Review Article
Vol. 5, Issue 2, 2025 · P1-11
Building Sustainable Partnerships for Cancer Health Equity
Anurag Agrawal, MD,Shanthi Sivendran, MD, MSCR, MBA,Arif Kamal, MD, MBA, MHS
Submission received: 2025-09-04 / Accepted: 2025-09-18 / Published: 2025-11-04
Abstract
In both high-income countries (HICs) and low- and middle-income countries (LMICs), sustainable partnerships are a key strategy to improve access and cancer health equity. Gaps in time to diagnosis and outcomes based on socioeconomic status (SES), rurality, and race/ethnicity persist in high-income countries (HICs), though mortality rates have improved over time. Mortality rates in LMICs are disproportionately high due to economic challenges and structural deficiencies such as siloing and duplication in cancer care delivery, resulting in poorer survival outcomes despite lower incidence rates compared to high-income countries (HICs). With population growth and aging in LMICs, the incidence of cancer is predicted to increase significantly by 2050. LMICs are currently poorly equipped to manage this increasing cancer burden. Parallel to this rising cancer burden, costs of cancer care are increasing, due to an economic focus on the medicalization of cancer management, at the detriment of patient- and caregiver-centered care and with increased financial toxicity, especially in disadvantaged populations. Linking such disadvantaged populations to comprehensive resources across the cancer continuum is required to ensure holistic and equitable care in all settings. Due to these persistent inequities, such as clinical trial enrollment, comprehensive supportive care services, survivorship, and patient-centered focus on quality of life (QOL), fostering innovative solutions and sustainable shared care models is required. Here, we describe solutioning led by the American Cancer Society in both HICs and LMICs, such as supporting the development of patient navigation services through multisectoral partnerships such as Roundtables. We also review additional examples of shared or networked partnerships among academic centers as well as between community oncology practices and academic centers, to improve access and quality of care. Though most of these examples are from HICs, the principles are equally applicable in LMICs. Finally, we summarize additional novel partnership strategies.
Take Home Messages
1. Managing complex cancer care equitably continues to have substantial challenges in all settings; sustainable partnerships are a key method to overcome barriers
2. The collective impact model can serve as a guide, where one organization may provide leadership and flexibility to achieve group consensus and impact
3. Cancer organizations, as well as academic-academic and community-academic networks, provide successful and innovative partnership models
4. Innovative strategies, including involving employers/insurers, task-shifting, and leveraging technology, are examples where partnerships can help overcome ongoing challenges in the cancer landscape
Background
Although cancer mortality in the United States has declined 34% over the last three decades, several persistent gaps have emerged, namely: 1) differential cancer screening rates based on race/ethnicity, socioeconomic status (SES) and insurance status; 2) mortality differences based on rurality, SES and race/ethnicity; and 3) lack of socioeconomic, rural and racial/ethnic diversity in clinical trials.1-14 Though less well-studied, differential cancer outcomes based on SES have been reported in diverse high-income countries (HICs).15-17 Largely for these disadvantaged populations, there is also increasing financial toxicity due to the unsustainable rate of rise in the cost of cancer care.18,19 This increasing cost of care has not come with a parallel focus on quality of life (QOL) and comprehensive, holistic cancer care.20-22
For low- and middle-income countries (LMICs), care remains fragmented with multiple key barriers including: 1) lack of medications; 2) financial toxicity; 3) inadequate hospital systems/infrastructure to appropriately treat cancer patients including lack of sophisticated and accurate diagnostics, data systems and localized clinical trials; 4) stigma inhibiting screening activities and delaying care seeking until a later, more likely incurable cancer stage; 5) an aging and growing population driving increased cancer incidence; and 6) modifiable risk factors being inadequately addressed.23-31
Workforce issues are an increasing challenge in both HICs and LMICs. In HICs, lack of diversity and increasing physician burnout are ongoing challenges.2,32-37 In LMICs, workforce shortages will be exacerbated by increasing cancer incidence, and task-shifting must be a key priority.26,30 Thus, the ongoing challenges in managing complex cancer care remain substantial in all settings; sustainable partnerships are a key method to overcome such outlined barriers.38
Solutioning Through Partnering
In HICs, disparities in outcomes have emerged as a core issue exacerbated by the concentration of pioneering therapies and clinical trials in academic centers, further leaving behind the majority of patients seen in community oncology practices, unable to benefit from this rapid pace of change.39 Innovative partnership models between community and academic oncology practices will be required to equitably treat populations, especially those as large and diverse as the United States (Figure 1).14,38,39 Cancer organizations such as the American Cancer Society (ACS) focus on supporting patient and caregiver needs by interacting with people with lived experience as well as providers and health systems and exemplify the benefits of convening and collaborating.
In order to achieve the American Cancer Society's (ACS) mission "to improve the lives of people with cancer and their families through advocacy, research, and patient support, to ensure everyone has an opportunity to prevent, detect, treat, and survive cancer," partnering is required. The American Cancer Society Cancer Action Network (ACS CAN) supports breakthroughs in cancer prevention, detection, treatment, and survivorship by advocating with partners in all 50 states, the District of Columbia, Puerto Rico, and Guam and at local, regional and national levels. Similarly, ACS Discovery has invested over $500 million in currently active grants driving research breakthroughs and has funded multi-year cancer research grants at over 220 institutions. Finally, the ACS Patient Support Pillar directly supports and educates people with cancer, their caregivers, and clinicians in more than 22,000 communities, with a focus on local, regional, national, and global initiatives.
Figure 1. Examples of collaborative opportunities between patients, caregivers, providers, and health systems
Fostering Partnerships
How do we cultivate partnerships across all organizations working in cancer care, considering the competitive economic landscape driving siloing, duplication, and fragmentation of care in both HICs and LMICs?
The first step is recognition. It is finally being acknowledged that the current systems of care are leaving whole groups of patients behind, and the patient and caregiver voice is not being sufficiently heard. We need to develop a universal realization that the cancer care environment is not working for most patients and their caregivers and that by collaborating, we can develop innovative models of care that are patient- and caregiver-centric, with a focus on comprehensive care, QOL, and addressing financial toxicity. Sustainable partnerships are a key component of these patient- and caregiver-centric models.
The next step is promoting collaboration, not just thinking about or discussing it. Moving from vision to process is a difficult initial step in the competitive and fast-paced environments in which we work. However, competition for funding and recognition must be balanced with the need to coordinate and collaborate with partners. The collective impact model can serve as a guide, where one organization may provide leadership towards stated goals with a shared understanding of the resources required, urgency of the issue, and need for responsiveness and flexibility to achieve group consensus and impact (Figure 2).40
Figure 2. Collective impact framework (with permission, Schaffer et al.40)
Examples of Effective Models
ACS Examples of Partnership
Across the ACS Patient Support Pillar, coordinating networks of collaborating partners and organizations allows us to support people with cancer, their caregivers, and health care providers throughout the United States and globally by connecting them to the resources they need. Examples of this within the community include the Road To Recovery® program, which connects volunteer drivers to patients with cancer who need assistance with transportation to their appointments, and the Cancer Survivors Network, an online peer support community for patients, caregivers, and survivors.
Development of patient navigation programs is another key method for connecting patients and their caregivers to the resources they need to access equitable care and break down barriers throughout the cancer continuum.41 The ACS Leadership in Oncology Navigation (ACS LION™) provides standardized training and credentialing to assist health systems in developing patient navigation programs that meet Centers for Medicare and Medicaid (CMS) training requirements for reimbursement. ACS LION trainings focused on supportive care and clinical trials further link patients and their caregivers with the comprehensive services needed to increase QOL and for resources to aid clinical trial enrollment to improve equitable access. Additionally, the ACS CARES™ (Community Access to Resources, Education and Support) app equips those facing cancer with curated content, programs, and services to fit their specific cancer journey. Additionally, patients and caregivers have the opportunity to be digitally navigated by trained peer volunteers to resources in their community, such as transportation through Road To Recovery® or community-based organizations through findhelp.org.
At a national level, ACS Roundtables are coalitions of public, private, and voluntary organizations, and invited individuals dedicated to reducing the incidence of and mortality from cancer in the United States through coordinated leadership and strategic planning. Roundtables are a clear example of the benefit of bringing together like-minded individuals and organizations to develop consensus and coalesce around key priorities in the cancer space.42-44 Globally, we leverage similar long-term relationships with civil society organizations (CSOs) and health system partners to implement sustainable programs adapted to the local context to support patients, caregivers and health care providers through technical assistance and catalytic grants, such as the African Cancer Coalition and the BEACON (Building Expertise, Advocacy and Capacity for Oncology Navigation) Initiative.45,46 The Global Alliance for Cancer Patient Navigation, like a national ACS Roundtable, was launched in 2025 to convene global stakeholders and unify the economic, research, and policy basis to build momentum for sustainable patient navigation capacity development in diverse non-U.S. settings.
Academic-Academic Partnerships
Identifying system-level deficiencies and developing best practices across academic cancer hospitals to better address inequalities in access and outcomes, and improving comprehensive services and QOL can serve as a model for more uniform cancer care across HICs and ultimately LMICs. Examples of such academic partnerships are limited. Quinn et al. report on an Alliance of six academic cancer hospitals to improve common health system deficiencies.47 This Alliance concentrated on the broader theme of improving coordination of cancer care through four domains, and the sites implemented multiple system and policy changes to improve care coordination, including: 1) improvements to electronic health records and telehealth; 2) policy change; 3) new protocols/guidelines; and 4) new positions/job codes. Most importantly, the Alliance was "intentional and deliberate in identifying, understanding, and overcoming system-level barriers faced by underserved patients" and likely to create sustainable change by focusing on health system and policy change.47 Practice guidelines created through cooperative groups such as the Children's Oncology Group (COG) or alliances such as the National Comprehensive Cancer Network® (NCCN) can also help foster standards of care across hospitals and community practices.48,49
Community-Academic Partnerships
Given that the majority of cancer patients are treated in the community setting, further linking community oncology practices to academic centers is a key model for improving equitable access and care across the cancer continuum.14,38,39,50,51 But this is even further complicated for rural communities where distances traveled to reach care are significantly increased.14,38,39,52 A regional or "hub-and-spoke" model can be one approach, given that the expectation that patients and their caregivers will be routinely able to travel long distances to access care is outmoded.14,38,39,52 Levit et al. highlight three examples, including the Ohio State University Comprehensive Cancer Center, Center for Health Equity, the Missouri Baptist Medical Center, Heartland Cancer Research, and the New Mexico Cancer Care Alliance. These programs utilize community-based partnerships, patient navigation, visits by oncologists to rural community sites and a hub-and-spoke model as well as participation in the National Cancer Institute Community Oncology Research Program (NCORP).51,52 Another similar example reported by Tucker et al. is the University of Kentucky Markey Cancer Center Affiliate Network, in which community hospitals showed significant increases in compliance with quality measures and achievement of Commission on Cancer accreditation after affiliation as compared to control hospitals.50
Decentralization of clinical trials is a key example of how such partnerships are required to improve equitable access.39,53 Examples include hybrid models with established partnerships between the research center and the community practice or shared-care models without a formal partnership.39 Examples from the global community can be helpful in the United States and vice versa.38,54 Munhoz et al. note examples from Canada and Australia that can be informative in providing improved services to rural and indigenous communities in the United States.38 Dee et al. review examples of excellence in LMICs, including Rwanda's Butaro Cancer Center of Excellence, India's National Cancer Grid, and São Paulo's Instituto do Câncer.54 Though quite heterogeneous LMICs, common themes emerged, including "engaging multiple stakeholders and facilitating collaborative dialogue." Within the ACS global program, we focus on aligned pathways for patients across the cancer continuum from the community health center to the regional hospital/cancer center (if it exists) to the national cancer hospital center (Figure 3).
Figure 3. Opportunities to consider overlapping priorities to de-silo, maximize resource utilization, and improve cancer care across LMICs
Discussion
Improving equitable access to comprehensive cancer services to enhance QOL, clinical trial enrollment, and ultimately patient outcomes requires a multi-pronged approach with partnerships as a key component in both HICs and LMICs. Partnering to engage all levels of the health system through cancer organizations and both academic-academic and academic-community alliances has shown benefit in these domains and deserves further extension and, ideally, universalization. Figure 4 provides a hub-and-spoke model involving academic and community networks to impact meaningful change.38,39
In addition to academic-academic and academic-community alliances, engagement of advocacy coalitions and community participants (including persons with lived experience) provides key insights for patient- and caregiver-centric care that should be universally sought and included in both HICs and LMICs.55-57 For instance, the inclusion of patient-reported outcome measures (PROMs) is patient-centric and may improve QOL and overall survival.58
Figure 4. A hub-and-spoke networked model for shared care in both HICs and LMICs, with partnership between academic/regional hospitals and between academic/regional hospitals and community hospitals/clinics
Novel Partnership Strategies
Involving Employers and Insurers
A key opportunity is to leverage employers and insurers who can influence coverage requirements and thus advocate for meaningful patient- and caregiver-centric initiatives. Management of health care pay or practices with a focus on system performance and population health can improve quality and value, ultimately resulting in healthier populations.59 In the United States, the provision of paid sick leave was found to increase visits for primary care, preventative, diagnostic, and subspecialist care.60 By further informing employers and insurers of the gaps in benefits and coverage for the employee with cancer (or the caregiver of a person with cancer), research can influence policy change.61 For instance, Rose et al. reported that out-of-pocket costs for privately insured individuals increased after a cancer diagnosis and were higher with increasing cancer stage.62 Given that symptom burden has been noted to correlate with financial toxicity, this is an important finding to inform employers and insurers.63 Finally, employers and insurers can implement policies and programs that can increase preventative care, patient navigation, and access to supportive and survivorship care resources.64,65
Task Shifting
Increased involvement of non-oncologists in comprehensive cancer care is required to meet demand in both HICs and LMICs. Through partnering, primary care physicians can play an essential role in cancer survivorship, including for adult survivors of childhood cancer.66-69 Pathways to integrate primary care physicians into cancer care through appropriate training and communication can address increasing demand while more effectively supporting patients and their caregivers.66-69 Task shifting is required in LMICs to meet the increasing demand and lack of sufficient health care providers. Multiple care areas in LMICs can be effectively managed by nonphysician health care providers, such as screening, education, and diagnosis, in addition to patient navigation.26,30,70
Leveraging Technology
Digital innovation provides an opportunity in both HICs and LMICs to access hard-to-reach populations, better connect patients and caregivers to resources, optimize partnering through de-siloing and de-duplication, and increase opportunities to provide and monitor innovative services at home and in the community rather than solely at cancer centers.71-74 However, reviews of digital health, telehealth, and artificial intelligence in cancer care show ongoing gaps for disadvantaged subpopulations that need to be addressed through partnership.72-76
Conclusions
Optimization of current partnership models, such as those led by cancer organizations as well as academic-academic and academic-community alliances, can be beneficial in both HICs and LMICs. Community, patient, caregiver, and advocate inclusion into partnership models is imperative to ensure prioritization of patient- and caregiver-centric care. By focusing and reflecting on the importance of partnerships in both HICs and LMICs, innovative strategies such as involving insurers and employers, task-shifting, and leveraging technology can be ensured to be collaborative from the outset, benefiting patients and caregivers in all settings and increasing collective impact.
Conflict(s) of Interest
N/A
Funding Information
N/A
Ethical Statements
N/A
Informed Consent
N/A
Data Availability Statement
N/A
Acknowledgements
N/A
Declaration of AI Use in Scientific Writing
N/A
Author Contributions
Concept and design: AA
Data acquisition: AA, SS, AK
Data analysis and interpretation: AA, SS, AK
Drafting of the manuscript: AA, SS, AK
Critical revision of the manuscript: AA, SS, AK
All authors (AA, SS, AK) approved the final version of the manuscript and agree to be accountable for all aspects of the work, in accordance with the International Committee of Medical Journal Editors criteria.
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