Evolving the Research Landscape Towards Cancer Health Equity: A Mini-Review on Cancer Health Disparities.

There is a growing urgency to address global equity challenges in cancer through interdisciplinary approaches and actionable solutions. By bringing together experts from academia, clinical medicine, and public health policy, innovation can reach out to minority communities who have traditionally been underrepresented in cancer and vaccine clinical trials.

Integrating scientific research with a deliberate drive to pursue equity in research participant, healthcare worker, and researcher representation remains important. Through collaborative community-driven engagement, researchers and clinicians can improve diversity and inclusion throughout the spectrum of clinical research to improve healthcare for all members of the diverse US population.

Herein, to emphasize these, we discuss following three topics in this review: 1) Coronavirus disease 2019 (COVID-19) era vaccine trial initiatives to improve minority participation in vaccine clinical trials; 2) How discrimination can adversely affect health-related quality of life (HRQoL) for people living with cancer; and 3) The broad-reaching effects of structural racism on healthcare and research worker representation.

Re-evaluating research strategies by prioritizing community engagement, particularly in this challenging era of dynamic shifts in federal funding and grant allocation, is of paramount importance. A review of the joint efforts between the COVID-19 Prevention Network (CoVPN) and Operation Warp Speed (a collaboration effort between the public and private sectors launched by the U.S. government to expedite the development, production, and distribution of COVID-19 vaccines, treatments, and diagnostic tools) highlights key challenges. Specifically, how longstanding systemic inequities and underrepresentation of minority populations in clinical trials exacerbated the COVID-19 burden for marginalized populations.^1,2 To address this challenge, CoVPN teams focused on the need for partnerships with local communities and the pursuit of sustained engagement with historically marginalized populations during the COVID-19 vaccine enrollment trials.

During the pandemic, CoVPN research teams noted very stark disparities in COVID-19 infection and outcomes among Native Americans, Alaskan Natives, African Americans, and Hispanics. The heightened risk of infection and serious illness was driven, in part, by structural barriers such as poverty, insurance status, and limited healthcare access.¹ These observed disparities prompted the research teams to reevaluate the current clinical trial framework to better focus on equity and representation among these marginalized groups. Early trial enrollment data disproportionately included White Americans, and the teams created a purposeful response to address participation imbalances in vaccine trials through community strategies.²

The CoVPN's Community Engagement Model (CEM) is a comprehensive engagement strategy focusing on community education, recruitment, and retention. The model provides a five-part framework promoting shared responsibility among researchers, stakeholders, and community members to foster trust and inclusion.

In Part 1 of the strategy, CoVPN scientists employed community-based participatory research approaches to meaningfully involve communities throughout the research process. The team aimed to bolster cultural sensitivity, language accessibility, and mutual understanding around complex issues like vaccine efficacy (defined as the percentage reduction of disease in a vaccinated group compared to unvaccinated groups in controlled trials), explain safety-related pauses in distribution, and engage communities in the vaccine development process.³

In Part 2, researchers prioritized collaboration with trusted community influencers through multi-language campaigns, culturally tailored messaging, and advertising across accessible platforms. These communication strategies included listening sessions and community feedback, increasing the likelihood of resonance with target populations.

In Part 3, investigators involved priority population expert panels, which included scientists and experts from underrepresented communities, to review trial protocols and guide inclusive research design.

In Part 4, community working groups convened regularly to provide input, using models like community advisory boards and action groups for ongoing engagement.

In Part 5, researchers followed the CEM to focus on relationship-building through virtual town halls and listening sessions with organizations such as the American Association of Retired Persons, National Association for the Advancement of Colored People, National Urban League, Young Men's Christian Association, and faith-based entities. One example is the CoVPN Faith Initiative, where the research team engaged faith ambassadors to address the intersection of spirituality and science while distributing culturally tailored materials to a broad audience of clergy and groups from many different faith traditions.

CoVPN introduced specific racial and ethnic recruitment targets to allow research teams to monitor progress, adjust strategies in real-time, and ensure broad representation among Black, Indigenous, and people of color (BIPOC). At the end of the study, across the four US government-funded COVID-19 vaccine clinical trials, 47% of participants enrolled at CoVPN sites in the US were BIPOC.² This value more closely mirrored the BIPOC composition in the larger US population compared to the earlier weeks of vaccine trial enrollment, wherein researchers noted White enrollees outpaced BIPOC populations significantly. Figure 1 (reproduced from Andrasik et al., 2021)² illustrates BIPOC enrollment across four major U.S.‑based COVID‑19 vaccine trials, highlighting both underrepresentation and the impact of targeted recruitment strategies.

Despite these advancements, more work remains, and systemic barriers persist.² Nevertheless, the work conducted by CoVPN shows that diversity in research cannot be achieved passively and requires sustained investment, equity-driven planning, and institutional momentum. Diversity in clinical trials should be the default, not the exception.²

Embedding community engagement and accountability into research is essential for achieving health equity and scientific integrity. Through community-informed strategies and commitment to inclusion, the research team was able to provide an important example and a blueprint of how to ensure that marginalized populations are represented and empowered in future research projects.

A research study funded by the National Institutes of Health (NIH) sheds light on the relationship between perceived discrimination in medical settings and the potential impact it may have on patients' physical and mental health.⁴ In this study, investigators gathered data collected from the NIH All of Us Research Program. Their goal was to investigate how experiences of discrimination influence HRQoL among cancer survivors. The investigators further aimed to determine if addressing these factors might reduce known racial and ethnic disparities in HRQoL. Perceived discrimination in medical settings (DMS), everyday perceived discrimination (PD), and HRQoL were reviewed and assessed for their associations with physical and mental health outcomes among cancer survivors via electronic surveys.

The sample population included 16,664 adult cancer survivors who participated in the All of Us program between 2018 and 2022. It included predominantly White (86%) and female (59%) patients, with a median age of 69 years (interquartile range [IQR (Q1, Q3)] = 59.9, 74.6 years).⁴ Table 1 details participant characteristics and key discrimination scores stratified by gender and race/ethnicity, reproduced from Arizpe et al. (2024). DMS and PD were scored using a binary indicator for fair-to-poor and good-to-excellent physical and mental health. Higher scores represented greater experiences of discrimination. HRQoL was assessed through the Patient-Reported Outcomes Measurement Information System (PROMIS-10) Global Health Scale.⁵

Findings revealed that for every 5-unit increase in DMS, there was a 66% greater likelihood of reporting fair-to-poor physical health and a 57% greater likelihood of reporting fair-to-poor mental health among cancer survivor participants. Similarly, a 5-unit increase in PD was associated with a 33% higher likelihood of reporting fair-to-poor physical health and mental health outcomes among cancer survivors.⁴

When the investigative team examined racial and ethnic disparities, they found that before adjusting for discrimination, non-Hispanic Black and Hispanic cancer survivors had a significantly higher odds ratio (1.79) of reporting fair-to-poor physical health and a significantly higher odds ratio (2.03) of reporting fair-to-poor mental health compared to their non-Hispanic White counterparts.⁴ After adjusting for DMS or PD, there was an improvement in these disparities. For example, among Black cancer survivors, adjusting for PD reduces the odds of reporting fair-to-poor mental health by 31%.⁴ Ameliorating PD could mitigate some racial disparities observed in HRQoL among cancer survivors.

Investigators also observed an association between discrimination (DMS and PD) and HRQoL among cancer survivors while exploring their potential roles in lessening racial and ethnic disparities in HRQoL. These results align with the findings of other research endeavors, wherein discrimination negatively impacts health outcomes. In a study by Shariff-Marco and colleagues, racial discrimination was linked to lower HRQoL among non-Hispanic Black and Hispanic survivors living in less diverse areas.⁶ Similarly, in a different research study, Karvonen and colleagues found that non-Hispanic Black, Hispanic, and other racial/ethnic minoritized cancer survivors reported worse physical and mental health outcomes when they experienced discrimination.⁷ These findings underscore the importance of addressing discrimination to improve health outcomes among cancer survivors.

There are benefits of reducing discrimination in healthcare settings and its ultimate impact on improved HRQoL. By implementing strategies centered around inclusionary measures, such as cultural competence training for healthcare providers and engaging with community members, healthcare team members can reduce discriminatory practices and improve HRQoL for racial and ethnic minority cancer survivors.

Addressing discrimination within medical settings and in everyday life is essential for improving the well-being of cancer survivors, regardless of their racial and ethnic background. The presentation concluded by pointing out that future research should continue to explore the complex dynamics between discrimination and health outcomes to promote policies and interventions aimed at improving health equity.

Racism, particularly structural racism, can be defined as the totality of ways in which societies precipitate racial discrimination through policy, housing, education, employment, healthcare, and criminal justice systems.⁸ These mechanisms reinforce inequities in resource distribution and shape cultural beliefs that further perpetuate discrimination.⁸ In the field of oncology, these systemic effects influence disparities across the entire cancer continuum, from prevention and diagnosis to treatment and survivorship.

One way in which structural racism affects patient care is access to healthcare. Minority racial and ethnic communities face issues with affordability, geographic availability, acceptability, and quality of healthcare services. An example of this is redlining, a discriminatory practice through which financial or governmental services (i.e., insurance options, credit access, or mortgage access) may be withheld from neighborhoods with a significant minority population. The practice traps these populations in an environment with underdeveloped health infrastructure, poor conditions, and limited economic opportunities, thus worsening health outcomes.⁸

Structural inequities affect different cancer burdens among different cancers and populations. For example, structural inequalities permeate the allocation of research funding and scientific focus. It is important to understand funding allocation because of its vital role in driving innovation in cancer care and research. In a recent study, Kamath and Chen assessed funding disparities across different cancers and compared incidence and mortality across different racial groups.⁹ They found that diseases with the largest combined National Cancer Institute (NCI) and nonprofit organization (NPO) funding between 2015-2018 were breast cancer—with $3.75 billion US dollars (USD)—and leukemia—with $1.99 billion USD.⁹ The diseases with the least amount of funding were endometrial ($94 million USD), cervical ($292 million USD), and hepatobiliary cancers ($348 million USD).⁹ Many of these cancers disproportionately affect Black populations and receive considerably less funding relative to cancers like breast and leukemia, which have stronger philanthropic and institutional support.⁹ The volume of clinical trials correlates closely with disease-specific funding, exacerbating inequities in innovation and therapeutic development.

The scientific workforce itself is also impacted by structural racism. Despite representing 12.4% of the US population, Black scientists comprise only 7.7% of the scientific workforce.¹⁰ NIH data from 2013-2020 showed that compared to white applicants, Black researchers were less likely to receive R01 biomedical and public health research grants from the NIH and less likely to resubmit applications after rejection.¹⁰ These factors contribute to disadvantages that hinder the advancement of racially diverse perspectives in cancer research.¹¹ Similar disparities also exist within the clinical workforce. For example, individuals from racially minoritized groups (i.e., Black, Hispanic, and American Indian/Alaskan Native) make up 11.2% of US full-time medical school faculty despite accounting for 32% of the US population.¹² In oncology, individuals from racially minoritized groups accounted for less than 8% of practicing physicians and less than 6% of faculty.¹¹

Disaggregated cancer data (data broken down by specific subgroups, such as race, ethnicity, gender, socioeconomic status, geographic location, and other demographic factors) will be vital to understanding the burden of cancers within diverse racial and ethnic minority populations. By establishing institutional trust and ensuring equitable use of cancer data that is more clearly analyzed by specific groups, we can better understand how cancer affects different populations, especially those from minority groups.

In conclusion, structural racism is a key driver across the cancer continuum, impacting cancer health disparities in the US. Structural racism is manifested through inequities in health access, patient outcomes, disparities in research funding, workforce diversity, and data collection practices. Addressing these multifactorial inequities necessitates that we develop and evaluate innovative community-driven interventions, including basic income experiments (i.e., universal income trials or guaranteed income studies), broadband internet expansion, and transportation infrastructure.⁸

Addressing racial and ethnic disparities in healthcare requires intentional inclusion and equity-driven practices. Community engagement and targeted recruitment strategies have proven effective in increasing participation of BIPOC populations in clinical vaccine trials. This ensures that research outcomes are broadly representative and beneficial.

Disparities in PD in medical settings substantially harm the HRQoL among BIPOC cancer survivors, highlighting long-term consequences of systemic bias. Structural racism continues to permeate many facets of the healthcare and research systems, further contributing to ongoing inequities.

Together, these sessions reinforce a key message: meaningful progress in health equity requires an evolution in how the research and medical system engages with historically marginalized communities. By integrating community voices, addressing discrimination, and establishing structural support, researchers and clinicians may move closer to a more inclusive and equitable healthcare system.

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Concept and design: TH, JI, DMA

Data acquisition: TH, JI, DMA

Data analysis and interpretation: TH, JI, DMA

Drafting of the manuscript: TH, JI, DMA

Critical revision of the manuscript: TH, JI, DMA

All authors (TH, JI, DMA) 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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9. Kamath SD, Chen Y. Disparities in National Cancer Institute and nonprofit organization funding disproportionately affect cancers with higher incidence among Black patients and higher mortality rates. JCO Oncol Pract. 2024;20(3):378-385. doi:10.1200/OP.23.00126

10. American Association for Cancer Research. Cancer Disparities Progress Report 2024. AACR; 2024. Accessed May 9, 2025. http://www.cancerdisparitiesprogressreport.org

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