ASO Education and Training: Taking the Next Step in Surgical Oncology Health Disparities Research: Identifying Root Causes and Targets for Actionable Change

Abstract

The Society of Surgical Oncology and its membership are committed to reducing and eliminating cancer disparities. Over the past several decades, plentiful research has identified marginalized populations who are at an elevated risk of developing cancer, are less likely to receive recommended cancer screenings and guideline-concordant care, and populations who have inferior oncologic outcomes after cancer treatment. Despite monumental strides in improving cancer outcomes, cancer disparities unfortunately remain a reality. Continued strategic efforts are needed to identify the root causes of these disparities and develop interventions to ensure equitable cancer care for all patients. This monumental task requires multidisciplinary and transdisciplinary team collaboration, input from community and patient stakeholders, investments from healthcare and hospital administrative leadership, and financial sponsorship to ensure sustainability. In this review, we discuss tools that surgical oncologists can use in developing programs and interventions to champion eliminating cancer disparities to ensure equitable oncologic outcomes for all patients at risk or diagnosed with cancer.

Cancer is the second-leading cause of death in both the United States and globally, with nearly 10 million annual global cancer deaths.^1,2 Thus, tremendous resources have been used to identify the biological etiology of cancer development, develop cancer screening tools to facilitate early detection, and optimize multidisciplinary cancer care. Despite the fact that cancer impacts all individuals, not all populations have benefited equally from improvements in cancer prevention, detection, and treatment.^3–7 Cancer disparities are defined by the National Cancer Institute as differences in cancer measures, such as incidence, prevalence, morbidity and mortality, survival, and screening across different populations.⁸ Specific examples of cancer disparities include increased risk for triple-negative breast cancer amongst non-Hispanic Black women compared with non-Hispanic White women, inferior survival outcomes amongst gender-diverse patients with cancer compared to cisgender patients, higher renal cell carcinoma mortality rates in American Indian and Native Alaskans compared with other racial groups, higher cancer mortality rates in rural areas compared with urban areas, and higher rates of alcohol and tobacco use amongst LGBTQIA individuals compared with heterosexual populations.^9–14 The etiology of these varying cancer disparities is a complex intertwinement of molecular and biologic underpinnings along with environmental and social constructs.¹⁵ While disparities in cancer outcomes are most apparent in pragmatic real-world observational datasets, they can still be seen in the setting of well-controlled cancer care through clinical trials, emphasizing the multi-faceted causes of cancer disparities.^16,17

Mitigating cancer disparities rests upon the principle of health equity, which is defined by the Centers for Disease Control and Prevention as when every person can attain their full health potential, and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance.^18,19 Achieving health equity is heavily influenced by one’s social determinants of health (SDOH), which are the nonmedical factors that influence health outcomes and include conditions, such as where someone is born and where they are raised, work, and live, which can influence their health risk and outcomes.²⁰ Recent research focused on cancer disparities, health equity, and SDOH has largely focused on identifying disparate outcomes and at-risk groups while suggesting areas for future work. While identifying and defining cancer disparities is imperative, it is also paramount for researchers to identify the root causes of these disparities and then implement interventions towards eliminating disparities. Achieving health equity is a challenging feat that requires investment from academic and community stakeholders, healthcare systems, and policy makers.^21,22 The aim of this paper is to serve as a guide for surgical oncologists embarking on methods and interventions to identify and eradicate cancer disparities to ensure equitable oncologic outcomes for all populations.

Opportunities to Facilitate and Support Research in Mitigating Cancer Disparities

Development of Patient and Community Advisory Boards

Community Advisory Boards (CABs) are essential to ensure that research and implementation efforts are enforced with the perspectives, priorities, and lived experiences of the populations facing cancer disparities.^23–26 CABs are usually comprised of 8–15 individuals, to optimize functionality and sustainability, who represent diverse perspectives that are representative of their communities. CABs provide a platform for a bidirectional conversation between community stakeholders and researchers to facilitate clinically and socially relevant research. Input and contributions from CABs can aid in prioritizing research topics, development of study protocols, maximizing participant recruitment and retention, supporting interpretation of study findings, and how to best implement study findings through pragmatic approaches. Through these contributions, CABs ultimately enhance the scientific rigor and practicality of cancer disparities research, ultimately advancing progress towards equitable outcomes. CABs may be project-focused in scope, or may be broad and inform/influence multiple projects or centers depending on resources and goals.

Several publicly available online toolkits can assist researchers in establishing and sustaining CABs.^27–29 Once researchers identify the scope of their work, obtain Institutional Review Board approval, and secure a funding source to support CAB activities, most CABs begin by creating a stakeholder map of ideal team members, including patient survivor/thrivers, caregivers, clinicians, etc. that also ensures diverse representation across racial, ethnic, socioeconomic, and gender/sex backgrounds. Next, teams must develop a recruitment process for CAB members that may include reaching out to select community partners and advocacy groups and conducting interviews with interested CAB members. Once the CAB is assembled, a written charter or semi-formal document detailing expectations, member roles, the decision-making process, reimbursement for time, authorship and acknowledgment policies, etc. is key to ensure all members have a clear vision for the work ahead. Frequency of CAB meetings, payment, and duration of the CAB will be dependent upon the CAB’s task(s) and funding. Continued bidirectional communication between CAB membership and research leadership is key to foster success, progress, and long-term sustainability.^27–29

CABs can have transformative implications to surgical oncology disparities research. An excellent example is the impact a CAB had on a randomized trial geared at improving colorectal cancer screening for low-income and minority patients cared for by a safety net hospital system.³⁰ Not only was the CAB highly involved in developing and editing study materials, but CAB members also played a key role in identifying practical methods for patients remaining engaged with the study and assisted in shaping result summaries for the general public.³¹ CABs can also play even more active roles by leading townhall meetings to educate survivors and the broader community, gather feedback on the relevance of planned research, and work with community stakeholders to ensure research findings can result in practical patient-centric approaches to eliminating disparities.³³

Using Qualitative and Mixed-methods Research

Qualitative and mixed-methods research are essential to develop interventions that promote health equity and reduce cancer disparities. These approaches center on lived experiences, perceptions, and social contexts, helping to uncover barriers to healthcare access, treatment adherence, and overall well-being. Insights gained from this form of research can guide culturally sensitive and contextually relevant interventions tailored to community needs. Effective use of these methods requires familiarity with theoretical paradigms and study designs. Qualitative research often aligns with positivist or postpositivist paradigms.³² Positivist frameworks treat social phenomena as objectively measurable, emphasizing causality and reproducibility, whereas postpositivist paradigms accept that social phenomena are probabilistic and not fully explainable, distinguishing social sciences from natural sciences. Regardless of the paradigm, common qualitative designs include ethnography, grounded theory, phenomenology, and narrative studies (Table 1). Interviews and focus groups with open-ended questions are central to exploring “how” and “why” outcomes occur.³³

Table 1.

Approaches to qualitative and mixed-methods research

Approach	Purpose	Key characteristics	Example citation
Qualitative
Ethnography	Understand cultural phenomena from participants’ perspective(s)	Immersive fieldwork, participant observation, and interviews	Yaramadi et al. BMC Med Ethics, 202441
Grounded theory	Develop a theory grounded in data collected from participants	Iterative coding and theoretical sampling	Ashcroft et al. Int J Equity Health, 202142
Phenomenology	Explore lived experiences and the essence of phenomena	In-depth interviews and thematic analysis focused on subjective meaning	Salisu et al. J Prim Care Community Health, 202343
Narrative research	Study the stories or life experiences of one or a few individuals	Storytelling and contextual analyses	Rother C et al. SSM Qualitative Research in Health, 202444
Mixed-methods designs Core designs
Convergent design	Merge qualitative and quantitative data to compare and interpret results	Parallel data collection, integration at interpretation, equal weight.	Martin et al. J Racial Ethn Health Disparities, 202345
Explanatory sequential	Use qualitative data to explain quantitative findings	Quantitative first, followed by qualitative; sequential timing.	Torabipour et al. BMC Health Services Research, 202546
Exploratory sequential	Use qualitative data to develop quantitative instruments or hypotheses	Qualitative first, followed by quantitative; instrument development.	Shiyanbola et al. Health Psychol Behav Med, 202147
Advanced designs
Intervention	Evaluate interventions using both qualitative and quantitative data	Embedded design, process and outcome evaluation, and integration	Mensa-Kwao et al. PLOS one, 202448
Case study	Explore a bounded system using multiple data sources	In-depth case analysis	Reid et al. Health Educ Behav, 201949
Community-based participatory	Collaborate with community stakeholders to address a clinical question or challenge	Co-researcher model, empowerment, and iterative feedback	Di Tosto et al. BMC Health Services Research, 202340

While qualitative research is embedded in philosophies of perspective, mixed-methods research has more concrete parameters for study design, because it includes a quantitative component.³⁴ Core designs include convergent, explanatory sequential, and exploratory sequential designs.³⁵ Convergent designs collect both data types simultaneously, while sequential designs gather them consecutively, allowing one to inform the other. Advanced designs include interventional, case study, and community-based participatory methods.³⁶

Sampling strategies also shape research outcomes.³⁷ Criterion sampling requires participant selection be guided by characteristics identified a priori. Purposive sampling, a subcategory of criterion sampling, describes participant selection based on prespecified rationale as which demographic might be the most informative. Convenience sampling is performed based on participant availability. Snowball sampling indicates that participants have referred other participants. While typical case sampling describes average participants that may provide generalizable data. Extreme case sampling targets participants with rare cases or circumstances.

While each type of qualitative and mixed-methods research offers unique strengths, novel community-based participatory approaches, such as Group Concept Mapping (GCM), can create complex knowledge structures to guide healthcare reform (Fig. 1).^38,39 GCM unfolds in several structured steps. First, stakeholders generate ideas in response to a focal question or challenging clinical scenario. Second, these ideas are then sorted into thematic clusters and rated based on criteria, such as importance and feasibility. The sorted and rated data are analyzed by using multidimensional scaling and hierarchical cluster analysis, which provide a visual representation of the relationships between ideas by placing items that were sorted together in similar spatial configuration. These visual representations help to identify priority areas to guide strategies to promote health equity. As an example, Di Tosto et al. recruited patients and clinicians to identify factors that were necessary for patient engagement.⁴⁰ Participants grouped factors into five clusters: 1) access, 2) external resources, 3) attitudes and behaviors, 4) internal resources, and 5) relationship with their provider. Rating of clusters demonstrated that the relationship with one’s provider is both the most important and most addressable dimension of patient engagement. The authors concluded that interventions to improve the relationship between clinicians and their patients could be used to encourage engagement. GCM illustrates how qualitative and mixed-methods research can generate nuanced, actionable insights into health disparities, guiding effective and equitable healthcare interventions. Execution of interventions informed by these approaches may be ultimately timelier and more cost-effective insofar as incorporating stakeholders’ perspectives can facilitate acceptance and organizational readiness. It is important to note, however, that rigorously designed studies may demand substantial and sustained financial and human investment that challenges feasibility in resource limited contexts. Moreover, challenges in disparity-focused research extends beyond merely deepening our understanding of disparities and requires significant progress in regard to insurance eligibility and reimbursement models. For surgical oncologists aiming to conduct qualitative and mixed-methods research, identifying collaborators with the expertise and experience to support the use of these methods are key for success.

Fig. 1.

Group concept mapping study design and example data analysis

The Role of Implementation Science

Implementation science is defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services.”⁵⁰ Advocacy from the NCI Cancer Moonshot Blue Ribbon Panel for the use of implementation science to address barriers in using evidence-based practice in cancer care led to the founding of the NCI Consortium for Cancer Implementation Science in 2019.^51,52 Implementation research addresses the persistent gap between evidence-based clinical practices and their routine use, and is especially valuable for advancing health equity interventions.^53,54

Implementation research is inherently complex, which stems from its roots in theories, models, and frameworks to evaluate why an intervention succeeds or fails. Dozens of validated frameworks can be used in implementation science and can be overwhelming to those less familiar with this methodology, but these frameworks are essential.⁵⁵ We focus on several frameworks that are relevant to interventions that address disparities in surgical oncology (Table 2). Most of these examples are determinant frameworks, which focus on characteristics of the intervention, the setting, or the stakeholders to better understand what factors might facilitate or hinder a particular intervention’s success.⁵⁵ Alternatively, the RE-AIM framework is used to assess the outcomes of an intervention. Whereas RE-AIM would indicate whether an implementation effort has been successful, the Consolidated Framework for Implementation Research (CFIR), a determinant framework indicates how modifiable contextual factors might influence the success or failure of an implementation effort. The selection among these or other frameworks will depend on the specific research question and the intervention one intends to study. It is important to note that implementation science is different from quality improvement. While it is possible that the results of research that use implementation science will lead to adjustments of interventions to facilitate uptake, the intervention itself has already been validated and the research is focused on utilization, rather than on effectiveness.

Table 2.

Selection of commonly used implementation science frameworks

Framework	Key domains/determinants	Important concepts	Examples
RE-AIM63	Reach, efficacy/effectiveness, adoption, implementation, maintenance	Serves to evaluate an intervention’s impact Primarily focused on outcomes rather than the characteristics of the intervention itself	Investigating implementation of patient reported outcome measures at a breast cancer clinic64
PRISM65 (Practical Robust Implementation and Sustainability Model)	Characteristics of the organization and patients, perspectives of the organization and patients, external environment, implementation, sustainability infrastructure	Highlights the perspectives of multiple levels of workers (senior, middlemen, frontline) Emphasizes need to bridge the gap between research and operations	Assessing the sustainability of a cancer screening patient navigation program for the medically underserved66
TDF67, 68 (Theoretical Domains Framework)	12 domains to explain behavior change (e.g., knowledge, skills, beliefs, motivation, social influences etc.)	Approaches implementation problems through the lens of behavioral change	Evaluating opioid prescribing after oncologic surgery69
PARIHS/i-PARIHS70, 71 (Promoting Action on Research Implementation in Health Services)	Quality and type of evidence, characteristics of the setting / context, facilitating factors	Facilitation is the key component Facilitating a new method of work among specific groups in a given context is critical to success	Improving uptake of a lung cancer screening program72
CFIR73 (Consolidated Framework for Implementation Research)	Intervention characteristics, outer setting, inner setting, individuals involved, process of implementation	Can be used in planning or evaluation stages Authors’ goal is to help users understand what works where and why	Informing pragmatic solutions from the Lancet Oncology Commission on Global Cancer Surgery74

Before choosing a framework, the multidisciplinary research team must first be established and include diverse community partners and stakeholders.^53,56 For instance, if one is implementing a tool on a hospital ward, it would be helpful to have representation from nurses, advanced practice providers, and patient care assistants on the team who are involved in the daily tasks of the hospital ward’s functions. Ideally, having trained implementation scientists as part of the team will be ideal, although this may not be possible at every institution. Still, it is best to involve advanced methodologists or statisticians early on as these studies often use mixed methods or complex quasi-experimental designs.⁵⁶ The first task of the team is to identify key priorities and clarify the implementation research question. After the question is formalized, the best framework can be selected that will then guide the design and operationalization of the study. When choosing among the many framework options (Table 2), it is essential to consider the individuals or groups involved, the stage of implementation (planning, enacting, or evaluating), data access, available resources, and the overall goal or purpose of the study.⁵⁷ Sometimes multiple frameworks will need to be employed to achieve the study objective.

Many adaptations of implementation science frameworks include equity as a central component of implementation.^58,59 The Practical Robust Implementation and Sustainability Model (PRISM) is a framework that provides a more comprehensive model that is often applied to health equity research. PRISM expands RE-AIM by incorporating contextual factors that might influence RE-AIM outcomes (e.g., patient, staff, and organizational factors).⁶⁰ For example, in one equity-driven adaptation of the PRISM and RE-AIM frameworks, the team emphasized the need to consider the structural drivers of inequity when evaluating the context, to question who is not represented at the table and why, and to document ways in which equity is being incorporated into the implementation process in order to promote sustainability.^60,61 For those who are studying the implementation of an intervention to specifically address disparities, the frameworks that have been adapted to prioritize equity may be particularly useful.

The selection of a central framework(s) to guide the research is the fundamental step in performing implementation research, after which the team can carry out the investigation, evaluate the outcomes, and publish the results using standard reporting guidelines (i.e., StaRI⁶²). While implementation is often setting-specific, the larger goal of implementation science is to uncover knowledge that can be generalized to help promote dissemination of an intervention and its use in other contexts.⁵⁶ Especially for interventions that are resource-intensive (e.g., those that require drug or device approval and clearance with large-scale validation), implementation requires long-term strategies that include sustained education of administrators, providers, patients, and community to support process adoption. Overall, increased awareness and use of implementation science will improve the uptake and spread of interventions in surgical oncology that aim to promote health equity and reduce cancer disparities.

Making Clinical and Systems Changes

Continued advancement in health equity requires not only robust research, supportive frameworks, and quality improvement initiatives, but also the buy-in of key hospital stakeholders and administrative leadership. Health system leaders play a pivotal role in ensuring the sustainability of equity initiatives through targeted investment in resources and the implementation of long-term strategies within healthcare systems. Health equity champions must clearly demonstrate to hospital administrators that equity-driven initiatives can be both mission driven and revenue generating with the potential to strengthen an institution’s patient outcomes and overall community positioning.

Patient navigation was established by Harold Freeman as a strategy to advance health equity in oncology care.⁷⁵ While we often think of patient navigation as a means to bridge the gap in health disparities in oncology care, in many ways, it also functions as a revenue driver for clinical systems by increasing patient retention, decreasing missed appointments, and improving continuity of patient care.⁷⁶ Navigation also improves quality-related metrics important in obtaining and maintaining cancer program accreditation.⁷⁷ In colorectal cancer, implementation of patient navigation as a method of increasing both access and adherence to screening colonoscopy was demonstrated to significantly increase revenue, even when accounting for the cost of the patient navigators themselves.⁷⁸ Beyond navigation, equity-driven strategies, particularly when integrated into multidisciplinary care models in oncology, offer a powerful business case for hospital leadership. In breast cancer care, each breast cancer patient retained within the system generates not only surgical revenue but also downstream income from diagnostic imaging, pathology, systemic therapy, radiation oncology, reconstructive surgery, and survivorship services.⁷⁹ Evidence shows that improving timeliness and continuity of care increases the likelihood of patients completing guideline-concordant multimodality treatment, which directly expands reimbursement opportunities across the continuum of oncology care, but more importantly ensures all patients receive optimal cancer care.⁸⁰

Improving access to cancer screening may also lead to an overall cost decrease for health systems by preventing unanticipated admissions associated with advanced or metastatic disease. In hepatocellular carcinoma, significant financial burdens to both patients and health systems may be ameliorated by connecting high risk patients to regular ultrasound examinations.⁸¹ This paradigm may be extended to many other solid organ cancers for which unanticipated admissions may result in significant added costs to institutions and patients.

Ultimately, the future of health equity in surgical oncology depends on viewing health disparities work as both beneficial to patients and the financial bottom line of healthcare systems. By demonstrating how interventions aimed at reducing cancer disparities, such as patient navigation and multidisciplinary care models, can improve patient outcomes and generate downstream revenue, equity champions can shift the conversation with hospital administrators from “cost” to “strategic investment,” with the goal of ensuring long-term financial viability of such initiatives.

Using Patient-Reported Outcomes

Patient-reported outcomes (PROs) are direct reports from patients about their health status, symptoms, and quality of life, without interpretation by clinicians. PROs can capture dimensions of pre- and postoperative care that traditional clinical endpoints alone cannot capture such as pain, fatigue, functional limitations, and psychosocial well-being.^82,83 In addition to providing a fuller picture of the patient experience, PROs can also be used to individualize treatment plans and inform clinical decision making. Importantly, PROs used in cancer care have been shown to improve patient satisfaction and self-efficacy, health-related quality of life (HRQOL), healthcare utilization, and survival.^84–90 Integration of PROs into clinical practice and cancer research is a standard for high-quality cancer care by the FDA and NIH.^91–97

PROs often reflect poorer physical and psychosocial health experiences by historically marginalized patient populations regarding cancer care, and PRO questionnaire response rates are often lower among these populations.^98–100 Electronic-PRO-monitoring interventions have been demonstrated to significantly improve patient HRQOL and overall survival in patients with advanced cancer. Web-based reporting of PROs has been shown to provide clinicians with more continuous and immediate datapoints, facilitating expeditious and actionable interventions for acute patient needs. One study that included patients undergoing chemotherapy for metastatic solid tumors found that those patients who had electronic patient reported symptom monitoring had improved survival compared to usual care, likely secondary to prompt intervention from medical providers due to web based symptom reporting. More recently, a large-scale randomized trial at 52 community oncology centers found that the use of electronic PRO surveys incorporating care team alerts, significantly improved patient symptoms and HRQOL.^{86,89,101,102}

One step in utilizing PROs to address health disparities is to translate patient-reported insights into changes in care delivery. This strategy includes developing culturally responsive PRO measures, ensuring equitable access to reporting, and embedding these findings into clinical decision-making and quality improvement efforts in an equitable and scalable fashion. PROs can be applied using well-established and validated tools in routine clinical care (i.e., PROMIS, BREAST Q, etc.), many of which have been robustly studied and are available in multiple languages and accessible health literacy levels.^103,104 For measures only available in English, multilingual access to PROs can be facilitated through a validated translation process, including options, such as pictograms, to visually communicate information for those with lower levels of health literacy. To ensure relevance and cultural sensitivity, research and clinical initiatives that include PROs should be developed and tested with patient, community, and stakeholder input.^105,106 Accounting for individual preferences related to technology use, structural barriers to digital access, as well as digital (and health) literacy, providing in-clinic tablets, paper, or phone options for PROs data collection, all can promote symptom monitoring that is readily accessible for patients and thus provides more accurate data for clinicians to intervene.

More recently, there has been increased attention to the potential for systematic, patient-reported assessments of social determinants of health, which, in combination with capture of symptom burden, has the potential to comprehensively identify and address barriers to access of care.¹⁰⁷ For example, if a patient reports uncontrolled pain and screens positive for transportation or financial insecurity, the alert could trigger not only clinician follow-up but also a referral to social work for medication delivery. Community engagement is also key when leveraging PROs to capture unmet social health needs as local resources may be available to address these needs. Continued feedback from patients, caregivers, and clinicians regarding PRO content, frequency, and mode of delivery can help optimize how we obtain, process, and meet the evolving needs and challenges experienced by cancer patients throughout their care trajectory. By aligning PRO-driven evidence with targeted interventions, surgical oncology can move from describing inequities to actively reducing them through promoting access to PROs, championing their uptake, and utilizing PRO data to improve clinical and psychosocial outcomes.

Anticipated Challenges

Ensuring sustainability is essential for health disparities initiatives; yet it remains one of the most significant obstacles to achieving a lasting impact. Many programs are designed around short-term grant cycles and are primarily evaluated through immediate outputs, such as the number of publications or proposals submitted. While these deliverables align with academic funding expectations, they rarely translate into durable change in institutional culture, infrastructure, or community trust.¹⁰⁸ Without long-term support, programs are often discontinued, which not only reinforces perceptions of resource wastefulness among institutional stakeholders but also deepens community mistrust and frustration. Populations disproportionately burdened by inequities—already contending with structural racism, economic exclusion, and limited access to care—experience “research fatigue” when efforts start and stop abruptly, fueling skepticism about whether research institutions are genuinely committed to equity.^109,110 For disparities research to be transformative rather than symbolic, it must be organized around long-term benchmarks, including measurable progress in recruitment, promotion, retention of underrepresented faculty, and demonstrable improvements in equitable patient outcomes. As mentioned previously, the collaboration and investment of healthcare systems is key to long-term success. These long-term benchmarks provide a reassuring roadmap for the future of disparities research.^108,109

Another critical challenge arises from personnel and engagement dynamics. Personnel-related challenges further constrain sustainability by shaping who defines, leads, and benefits from disparities research. Historically, marginalized communities have been positioned as passive subjects of study rather than active partners in the research process. This imbalance perpetuates an extractive dynamic in which knowledge flows out of communities without corresponding empowerment or control.¹¹¹ Participatory and community-based models are widely recognized as essential for advancing equity.¹¹² However, the very populations most likely to benefit from inclusion—those facing systemic poverty, prejudice, or marginalization—often lack the resources, flexible schedules, or social support needed for effective participation in research projects using CABs.¹¹³ This dual challenge underscores the urgent need for a two-pronged investment: training researchers to engage communities in culturally responsive conversation,¹¹⁵ and building community capacity to directly shape research priorities and infrastructure.¹¹⁶ Without dismantling these power asymmetries, disparities research risks reproducing inequities rather than addressing and ameliorating them.

Within academic institutions, disparities researchers, particularly faculty from underrepresented backgrounds, often shoulder disproportionate service obligations. Tasks, such as mentoring underrepresented trainees, serving on diversity-related committees, and leading equity programming, are essential for institutional progress yet can remain undervalued in promotion and tenure evaluations.¹¹⁷ This burden, known as the “minority tax,” leads to cumulative overwork, burnout, and reduced scholarly productivity in areas measured by traditional metrics. Equity-focused research itself is frequently undervalued, thereby compounding this inequity and creating a structural disincentive for sustained engagement in scholarship on disparities research.¹¹⁸ Unless institutions explicitly reward and compensate equity-related service and scholarship on par with other forms of academic output, progress will remain dependent on a small, overburdened group of faculty, thus undermining long-term efforts of conducting work to eliminate disparities.

Research funding instability represents a significant threat to the durability of healthcare disparities initiatives. Philanthropic and institutional grants often prioritize short-term research products over long-term community benefits, leaving gaps in infrastructure and sustainability. National research funding has historically underfunded health disparities research relative to other biomedical initiatives and recent changes to federal research priorities are likely to further alter access to federal funding for this work.^119,120 In this shifting landscape of research funding, securing reliable, multi-year funding for equity-focused research is increasingly complex. Long-term investment in equity infrastructure, coupled with equitable compensation for both researchers and community partners, is not optional; it is essential to long-term success in eliminating cancer disparities. Without such commitment, disparity research remains vulnerable to instability, burnout, and erosion, risking relegation to symbolic initiatives rather than the structural transformation it aims to achieve.

Conclusion

Dismantling disparities in surgical oncology and cancer care is an urgent and complex endeavor that requires strategic financial investment and collaboration between researchers, clinicians, community, and hospital administrators. Additionally, building trusting and open relationships between stakeholders and minoritized populations is essential to conducting work to dismantle cancer disparities and sustain efforts. This work also requires utilization of novel frameworks to support research required to inform actionable clinical and community transformation. By focusing on identifying practical and sustainable solutions to eliminate cancer disparities, we have the opportunity to transform cancer care delivery and move towards a future where health equity is not an aspiration but the standard for all patients.