‘Cancer Alley’ oncologist leads march toward equity in care, diversity in trials
Editor’s note: This is the third in a series of five stories from ASCO Voices, a session during ASCO Annual Meeting focused on the human side of oncology.
Rajasree Pia Chowdry, MD, recalls the weathered look of the patient she wasn’t able to save from the area of rural Louisiana known informally as “Cancer Alley.”
“His eyes, tired and sunken from treatment, spoke volumes, like the whole world had given up on him,” said Chowdry, associate professor of medical hematology and oncology at Louisiana State University Health Sciences Center. “I met his knowing gaze and we both acknowledged the truth — he was dying. There were no more standard treatments left for me to give him. I asked him the question I already knew the answer to: Would he be able to travel hours away to participate in clinical trial?”
The man’s eyes met Chowdry’s and he gave her the answer she wished she hadn’t been able to predict.
“As his wasted muscles twisted into a coy smile, he said, ‘Doc, I can barely make it here.’”
Misaligned priorities
Chowdry admitted that at first, she harbored doubts about practicing in Cancer Alley. As a young oncologist who had lost both her parents to cancer, Chowdry came to the profession on a mission to make a major impact. Intrigued by the novel treatments and clinical trials being launched at major academic medical centers, Chowdry dreamed of being at the forefront of these cutting-edge medical developments.
“Cancer had made me an orphan, and losing both parents when I was young led me to believe that somehow I had to make a difference in this field,” Chowdry said. “Then I was placed at this small, rural, critical access hospital far away from the big city and worlds apart from what I was used to. It was both literally and metaphorically as far away from academic oncology as one can imagine. These were people who had nowhere else to go, either due to distance or lack of insurance. Most of them were socioeconomically disadvantaged and minorities.”
It wouldn’t take long for Chowdry to recognize that these were the patients who needed her the most.
“It was only supposed to be a temporary position, but that temporary position turned into years,” she said. “And after years of practicing at an area known to the rest of the country as Cancer Alley, caring for patients with far greater obstacles than advanced cancer, I realized that my priorities were completely misaligned.”
‘Honor our purpose’
Once Chowdry understood the importance of bringing quality cancer care to rural Louisiana, she became devoted to cancer care equity. Although the medical profession overall has increased its awareness of and focus on this issue, change has been slow.
“Cancer care is still segregated,” she said. “It is arguably those patients who need clinical trials the most who have the least access to them.”
Chowdry discussed the patients she has seen in Cancer Alley, including those who struggle with gas money to drive to the clinic and those diagnosed with tumors at an early age. Many of these patients had very little choice in where they lived in relation to major academic medical centers, Chowdry said.
“Clinical trials are the foundation of cancer research, but have you ever wondered why the results of big, practice-changing trials aren’t replicated in your patients? There’s often a blatant mismatch between study populations and real-world patients,” Chowdry said. “These disparities, whether they are racial or socioeconomic, can significantly alter the validity of clinical trial results.”
Chowdry said her youthful excitement about cancer clinical trials once distracted her from the less “glamorous” mission of providing care to disadvantaged populations. Yet, she hasn’t lost her attraction to the scientific strides being made at large academic medical centers.
“Most of us went into this field for similar reasons — we wanted to help patients with cancer, whether it’s curing them, improving their survival or palliating their symptoms,” she said. “However, we also do this because we’re intrigued by the science.”
Over the years, Chowdry said she has concluded that the best way for oncology providers to fulfill this dual attraction to service and science is to bring the science to these underserved patient populations.
“Years of practicing at a critical access hospital in rural Louisiana has taught me that the best way to honor our purpose for going into this field is to increase access to care and diversify clinical trials,” Chowdry said. “It is both scientifically necessary and ethically essential. It should be our duty to bring the trials to them, not the other way around.”
A call to action
Chowdry discussed ideas for improving access to clinical trials for individuals in disadvantaged communities. As a first step, she advised designing a mobile clinical trials unit that prioritizes underserved areas with high cancer rates. Next, she suggested leveraging technology to enroll patients virtually, eliminating distance as a barrier.
“Lastly, we need to increase funding to these critical access safety net institutions, so that they can remain open and we can help create community outreach programs to help educate patients on the value and importance of clinical trials,” she said.
Some of these efforts are already underway, Chowdry said. She cited Project Equity, a program the FDA created to increase diversity in clinical trial enrollment, and the Association of Community Cancer Centers’ collaboration with ASCO to create a platform for assessing clinical trial enrollment biases.
“Yet we still have miles to go, and the reality is, it takes a village to create a significant change,” she said. “There needs to be a cultural change and a paradigm shift in the oncologic research landscape.”
This shift is particularly important during the Cancer Moonshot era, Chowdry said, emphasizing that cancer statistics will not meaningfully change until equitable access is ensured for all patients.
“The road to equity is long, especially for my patients in Cancer Alley, where in some areas, nearly every household has been affected by cancer,” she said. “I know there are some things we can’t change, but we can improve the care that we give to the patients here and in similar places.”
Chowdry concluded with a call to action to her oncology colleagues.
“Let us break the barriers of equitable cancer care,” she said. “All the incredible advances in oncology are meaningless if we can’t help the people who need them the most.”
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“The Long Road to Equity: Life in Cancer Alley.” ASCO Voices Session. Presented at: ASCO Annual Meeting; June 2-6, 2023; Chicago.
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