State of Cancer Care in America: Achieving Cancer Health Equity Among Sexual & Gender Minority Communities

Abstract

In 2017, the American Society of Clinical Oncology (ASCO) issued the position statement, Strategies for Reducing Cancer Health Disparities Among Sexual and Gender Minority Populations, outlining five areas of recommendations to address the needs of both sexual and gender minority (SGM, e.g., LGBTQ+) populations affected by cancer and members of the oncology workforce who identify as SGM: (1) patient education and support; (2) workforce development and diversity; (3) quality improvement strategies; (4) policy solutions; and (5) research strategies. In 2019, ASCO convened the SGM Task Force to help actualize the recommendations of the 2017 position statement. The percentage of the US population who publicly identify as SGM has increased dramatically over the past few years. While increased national interest in SGM health equity has accompanied a general interest in research, policy change, and education around diversity, equity, and inclusion, resulting from public concern over discrimination in health care against Black, Indigenous, and People of Color (BIPOC), this has been accompanied by a surge in discriminatory legislation directly impacting the SGM community. Though much progress has been made in advancing SGM cancer health equity since 2017, more progress is needed to reduce disparities and advance equity. The five focus areas outlined in the 2017 ASCO position statement remain relevant, as we must continue to promote and advance equity in quality improvement, workforce development, patient care, research, and SGM-affirming policies. This article reports on the progress toward reducing SGM cancer disparities and achieving equity across these five areas and identifies future directions for the work that still remains.

Introduction

In 2017, members of the American Society of Clinical Oncology’s (ASCO) Health Equity Committee convened a working group to outline the cancer-related health needs of sexual and gender minority (SGM), i.e.., lesbian, gay, bisexual, transgender, queer, intersex (LGBTQ+), patients and survivors. Patients, survivors, and community members typically identify themselves using the acronym LGBTQ+; in this manuscript, we use the acronym SGM to align with other guidelines and policy documents but acknowledge that this terminology is researcher-centric and evolving. The ASCO working group created a position statement detailing the need to improve cancer health equity for SGM communities, which was endorsed by GLMA: Health Professionals Advancing LGBTQ Equality, and was published in the Journal of Clinical Oncology.¹ In 2019, ASCO convened a SGM Task Force to help actualize the recommendations of the 2017 position statement. In the current paper, we briefly summarize the five focus areas outlined in the 2017 position statement, review progress made toward reducing SGM cancer disparities and achieving equity within each area and describe future directions. For this paper, we organize the five focus areas as: 1) Quality Improvement Strategies, 2) Workforce Development and Diversity, 3) Patient Education and Support, 4) Research Strategies, and 5) Policy Solutions.

The percentage of the US population who identify as SGM has increased dramatically over the past few years. In 2017, only 4.5% of the population identified as SGM, compared to 7.2% in 2022.² Coinciding with this increase, awareness of and concern about health disparities and experiences by SGM people in the US has increased. Over the last several years, from the Orlando Pulse nightclub shooting in 2016 to the murder of George Floyd in 2020 and the 2021 Atlanta spa shootings, violence and discrimination against SGM, Black, Asian American and Pacific Islander individuals has worsened longstanding health disparities in these communities, particularly in the midst of the COVID-19 pandemic.^3–5 Thus, national interest in SGM health equity accompanies a general interest in research, policy change, and education around diversity, equity, and inclusion, resulting from public concern over discrimination in health care against Black, Indigenous, and People of Color (BIPOC). Unfortunately, increased interest in SGM health equity has also been accompanied by a surge in discriminatory legislation directly impacting the SGM community, including legislative barriers to gender affirming care. In 2023, the Human Rights Campaign, the largest SGM political lobbying organization in the United States, declared a “state of emergency” for SGM people in the U.S. after more than 75 anti-SGM bills were signed into law.⁶ Further, the U.S. Supreme Court issued a ruling limiting protection of SGM rights, which could worsen disparities.⁷ The case does not address barriers to patient care; however, discrimination, no matter the circumstances, diminishes the ability of marginalized people to thrive in society and potentially limits the ability to access—and comfort with accessing—necessary health services. While throughout this paper we highlight the progress that has been made in all five focus areas of the 2017 ASCO position statement, there is still much work to do to achieve true cancer health equity for SGM people.

Quality Improvement Strategies

What we said in 2017:

The 2017 ASCO position statement focused on two pillars related to quality improvement in SGM cancer care.¹ First, ASCO advocated for collection and use of SGM-relevant data for quality improvement. Oncology settings were encouraged to collect sexual orientation and gender identity (SOGI) data systematically and use SOGI data to inform delivery of cancer treatment, palliative care, and hospice. Second, ASCO stressed the importance of ensuring prompt follow-up and continuity of care for SGM patients. Addressing barriers such as mistrust was viewed as a critical step in delivering high-quality care across the cancer continuum for SGM patients.

Progress to date:

Since the 2017 statement, much work has occurred on the national front around SOGI data collection. First, in 2020 the National Academies of Sciences, Engineering, and Medicine (NASEM) published an update to their 2011 report on the “Health of LGBTQI+ People.”⁸ Second, in 2022 NASEM, at the behest of the National Institutes of Health’s SGM Research Office, published a consensus report on evidence-based practices for collection of SOGI data.⁹ In this report, NASEM outlined sample items that healthcare and other institutions could use to collect SOGI, along with rationale and methodology for choosing these items. NASEM also recommended that SOGI data should be routinely collected across all research and healthcare settings. Many organizations, including ASCO, released their own guidance around collecting SOGI data in response to this report.^10–13

As a further testament to progress, in 2017, a survey conducted by the National Cancer Institute (NCI) Community Oncology Research Program (NCORP) found that only 10% of community oncology practices were collecting sexual orientation data, while 23% were collecting gender identity data that went beyond male/female.¹⁴ A 2022 update to the 2017 NCORP survey found that 42% of community oncology practices were now collecting sexual orientation data, while 58% were collecting gender identity data.¹⁵ This steady increase highlights the attention being paid to SOGI as an important data element in delivering high quality care.

Despite an increase in SOGI data collection, little data is available on the quality of the cancer care received by SGM patients using standard metrics. The National LGBT+ Cancer Network queried SGM patients’ cancer care experiences in their online Out Survey, which sampled over 3,700 respondents.¹⁶ Findings from the survey indicate that 81% of respondents felt they were respected and 89% felt welcomed during their cancer journey.¹⁶ While 87% of respondents felt their cancer center was safe for SGM patients, over 10% did not feel safe.¹⁶ The report also suggests disparities in crucial areas of care such as fertility preservation, with over 80% of respondents failing to recall any fertility discussions during their cancer care.¹⁶ Similar studies looking at the experiences of SGM people across the cancer care continuum are underway and will help clarify the quality of care offered and received.

Future Directions:

Organizational change is needed to ensure SOGI data are collected routinely across cancer centers and are used to ensure equitable outcomes among SGM people treated for cancer. As a follow-up to their 2020 survey,¹⁷ ASCO supported a qualitative study to gather in-depth interview data from providers and staff at selected cancer care practices around the US about SOGI data collection. Initial results indicate that even in systems where SOGI data are being collected, it is rarely used to inform delivery of high-quality cancer care. Cancer centers interested in engaging in quality improvement for SGM and other minoritized patients may consider signing onto standardized, inclusive quality metrics, such as ASCO’s Quality Oncology Practice Initiative (QOPI^®). Given concerns expressed by SGM communities about safety and confidentiality when disclosing SOGI, centers should be aware of the protections and limitations offered by HIPAA, and ensure data privacy within their setting through clear data use policies that prevent unauthorized access to and exposure of SOGI data.^9,18

Workforce Development and Diversity

What we said in 2017:

The 2017 ASCO position statement had four primary pillars related to developing a diverse workforce capable of addressing SGM cancer health equity.¹ First, ASCO expressed commitment to expanding and promoting cultural competency training for oncology providers, staff, and patient navigators. Second, ASCO advocated for inclusion of SGM training in healthcare accreditation processes, medical curricula, and education for oncology professionals. Third, ASCO highlighted the importance of fostering safe environments in oncology for SGM providers and staff, ensuring that antidiscrimination policies applied to employees as well as patients. Finally, ASCO discussed incorporating SOGI into efforts to enhance workforce diversity, to ensure protections for SGM oncology professionals.

Progress to date:

Progress has been made in promoting training for the oncology workforce around SGM health disparities. Several manuscripts on SGM trainings have been published in ASCO journals, including Journal of Clinical Oncology (JCO).^19–22 These publications have begun moving away from the idea of “cultural competence” and toward the concept of “cultural humility,” which advocates for an orientation toward patient centeredness and lifelong learning. Since the 2017 ASCO position statement, opportunities for SGM-relevant cultural humility training in oncology are more widely available, including the Together Equitable Accessible Meaningful Cancer Care for SGM Patients (TEAM SGM) training offered at no cost by George Washington University and the Welcoming Spaces Program from the National LGBT+ Cancer Network in association with the Society of Gynecologic Oncology. ASCO presented their own work in this area at the LGBTQ Health Workforce Conference and will continue to partner with Building the Next Generation of Academic Physicians (BNGAP) to encourage SGM trainees with an interest in careers in oncology.

In the current milieu of diversity, equity, and inclusion initiatives, cancer centers have begun developing, implementing, and enforcing institutional non-discrimination policies protecting SGM and BIPOC workers. Calls to review promotion criteria and enhance mentoring for groups who experience discrimination at work have also increased. ASCO recommends that these policies and criteria should explicitly forbid discrimination on the basis of sexual orientation, gender identity, and gender expression.

To increase oncology workforce diversity, ASCO has launched the Oncology Summer Internship program in the summer of 2021, which is an immersive, four-week summer internship for rising second-year medical students from groups underrepresented in medicine, with several trainees to date who have identified as both BIPOC and SGM. To better identify and address the needs of ASCO’s SGM members, ASCO recently implemented efforts to collect SOGI data from its members, in addition to ongoing efforts to collect race and ethnicity data.

Future directions:

Though publications have revealed widespread experiences of discrimination, microaggressions, and pay disparities experienced by women and BIPOC oncology workforce members, it is unknown if SGM workers have similar experiences. Consequently, to understand, recruit, compensate, and retain SGM and BIPOC oncology workers, cancer centers should: 1) collect data on their workforce using an intersectional lens; 2) use these data to inform mentorship and promotion programs; and 3) attend to microaggressions from co-workers as well as patients.

Intersectionality recognizes the multiple interwoven social identities of an individual, including race, ethnicity, culture, religion, age, ability, immigration status, and socioeconomic position.²³ The collection of complete and accurate data on race, ethnicity, and SOGI of the oncology workforce is critical, as SGM workers come from a variety of backgrounds and hence their diversity of experiences is incredibly vast. Collection of data on oncology workers’ intersectional identities could inform needs assessments within cancer centers, with purposive feedback from diverse SGM persons.

This assessment in turn could lead to customized mentorship and support programs for SGM oncology workers. Alongside the programs to train staff, providers, and leadership in creating welcoming environments for SGM and BIPOC patients, cancer centers should dedicate institutional resources to create programs and networking opportunities to cultivate SGM leaders. The creation of these programs is critical to address burnout and enhance retention among SGM and BIPOC members of the oncology workforce.

To achieve a safe and welcoming environment for SGM workers, cancer centers should also focus on the experiences of their workforce when interacting with patients. Given the recent surge in anti-SGM legislation, many SGM people in the oncology workforce fear a concomitant surge in discrimination from patients or patients’ caregivers. Such discriminatory experiences contribute to burnout and violation of psychological safety. Institutions should publicly display zero-tolerance policies for overt discrimination and hate speech to protect all workers, including those who identify as SGM and/or BIPOC.

Patient Education and Support

What we said in 2017:

The 2017 position statement acknowledged the unique psychosocial challenges experienced by SGM people facing cancer and called for culturally tailored and appropriate resources to be developed to support SGM patients, their loved ones, and their caregivers.¹ In particular, there was a call for enhanced cancer prevention education for SGM individuals as well as SGM cancer patients and survivors, expanded SGM-focused patient navigation and care coordination, and attention to creating safe spaces for SGM patients and caregivers.

Progress to date:

As stated above, the need to educate the oncology workforce to create culturally humble spaces and provide quality care for SGM people requires changes at system-, clinic- and individual-levels. Since 2017, several non-profits and academic centers have developed support groups, patient education materials, sexual health and screening programs designed to provide accurate information and support to SGM patients and their loved ones. However, there is a lack of consensus on the best way to reach SGM patients and their caregivers and a lack of consensus on the best way to support SGM patients once they are reached. This is in part due to variable state-level regulations around SGM identities and levels of cultural humility and bias across cancer care settings. Currently, Cancer.Net has a webpage listing resources for SGM people with cancer. In addition, to make the best resources more readily available, ASCO’s website now includes a list of resources for SGM patients and their families with links to patient education material as well as information for providers and researchers working with SGM populations. Other websites and online services, including the National LGBT+ Cancer Network, also offer support groups and other resources for SGM individuals with cancer (Table 1).

Table 1:

Resources to Support Patient & Clinician Education

Website	Description
www.Cancer.net *	Patient facing website that brings the expertise and resources of ASCO to people living with cancer and those who care for and care about them. Resources include links to national organizations that have information and resources for LGBTQ+ people with cancer and LGBTQ+ caregivers, podcasts and commentaries from clinicians and researchers discussing the unique challenges faced by LGBTQ+ people with cancer.
www.ASCO.org/equity *	Caring for LGBTQ+ Individuals: ASCO has also compiled resources for clinicians and researchers to help increase awareness of the unique challenges confronted by SGM populations in the context of cancer.
www.Cancer-network.org	The National LGBTQ Cancer Network offers resources to educate the LGBT community about the increased cancer risks and the importance of screening and early detection; and training for health care providers to offer more culturally competent, safe and welcoming care.
www.lgbtcancer.org	The National LGBT Cancer Project offers peer to peer support, patient navigation, education and advocacy resources.
https://www.lgbtagingcenter.org/	The National Resource Center on LGBTQ+ Aging provide ongoing and sustainable resource development, technical assistance, education, and training that supports the Aging and Disability Networks in providing culturally competent services to LGBTQ+ older adults and their caregivers.
https://www.lgbtqiahealtheducation.org/	The National LGBTQIA+ Health Education Center, a program of the Fenway Institute, provides educational programs, resources and consultation to health care organizations to optimize the quality and cost-effectiveness of care for LGBTQIA+ people.

^*LGBTQ+ is used on the Cancer.net and ASCO websites, and so we use that terminology here.

Future directions:

Culturally humble care settings are sparse for SGM patients with cancer, and these sites can be hard for patients to identify and access. Widespread distribution of evidence-based patient education materials for SGM individuals across the cancer continuum is still needed. Quality metrics that include SOGI variables can be used to determine which areas of patient care may need to be enhanced to promote cancer equity. Such metrics can also inform priority areas for patient education and support programs that can address the unique challenges experienced by SGM people in cancer care.

Research

What we said in 2017:

To facilitate research on SGM populations in the context of cancer, the 2017 ASCO position statement had three primary pillars.¹ First, ASCO advocated for the inclusion of SOGI as a required data element in cancer registries and clinical trials. Such data will help characterize cancer-related disparities in SGM communities and ensure equitable access to clinical trials for SGM cancer patients. Second, ASCO advocated for promotion of research among diverse SGM populations affected by cancer. This research should span the cancer control continuum, from prevention through end of life; reflect the diversity in race, ethnicity, disability status, and other demographic characteristics seen within SGM populations; and be the target of specific funding initiatives. Third, ASCO emphasized the need to train the next generation of researchers to conduct studies on SGM cancer health equity. ASCO proposed initiatives including dedicating Young Investigator and Career Development funding to support SGM research and creating a partnership with NIH and other institutions to promote development of a SGM cancer research portfolio.

Progress to date:

Since 2017, the volume of research on cancer in SGM populations has continued to increase, from an estimated 92 publications in 2017 to 220 publications in 2022. Promotion of SGM health equity research at national conferences has similarly increased, and ASCO has featured SGM content in both their Education Program and in podium sessions at their annual conference every year for the past 5 years.

Due to this interest and attention, progress has been made on each of the three pillars outlined in the 2017 position statement. First, in terms of inclusion of SOGI data in research, in 2022 the NCI dedicated supplemental funding to NCI designated cancer centers to support implementation of SOGI data in oncology practice. Large national studies, such as the ‘All of Us’ research program, have included SOGI in their data collection elements. ASCO released guidance for cancer clinical trialists on how best to use the NASEM report and other resources to integrate SOGI into cancer clinical trials.¹⁰ Additionally, an NCI working group continues to refine and test items based on the NASEM recommended measures. Second, in terms of advocating for promotion of diverse research, the NIH SGM Research Office has reported that $27 million per year has gone to fund SGM cancer research since 2017, spanning from epidemiological studies of cancer incidence to intervention research with SGM cancer survivors.²⁴ Intersectionality, as mentioned above, has been explicitly referenced in many of these funded studies. Third, innovative new approaches to mentoring and supporting early-stage investigators interested in SGM cancer research have been tested and disseminated. One example is the Sexual and Gender Minority Cancer Curricular Advances for Research and Education (SGM Cancer CARE) R25 funded through NCI in 2021. This grant uses a tested curriculum to guide learners through the process of developing a cancer research protocol focused on SGM communities.

Future directions:

While this progress is encouraging, more attention needs to be paid to many aspects of cancer research for SGM populations. Given historically-justified high levels of mistrust, special effort to include SGM patients in clinical trials is needed. These efforts must address the safety and confidentiality of participants, particularly where disclosure of SOGI is concerned; appropriate risks and protections of data disclosure should be outlined in Institutional Review Board-approved protocols, and where possible, data should be reported in aggregate to protect individual participants. However, it is important to require SOGI data as a standard for institutions, even while always providing an option for patients to not disclose for safety or personal reasons. Studies to address fundamental safety questions for transgender and gender diverse people with cancer are needed as well. For example, transgender and gender diverse communities have asked and continue to ask about potential links between long-term hormone use and increased cancer risk, and also whether gender affirming hormones can be utilized by patients undergoing cancer treatment. These questions have yet to be answered. Longitudinal studies describing differences in treatment efficacy and health outcomes based on chromosomal signature and hormone balance are needed to inform future clinical guidelines. In addition, while efforts to implement SOGI data collection are encouraging, the success and impact of these efforts are yet to be determined. It is also unclear whether any SOGI data collected will be utilized effectively by cancer care providers to improve care. SOGI data implementation has historically under-emphasized assessment of intersex individuals and those with disorders of sexual development (DSD), and the cancer-related needs of these populations are largely unknown and unexamined.^19,25,26 Finally, while research funding has increased in some areas, more training for and grants to early-stage investigators interested in SGM cancer research are still needed to ensure a strong pipeline of researchers.

Policy Solutions

What we said in 2017:

The 2017 ASCO position statement called for three major developments in the area of policy.¹ First, it called for creation and enforcement of policies ensuring access to culturally humble, equitable cancer care. Policies ensuring such care would include informed decision-making through clear communication and information as well as access to health care services, diagnostic testing that might be discordant with the sex of record, gender-neutral bathrooms, and respect for patient choices in care. Second, it called for adequate insurance coverage to meet the needs of SGM individuals affected by cancer. This includes access to coverage and services that are driven by anatomy rather than sex of record, as well as provision of SGM-affirming healthcare. Finally, it called for policies prohibiting discrimination. At the time of the 2017 statement’s publication, the U.S. Department of Health and Human Services (HHS) had issued the final rule of Section 1557 of the Patient Protection and Affordable Care Act (ACA), effective May 13, 2016. Section 1557 is the nondiscrimination provision that ensures protection based on a number of classifications, including race, color, national origin, age, disability, sex, gender identity, and sexual orientation.

Progress to date:

The interplay of the judicial and executive powers has created inconsistent progress in the implementation of nondiscrimination protections in the US. In 2020, the Trump Administration repealed protections specified in Section 1557. In response to judicial pushback in Franciscan Alliance, Inc. V. Becerra (2021), the Biden Administration issued a new Proposed Rule on Section 1557 to restore the definition of sex discrimination to include “discrimination on the basis of sex stereotypes; sex characteristics including intersex traits, pregnancy or related conditions; sexual orientation and gender identity.”²⁷ The Proposed Rule also expands its scope to health care entities and insurers that receive federal funds, including Medicare Part B payments.²⁷ Also in 2022, Congress passed the Respect for Marriage Act, protecting same-sex and interracial marriage.²⁸ Given this judicial-executive tug-of-war, championing policy change to protect SGM equity at the institutional level remains critical.

Progress has also been made in de-gendering oncology research eligibility criteria and treatment guidelines. By 2023, the NCCN de-gendered nearly 95% of their clinical guidelines; ASCO’s own efforts to de-gender language in its guidelines is underway and will continue as these are updated or developed de novo. The US Preventive Services Task Force published their intention to be inclusive in their evidence review going forward to identify clinical issues important to sex and gender at the start of new guideline development and assess available evidence relevant to sex and gender. The American College of Radiology and Society of Breast Imaging published breast cancer guidelines that include screening transgender populations based on “sex assigned at birth, use and duration of hormones, and surgical history” while noting the limited evidence available.²⁹ Specifically, mammography for transgender women who are over age 40 and have used estrogen for five or more years and for transgender men without top surgery was recommended.²⁹

Future directions:

Full implementation of privacy and nondiscrimination protections remains important to ensure high quality, accessible healthcare for SGM people. Health care institutions can put in protections for all of their patients regardless of the local political environment. Universal training is also needed so that we can create affirming clinical care environments. In 2022, standards for SGM cultural competency and humility training were published³⁰; widespread implementation however is still to come and cancer centers wishing to provide equitable care must mandate such trainings for their workforce. Beyond implementing policies within their institutions, oncology providers and leaders can and should be involved in state and national efforts to change policy and improve cancer health equity for SGM and other populations. ASCO’s State/Regional Affiliate Program work across the US to support members in their regions and may be a promising vehicle for addressing local policy (Table 2).

Table 2:

Advocacy Opportunities

ASCO’s ACT Network	The ACT Network is a central hub for learning about and taking action on ASCO’s cancer care priorities. https://asco.quorum.us/
ASCO’s State and Regional Affiliates	State and regional oncology societies offer opportunities to engage in local advocacy efforts to impact state legislative outcomes. https://old-prod.asco.org/get-involved/advocacy/state-regional-affiliates/contact
GLMA: Health Professionals Advancing LGBTQ+ Equality	GLMA is the world’s largest and oldest association of LGBTQ+ healthcare professionals with the mission of ensuring equality in healthcare for LGBTQ+ individuals and healthcare professionals. https://www.glma.org/
GLAAD	GLAAD is a non-profit organization focused on LGBTQ advocacy and cultural change. https://glaad.org/
The National LGBTQ Task Force	The Task Force supports action and activism on behalf of LGBTQ people. The organization’s Creating Change conference offers a skills-building event for community and allies each year. https://www.thetaskforce.org/

Conclusion

While much progress has been made in advancing SGM cancer health equity since 2017, more progress is needed to reduce disparities and advance equity. The five focus areas outlined in the 2017 ASCO position statement remain relevant, as we must continue to promote and advance equity in quality improvement, workforce development, patient care, research, and SGM-affirming policies (Table 3). This is particularly critical in the in the face of legislative roadblocks and systematic discrimination. ASCO is committed to continuing this work and remaining a global leader in addressing SGM cancer disparities. Given the progress reported in this paper, the work of the ASCO SGM Task Force and allies in the oncology community suggest an ongoing, concerted effort is needed to significantly close the gaps in cancer equity among SGM individuals.

Table 3:

Snapshot of Previous Recommendations and Future Directions

	2017 Recommendations	Future Directions
Quality Improvement Strategies	• Collect and use SGM-relevant data for quality improvement • Ensure prompt follow-up and continuity of care	• Organizational change is needed to ensure SOGI data are collected routinely across cancer centers and are used to ensure equitable outcomes among SGM people treated for cancer • Cancer centers may consider signing onto standardized, inclusive quality metrics
Workforce Development & Diversity	• Expand and promote cultural competency training • Incorporate SGM training into curricula, training requirements and certification exam content • Foster safe environments for SGM staff and providers • Integrate a focus on SGM physicians in oncology workforce diversity efforts through SOGI collection	• Cancer centers should collect data on their workforce using an intersectional lens • These data should then be used to inform mentorship and promotion programs • SGM members of the workforce should be protected against microaggressions from co-workers as well as patients.
Patient Education & Support	• Enhance patient navigation and care coordination • Expand education for SGM patients with cancer and survivors • Increase patient access to culturally competent support services • Create safe space for SGM patients • Increase cancer prevention education for SGM individuals	• Widespread distribution of evidence-based patient education materials for SGM individuals across the cancer continuum is still needed • Quality metrics that include SOGI variables can help determine which areas of patient care need to be enhanced and prioritize patient education and support programs
Research	• Promote the inclusion of SOGI as a required data element in cancer registries and clinical trials • Promote research among SMG populations • Train the next generation of researchers	• Concerted effort to include SGM patients in cancer clinical trials is needed • Increase the number of studies addressing fundamental questions for transgender and gender diverse people with cancer • More training for and grants to early-stage investigators interested in SGM cancer research are still needed to ensure a strong pipeline of researchers.
Policy Solutions	• Create and enforce policies ensuring access to culturally affirming, equitable cancer care • Ensure adequate insurance coverage to meet the needs of SGM individuals affected by cancer • Ensure policies prohibiting discrimination	• Health care institutions should fully implement robust privacy and nondiscrimination protections for all patients • Universal training is needed to create affirming clinical care environments; cancer centers should mandate SGM cultural competency and humility training for their workforce • Oncology providers and leaders should advocate at state and national levels to change policies that contribute to inequitable care for SGM patients and other populations