
proposed?
NO
YES
Go To Decision Tree for Inclusion of Minorities
(not an NIH-Defined Phase III Clinical Trial)
Is minority representation acceptable? 1. Strong
evidence exists for significant racial or ethnic
differences in intervention effect and study
design or analysis can answer primary question(s)
separately for each relevant subgroup and the
analysis plan can detect significant differences
in intervention effect? (Code M1 both U.S.
minorities and non-minorities included) or 2.
Strong evidence exists for NO significant racial
or ethnic differences in intervention effect?
(Code M1 both U.S. minorities and
non-minorities, or Code M2 U.S. minorities only,
or Code M3 U.S. non-minorities only) or 3. No
clear evidence exists for or against significant
racial or ethnic differences in intervention
effect and study design and analysis plans will
permit valid analysis of a differential
intervention effect? (Code M1 both U.S.
minorities and non-minorities) or 4. Some or all
minority groups or subgroups are excluded because
inclusion is inappropriate with respect to their
health or because the research question is not
relevant to them? (Code M1 both U.S. minorities
and non-minorities, or Code M2 U.S. minorities
only, or Code M3 U.S. non-minorities only) or 5.
ONLY foreign (non-U.S.) subjects are involved and
study design addresses any known scientific
reasons for examining in-country minority group
or subgroup differences (Code M5 no U.S.
subjects involved)
YES
NO
ACCEPTABLE M1A, M2A, M3A, M4A, or M5A Describe
inclusion plan, any exclusions of minority
subpopulations, plans for analysis and outreach.
State why this is scientifically acceptable.
ABSENT No Information
UNACCEPTABLE M1U, M2U, M3U, M4U, or M5U Negative
impact on score. Describe inclusion plan, any
exclusions of minority subpopulations, plans for
analysis and outreach. State why this is
scientifically unacceptable.
UNACCEPTABLE Contact Scientific Review
Administrator
Summary of Codes Representation is
scientifically Minority Representation Acceptab
le Unacceptable Both minorities and
non-minorities included M1A M1U Minorities
only M2A M2U Non-minorities only M3A M3U Unkn
own (cannot be known) M4A M4U ONLY foreign
(non-U.S.) subjects in study M5A M5U
NIH/OER April 26, 2001
48
(No Transcript)
49
(No Transcript)
50
NIH Policy on Reporting Race and Ethnicity Data
Subjects in Clinical Research FY2002
  • NIH adopted 1997 OMB revised minimum standards
  • The categories in this classification are
    social-political constructs and should not be
    interpreted as being anthropological in nature
  • Using self-reporting or self-identification to
    collect an individuals data on ethnicity and
    race, investigators should use two separate
    questions with ethnicity information collected
    first followed by the option to select more than
    one racial designation.

Farley et al. SGO 2000
DHHS NIH Monitoring Adherence to the NIH policy
on the Inclusion of Women and Minorities as
Subjects in Clinical Research NIH
Tracking/Inclusion Committee 2005
51
OMB Revised Minimum Standards for Federal Data on
Race and Ethnicity Directive 15
  • Ethnic Categories
  • Hispanic or Latino a person of Cuban, Mexican,
    Puerto Rican, South or Central American, or other
    Spanish culture or origin, regardless of race.
  • Not Hispanic or Latino

DHHS NIH Monitoring Adherence to the NIH policy
on the Inclusion of Women and Minorities as
Subjects in Clinical Research NIH
Tracking/Inclusion Committee 2005
52
OMB Revised Minimum Standards for Federal Data on
Race and Ethnicity Directive 15
  • Racial Categories
  • American Indian or Alaska Native A person having
    origins in any of the original peoples of North,
    Central, or South America, and who maintains
    tribal affiliations or community attachment.
  • Asian A person having origins in any of the
    original peoples of the Far East, Southeast Asia,
    or the Indian subcontinent including for example,
    Cambodia, china, India, Japan, Korea, Malaysia,
    Pakistan, Philippine Islands, Thailand, and
    Vietnam.
  • Black or African American A person having
    origins in any of the black racial groups of
    Africa.
  • Native Hawaiian or Other Pacific Islander A
    person having origins in any of the original
    peoples of Hawaii, Guam, Samoa, or other Pacific
    Islands.
  • White A person having origins in any of the
    original peoples of Europe, the Middle East, or
    North Africa.

DHHS NIH Monitoring Adherence to the NIH policy
on the Inclusion of Women and Minorities as
Subjects in Clinical Research NIH
Tracking/Inclusion Committee 2005
53
SMS Race/Ethnicity Data Collection
54
CDB Race Data Collection
55
CDB Ethnicity Data Collection
56
Race and Ethnicity Data at MSKCC Who Uses It?
  • Clinical Research Database
  • OMS
  • Cardiology
  • Laboratory
  • Electronic Medical Record
  • Pathology
  • Disease Management System
  • Transition for Quality
  • PACS
  • Philips Echo system
  • Guttman Radiology system

57
Race/Ethnicity in Disparities Research
Challenge of Reporting Data
  • 1/89-10/00 NEJM, JAMA, Ann Int Med 253 trials
    in diabetes, cardio-vascular, HIV/AIDS, cancer
  • 46 reported only 1 or 2 categories
  • 2 trials reported results by race/ethnicity

Corbie-Smith et al. J Clin Epidemiol.
200356416-20.
58
Diversity Challenges Cancer Clinical Trials
59
Barriers to Clinical Trial Participation
  • NCI Comprehensive Cancer Center Survey Study
    n319 newly diagnosed
    patients with breast cancer 33 were
    offered participation in a trial
    Age and race were only predictors of
    investigator offer 42 whites vs 21 of
    blacks were offered CT (p.0009)
  • Clinical Trial Barriers at Howard University
    Cancer Center n235 newly diagnosed cancer
    patients 8.5 eligible
    , 60 of eligible enrolled
    27 of pts not eligible due to
    co-morbidities, performance status, premature
    death, or short life expectancy

Adams-Campbell et al J Clin Oncol
200422730-34 Simon et al J Clin Oncol
2004222046-52
60
Consent Rates for Health Research byRace and
Ethnicity
  • Non-Therapeutic Trials
  • African-Americans 82.2
  • Non-Hispanic Whites 83.5
  • Hispanics 86.1
  • Therapeutic Trials
  • African-Americans 45.3
  • Non-Hispanic Whites 41.8
  • Hispanics 55.9
  • Surgery Trials
  • Minorities 65.8
  • Non-Hispanic Whites 47.8

Wendler D, et al Are racial and ethnic minorities
less willing to participate in health research?
PLoS Med 3(2)e19
61
Barriers to Minority Participation in Cancer
Clinical Trials
  • Mistrust
  • Lack of awareness
  • Lack of invitation
  • Cultural Beliefs
  • Eligibility criteria/comorbid conditions
  • Cost/lack of insurance
  • Language/linguistic differences
  • Physician lack of awareness

Intercultural Cancer Council. Cancer Clinical
Trials Participation by Underrepresented
Populations http//iccnetwork.org/cancerfacts/cfs1
1.htm
62
Minority Accrual to NCI-sponsored Trials in
Colorectal, Breast, Lung and Prostate Cancer
Murthy VH. Participation in Cancer Clinical
Trials Race, Sex and Age-Based Disparities. JAMA
20042912720-2726.
63
Minority Enrollment NCI Cancer Clinical Trials
Colorectal, Breast, Lung and Prostate
Murthy VH. Participation in Cancer Clinical
Trials Race, Sex and Age-Based Disparities. JAMA
20042912720-2726.
64
Accruals to MSKCC Protocols 2005by Race and
Ethnicity
65
MSKCC Office of Diversity Programs Goals
  • Enhance institutional diversity through training,
    recruitment, and retention of underrepresented
    minority faculty and professional staff
  • Increase utilization of MSKCC prevention,
    screening, and treatment programs by
    racial/ethnic minorities and the underserved
  • Increase participation of racial/ethnic
    minorities and the underserved in the MSKCC
    clinical trials program
  • Develop a Research Program whose focus is the
    reduction and elimination of cancer health
    disparities

66
Clinical Care Strategies
  • Publicize existing community outreach to minority
    patients and their referring physicians
  • Breast Examination Center of Harlem
  • Ralph Lauren Center for Cancer Care and
    Prevention
  • Disease based assessment of minority patient
    issues and development of disease-specific
    strategies to provide culturally competent care
  • Expand services for LEP patients
  • Targeted marketing of minority populations who
    could utilize Regional Network satellites

67
MSKCC Office of Diversity Programs Goals
  • Enhance institutional diversity through training,
    recruitment, and retention of underrepresented
    minority faculty and professional staff
  • Increase utilization of MSKCC prevention,
    screening, and treatment programs by
    racial/ethnic minorities and the underserved
  • Increase participation of racial/ethnic
    minorities and the underserved in the MSKCC
    clinical trials program
  • Develop a Research Program whose focus is the
    reduction and elimination of cancer health
    disparities

68
Research Core Strategies
  • Office of Clinical Research Outreach Group
  • MSKCC protocols at minority-serving institutions
  • Collaborative research with minority serving
    institutions
  • Outreach to minority patient advocacy groups for
    design and conduct of clinical research in their
    disease site and population

69
Opportunities for Research MSKCC
  • CCNY/MSKCC U56 Partnership Grant
  • Queens Cancer Center
  • SUNY Downstate Medical Center
  • Ralph Lauren Center for Cancer Care and
    Prevention
  • Breast Examination Center of Harlem

70
Queens Health Network Service Area
Community Profile
Service Area Facilities
  • Approximately 1 million people in NW Queens
  • Diverse population of recent immigrants
  • Hispanic and Asian predominant in NW Queens
  • Approximately 600,000 people in South Queens
  • Growing immigrant population from India,
    Pakistan, Bangladesh Caribbean in South Queens
  • African-American Hispanic predominant in South
    Queens

Kemeny QCC 2004
71
Queens Cancer Center
  • Grants submitted with MSK
  • To NCI Multiethnic Patient Navigators Program
  • To NY State DOHSmoking Cessation Program
  • To NCIColorectal Screening in Public Hospital
    Primary Care Practices
  • To CDCMethods to Increase Colorectal Screening
    in NYCs Public Hospital System
  • To Lance Armstrong Foundation ENACCT Pilot
    Education Program
  • To NCI Networking

Kemeny QCC 2004
72
Resources for MSKCC Investigators
  • Office of Diversity Programs
  • Office of Clinical Research
  • Behavorial and Psychosocial Research Consultation
    Service
  • Language Assistance Program

73
Research Core Strategies
  • Coordinate existing, and develop new laboratory,
    clinical, and outcomes research focused on
    reduction and elimination of cancer disparities
  • CCNY/MSKCC Partnership U56 grant
  • Health Outcomes Research Group Projects
  • BCRF Navigator Grant RLCCP
  • Lance Armstrong Foundation Survivorship Community
    Partners Grant

74
Diversity in Academia/Research Strategic Plan
  • Affirm the value of diversity to the Institution
  • Assess the institutional climate for diversity
  • Develop a plan, guided by research, experiences
    at peer institutions, and results from the
    systematic assessment of the campus climate for
    diversity, for implementing constructive change
    that includes specific goals, time-table and
    pragmatic activities.

In the Nations Compelling Interest Ensuring
Diversity in the Health Care Workforce. IOM,
Washington 2004 p153.
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