Meet the Researcher
The underrepresentation of BICOP patients in cancer clinical trials negatively impacts patient care and slows medical advancements. Without the inclusion of racial and ethnic minorities, clinical trial results do not accurately reflect how treatments work across a broad population.
In her 2021 study, Cancer Disparities and Black American Representation in Clinical Trials Leading to the Approval of Oral Chemotherapy Drugs in the United States Between 2009 and 2019, Veronica B. Ajewole, PharmD, BCOP, laid out a pretty stark reality. “When I looked at trial studies for the top three cancers that utilize oral chemotherapy drugs, 50% did not have a racial breakdown of clinical trial patients. In the half that reported racial breakdowns, the white population was overrepresented.”
Build Trust – and Awareness
While achieving diversification in clinical trials requires sustained and coordinated efforts across healthcare delivery, the starting point is simpler. “Trust is the first major factor to consider when improving representation,” says Veronica.
“Many in these communities are unaware that, since Tuskegee, there are a lot more checks and balances. There is informed consent and there are processes in place to keep something like that, or another Henrietta Lacks situation, from happening again.” Still, many BIPOC individuals with cancer simply are not aware that the latest treatments may be available to them through clinical trials.
Some surveys show that most African Americans with cancer are not even asked about participating in clinical research. The presumption is that they would not want to be treated as test subjects. “There is that implicit bias,” says Veronica. But, she says, oncology pharmacists are in a unique position to help make clinical trials more equitable. “As pharmacists, we have opportunities to fill in these gaps and move the needle in the right direction.”
Education and Resources Needed
The healthcare system is complex and difficult for many people to navigate – especially those who have very little experience consuming healthcare. “[Low] health literacy impedes understanding of our very complicated healthcare system,” says Veronica. This is in addition to other pervasive barriers standing between many BIPOC patients and cancer clinical trial enrollment.
“Living in an underserved community means inadequate resources,” says Veronica. Common barriers to good health outcomes include the need to find – and pay for – childcare, the lack of paid time off, and the demands of caring for a family. And, these factors play a role long before a cancer diagnosis or treatment. “For some of my patients it becomes a choice between ‘Do I make dinner for my family, or do I get a mammogram?’”
Furthermore, some patients from marginalized communities are not close to a treatment center and do not have reliable transportation.
“Here in Houston, one of the most underserved communities sits in the shadow of the largest medical center in the world, Texas Medical Center,” says Veronica. “So it isn’t just a matter of proximity or access.” Most patients also need help navigating insurance and patient assistance programs in addition to understanding their diagnosis and treatment plan.
A Call to Action for All of Us
In recent years, the FDA has committed to addressing underrepresentation of BIPOC individuals in drug clinical trials. And the Oath of a Pharmacist has evolved to better address healthcare disparities. “Updates to the Oath of a Pharmacist seek to advance health equity by addressing implicit bias and embracing diversity and inclusion,” says Veronica. The oath was last updated in 2021 by the American Pharmacist Association (APhA).
Across the continuum of care, oncology pharmacists can be advocates for better clinical trial representation. “Those of us in academia have an opportunity to spotlight this need with the upcoming generations, while those in the pharmaceutical industry are often in the rooms and meetings where decisions are made about patient enrollment,” says Veronica. “Pharmacists can ask, ‘are we making a conscious effort to enroll BIPOC individuals impacted by cancer? And, are we asking these patients the right questions?’”
The problem of underrepresentation of BIPOC patients in clinical trials is indeed multi-layered. Sustained and coordinated efforts across healthcare and patient advocacy organizations does lead to improvement. “The problem wasn’t created in one day and it won’t be solved in one day,” says Veronica.
Conclusion
Clinical oncology pharmacists may be in the best position to help build awareness and provide BIPOC patients with education and resources. But everyone has a role to play. “Regardless of [your] race, you can advocate for Black patients,” says Veronica. “It’s a matter of advocating for the improved health of humanity.”
To assist oncology pharmacists in starting culturally aware conversations, HOPA has created Time to Talk Diversity in Clinical Trials, with a downloadable conversation guide.
5 Questions with Veronica B. Ajewole, PharmD, BCOP
HOPA staff recently conducted a Q&A with Veronica B. Ajewole, PharmD, BCOP, Associate Professor in the Department of Pharmacy Practice at Texas Southern University and Adjunct Assistant Professor of Oncology at Houston Methodist Hospital. Answers have been edited for length and clarity.
- What inspired you to become an oncology pharmacist?
I attribute coming into Oncology Pharmacy to a few things. I was blessed to have really great professors and mentors in pharmacy school who inspired me to learn more about oncology practice. I like a challenge and I knew oncology was a field where you constantly learn new things.
There was also the need for more research and more opportunities to meet patient needs. I started out in an infectious diseases lab, which spurred my interest in research. That experience exposed me to what research can be and how it can help us understand the needs of patient care.
- What was your path to oncology pharmacy?
I went to MD Anderson Cancer Center for my first research internship when I was a second-year pharmacy student. I did the summer fellowship there twice, where we looked at cancer prevention and risk factors. With that knowledge, I just felt I was being guided in the right direction and when the time came for rotations, I specifically requested oncology.
Carrying that knowledge into patient care, I was a breast cancer pharmacist at Texas Southern University (TSU). I have always been passionate about empowering people with knowledge, and I was able to interact with the nurses and patients there. It was very free-flowing and I thought, "This was where I needed to be." I needed to choose a career I would enjoy doing and where I could do research for improving patient care.
- Where does HOPA factor into your journey?
I came across HOPA during my PGY1 residency training in general practice at Houston Medical Center. I requested oncology for one of my rotations, and met an amazing physician called Dr. Daniel Lehane.
Within four weeks of being on rotation with him, he taught me the history of how drugs like cisplatin and carboplatin were formed; he knew the mechanism of action, he went beyond bedside consultations for me. I was able to commit to the PGY2 program early, and that's when I came across HOPA and became a member in 2016.
- What impact has a HOPA membership had on your career?
HOPA membership was a transformative experience for me right from the start. I attended my first conference, met like-minded individuals, and got exposed to the concept of board certification. I learned about the different types of oncology practice, career paths, and networking options. In an ever-evolving field, HOPA gave me a platform that met my need for ongoing education.
In 2018, my poster was identified as one of the top 10 at HOPA's Annual Conference. I remember presenting it when I was pregnant with my daughter. It was been a really rewarding journey.
- What career achievement, to date, are you most proud of?
I am proud to have been among the first pharmacists to become board certificated in oncology immediately after residency. I sat for and passed the exam the same year I finished residency training, which was July of 2017. At that time, that wasn't very common but I had too much energy to wait!
That energy has carried into my academic career and when I see a problem, I need to try and find a solution. By nature of always looking for opportunities, I have been involved in many first-of-their-kind initiatives.
I started an oral chemotherapy clinic at Houston Methodist Hospital and was founding director of TSU's Community Engagement Corps. I'm involved in establishing a clinical trial satellite center where TSU collaboratively partners with health systems to build trust and bridge the clinical trials gaps. I also lead TSU's Mobile Unit so we can perform health screenings in rural communities.
HOPA Member Research
Among her notable achievements, Veronica has co-authored articles and abstracts on racial disparities, health inequities, and a lack of representation of Black, Indigenous, and People of Color (BIPOC) individuals in clinical trials. These include:
- "Cancer Disparities and Black American Representation in Clinical Trials Leading to the Approval of Oral Chemotherapy Drugs in the United States Between 2009 and 2019"
- "Community Engagement Practices at Research Centers in U.S. Minority Institutions: Priority Populations and Innovative Approaches to Advancing Health Disparities Research"
- "Trends and Racial/Ethnic Disparities in the Rates of Pre-eclampsia by HIV Status in the US"
