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Figure.  Representation Trends Across Oncology Specialty Groups From 2015-2016 to 2019-2020
Representation Trends Across Oncology Specialty Groups From 2015-2016 to 2019-2020
Table.  Absolute Percentage Change in URM Representation and AAPC Across Study Years
Absolute Percentage Change in URM Representation and AAPC Across Study Years
1.
Xierali  IM, Nivet  MA.  The racial and ethnic composition and distribution of primary care physicians.   J Health Care Poor Underserved. 2018;29(1):556-570. doi:10.1353/hpu.2018.0036PubMedGoogle ScholarCrossref
2.
Nieblas-Bedolla  E, Williams  JR, Christophers  B, Kweon  CY, Williams  EJ, Jimenez  N.  Trends in race/ethnicity among applicants and matriculants to US surgical specialties, 2010-2018.   JAMA Netw Open. 2020;3(11):e2023509. doi:10.1001/jamanetworkopen.2020.23509PubMedGoogle Scholar
3.
Oncology AS of C. Diversity in Oncology Initiative. Published 2019. Accessed September 1, 2021. https://www.asco.org/practice-policy/cancer-care-initiatives/diversity-oncology-initiative
5.
Clegg  LX, Hankey  BF, Tiwari  R, Feuer  EJ, Edwards  BK.  Estimating average annual per cent change in trend analysis.   Stat Med. 2009;28(29):3670-3682. doi:10.1002/sim.3733PubMedGoogle ScholarCrossref
6.
Lett  LA, Murdock  HM, Orji  WU, Aysola  J, Sebro  R.  Trends in racial/ethnic representation among US medical students.   JAMA Netw Open. 2019;2(9):e1910490. doi:10.1001/jamanetworkopen.2019.10490PubMedGoogle Scholar
1 Comment for this article
EXPAND ALL
Prism
Dilipsinh Solanki, MD | Oncology Private Practice
I am South Asian, from India. Indians at one time overwhelmingly choose cardiology, GI, and pulmonary, as specialities, all procedure-oriented and thus lucrative. "No one goes into hematology" said an older Indian doctor whose counsel I had sought (Oncology didn’t exist then). I became one later.

Oncology is now lucrative but far behind those three. It is a very satisfying field personally but also extremely demanding of one’s time. My days were 12 -14 hours. The only procedure we do is chemotherapy and it actually increases work and time spent. The young generation looks at quality of life,
and oncology is lower down on their list.

It has almost become a necessity that one looks at every issue in every field through the prism of race or discrimination. The authors did not ask why Asians are near the top. Almost all are children of immigrants, often came here with nothing more than a desire and drive to succeed, and they passed that on to their children. They used the same system offered by America and the majority did not have high social or economic standing. So there must be something else.

The authors chose not to look for that “something else.” I am sure they know that If one removes all traces of discrimination by race or anything else, suddenly there would not be a flood of minority physicians in this country. Then don’t make that as the central theme of these statistics. Look deeper even if it is like Oncology: hard!

CONFLICT OF INTEREST: None Reported
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Research Letter
Diversity, Equity, and Inclusion
October 7, 2021

Trends in Race and Ethnicity Among Matriculants to US Oncology Training Programs, 2015-2020

Author Affiliations
  • 1University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
  • 2Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston
  • 3Office of Student Affairs and Department of Urology and Transplantation, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
JAMA Netw Open. 2021;4(10):e2128530. doi:10.1001/jamanetworkopen.2021.28530
Introduction

The demographics of practicing physicians in the US have not represented the diverse populations they serve, and there is no exception in oncology care.1,2 Recognizing the detrimental effects of these disparities on public health, oncology training programs have instilled benchmarks and initiatives to increase diversity among oncology physicians nationwide.3 However, data about representation in oncology specialties and the impact of these initiatives is lacking. This study aims to assess underrepresented minority (URM; ie, Black or African American individuals, Hispanic or Latino individuals, and Native American, American Indian, or Alaskan Native individuals) representation trends across training programs in oncology specialties from 2015 to 2020.

Methods

This cross-sectional study was exempt from institutional review board review at the University of Toledo and informed consent was waived because data was deidentified. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

This study uses trainee self-reported race and ethnicity data collected by the Accreditation Council for Graduate Medical Education (ACGME) from the 2015 to 2016 to the 2019 to 2020 academic calendar years.4 Trainees self-identified as Asian or Pacific Islander (or Native Hawaiian in 2019-2020); Black or African American; Hispanic or Latino; Native American, American Indian, or Alaskan Native; White; or other. Per ACGME resource books, the category other indicates a known ethnicity other than the ones available in the selection. Trainees were grouped into all oncology specialties, including hematology and medical oncology, gynecologic oncology, pediatric hematology and oncology, radiation oncology, complex general surgical oncology, and all other specialties. χ2 analysis was used to compare URM representation, which was defined as the proportion of trainees self-identifying as Black or African American, Hispanic or Latino, or Native American or Alaskan, across groups. Joinpoint regression was used to determine Average Annual Percentage Change (AAPC) in representation for all groups.5 Joinpoint Regression Software was used to calculate AAPC. Stata Statistical Software version 14.2 (StataCorp) was used for χ2 analysis. All tests were 2-tailed. Significance was determined at P < .05.

Results

Of the 13 853 total oncology trainees included in this study, 4315 trainees (31.1%) identified as Asian or Pacific Islander (or Native Hawaiian in 2019-2020); 520 trainees (3.8%) identified as Black or African American; 708 trainees (5.1%) identified as Hispanic or Latino; 22 trainees (0.2%) identified as Native American, American Indian or Alaskan native; 7219 trainees (52.1%) identified as White; and 1069 trainees (7.7%) identified as other. Only 1250 (9.0%) of 13 853 trainees were URM individuals.

URM representation in oncology was significantly lower than all other specialties across all study years combined (9.0% [95% CI, 8.5%-9.5%] vs 13.1% [95% CI, 13.1%-13.2%]; P = .001). Of the oncology specialty groups, only gynecologic oncology (22.7% [95% CI, 8.2%-39.1%]; P = .02) and hematology and medical oncology (3.0% [95% CI, 0.4%-5.7%]; P = .04] demonstrated significant positive AAPCs (Table and Figure).

Discussion

To our knowledge, this study is the first to investigate URM representation trends among oncology training programs in the US. It found that the continued disparities in URM representation exist within oncology training.3 From 2015 to 2020, only 3.8% of oncology trainees identified as Black or African American, 5.1% as Hispanic or Latino, and 0.2% as Native American, American Indian, or Alaskan Native, while individuals identifying as these races and ethnicities make up 13%, 18%, and 1.3% of the total US population in the 2020 census, respectively. This finding is consistent with studies demonstrating persistent URM underrepresentation across both surgical and nonsurgical specialties.2

One limitation of this study was the exclusion of residents of unknown racial/ethnic identity, because URM individuals are more likely to report as unknown. Trainees are also counted in multiple years because of the nature of residency programs. Furthermore, because of ACGME changes, this study does not include Pacific Islander and Native Hawaiian groups in the definition of URM, and individuals who identified as Spanish origin were included in the Hispanic or Latino groups in 2019 to 2020.

It is important to consider these results in the context of persistently low rates of URM representation in graduate medical education because of structural racism and other potential factors, which limit representation in training programs across all specialties.2,6 However, rates of representation in oncology remain significantly lower than all other specialties combined. Potential contributing factors to this disparity, including trainee preferences for specialties in primary care, length of training, recruitment strategies, pipeline specialty demographics, and specialty workforce demographics, must be studied further in order to address this disparity and create a diverse and representative workforce that meets the health needs of the diverse populations served.

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Article Information

Accepted for Publication: August 5, 2021.

Published: October 7, 2021. doi:10.1001/jamanetworkopen.2021.28530

Correction: This article was corrected on November 5, 2021, to fix a duplicated label in the legend of the Figure. The duplicate label was changed from radiation oncology to complex general surgery oncology.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Lang JJ et al. JAMA Network Open.

Corresponding Author: Obi Ekwenna, MD, Department of Urology and Transplantation, University of Toledo College of Medicine and Life Sciences, 3000 Arlington St, Mail Stop 1091, Toledo, OH 43614 (obinna.ekwenna@utoledo.edu).

Author Contributions: Mr Lang and Dr Ekwenna had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lang, Lombardi, Oke, Ekwenna.

Acquisition, analysis, or interpretation of data: Lang, Issa, Garcia.

Drafting of the manuscript: Lang, Issa, Lombardi.

Critical revision of the manuscript for important intellectual content: Lang, Lombardi, Garcia, Oke, Ekwenna.

Statistical analysis: Lang, Issa.

Supervision: Lombardi, Oke, Ekwenna.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This work was presented at the American Society of Clinical Oncology Annual Meeting 2021; June 5th, 2021; Virtual.

Additional Contributions: We would like to thank Mary Lee Brown, MPH, RN, (University of Toledo College of Medicine and Life Sciences, Department of Urology and Transplantation) for her dedication and contribution to the study. We would also like to thank the ACGME, specifically those responsible for compiling the Data Resource Books, for their work and permission of data use.

References
1.
Xierali  IM, Nivet  MA.  The racial and ethnic composition and distribution of primary care physicians.   J Health Care Poor Underserved. 2018;29(1):556-570. doi:10.1353/hpu.2018.0036PubMedGoogle ScholarCrossref
2.
Nieblas-Bedolla  E, Williams  JR, Christophers  B, Kweon  CY, Williams  EJ, Jimenez  N.  Trends in race/ethnicity among applicants and matriculants to US surgical specialties, 2010-2018.   JAMA Netw Open. 2020;3(11):e2023509. doi:10.1001/jamanetworkopen.2020.23509PubMedGoogle Scholar
3.
Oncology AS of C. Diversity in Oncology Initiative. Published 2019. Accessed September 1, 2021. https://www.asco.org/practice-policy/cancer-care-initiatives/diversity-oncology-initiative
5.
Clegg  LX, Hankey  BF, Tiwari  R, Feuer  EJ, Edwards  BK.  Estimating average annual per cent change in trend analysis.   Stat Med. 2009;28(29):3670-3682. doi:10.1002/sim.3733PubMedGoogle ScholarCrossref
6.
Lett  LA, Murdock  HM, Orji  WU, Aysola  J, Sebro  R.  Trends in racial/ethnic representation among US medical students.   JAMA Netw Open. 2019;2(9):e1910490. doi:10.1001/jamanetworkopen.2019.10490PubMedGoogle Scholar
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