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. Manhattan - Memorial Hospital for Cancer and Allied Diseases - Breast Examination Center of Harlem - Integrative Medicine Outpatient Center - MSK 64th Street - MSK Counseling Center - MSK Guttman Diagnostic Center - Rockefeller Outpatient Pavilion - Sidney Kimmel Center for Prostate and Urologic Cancer Long Island - MSK Suffolk Outpatient Center (Commack) - MSK at Suffolk (Hauppauge) - MSK at Mercy Medical Center New Jersey - MSK at Saint Clare's in Denville - MSK at Saint Clare's in Dover Westchester - MSK at Phelps Memorial Hospital Center 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 MD’s and PhD’s, • 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 MSKCC:The 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/factsandfigures

18. Castillo-Page Minorities in Medical Education Facts and Figures 2005 AAMC www.aamc.org/factsandfigures

19. Castillo-Page Minorities in Medical Education Facts and Figures 2005 AAMC www.aamc.org/factsandfigures

20. Castillo-Page Minorities in Medical Education Facts and Figures 2005 AAMC www.aamc.org/factsandfigures

21. Castillo-Page Minorities in Medical Education Facts and Figures 2005 AAMC www.aamc.org/factsandfigures

22. Castillo-Page Minorities in Medical Education Facts and Figures 2005 AAMC www.aamc.org/factsandfigures

23. Castillo, L Diversity in the Physician Workforce Facts and Figures 2006 AAMC www.aamc.org/factsandfigures

24. Castillo, L Diversity in the Physician Workforce Facts and Figures 2006 AAMC www.aamc.org/factsandfigures

25. Castillo, L Diversity in the Physician Workforce Facts and Figures 2006 AAMC www.aamc.org/factsandfigures

26. Castillo, L Diversity in the Physician Workforce Facts and Figures 2006 AAMC www.aamc.org/factsandfigures

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 12:61-68,2001.

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 andnon-minorities included)or • 2. Strong evidence exists for NO significant racial or ethnic differences in intervention effect? • (Code M1: both U.S. minorities andnon-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 andnon-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 andnon-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 Acceptable Unacceptable Both minorities and non-minorities included M1A M1U Minorities only M2A M2U Non-minorities only M3A M3U Unknown (cannot be known) M4A M4U ONLY foreign (non-U.S.) subjects in study M5A M5U NIH/OER April 26, 2001

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 individual’s 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