Addressing Social Risks to Accelerate Health Equity in Cancer Prevention and Control

Abstract

Addressing social risks in cancer prevention and control presents a new opportunity for accelerating cancer health equity. As members of the American Society of Preventive Oncology (ASPO) Cancer Health Disparities Special Interest Group, we describe the current state of science on social risks in oncology research and practice. To reduce and eliminate the unjust burden of cancer, we also provide recommendations for multilevel research examining social risks as contributors to inequities and the development of social risks-focused interventions. Suggestions for research and practice are provided within levels of the socio-ecological model, including the interpersonal, organizational, community, and policy levels.

Introduction

Tremendous progress in cancer prevention and control has led to declining cancer mortality and an increase in the number of cancer survivors in the United States. However, the substantial burden of cancer, including high out-of-pocket diagnosis costs, treatment, and lost wages, may contribute to widening socioeconomic disparities. Persistent socioeconomic inequities throughout the United States also result in many individuals facing several social risks prior to their cancer diagnoses. These social risks, social needs, and social determinants of health (SDoH) impact quality of life and clinical care for cancer survivors. Increasing evidence of the relationship between SDoH and cancer outcomes suggests that reducing food insecurity, housing instability, and transportation challenges, among other social risks, could reduce cancer disparities.

SDoH, social risks, and social needs are often used interchangeably, but are in fact, different concepts (see definitions of SDoH and related concepts in Table 1). SDoH includes income, education, employment, housing, neighborhood and built environment, racism, discrimination, transportation, health care access and quality, social connections, as well as other structural or systemic social factors. Social risks are conditions that lead to adverse health outcomes, such as food insecurity, housing instability, and transportation challenges (1). These social risks become social needs when patients identify a desire for assistance in addressing them.

Table 1.

Definitions of social determinants of health and related concepts.

Health equity	Defined by the NCI as a situation in which all people are given the chance to live as healthy a life as possible regardless of their race, ethnicity, sex, gender identity, sexual orientation, disability, education, job, religion, language, where they live, or other factors.
Health disparity	Defined by the NCI as a type of preventable health difference that is closely linked with social, political, economic, and environmental disadvantage. Health disparities may occur because of race, ethnicity, sex, gender identity, sexual orientation, age, religion, disability, education, income, where people live, or other characteristics.
Social determinants of health (SDoH)	Defined by the U.S. Department of Health and Human Services (Healthy People 2030) as the conditions in the environments where people are born, live, learn, work, play, worship, and age, and they affect a wide range of health, functioning, and quality-of-life outcomes and risks.
Social needs	A patient-centered concept that incorporates a person’s perception of their own health-related needs.
Social risks	Social determinants that may be associated with negative health outcomes, such as food insecurity, housing instability, or transportation challenges.

The American Society of Preventive Oncology (ASPO) is committed to promoting research on structural and social determinants of cancer inequity. The two-fold purpose of this report is to increase awareness of the high prevalence of social risks among cancer survivors and to discuss the state of the science of research focused on social risks in cancer prevention and control. As members of the ASPO Cancer Health Disparities Special Interest Group, we provide recommendations for (i) rigorous etiologic research examining social risks as contributors to disparities, and (ii) the development and evaluation of social risks-focused interventions to reduce and eliminate the unequal burden of cancer.

Relationship Between Social Risks and Disparities in Cancer Prevention and Control

Social risks have the potential to impact outcomes across the cancer control continuum. Individuals with unmet social risks may engage in adaptive behaviors that negatively affect cancer prevention or early detection efforts. For example, people experiencing food insecurity often consume fewer fruits and vegetables than people with secure food access, which affects carcinogenesis. People who lack access to reliable transportation may delay medical care, including receipt of cancer screening, which could contribute to later-stage diagnosis and poorer prognosis. Moreover, lack of adequate food, transportation, or housing during and after cancer treatment poses serious threats to the ability of patients to attend medical appointments, follow prescribed treatment regimens, engage in follow-up and ongoing surveillance, or fully enjoy life in the posttreatment survivorship period.

Multiple levels of the social-ecological framework contribute to the experience of social needs and their impact on cancer outcomes. Public policy—including national, state, and local laws and regulations—determines eligibility for social assistance programs that could ameliorate unmet social risks. For example, the California Cancer Care Equity Act (SB 987) expands access to novel therapies and clinical trials for low-income Medi-Cal (California’s Medicaid health care program) enrollees, providing a path to receive treatment at NCI-Designated Comprehensive Cancer Centers, sites affiliated with the NCI Community Oncology Research Program (NCORP), or qualifying academic cancer centers. Community resources, including social service organizations, influence whether cancer survivors can access resources to respond to social risks. Programs available at cancer centers and clinics, such as patient navigation and social work, aim to address social risks; however, social risk screening has not yet been systematically integrated into cancer care delivery. Moreover, investment in programs to address social risks is often tenuous, with few resources existing in the healthcare or community settings. At the interpersonal level, social risks can influence relationships among providers, patients, and caregivers. For example, when patients are unable to attend appointments because of transportation challenges, trust between patients and providers may suffer. Moreover, at the interpersonal level, unmet social risks may influence cancer health outcomes via behavioral, psychosocial, and physiologic pathways.

Opportunities to Address Social Risks Through Screening and Interventions

Advancing the study of social risks in cancer prevention and control begins with collecting social risk data. Numerous tools exist for the collection of SDoH, including self-reported measures, such as the NIH PhenX Social Determinants of Health Assessments Collection, and area level measures and data, such as Feeding America’s county-level food insecurity estimates and the Area Deprivation Index. Integration of social risk tools into the electronic health record is underway in many oncology practices, in part to meet calls to document SDoH data from the Joint Commission and other accreditation bodies. Researchers may leverage these existing tools when working in clinical settings; however, population-based studies may benefit from the addition of social risk screening tools. As suggested from the definitions in Table 1, the distinction between measuring SDoH and social risk emerges through the purpose. SDoH measures are appropriate for describing or including social conditions. When expressly relating these conditions to health outcomes, however, we are then measuring social risk.

Including social risk screening tools or survey measures in cancer research will enhance our knowledge of the prevalence of social risks in diverse settings and populations. Moreover, including social risks data in studies provides the opportunity to statistically adjust for social position or investigate social risks as exposures, mediators, or interacting factors. Collecting social risk data may also increase our understanding of the interactions across various SDoH factors and their impact on cancer outcomes. This research advance would accurately depict the root causes of outcome disparities, thus advancing health equity in cancer prevention and control research.

Addressing social risks in cancer care delivery is a current research focus at the NCI, as evidenced by the “Addressing Social Risk in Cancer Care Workshop” held in 2021, the NIH—Health Disparities Interest Group’s Inaugural Workshop “Integrating Social Determinants and Structural Influence Measures in Biomedical Research” held in 2022, and the growing portfolio of NCI-funded social risk research grants. Universal screening for social risks is emerging as a key element of identifying and addressing social needs. However, providers’ and healthcare systems’ concerns about how they should respond to information about social risks gathered from screening tools may prevent the widespread adoption of social risk screening in the absence of evidence-based interventions. This barrier highlights the urgent need for impactful, efficient, and disseminable interventions for addressing social needs.

Indeed, a number of interventions for addressing social needs have been implemented in cancer care delivery. Figure 1 highlights interventions specifically targeting food insecurity, transportation challenges, and housing instability. In addition to these interventions designed to address specific social risk, several interventions provide direct financial resources in the form of unconditional or conditional cash transfers, guaranteed income, or microloans and other forms of direct investment in patients. Investing directly in patients with social risks is a strategy that considers patients’ multifaceted and interconnected needs. This process also respects patients’ ability to prioritize and address their own needs with supplemental financial resources. It is estimated that addressing unmet social needs in primary care costs, on average, $60 per patient per month, with $5 of that going to screening and referral (2). Additional research is needed to estimate the costs and potential effects of addressing social needs in oncology settings.

Figure 1.

Example interventions to address social risk in clinical settings. As efforts to screen for and address social risks in oncology practice gains momentum, the metrics and outcomes used to measure progress become critically important. Current studies of social risk interventions tend to measure outcomes that fall into three broad categories: (1) patient-centered outcomes such as quality of life, financial distress, and symptom control; (2) resolution of social needs; and (3) health care and social service utilization.

Conclusions/Recommendations/Call to Action

To effectively accelerate progress towards health equity in cancer prevention and control, we offer recommendations for addressing social risks at each level of the socio-ecological model. As members of the ASPO Cancer Health Disparities Special Interest Group, we recognize the need for structural and multilevel interventions to address social risks in cancer care. Current gaps exist at all levels, and Table 2 highlights opportunities to advance the cancer prevention and control field from individual to policy interventions. The recent NCI portfolio analysis by Sanchez and colleagues highlights the current lack of community-level social risk interventions (3). However, new initiatives, such as the National Institute of Health Common Fund’s Community Partnerships to Advance Science for Society program, may provide opportunities to develop organizational, community, and policy solutions to address social risks.

Table 2.

Recommendations for addressing social risks to accelerate health equity in cancer prevention and control.

Socio-ecologic Model	Recommendations
Individual	No recommendations
Interpersonal	1. Interventions, resources, and compensation to support the financial and psychosocial burden of survivorship and informal caregiving.
Organizational	2. Implement and evaluate social risk screening programs within organizations across health and non-health sectors.
	3. Mandate universal social risk screening as a component of NCI cancer center designation.
	4. Prioritize and coordinate specific tracks or calls for abstracts for social risk screening-focused research at conferences held by cancer research organizations (e.g., ASPO, American Association for Cancer Research, American Society of Clinical Oncology).
	5. Use electronic medical records to identify, track referrals, and address social risk longitudinally.
	6. Collect data on the burden of social risks as well as information on resources available to communities for mitigating social risks.
	7. Invest in patient navigation programs to coordinate resource referral and help patients navigate available social services.
Community	8. Assure appropriate and equitable budget allocations for academic, community members, and community organization research partnerships.
	9. Establish community-clinic linkages between cancer centers as well as community-based organizations and social service organizations.
Public policy	10. Increase NCI funding support for cancer-related social risks, needs, and SDoH research that address gaps in understudied factors (e.g., community and health system level approaches).