ASCO Palliative Care Expert Panel Provides Recommendations to Integrate Health Equity Into Guideline Development

The ASCO Palliative Care Expert Panel, in collaboration with ASCO’s Health Equity and Outcomes Committee, has published recommendations for integrating health equity measures into future guideline updates.¹

Recommendations advocated for partnerships with increased representation from historically marginalized groups and patient and community-based advocates; a reinforcement of implicit bias training for Expert Panel members as a component of guideline preparation; stratified recommendations and/or guidelines for additional groups; and the review and appraisal of future recommendations by the Expert Panel, patient as well as community advocates, and ASCO reviewers for the inclusion of proper health equity measures before publication.

The recommendations also noted that future Expert Panels involved in guideline updates should consider whether observational data regarding marginalized groups should be evaluated for guideline inclusion in the absence of randomized, controlled evidence. They added that Expert Panel chairs should promote a general culture of inclusivity, accountability, and respect, and lead discussions about health equity in each Expert Panel.

Finally, the Palliative Care Expert Panel noted that the ASCO Equity, Diversity and Inclusion Committee and other health equity stakeholders should be invited to review the guidelines and provide input. The Panel hopes that this will continue to emphasize an internal focus on health equity within ASCO.

“The ASCO clinical practice guidelines are multidisciplinary expert initiatives that provide clinicians with evidence-based recommendations,” William E. Rosa, PhD, MBE, APRN, assistant attending behavioral scientist at Memorial Sloan Kettering Cancer Center in New York, New York, and the other expert panel members wrote. “ASCO has long expressed a commitment to health equity, and guidelines serve the implicit function of optimizing care, services, and treatment options for all people with cancer and those who care for them. Yet, disparities persist across the trajectory of cancer and in multiple domains of clinical care, education, and research, in the US and internationally.”

During the development of the Palliative Care for Patients with Cancer: ASCO Guideline update, the Palliative Care Expert Panel discussed several questions that were relevant to offering equitable care to patients with cancer. The panel consisted of a geographically diverse multidisciplinary group of clinicians, researchers, and a patient advocate. The ASCO Guidelines staff provided questions to help further examine equity considerations, which consisted of:^1,2

• What disadvantaged populations are included in the identified target audience? Do subpopulations have different baseline risks?
• In what settings will the interventions be implemented? What resources do these settings have?
• Are key equity issues incorporated in the guideline’s population/patient/problem, intervention, comparison, outcome questions, or should they be addressed in their own section?
• Are there areas where there is limited/indirect evidence, but the panel would like to make good practice statements to address equity issues?
• What considerations are there for clinicians when implementing interventions/controls equitably? How can inequities be reduced?
• Are there specific terms to include in the literature search for health inequities in this patient population? Consider resource use, cost, effect on equity, feasibility, and acceptability of interventions.

The group also sought to identify equity concerns within the palliative care guideline update process. To do so, one coauthor performed a screening of the 38 abstracts that made up the Expert Panel’s systematic review. Fifteen of the abstracts met the criteria to be considered studies on health equity and marginalized populations; 13 were descriptive studies, 1 was a secondary analysis of a randomized trial, and 1 was a systematic review. However, only 9 of these studies specifically included the investigation of historically marginalized groups in their study aims and only 2 randomized controlled trials included in the full ASCO guideline specifically included racially minoritized groups.¹

“The ASCO guidelines provide an important opportunity for multidisciplinary experts, patients with lived experience, and community advocates to partner in translating health equity from theory to practice,” Rosa and coauthors wrote in conclusion. “Furthermore, the guideline development process invites Expert Panel members, in collaboration with ASCO staff, to participate in self-, group-, and system-level reflection and critical discourse about the role of health equity in relation to the given topics that will inform oncology practice and provision on national and global scales.”

References

1. Rosa WE, Garcia CA, Mardones MA, Temin S, Sanders JJ. Integrating health equity in the ASCO guideline agenda: recommendations from members of the palliative care expert panel. JCO Oncol Pract. Published online August 12, 2024. doi:10.1200/OP.24.00291
2. Sanders JJ, Temin S, Ghoshal A, et al. Palliative care for patients with cancer: ASCO guideline update. J Clin Oncol. 2024;42(19):2336-2357. doi:10.1200/JCO.24.00542