Nov 3, 2022
Shannon Westin, Pamela Kunz, and Rachna Shroff discuss the lack of gender equity on oncology industry advisory boards.
The guest on this podcast episode has no disclosures to declare.
Dr. Shannon Westin: Hello, everyone, and welcome to another episode of the JCO After Hours podcast; our podcast where we get in-depth for articles in the Journal of Clinical Oncology.
I am your fearless leader, and host, Shannon Westin, the Social Media Editor for the JCO, as well as a Professor of Gynecologic Oncology at MD Anderson Cancer Center. And I am so excited to introduce our two guests today. We are going to be discussing the article from the JCO, 'Where Are All the Women in Industry Advisory Boards?'
And none of my guests have Conflict of Interest related to this work.
So, first, let me introduce Dr. Rachna Shroff, she is from the University of Arizona, Tucson. She's not only the Interim Chief of the Division of Hematology/Oncology, she's the Associate Dean of Clinical and Translational Research, and Associate Professor of Medicine, the Chief of the Section of GI Medical Oncology, and the leader of the GI Clinical Research team. And somehow, we got her on this podcast. I don't know how she had the time. Welcome.
Dr. Rachna Shroff: Thank you. So excited to be here.
Dr. Shannon Westin: She is the first author on this paper, and she's also accompanied by the last author on this paper, Dr. Pamela Kunz, from the Yale School of Medicine, where she serves as Associate Professor of Internal Medicine, the Director of the Center for Gastrointestinal Cancers at Smilow Cancer Hospital, and Yale Cancer Center, the Chief of GI Medical Oncology, and the Vice Chief of Diversity, Equity, and Inclusion in Medical Oncology. Welcome.
Dr. Pamela Kunz: Thank you. Really excited for this.
Dr. Shannon Westin: I have to step up my game, man. This is an esteemed panel here. So, we're going to get right to it. I think this is such an important topic because you know, we've been seeing quite a bit of focus on gender equity in Oncology, I would say, really over the last five years, really, especially - yay. Where do you all see the biggest gaps? Like, what are we missing? What do we need to do?
Dr. Rachna Shroff: Well, I'm happy to chime in, and I know that Dr. Kunz has her thoughts as well, but I agree with you. I think the first step to trying to address these gaps is just opening the conversation, and I think we have made tremendous strides in that regard. In terms of gaps, I mean, half of the reason that we even started thinking about this topic was really related to research, and opportunities for clinical trials, clinical research, drug development, and where women can try to increase their visibility and their opportunities. And the honest truth is, some of these things we see day-to-day when we see the number of women at the podium presenting pivotal trials, and the number of women that are lead authors on practice-changing papers. And that, I think, is really an area that needs to be talked about.
And then, we need to work on the opportunities for solving these problems and coming up with solutions with everybody around the table, all of the key stakeholders engaged.
Dr. Pamela Kunz: I completely agree. And you know, I think that because Dr. Shroff and I are both in the clinical trials space, you know, she and I have talked about this, and I think that industry-sponsored clinical trials are certainly one space, national clinical trial network trials are another space that we are also trying to move the needle, and I think that we really all have a collective responsibility in whatever we're doing to really try to ensure equity and representation, both of women, but also underrepresented minorities. And I think that the way I really like to personally think about this is, as Dr. Shroff said, if we can diversify the people who are leading the science, whether it's clinical trials, basic or translational, our science will in fact be better. We will ask more innovative, creative questions, and our patients will benefit from it. We will have more, I think, health equity because different people will be thinking about how to do the science. So, it's really critical and I think it's something that it is really exciting. I agree with you, Dr. Weston, that it's, "Yay," that we're having some recognition of this. And I think really step one is collecting data, benchmarking, figuring how we can do better.
Dr. Shannon Westin: Yes. And I think that's a really nice segue to get into kind of what led you to explore this current area of focus around advisory board participation, and why that matters
Dr. Pamela Kunz: Dr. Shroff, should I tell the story?
Dr. Rachna Shroff: I was going to say, "Should we share our story?"
Dr. Shannon Westin: Oh, I love a story. Yeah, definitely.
Dr. Pamela Kunz: Oh, it's a good story. It's a good story. It involves Dr. Brian Alexander, who is one of our co-authors in this and is at Foundation. So, I was invited to participate in a Foundation Advisory Board, this was now, probably two years ago. And I have, as a practice, I now ask, "Who else is on the Advisory Board, and who is chairing the Advisory Board?" Because I've ended up, as I'm sure Dr. Shroff has as well, on advisory boards where I'm the only woman. And so, I've just as a policy, tried asking, and then I will also nudge if I notice that there's not great representation of women. And so, this was one of those times, and there were no other women advisors invited, and I objectively had a conflict, so I could not attend.
And this was before I even knew Brian. I was like, "I'm going to email the CEO and the COO of Foundation." And I did, and immediately got a response. And in fact, really to Dr. Alexander's credit, he called me the next day and said, "We can't let this happen. How can we be part of the solution? We have some other fantastic industry partners intentionally as part of this author list, and I think we're really eager to try to partner in this. I think it takes an academic-industry partnership to try to move the needle here." So, I think it took some real vulnerability on Dr. Alexander's part to say, "We need to do better and to really do a deep dive." Dr. Shroff, any comments on that? And then you and I started texting, I think.
Dr. Rachna Shroff: Yeah, No. So, similarly, I was asked to participate in I think, the same advisory board, but I also had a conflict, which is why Dr. Kunz did not see that I was one of the invitees. And so, that's how we started talking about it. And I agree. I think what was truly admirable was, of course, not just the immediate responsiveness, but the, "Let us be part of the solution." Like, "What can we do intentionally to try to shine a light on this?" And then, "What can we do to help find solutions?" But you know, I think it was interesting because once Dr. Kunz and I started talking about it, I also mentioned to her that I have had the privilege because I work in a very small research space of cholangiocarcinoma, that I have had the privilege of participating in an all-female advisory board. And it was again, a very purposeful creation and composition of an advisory board in partnership with industry and myself. I helped chair that advisory board, and it was night and day in terms of the way that the advisory board ran, the way in which there was engagement and participation. And so, we kind of started talking about, "Well, what if we started coming up with these types of solutions, and how could we flip the script and be able to see positive impact?"
Dr. Shannon Westin: I'm an advisory board participant myself, in a predominantly female-driven cancer, and a female-dominant physician, and still, we have a long way to go in GYN oncology as well. I'm often the only woman at the table, and so, I'm so grateful to your leadership for kind of calling this out. I guess before we get too much into your paper, I want to be mindful for listeners that maybe don't participate in these advisory boards, can you give us a little bit of a rundown with what happens at these tables?
Dr. Pamela Kunz: Dr. Shroff, I'm happy to let you start if you want to.
Dr. Rachna Shroff: Okay. So, you know, advisory boards are typically composed of anywhere from five to 15, 20, sometimes participants. And usually, the composition is what are historically called KOLs. So, people who are thought of as thought leaders in a specific space, and advisory boards are typically organized by an industry partner, and that partner decides on the question, the question that they want the advisors to address. Oftentimes, it's related to a drug that they are developing, and it could be as early as, you know, "How do we design the initial clinical trials,” to “How do we bring this to a phase III, and to the FDA, and to market?" So, it can be anywhere along the continuum of drug development.
And the advisors are basically often given some, maybe a little bit of pre-reading and homework, but we basically come together. Pre-COVID, we came together in person, I think since COVID, it's been a little bit of a mix in terms of virtual opportunities as well as in-person opportunities. And it's anywhere from three-hour up to full-day, if not a day and a half of discussions in a room where the company, or the sponsor is asking very specific questions in terms of helping pick our brains and ask us to help develop their drug, and trial design, and help them focus their efforts in a very specific manner.
Dr. Pamela Kunz: Yeah, maybe I'll add to that. So, the KOLs that Dr. Shroff mentioned are Key Opinion Leaders, and I think what's really interesting-- and I certainly learned more about this process in the course of writing the paper, but Key Opinion Leaders are really selected on the basis of metrics that are themselves biased. So, it's number of podium talks, number of publications, number of times you've maybe chaired a prior advisory board, or participated in an advisory board, or been on a steering committee, or PI’ed a clinical trial. And I think as our audience likely knows, many of these metrics were themselves skewed and there are disparities to many of these metrics, I think, as Dr. Shroff mentioned in the beginning.
And I think the other really interesting thing is that companies don't often have standardized ways to approach or track who they are inviting to their advisory boards, and the composition of advisory boards, and they are often, sometimes third parties will often organize the advisory board. So, it really has historically not been done in a very intentional or deliberate way.
Dr. Shannon Westin: Those are really great points, and I think we're seeing it all the time. I also think that it's kind of like that idea, like the rich get richer, right? And so, it's on us to some degree too. As we rise and become the lead authors, and are the chairs of the steering committee, and that's what I heard you say, Dr. Shroff, is like being very mindful about who you select, or who you ask your industry partner to select. So, I think there is a role there. I completely agree with you that calling attention to this is going to make it-- because it can't just be a couple of people doing it. It needs to be a widespread movement.
I guess the next question-- we've talked a little bit about how these boards are selected. How does the lack of women at the table impact the patients? How does it impact the women themselves? Like, why does this matter?
Dr. Rachna Shroff: Well, I mean, I can start with the latter in the sense of how does it impact the women? And it's like you said, the rich get richer. And so, I think because these advisory boards are often the first place that trials are discussed and or developed, those advisors tend to lend themselves to having pivotal roles in the trials that are being designed. And pivotal roles include Global Steering Committee participation. And Steering Committees are formed usually at the get-go of a clinical trial, and typically authorship for the subsequent publication, and or presentations, are determined by the Steering Committee composition. And so, if you don't have a seat at the table at the advisory board, you are more than likely not going to have a seat at the table on the Steering Committee, which then leads to not necessarily being at the podium, and or the first or senior author on the subsequent publication.
And so, unfortunately, it's very much a snowball effect in terms of not being able to have women participate along the continuum of the development of a drug or a therapy in a specific disease site. And then of course, those things potentially impact the advancement of the woman in terms of her career, right? Because at the end of the day, there are still very somewhat outdated, promotion and tenure, things that are looked at, including authorship, and lead and senior authorship, and platform presentations, and how many practice-changing studies you've been involved in. And so, if you don't necessarily start at that advisory board, you may have that impact affect your ability to get promoted and advance in your career as well.
And then, Dr. Kunz, I'm sure you'd love to talk a little bit about the other.
Dr. Pamela Kunz: I agree. I think you really painted a nice story of like this massive domino effect that not being at that first table has on a woman's scientific opportunities, and really on their career. And so, I think that it's really trying to help create opportunities for women. I will also-- we may get to talk about this a little bit later, Dr. Westin, but really women and underrepresented minorities and really looking at sort of the intersectionality of gender and other underrepresented characteristics, because I think we really also want to indicate that we need really a diversity of all types of voices on these advisory boards.
Dr. Rachna Shroff: And I just will say that, you know, just like Dr. Kunz mentioned that there's something to be said because the more diversity of representation we have at the table, the diversity of thought there is in clinical trial design. And to your question, Dr. Westin, smarter, more innovative, more equitable, and more accessible clinical trials will inevitably come out of diverse voices that are helping to design that trial.
Dr. Shannon Westin: Yeah, and I think that's what we want, right? There's obviously two major issues here. We want women to succeed so they can do more research and help our patients, and we want our patients to have the best possible outcomes, and get the best drugs, and have access to them across all types, you know, no matter where they are or where they're from. So, we've touched on those two critical issues.
I do want to expand a little bit. Do you have information of how this lack of gender parity may intersect with traditionally disenfranchised groups? You were kind of starting to get at this, I think, Dr. Kunz.
Dr. Pamela Kunz: I can certainly touch on that. I mean, I think that this concept of intersectionality was actually coined by a law professor, Kimberlé Crenshaw, and it really speaks to the fact that a number of underrepresented characteristics when experienced together, those individuals can experience an extra burden of discrimination. And I think we can see that, where whether they're women of color, or who have other underrepresented characteristics such as disability, et cetera, really don't have a voice at the table. And I think we need to be especially mindful of that. And I think that we want to be certain, I think that we know that our patients, certainly there are a number of health inequities, health disparities, and I think that if we can have more diverse voices designing trials and being really mindful of how we accrue more underrepresented minority patients to clinical trials, how we design eligibility criteria that aren't unintentionally exclusive, there really needs to be, I think, a revolution of how we think about being more inclusive in our clinical trial designs so that we get answers that are reflective of our diverse populations.
Dr. Shannon Westin: Now let's hit where the rubber meets the road. There's an issue, right? What do we do? What can we do?
Dr. Rachna Shroff: Well, I think, like I said, shining a light on it is obviously the first step. And when we went to write this paper, we realized the paucity of data that is out there, quantifiable data for us to kind of support certain comments and anecdotal thoughts that we had. And so, I think the first step is to be able to partner with industry. And I know that that has a little bit of a taboo component to it when we talk about clinical research and academia, but the honest truth is that the only way we're going to be able to come up with solutions, is by having everybody on the same page about the fact that we need to remedy this. And so, I think we talk in our paper, about a number of actions that companies and sponsors can take in terms of just intentional leadership, and asking for those that are involved in designing and planning advisory boards to strive for equity.
But also, to your point about rubber meets the road, more hard data. How can we better quantify where we're at? And what benchmarks and milestones we want to hit in terms of equity and diversity across the board, not just gender. And that way, the companies have milestones to hit and know how far a way they have to go. I think that's really the first place to start. And then, you know, there are small things that can be done. Again, just like I said, we had this all-female advisory board. I mean, creating spaces for women where they may be able to engage more or differently with industry so that they are better known, and develop relationships with the companies so that for the next advisory board or the next Steering Committee, their names are at the top of these people's minds, I think is really, really important.
But I'm sure Dr. Kunz has some other thoughts as well.
Dr. Pamela Kunz: Yeah. No, all of those are great ideas. So, I completely agree that step one is collecting the data, and I think that's easier said than done, and I think it requires just this incredible intentionality about it. And I'm going to be really bold. Like, what if we required advisory boards to have like 50% women and a certain number of underrepresented minorities? We're doing that on certain committees, on kind of university settings. What if they were required to publish those in the accompanying papers? Or what if that was required to be on: clinicaltrials.gov? And I think that it requires probably some centralization of how companies track their advisory boards, because I think what we also learned is that they're often not tracked centrally. It may be one person in one disease group organizing one advisory board, yet in the rest of the company, it's not really coordinated. Or again, a third party may actually be doing it, and the company may have no idea. So, some real intentionality around the organization and composition of advisory boards. I loved Dr. Shroff's example of sort of the all-women advisory board.
Another example, and I think one area of also disparity is that junior physicians are not often invited to advisory boards, so therefore we get like the same old voices. Often, that limits being innovative and creative. And so, I was part of an advisory board for junior faculty where I actually helped moderate it, but we invited what we, you know, called ‘rising stars’ and that was really fun. I don't know Dr. Shroff or Dr. Westin if you remember your first advisory board. It's really scary. I think you don't know what to say, when to talk, how to be a good contributor. And so, I think at this advisory board, we gave some tips on how to be a good advisor, and I think there are lots of really great opportunities that I think our industry partners would, I think, find really compelling.
Dr. Shannon Westin: Yeah. That's an awesome point because when you first start, it's not just like they're senior voices, they're also sometimes the loudest voices. You tend to, at least I did, tend to kind of just sit back and take it all in, and then have maybe some small conversations and a few times like pipe up. But I agree.
Well, this has gone by super-fast, and has been incredibly engaging and educational. I guess the last question I have for you all is, what's next for you guys? What are you doing next in this work?
Dr. Pamela Kunz: That's a good question. I mean, Dr. Shroff and I need to talk about that. But my goal from this is to really spread the word. So, I thank you, Dr. Westin, for inviting us to this podcast, that's part of that. I'll give one example of something that I did with one of the other co-authors. So, I spoke at the Medical Affairs Professional Society meeting, which is an industry-related meeting, but really just to get the word out to medical science liaisons we all work with. So, I think we need to figure out how to really partner, and I think to Dr. Shroff's point, this can't be taboo. This has to be something that we really work on together. I think there are other arenas, as we'd said, like National Clinical Trial Network trials, investigator-initiated trials of really diving deeper into how we can create opportunities in those spaces as well. Dr. Shroff?
Dr. Rachna Shroff: And I think that we can even go-- obviously, partnering with industry is going to be key, but some of the other things that Dr. Kunz and I have been doing, and/or are working on, is partnering with everybody that sees the need for this. So, to her point about the NCI and the NCTN, and increasing representation for leadership across the NCI-sponsored studies. ASCO has been amazing in terms of their commitment to increasing diversity at the podium. I mean, they do a great job with their educational programming, but they're really interested in, "How can we increase diversity in terms of the scientific programming?" You know, "How do we make sure it's not just nine oral abstracts with eight men and one woman? What can we do to increase that representation?" And so, I think it's going to require, like I said earlier, all of the stakeholders to buy in, and to work together hand-in-hand to figure out how we can come up with those solutions. And I think myself, Dr. Kunz, and a lot of other people are very much committed to being those bridges and bringing all these people together.
Dr. Shannon Westin: Well, you've inspired me to do the same, and I intend to recruit all the women in GYN oncology to help me.
Well, thank you both so much. This was such a great podcast, and I hope everyone learned a lot.
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This podcast was about, 'Where are all the Women in Industry Advisory Boards?' Please go read that paper and learn a ton. Take care.
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