CQI Program Director Wins National “Excellence in Equity” Award

Lori Pierce, MD, is the recipient of the 2024 American Society of Clinical Oncology, endowed by the American Cancer Society. This award recognizes Dr. Pierce’s dedication and contributions to the field of global oncology. Dr. Pierce is the Program Director of the Michigan Radiation Oncology Quality Consortium (MROQC) and Professor of Radiation Oncology at Michigan Medicine. (Note: Interview lightly edited for length and clarity.)  

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Q: Dr. Pierce, you’ve received numerous awards over your career. What stands out about ASCO’s Excellence in Equity award?

Pierce: I have been fortunate in my career to be acknowledged for work that I, in collaboration with many others, have done, but the ASCO Excellence in Equity award is a particularly special honor because it recognizes those who promote high quality, equitable care for all.  

As oncologists, we seek to develop new cancer therapies which are tested through randomized trials to find the best care options. Those options are, in turn, offered in the clinic to cancer patients. But if all cancer patients are not offered these therapies, then the health care system has failed these patients. This award acknowledges efforts made to promote equitable care for all regardless of race, ethnicity, sexual orientation, disability, and/or financial or geographical limitations.  

During my year as ASCO President, I led an effort to promote equitable accrual to clinical trials as well as equitable cancer care overall. Programs at ASCO were expanded and now equity, diversity and inclusion crosses over all ASCO domains and is incorporated into every ASCO program and initiative. Equity has truly been woven into the fabric of the organization which is what is needed to sustain this work. It was truly an honor for me to incorporate my presidential theme “Equity. Every patient. Every day. Everywhere.” into the programs at ASCO.

Q: What is most important for people living in Michigan to know about MROQC’s contributions to health care?

Pierce: It is important for people living in Michigan to know that MROQC exists and that its purpose is to improve the care of cancer patients receiving radiation throughout the state. Participation by radiation practices is voluntary but for those who participate, metrics are chosen that focus on optimizing radiation delivery such that radiation side effects are reduced while meeting national standards for radiation treatment.  

Patients who are treated in MROQC centers provide important feedback which helps shape consortium recommendations for radiation care. Consortium-wide meetings are held three times a year with radiation oncologists, medical physicists, dosimetrists, administrators, and data managers in which national cancer leaders discuss cutting-edge cancer care which inform collaborative-wide initiatives. These meetings also provide opportunities for a rich exchange of information between practices to elevate care across the state.  

MROQC has changed radiation treatment practices and outcomes through the years. Examples of changes made possible through MROQC include advances in the use of shorter more patient-friendly treatment courses in breast cancer and bone involvement by cancer, significant increases in the use of techniques that take breathing motion into account when planning lung cancer fields, and use of radiation techniques that reduce skin irritation following treatment for early-stage breast cancer. And it is important that citizens in Michigan know that MROQC has been made possible through a partnership between radiation oncology practices across the state and Blue Cross Blue Shield of Michigan and Blue Care Network.  We are all working together to improve the outcomes of cancer patients in the state of Michigan by listening to the patients we serve and incorporating their needs into the treatments we deliver.  

Q: How has your opinion of quality improvement in radiation oncology shifted during your years with MROQC?  Or has it not?

Pierce: I am proud of the work the MROQC community has done to improve quality and patient care even when the work has not been easy. The members of MROQC are driven by what is best for the patient rather than what might be better for the practice. Specifically, many radiation fractionation regimens can now be delivered in a shorter timeframe, meaning fewer treatments and less reimbursement to practices. Due to trials showing equal efficacy between shorter and longer fractionation schemes and therefore, greater convenience for patients treated with fewer fractions, shorter courses have become the standard of care for MROQC institutions.  

MROQC also obtains patient-reported outcomes which are strongly considered in the selection and design of collaborative-wide metrics. These patient-based metrics improve patient care. Furthermore, by selecting uniform practice metrics for all patients, we are ensuring equity of care for all patients since all practices and providers are held to the same standard.  It is clear quality of care has improved for all MROQC institutions and that MROQC members are focused not only on physician-led and physics-led directives but also patient-led directives.  

Q: It’s easy to have bursts of inspiration and action in support of diversity, equity and inclusion. What keeps you motivated after all these years?

Pierce: DEI work is truly a marathon, not a sprint. If it were easy, societal inequities would have been addressed years ago. But the fact that many of the issues are based upon decades of inequality makes it clear that resolutions will not come overnight. Recent national and global events have made it clear to many that the status quo is not acceptable.  People are demanding change. In recent years, we witnessed aggressions toward minority populations which are not new but have been increasingly publicized due to the use of social media. These acts have brought widespread condemnation and calls for change. At the same time, the world experienced a pandemic during which the most vulnerable were disproportionally affected. The pandemic highlighted the severity and consequences of extreme societal inequities.  These tragedies have led to the examination of policies that disadvantage one population relative to another and to questions asking why and what can be done to promote equity. These challenges to the status quo indeed motivate me to a part of change going forward.  

Q: What topic do you wish oncology patients would discuss more frequently/openly with their providers?

Pierce: Understanding barriers to cancer care is the first step in helping to remove whatever obstacles exist. Some barriers may be squarely within the domain of the care team to address. An example in radiation oncology is the scheduling of treatment times. For some patients, coming at certain times of the day is disruptive to family life and work schedules, so something as simple as changing a treatment time can make a big difference in patient compliance. Other barriers, such as transportation challenges and food insecurity, may require the input and assistance of others. But regardless, knowledge of what the barriers are is critical to meeting the needs of the patient and ensuring equitable care.  But contrary to how the question was asked, the burden should not be placed on the patient to necessarily initiate discussion but rather on the provider to ask.  Providers need to ask the right questions and engage in discussions with patients, so patients feel comfortable sharing their concerns.   We all need to be more culturally competent and take the time to ask the right questions and then listen to what our patients are saying and, in some cases, not saying.  

Q: Are there any developments in radiation oncology that have happened more quickly or slowly than you expected?

Pierce: Radiation oncology has always been a discipline where treatment field design has been tailored to the patient’s diagnosis. Larger fields are used when regional nodes require treatment. Conversely, smaller fields are used when only the primary cancer is to be treated. And in some early-stage cancers such as breast cancer, very limited fields such as partial breast radiation can be utilized.  These types of treatment modifications and the technologies needed to accurately treat the desired target volumes with limited side effects have progressed rapidly.  However, knowledge regarding how best to incorporate biologic factors from specific cancers into treatment plans has been slower to adopt. Genetic signatures are used widely by medical oncologists to assess tumor biology. For example, OncoType is a signature that determines the benefit, or lack of benefit, of chemotherapy when added to endocrine therapy in hormone receptor positive breast cancer. Current trials are now asking whether the use of existing genetic signatures used for systemic therapies can also inform radiation treatment decisions in certain cancer groups. Meanwhile, other studies are seeking to identify new signatures that are radiation specific and can take into account radiation sensitivity differences within individual cancers. All of these efforts are likely to yield information that will allow us to further tailor radiation recommendations by incorporation of tumor biology.