Promoting Health Equity in Cancer Care
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Erin Balogh, Francis Amankwah, Theresa Wizemann, and Sharyl Nass, Rapporteurs
National Cancer Policy Forum
Roundtable on the Promotion of Health Equity
Board on Health Care Services
Health and Medicine Division
Proceedings of a Workshop
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by Contract No. 200-2011-38807 (Task Order No. 75D30120F00089) and Contract No. HHSN263201800029I (Task Order No. HHSN26300008) with the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health, respectively; American Association for Cancer Research; American Cancer Society; American College of Radiology; American Society of Clinical Oncology; Association of American Cancer Institutes; Association of Community Cancer Centers; Bristol Myers Squibb; Cancer Support Community; Flatiron Health; Merck & Co., Inc.; National Comprehensive Cancer Network; National Patient Advocate Foundation; Novartis Oncology; Oncology Nursing Society; Partners in Health; Pfizer Inc.; Sanofi; and Society for Immunotherapy of Cancer. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-69189-5
International Standard Book Number-10: 0-309-69189-3
Digital Object Identifier: https://doi.org/10.17226/26661
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Promoting health equity in cancer care: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/26661.
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WORKSHOP PLANNING COMMITTEE1
GWEN DARIEN (Co-Chair), Executive Vice President, Patient Advocacy and Engagement, National Patient Advocate Foundation
REGINALD TUCKER-SEELEY (Co-Chair), Vice President of Health Equity, Zero—The End of Prostate Cancer; and Edward L. Schneider Chair in Gerontology, University of Southern California
NICOLE F. DOWLING, Associate Director for Science, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention
CHANITA HUGHES-HALBERT, Vice Chair for Research and Professor, Department of Preventive Medicine; and Associate Director for Cancer Equity, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California
RANDY A. JONES, Professor and Associate Dean for Partner Development and Engagement, University of Virginia School of Nursing, and Assistant Director, Community Outreach and Engagement, Emily Couric Clinical Cancer Center, University of Virginia
CHRISTOPHER S. LATHAN, Chief Clinical Access and Equity Officer, Dana-Farber Cancer Institute; Associate Medical Director, Dana-Farber Cancer Institute Network; and Assistant Professor of Medicine, Harvard Medical School
CLEO A. RYALS, Head of Health Equity and Health Disparities Research, Flatiron Health
LAWRENCE N. SHULMAN, Professor of Medicine, Deputy Director for Clinical Services, and Director, Center for Global Cancer Medicine, Abramson Cancer Center, University of Pennsylvania
SHOBHA SRINIVASAN, Senior Advisor for Health Disparities, Office of the Director, Division of Cancer Control and Population Sciences, National Cancer Institute
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1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
ROBERT A. WINN, Director, Massey Cancer Center; and Senior Associate Dean for Cancer Innovation, Professor of Pulmonary Disease and Critical Care Medicine, and Lipman Chair in Oncology, School of Medicine, Virginia Commonwealth University; and President-Elect, Association of American Cancer Institutes
ROBIN YABROFF, Scientific Vice President of Health Services Research, American Cancer Society
Project Staff
FRANCIS AMANKWAH, Program Officer
KAT ANDERSON, Senior Program Officer, Roundtable on the Promotion of Health Equity
RACHEL AUSTIN, Senior Program Assistant
LORI BENJAMIN BRENIG, Research Associate
ANNALEE GONZALES, Administrative Assistant
ARZOO TAYYEB, Finance Business Partner
ERIN BALOGH, Co-Director, National Cancer Policy Forum
SHARYL NASS, Co-Director, National Cancer Policy Forum; and Senior Director, Board on Health Care Services
NATIONAL CANCER POLICY FORUM1
EDWARD J. BENZ, JR. (Chair), President and Chief Executive Officer, Emeritus, Dana-Farber Cancer Institute; and Richard and Susan Smith Distinguished Professor of Medicine, Genetics and Pediatrics, Harvard Medical School
PETER C. ADAMSON, Global Head, Oncology Development and Pediatric Innovation, Sanofi
GARNET L. ANDERSON, Senior Vice President and Director, Public Health Sciences Division, Fred Hutchinson Cancer Center; Affiliate Professor, Department of Biostatistics, University of Washington; and Principal Investigator, Women’s Health Initiative Clinical Coordinating Center
KAREN BASEN-ENGQUIST, Annie Laurie Howard Research Distinguished Professor; Professor of Behavioral Science; and Director, Center for Energy Balance in Cancer Prevention and Survivorship, The University of Texas MD Anderson Cancer Center
SMITA BHATIA, Professor and Vice Chair of Outcomes for Pediatrics; Gay and Bew White Endowed Chair in Pediatric Oncology; Director, Institute for Cancer Outcomes and Survivorship; and Associate Director for Outcomes Research, Comprehensive Cancer Center, The University of Alabama at Birmingham
CHRIS BOSHOFF, Chief Development Officer, Oncology, Global Product Development, Pfizer Inc.
CATHY J. BRADLEY, David F. and Margaret Turley Grohne Endowed Chair for Cancer Prevention and Control Research; Professor and Associate Dean for Research, Colorado School of Public Health; Bunn Chair of Cancer Research and Deputy Director, University of Colorado Comprehensive Cancer Center
OTIS W. BRAWLEY, Bloomberg Distinguished Professor, Department of Epidemiology and Oncology, Bloomberg School of Public Health and Department of Oncology, School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University
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1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
ROBERT W. CARLSON, Chief Executive Officer, National Comprehensive Cancer Network
CHRISTINA CHAPMAN, Assistant Professor of Radiation Oncology, Baylor College of Medicine
GWEN DARIEN, Executive Vice President, Patient Advocacy and Engagement, National Patient Advocate Foundation
NANCY E. DAVIDSON, Executive Vice President for Clinical Affairs, Senior Vice President, and Professor, Clinical Research Division, Fred Hutchinson Cancer Center; Professor and Head, Division of Medical Oncology, Department of Medicine, University of Washington, and Raisbeck Endowed Chair for Collaborative Cancer Research
JAMES H. DOROSHOW, Director, Division of Cancer Treatment and Diagnosis; Deputy Director for Clinical and Translational Research; and Head, Oxidative Signaling and Molecular Therapeutics Group, National Cancer Institute of the National Institutes of Health
NICOLE F. DOWLING, Associate Director for Science, Division of Cancer Prevention and Control, National Center for Chronic Disease Control and Prevention, Centers for Disease Control and Prevention
SCOT W. EBBINGHAUS, Vice President and Therapeutic Area Head, Oncology Clinical Research, Merck Research Laboratories
KOJO S. J. ELENITOBA-JOHNSON, Director, Center for Personalized Diagnostics and Division of Precision and Computational Diagnostics; and Professor, Perelman School of Medicine, University of Pennsylvania
STANTON L. GERSON, Dean and Senior Vice President, Medical Affairs, Case Western Reserve University School of Medicine; Acting Director, Case Comprehensive Cancer Center; Asa & Patricia Shiverick—Jane B. Shiverick (Tripp) Professor of Hematological Oncology and Distinguished University Professor, and Director, National Center for Regenerative Medicine, Case Western Reserve University
JULIE R. GRALOW, Chief Medical Officer and Executive Vice Present, American Society of Clinical Oncology
ROY S. HERBST, Ensign Professor of Medicine and Professor of Pharmacology; Chief of Medical Oncology, Associate Director for Translational Research, Yale Comprehensive Cancer Center and Yale School of Medicine
HEDVIG HRICAK, Chair, Department of Radiology, Memorial Sloan Kettering Cancer Center
CHANITA HUGHES-HALBERT, Vice Chair for Research and Professor, Department of Preventive Medicine; and Associate Director for Cancer Equity, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California
ROY A. JENSEN, Professor of Pathology and Laboratory Medicine, William R. Jewell, MD Distinguished Masonic Professor of Cancer Research, and Director, The University of Kansas Cancer Center; Director, Kansas Masonic Cancer Research Institute; and Past President, Association of American Cancer Institutes
RANDY A. JONES, Professor and Associate Dean for Partner Development and Engagement, University of Virginia School of Nursing, and the Assistant Director, Community Outreach and Engagement, Emily Couric Clinical Cancer Center, University of Virginia
BETH Y. KARLAN, Vice Chair, Women’s Health Research; Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine; and Director, Cancer Population Genetics, Jonsson Comprehensive Cancer Center, University of California, Los Angeles
SAMIR N. KHLEIF, Director, Jeannie and Tony Loop ImmunoOncology Lab; Biomedical Scholar and Professor of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center; and Member, Society for Immunotherapy of Cancer
MIA LEVY, Chief Medical Officer, Foundation Medicine
SCOTT M. LIPPMAN, Director, Moores Cancer Center; Distinguished Professor of Medicine, Senior Associate Dean, and Associate Vice Chancellor for Cancer Research and Care; and Chugai Pharmaceutical Chair in Cancer, University of California, San Diego
LARISSA NEKHLYUDOV, Professor of Medicine, Harvard Medical School; Internist, Brigham and Women’s Hospital; and Clinical Director, Internal Medicine for Cancer Survivors, Dana-Farber Cancer Institute
RANDALL A. OYER, Clinical Professor of Medicine, Perelman School of Medicine; and Executive Medical Director, Ann B. Barshinger Cancer Institute; Penn Medicine Lancaster General Health; and Past President, Association of Community Cancer Centers
CLEO A. RYALS, Head of Health Equity and Health Disparities Research, Flatiron Health
RICHARD L. SCHILSKY, Principal Investigator, ASCO TAPUR Study; and Professor Emeritus, University of Chicago
JULIE SCHNEIDER, Associate Director, Research Strategy and Partnership, Oncology Center of Excellence, Food and Drug Administration
SUSAN M. SCHNEIDER, Associate Professor Emerita, School of Nursing, Duke University
LAWRENCE N. SHULMAN, Professor of Medicine, Deputy Director for Clinical Services, and Director, Center for Global Cancer Medicine, Abramson Cancer Center, University of Pennsylvania
HEIDI SMITH, Vice President, Center of Operations and Research Excellence, US Clinical Development and Medical Affairs, Oncology, Novartis Pharmaceuticals
LARA STRAWBRIDGE, Director, Division of Ambulatory Payment Models, Patient Care Models Group, Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services
GEORGE J. WEINER, C. E. Block Chair of Cancer Research, Professor of Internal Medicine and Pharmaceutical Science; and Director, Holden Comprehensive Cancer Center, University of Iowa
ROBERT A. WINN, Director, Massey Cancer Center; and Senior Associate Dean for Cancer Innovation, Professor of Pulmonary Disease and Critical Care Medicine, and Lipman Chair in Oncology, School of Medicine, Virginia Commonwealth University; and President-Elect, Association of American Cancer Institutes
ROBIN YABROFF, Scientific Vice President, Health Services Research, American Cancer Society
National Cancer Policy Forum Staff
FRANCIS AMANKWAH, Program Officer
RACHEL AUSTIN, Senior Program Assistant
LORI BENJAMIN BRENIG, Research Associate
ANNALEE GONZALES, Administrative Assistant
ARZOO TAYYEB, Finance Business Partner
ERIN BALOGH, Co-Director, National Cancer Policy Forum
SHARYL J. NASS, Co-Director, National Cancer Policy Forum; and Senior Director, Board on Health Care Services
Reviewers
This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
REBEKAH S. M. ANGOVE, Patient Advocate Foundation
MONICA L. BASKIN, University of Pittsburgh, UPMC Hillman Cancer Center1
EVAN M. GRABOYES, Medical University of South Carolina
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by VIVIAN W. PINN, University of South Florida. She was responsible for making certain that an independent examination
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1 At the time of the workshop, Dr. Baskin was affiliated with the University of Alabama at Birmingham.
of this proceedings was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.
Acknowledgments
Support from the many annual sponsors of the National Academies of Sciences, Engineering, and Medicine’s National Cancer Policy Forum is crucial to the work of the forum. Federal sponsors include the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health. Non-federal sponsors include the American Association for Cancer Research; American Cancer Society; American College of Radiology; American Society of Clinical Oncology; Association of American Cancer Institutes; Association of Community Cancer Centers; Bristol Myers Squibb; Cancer Support Community; Flatiron Health; Merck; National Comprehensive Cancer Network; National Patient Advocate Foundation; Novartis Oncology; Oncology Nursing Society; Partners in Health; Pfizer Inc.; Sanofi; and Society for Immunotherapy of Cancer.
The forum wishes to express its gratitude to the expert speakers whose presentations and discussions helped inform efforts to advance progress in promoting health equity in the delivery of high-quality cancer care. The forum also wishes to thank the members of the planning committee for their work in developing an excellent workshop agenda.
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Contents
SOCIAL DETERMINANTS OF HEALTH AND STRUCTURAL RACISM IN CANCER CARE
Elements of an Equitable Cancer Care Delivery System
Incorporating Key Voices in Cancer Care
Countering Resistance to Change
APPROACHES TO OPERATIONALIZING EQUITY
Undoing Racism: Five Focus Areas for Operationalizing Equity
Social Risk Screening and Social Needs Navigation
Building Trust as the Foundation for Operationalizing Equity
Creating the Infrastructure to Operationalize Equity in Health Insurance Plans
IMPROVING EQUITABLE DELIVERY OF HIGH-QUALITY CANCER CARE
The Role of Health Care Professionals in Improving Access to Equitable Cancer Care
The Role of Payers and Health Care Systems in Supporting Access to Equitable Cancer Care
Reimagining the Current Health Care Financing and Delivery System for Health Equity
IMPACT OF GEOGRAPHY AND SETTINGS OF CARE ON ACCESS TO HIGH-QUALITY CANCER CARE
The Intersection of Race, Place, and Cancer Mortality
High-Quality Cancer Care for Rural Communities
High-Quality Cancer Care for Indigenous Communities
High-Quality Cancer Care at Safety Net Hospitals
Reducing Disparities in Cancer Screening and Follow-Up Care
OPPORTUNITIES TO SPUR PROGRESS TOWARD EQUITY IN CANCER CARE
Building on the Momentum of NIH’s “Great Awakening”
Opportunities to Improve Equity in Cancer Care for Rural and Indigenous Communities
Opportunities for Nurses to Improve Equity in Cancer Care
Using Accreditation to Spur Progress in Health Equity in Cancer Care
Public Health Opportunities to Accelerate Health Equity in Cancer Care
Opportunities to Advance Health Equity Through Oncology Value-Based Care Models
Opportunities to Address the Impact of Intersectionality on Equitable Cancer Care
Primary Care Opportunities to Advance Cancer Care Equity
Leveraging Partnerships to Advance Equity in Cancer Care
FROM ASPIRATION TO IMPLEMENTATION: THE ROLE OF ACADEMIC CANCER CENTERS IN PROMOTING HEALTH EQUITY
Cancer Centers Expanding the Scope of Cancer Research to Expand Who Benefits
Innovative Models of Partnership and Engagement at Cancer Centers
The Role of ACS in Supporting Cancer Centers
Building the Table: Community Engagement in Cancer Care and Cancer Research
Boxes and Figures
BOXES
1 Examples of Key Terms Shared by Individual Speakers
3 Suggestions from Individual Workshop Participants to Promote Health Equity in Cancer Care
4 The Greensboro Health Disparities Collaborative (GHDC)
5 Messengers for Health: Improving Cancer Awareness and Screening by Building Trust
7 Events Leading to the “Great Awakening” at the National Institutes of Health (NIH)
FIGURES
1 Mutually reinforcing pathways from structural racism to inequities
3 The role of primary care across the cancer control continuum
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Acronyms and Abbreviations
| ACA | Patient Protection and Affordable Care Act |
| ACS | American Cancer Society |
| BSPAN | Breast Screening and Patient Navigation |
| CAR-T | chimeric antigen receptor T-cell |
| CDC | Centers for Disease Control and Prevention |
| CHA/P | Community Health Aide/Practitioner |
| CMMI | Center for Medicare & Medicaid Innovation |
| CMS | Centers for Medicare & Medicaid Services |
| CoC | Commission on Cancer |
| CPRIT | Cancer Prevention and Research Institute of Texas |
| ECANA | Endometrial Cancer Action Network for African-Americans |
| EHR | electronic health record |
| GHDC | Greensboro Health Disparities Collaborative |
| HCI | Huntsman Cancer Institute |
| HOPE | Center for Health Outcomes and Population Equity |
| IHS | Indian Health Service |
| JMH | Jackson Memorial Hospital |
| MCCAN | Markey Cancer Center Affiliate Network |
| NCI | National Cancer Institute |
| NIH | National Institutes of Health |
| NIMHD | National Institute on Minority Health and Health Disparities |
| PSA | prostate specific antigen |
| SDOH | social determinants of health |
| SIREN | Social Interventions Research and Evaluation Network |
| SKCC | Sidney Kimmel Cancer Center |
| SMART | specific, measurable, achievable, relevant, time-related |
| SMARTIE | specific, measurable, achievable, relevant, time-related, inclusion, equity |
| USP | U.S. Pharmacopeia |
| UT | University of Texas |
| VA | U.S. Department of Veterans Affairs |
| VCU | Virginia Commonwealth University |
