Health Equity and Health Disparities in Cancer Survivorship

Advancing health equity in cancer survivorship is central to the Office of Cancer Survivorship (OCS) mission to enhance the quality and length of survival of all persons diagnosed with cancer.

All cancer survivors should have the opportunity to achieve their highest level of health possible, also known as health equity. Unfortunately, there are obstacles to health that can affect where cancer survivors live, grow, learn, work, play, worship, access care, and age. These barriers can create differences in healthcare utilization, quality of care, and health outcomes, also known as health disparities.

How is NCI Addressing Issues Related to Health Disparities?

Some cancer survivors may experience obstacles to health based on their racial or ethnic group; religion; socioeconomic status; age; mental health; cognitive, sensory, or physical disability; sexual orientation; gender identity; geographic location (place/context); or other characteristics historically linked to discrimination or exclusion.

The causes of health disparities are therefore multiple, multilevel, complex, and intertwined. However, researchers, advocacy groups, community organizations, health systems, clinicians, cancer survivors, caregivers, and other collaborators can work together to advance health equity in survivorship by identifying and intervening upon the modifiable obstacles, pathways, and mechanisms that create and amplify health disparities.

Selected examples of health equity research in cancer survivorship include the following:

addressing the available resources, opportunities, and built environment to help cancer survivors engage in and sustain healthy behaviors
advancing equitable access to survivorship care by testing new models of care, implementing the newly developed National Standards for Cancer Survivorship Care, and examining the roles of expanded health coverage and access to specialized cancer centers and survivorship services
exposing how structural drivers of poverty create conditions that lead to financial toxicity or material hardship

Areas of Research Emphasis

OCS, along with other divisions, programs, and offices of NCI and NIH, supports innovative health equity and health disparities research. A recent analysis of the NIH Cancer Survivorship Portfolio from Fiscal Years 2017 to 2022 identified 147 grants focused on NIH-designated populations that experience health disparities.

Read the complete report.

Diversity and Inclusion

Seventy-four percent of those identified NIH grants were focused on cancer survivors from racial and ethnic minority groups. However, there was a lack of grants focused on cancer survivors from American Indian and Alaska Native populations, Native Hawaiian and other Pacific Islander populations, and sexual and gender minority populations.

Note: Grants may focus on more than one of these populations. Therefore, the sum of the percentages is more than 100.

Data source: Doose M, Mollica MA, Acevedo AM, Tesauro G, Gallicchio L, Reed C, Guida J, Maher ME, Srinivasan S, Tonorezos E. Advancing health equity in cancer survivorship research: National Institutes of Health 2017-2022 portfolio review. J Natl Cancer Inst. 2024 Mar 27:djae073. doi: 10.1093/jnci/djae073. Epub ahead of print. PMID: 38544292.

Drivers of Health Disparities

Eighty-two percent of those identified NIH grants measured or intervened upon health disparities at the individual level, such as cancer survivors’ behaviors and healthcare use. The societal level and physical and built environment were least addressed (see figure below).

Drivers of health disparities beyond the individual were also measured or intervened upon in 65% of the grants, including

thirty-three percent at the interpersonal level (e.g., relationships between cancer survivor and caregiver, or social networks)
forty-two percent at the community level (e.g., hospitals or neighborhoods)
twelve percent at the societal level (e.g., states or countries)

Note: This graph shows the distribution of grants that measured or intervened upon health disparities at each domain and level of influence. Each grant could measure at multiple domains and levels, and therefore the total exceeds 147 grants.

Selected Drivers of Health Disparities Currently in the NIH Cancer Survivorship Grant Portfolio

The figure below highlights selected grant topics from the NIH Cancer Survivorship Portfolio from Fiscal Years 2017 to 2022. Italicized text represents areas of research currently not in the portfolio. Opportunities to understand and address health disparities beyond the individual level of influence include policies and laws that affect behaviors at the societal level (e.g., alcohol or tobacco policies) and the physical and built environment within communities (e.g., housing, green space).

		LEVELS OF INFLUENCE
		Individual	Interpersonal	Institutional/community	Societal
DOMAINS OF INFLUENCE	Biological	Biologic/genetic/epigenetic pathways—allostatic load Biological responses—Disease symptoms, inflammation	Caregiver-survivor interaction Family microbiome	Community illness exposure Herd immunity	Immunization Pathogen exposure
	Behavioral	Health behaviors – patient activation, self-management Coping strategies Quality of life—physical, mental, psychosocial well-being	Caregiver-survivor dyads or families—support, interactions, functioning, attachment, communication School and work functioning	Community functioning	Policies and laws
	Physical/built environment	Personal environment Living conditions Residential history	Employment environment	Neighborhood environment—walkability, food access, green spaces, orderliness, population density, street connectivity	Climage events Federal housing program
	Sociocultural environment	Sociodemographics Social and cultural identity, attitudes, language Social isolation Perceived stress and resilience	Culturally responsive social support Family/peer norms and influences Social networks Social engagement/integration	Community resilience Residential segregation/Ethnic enclaves Neighborhood social stressors, resources, and opportunities	Structural racism Societal norms
	Healthcare system	Insurance coverage Receipt of survivorship care plans Utilization/adherence to care Treatment preferences	Patient-clinician relationship/communication Share decision-making Healthcare team functioning Provider preferences or bias	Availability and accessibility of health services Infrastructure needs and workflow within and across clinics and health systems Coordination and navigation services	Health policies—Affordable Care Act, Medicaid expansion, high-volume facilities, medical homes Consolidation/integration of oncology practices Hospital closures

Doose M, Mollica MA, Acevedo AM, Tesauro G, Gallicchio L, Reed C, Guida J, Maher ME, Srinivasan S, Tonorezos E. Advancing health equity in cancer survivorship research: National Institutes of Health 2017-2022 portfolio review. J Natl Cancer Inst. 2024 Mar 27:djae073. doi: 10.1093/jnci/djae073. Epub ahead of print. PMID: 38544292.

Selected OCS Staff Publications

Included below is a selection of recent OCS staff publications related to health disparities and health equity research in cancer survivorship.

Selected OCS Staff Publications

Doose M, Mollica MA, Acevedo AM, Tesauro G, Gallicchio L, Reed C, Guida J, Maher ME, Srinivasan S, Tonorezos E. Advancing health equity in cancer survivorship research: National institutes of health 2017-2022 portfolio review. J Natl Cancer Inst. 2024 Mar 27:djae073. doi: 10.1093/jnci/djae073. Epub ahead of print. PMID: 38544292.
Verhoeven D, Doose M, Chollette V, Weaver SJ. Team complexity and care coordination for cancer survivors with multiple chronic conditions: a mixed methods study. J Cancer Surviv. 2024 Feb 14. doi: 10.1007/s11764-023-01488-w. Epub ahead of print. PMID: 38353854.
Mollica MA, Zaleta AK, Gallicchio L, Brick R, Jacobsen PB, Tonorezos E, Castro KM, Miller MF. Financial toxicity among people with metastatic cancer: findings from the Cancer Experience Registry. Support Care Cancer. 2024 Jan 30;32(2):137. doi: 10.1007/s00520-024-08328-2. PMID: 38286846.
Tonorezos E (editor). Journal of Cancer Survivorship Special Section: Hearing Loss in Cancer Survivorship. https://link.springer.com/collections/acfafeaiai
Brick R, Tonorezos ES. Addressing Disability in Cancer Survivors. J Clin Oncol. 2024 May 9:JCO2400479. doi: 10.1200/JCO.24.00479. PMID: 38723210
Doose M, Kennedy AE, Williams SD, Srinivasan S. The Context of Poverty and Cancer: Denying Human Potential. Cancer Epidemiol Biomarkers Prev. 2024 Nov 1;33(11):1402-1404. doi: 10.1158/1055-9965.EPI-24-0953. PMID: 39482971

Selected Funding Opportunities

A list of funding opportunities related to health disparities and health equity in cancer survivorship research at NIH can be found on this Apply for Cancer Control Grants page.

Featured Webinars

The NCI OCS events webpage has archived webinars related to health equity and health disparities research in cancer survivorship. Here is a selected list of webinars.

Featured Webinars

Additional Resources

Contacts

Michelle Doose, PhD, MPH

Program Director
OFFICE OF CANCER SURVIVORSHIP

SECONDARY APPOINTMENT:
HEALTH COMMUNICATION AND INFORMATICS RESEARCH BRANCH
BEHAVIORAL RESEARCH PROGRAM

michelle.doose@nih.gov

Crystal Reed, MHA

HEALTH SCIENTIST ADMINISTRATOR
OFFICE OF CANCER SURVIVORSHIP

crystal.reed@nih.gov

Last Updated

December 12, 2024

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