Proceedings of a Workshop
NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by Contract No. 75D30121D11240 (Task Order No. 75D30124F00042) and Contract No. HHSN263201800029I (Task Order No. 75N98023F00019) with the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health, respectively, and by the American Association for Cancer Research; American Cancer Society; American College of Radiology; American Society of Clinical Oncology; Association of American Cancer Institutes; Association of Community Cancer Centers; Cancer Center at Illinois; Flatiron Health; Merck; National Comprehensive Cancer Network; Novartis Oncology; Oncology Nursing Society; Partners In Health; Patient Advocate Foundation; and Pfizer Inc. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-72906-2
International Standard Book Number-10: 0-309-72906-8
Digital Object Identifier: https://doi.org/10.17226/28034
This publication is available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
Copyright 2025 by the National Academy of Sciences. National Academies of Sciences, Engineering, and Medicine and National Academies Press and the graphical logos for each are all trademarks of the National Academies of Sciences. All rights reserved.
Printed in the United States of America.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Biological effectors of social determinants of health in cancer: Identification and mitigation: Proceedings of a workshop. Washington, DC: National Academies Press. https://doi.org/10.17226/28034.
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.
The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president.
The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.
The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.
Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.
Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.
Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.
Rapid Expert Consultations published by the National Academies of Sciences, Engineering, and Medicine are authored by subject-matter experts on narrowly focused topics that can be supported by a body of evidence. The discussions contained in rapid expert consultations are considered those of the authors and do not contain policy recommendations. Rapid expert consultations are reviewed by the institution before release.
For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.
PLANNING COMMITTEE1
CHANITA HUGHES-HALBERT (Co-Chair), University of Southern California
STANTON L. GERSON (Co-Chair), Case Western Reserve University
SMITA BHATIA, University of Alabama at Birmingham
CATHY BRADLEY, Colorado School of Public Health
OTIS W. BRAWLEY, Johns Hopkins University
GWEN DARIEN, Patient Advocate Foundation
SCARLETT LIN GOMEZ, University of California, San Francisco
LARISSA NEKHLYUDOV, Brigham and Women’s Hospital; Dana-Farber Cancer Institute; Harvard Medical School
LISA C. RICHARDSON, Centers for Disease Control and Prevention
CLEO A. RYALS, Flatiron Health
LAWRENCE N. SHULMAN, University of Pennsylvania
ROBERT A. WINN, Virginia Commonwealth University
ROBIN YABROFF, American Cancer Society
CLAYTON C. YATES, Johns Hopkins University
Project Staff
ANNA ADLER, Senior Program Assistant
TORRIE BROWN, Program Coordinator
CHIDINMA CHUKWURAH, Senior Program Assistant (until April 2024)
EMMA WICKLAND, Research Associate
JULIE WILTSHIRE, Senior Finance Business Partner
JENNIFER ZHU, Associate Program Officer
ERIN BALOGH, Co-Director, National Cancer Policy Forum (until June 2024)
LAURENE GRAIG, Senior Program Officer (June–July 2024)
FRANCIS AMANKWAH, Co-Director, National Cancer Policy Forum (from July 2024)
SHARYL NASS, Co-Director, National Cancer Policy Forum; Senior Director, Board on Health Care Services
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
This page intentionally left blank.
NATIONAL CANCER POLICY FORUM1
ROBERT A. WINN (Chair), Virginia Commonwealth University
ROHIT BHARGAVA, Cancer Center at Illinois
SMITA BHATIA, University of Alabama at Birmingham
GIDEON BLUMENTHAL, Merck
CHRIS BOSHOFF, Pfizer Inc.
OTIS W. BRAWLEY, Johns Hopkins University
CHRISTINA CHAPMAN, Baylor College of Medicine; Michael E. DeBakey VA Medical Center
GWEN DARIEN, Patient Advocate Foundation
CRYSTAL DENLINGER, National Comprehensive Cancer Network
JAMES H. DOROSHOW, National Cancer Institute
S. GAIL ECKHARDT, Baylor College of Medicine
CHRISTOPHER R. FRIESE, University of Michigan
STANTON L. GERSON, Case Western Reserve University
SCARLETT LIN GOMEZ, University of California, San Francisco
JULIE R. GRALOW, American Society of Clinical Oncology
ROY S. HERBST, Yale University; American Association for Cancer Research
HEDVIG HRICAK, Memorial Sloan Kettering Cancer Center
CHANITA HUGHES-HALBERT, University of Southern California
ROY A. JENSEN, University of Kansas; Association of American Cancer Institutes
RANDY A. JONES, University of Virginia
BETH Y. KARLAN, University of California, Los Angeles
SAMIR N. KHLEIF, Georgetown University; Society for Immunotherapy of Cancer
ELENA MARTINEZ, University of California, San Diego
LARISSA NEKHLYUDOV, Brigham and Women’s Hospital; Dana-Farber Cancer Institute; Harvard Medical School
CLEO A. RYALS, Flatiron Health
RICHARD L. SCHILSKY, ASCO TAPUR Study; University of Chicago
JULIE SCHNEIDER, Oncology Center of Excellence, U.S. Food and Drug Administration
SUSAN M. SCHNEIDER, Duke University
LAWRENCE N. SHULMAN, University of Pennsylvania
HEIDI SMITH, Novartis Pharmaceuticals
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
KATRINA TRIVERS, Centers for Disease Control and Prevention
ROBIN YABROFF, American Cancer Society
Forum Staff
ANNA ADLER, Senior Program Assistant
TORRIE BROWN, Program Coordinator
CHIDINMA CHUKWURAH, Senior Program Assistant (until April 2024)
EMMA WICKLAND, Research Associate
JULIE WILTSHIRE, Senior Finance Business Partner
JENNIFER ZHU, Associate Program Officer
ERIN BALOGH, Co-Director, National Cancer Policy Forum (until June 2024)
LAURENE GRAIG, Senior Program Officer (June–July 2024)
FRANCIS AMANKWAH, Co-Director, National Cancer Policy Forum (from July 2024)
SHARYL NASS, Co-Director, National Cancer Policy Forum; Senior Director, Board on Health Care Services
Reviewers
This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this proceedings was overseen by VINCENT GUILAMO-RAMOS, Institute for Policy Solutions at the Johns Hopkins University School of Nursing. He was responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.
This page intentionally left blank.
Acknowledgments
The National Cancer Policy Forum is grateful for the support of our many annual sponsors. Federal sponsors include the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health. Nonfederal sponsors include the American Association for Cancer Research; American Cancer Society; American College of Radiology; American Society of Clinical Oncology; Association of American Cancer Institutes; Association of Community Cancer Centers; Cancer Center at Illinois; Flatiron Health; Merck; National Comprehensive Cancer Network; Novartis Oncology; Oncology Nursing Society; Partners In Health; Patient Advocate Foundation; and Pfizer Inc.
The forum wishes to express its gratitude to the expert speakers whose presentations and discussions helped inform opportunities to advance health equity in cancer by identifying promising avenues for future research, as well as policies and interventions aimed at mitigating the negative impacts of social determinants of health on cancer-related health outcomes. The forum also wishes to thank the members of the planning committee for their work in developing an excellent workshop agenda.
This page intentionally left blank.
Contents
HEALTH DISPARITIES AND SOCIAL DETERMINANTS OF HEALTH IN CANCER
Defining Social Determinants of Health
Connecting Social Determinants of Health with Cancer Risk and Outcomes
EMERGING RESEARCH ON POTENTIAL BIOMARKERS RELEVANT TO SOCIAL DETERMINANTS OF HEALTH
Examining the Interplay of Place, Space, and Ancestry
Genomic Pathways Connecting Exposures with Health Outcomes
Characterizing Cancer Subtypes and Social Determinants of Health with Population-Based Research
OPPORTUNITIES FOR HEALTH CARE SYSTEMS TO ADDRESS SOCIAL RISK FACTORS
Recognizing the Influence of Upstream Factors on Health
The Role of Trust and Communication
Integrating Social Determinants of Health into the Care Continuum
DATA ISSUES AND GAPS RELEVANT TO SOCIAL DETERMINANTS OF HEALTH
Examples of Social Determinants of Health Screening Tools for Research and Clinical Support
Considerations for Using Electronic Health Records
Considerations for Using Questionnaires
The Importance of Trust in Data Collection and Use
POTENTIAL AREAS OF FOCUS FOR FUTURE RESEARCH
Diversifying Clinical Studies and Trials
Collaborating Across Disciplines and Communities
Advancing Meaningful Community Engagement
OPPORTUNITIES TO INVEST IN IMPLEMENTATION
Advancing Prevention and Early Life Interventions
Focusing on Underserved Communities
Supporting Equitable Care Delivery
Integrating Interventions for Social Determinants of Health into Clinical Workflows
Moving from Ideas to Implementation to Advance Health Equity
Boxes and Figures
BOXES
FIGURES
3 Interacting factors that can contribute to inequities across the cancer care continuum
This page intentionally left blank.
Acronyms and Abbreviations
| CECS | Carolina Endometrial Cancer Study |
| CMS | Centers for Medicare & Medicaid Services |
| CTRA | conserved transcriptional responses to adversity |
| DNA | deoxyribonucleic acid |
| EHR | electronic health record |
| EOM | Enhancing Oncology Model |
| ePRO | electronic patient-reported outcome |
| EV | extracellular vesicle |
| FDA | U.S. Food and Drug Administration |
| HANDLS | Healthy Aging in Neighborhoods of Diversity Across the Lifespan |
| NCI | National Cancer Institute |
| NGS | next-generation sequencing |
| NIH | National Institutes of Health |
| PCP | primary care provider |
| RWD | real-world data |
| SDOH | social determinants of health |
| SES | socioeconomic status |
| TCGA | The Cancer Genome Atlas |
