Experts Issue a Call to Action for Oncology Care Equity

Achieving health equity is a persistent challenge in cancer care, shaped by socioeconomic disparities, health policy, insurance benefit design, and site-of-care restrictions that disproportionately affect some communities. Further, although therapies can offer transformative potential, significant challenges and payer-related barriers often limit equitable care access and delivery. Therefore, expanding access to advanced cancer therapies and elevating the value of current and future care require trusted strategic academic-community partnerships among community oncology practices, hospitals, and key industry stakeholders.

Mitigating barriers is crucial to ensuring all patients receive high-quality, timely treatment. Standardizing care across networks, implementing structured education for health care professionals and patients, fostering multidisciplinary expertise, and empowering physician champions to drive treatment are essential to more equitable oncology care.

Part of the Elevating Value in Cancer Care regional series, the January 30, 2025, Institute for Value-Based Medicine® event in Nashville, Tennessee, brought together experts from the top cancer centers, hospitals, and care networks in the region to address how collaboration can bridge critical gaps in care delivery. Panelists and presenters alike emphasized the need to address social determinants of health and health-related social needs to ensure timely and equitable access to treatment.

They examined the broader societal and systemic conditions that influence health and the immediate, tangible needs that affect an individual’s ability to receive care. Additionally, they explored the intersection of health equity and value-based cancer care, emphasizing the importance of innovative collaborations and systemic changes to ensure all patients, regardless of background, have access to high-quality treatment.

Health Equity in Cancer Care Delivery

Karen Winkfield, MD, PhD | Image credit: Vanderbilt-Ingram Cancer Center

“I think it’s important if we are in the system, if we want to make an impact, if we want to think about equity, particularly in today’s climate when there are pushbacks against accessibility and equity—because, unfortunately, the terms DEI [diversity, equity, and inclusion] and equity have been conflated, [and] they’re not the same––[that] we…understand the difference so…we can advocate to make sure we’re reducing barriers in terms of cancer care and cancer care delivery,” said Karen Winkfield, MD, PhD, Ingram Professor of Cancer Research at Vanderbilt Ingram Cancer Center, professor of radiation oncology, Vanderbilt University Medical Center; professor of medicine at ; and executive director of the Meharry-Vanderbilt Alliance, who moderated this panel discussion.

Ricky Martin III, MD, MPH | Image credit: Tennessee Oncology

Winkfield was joined by Kate Baker, MD, MMHC, medical oncologist and medical director of value-based care at Tennessee Oncology; Cathy Eng, MD, FACP, FASCO, gastrointestinal program leader for research, executive director of the young adult cancers program, and associate director for research partnerships, School of Global Health, Vanderbilt Ingram Cancer Center; and Ricky Martin III, MD, MPH, medical oncologist and medical director for health equity and community engagement at Tennessee Oncology.

Their overall message was that for meaningful and lasting change to advance health equity, there must be sustainable and genuine engagement through community-driven solutions from everyone involved. These solutions need to look at the short- and long-term future of health equity through the lens of social determinants of health, the wide-sweeping but often nuanced societal shortcomings that shape patient health, and health-related social needs, which are more immediate and tangible and directly impact the ability to even receive care.

“There are microenvironments that exist, and it’s [a matter of] recognizing that those landscapes are fairly intentional,…there are societal reasons for the conditions that exist and the people who have to live their lives in those settings, and…there is the capacity to change them,” Martin said. Social determinants are modifiable, he emphasized, and they can be changed through targeted interventions.

These structural barriers point to policy as a principal determinant of health disparities in cancer care, evidenced through insurance benefit design and how that influences financial toxicity. For an accurate representation of how this is playing out in Tennessee, one need look no further than the nonexpansion of Medicaid and the apparent hoops of qualification individuals must jump through to qualify for coverage.

Tennessee is 1 of 10 states that have not expanded Medicaid coverage under the Affordable Care Act as of 2025.¹ However, in 2024, the state expanded eligibility for low-income parents from 89% to 105% of the federal poverty level.² Frequently, the result is a coverage gap, where individuals seeking assistance through Medicaid have too high an income to qualify for coverage but are still unable to afford coverage through private insurance. Winkfield noted that these challenges are sometimes mistakenly assumed to affect only individuals in lower socioeconomic brackets, but those with midrange salaries also may encounter this form of financial toxicity due to a lack of affordable insurance options. This underscores the pervasive nature of the problem, which extends beyond traditional notions of poverty.

Health equity in cancer care does not merely concern race, according to the panel. The impact of insurance benefit design on health disparities was one of the most pressing issues they highlighted. Baker pointed out how “formulary coverage and high deductibles” can create significant barriers to care. She shared the story of a patient who “had to be admitted twice to get inpatient chemotherapy because she wasn’t able to get the intravenous access…she needed…to get outpatient chemo, and that was really just because of the insurance that she had.”

Cathy Eng, MD | Image credit: Vanderbilt-Ingram Cancer Center

Eng brought attention to the unique challenges young adults face and illustrated the profound impact of systemic failures on individuals and families. For young adults, the top issues are “job security and insurance issues” and advocating for their care. Often, they are forced to take months off work for treatment or laid off from their jobs, and their care team must jump in and appeal, according to Eng. She also shared her parents’ experiences with language barriers and insurance issues, describing them as “horrible health care.”

The panel also explored potential solutions and initiatives aimed at fostering health equity. Baker discussed Tennessee Oncology’s efforts to “decrease the cost of care and participate in the Enhancing Oncology Model” of payment for value and quality vs fee-for-service–based payment. Eng emphasized the importance of “multidisciplinary efforts and working with social workers and pharmacists to support patients,” mentioning various programs and foundations providing essential patient resources, such as counseling.

Martin stressed the significance of “showing up and building trust with patients” and the necessity for “sustainability in health equity programs.” He highlighted the crucial role of “community advisory boards and the importance of co-ownership in health equity initiatives,” advocating for a collaborative approach to addressing these issues.

Winkfield concluded the discussion by emphasizing the importance of “inclusive participation in clinical trials”—a call to action that underscored health care professionals’ collective responsibility to bridge the gap between research and real-world application, ensuring that advancements in medicine benefit all members of society. She expressed this sentiment in a previous interview with The American Journal of Managed Care, sister publication to Evidence-Based Oncology, where she said, “It’s important for our researchers to be able to articulate their research in a way that is meaningful to the community. [They] must learn how to talk about their research in a way that the communities…we serve can really understand.”³

Academic, Hospital, and Community Partnerships
This panel discussion focused on improving patient access to safe and effective advanced cancer therapies across an evolving oncology landscape. The panelists addressed why partnerships between academic hospitals, community oncology practices, and private institutions are essential to achieving this outcome.

Samyukta Mullangi, MD, MBA | Image credit: Tennessee Oncology

“How can we scale delivery and access to novel drug therapies?” Samyukta Mullangi, MD, MBA, senior medical director at Thyme Care and medical oncologist at Tennessee Oncology, asked the gathered experts. “This includes relatively increasingly off-the-shelf interventions, like CAR T [chimeric antigen receptor T-cell therapy] and bispecific antibodies, but also access to clinical trials.”

Sylvia Richey, MD | Image credit: West Cancer Center

Sylvia Richey, MD, medical oncologist and chief medical officer at West Cancer Center and Research Institute, explained that selecting hospital partners that accept all payers is critical to expanding access. However, it is also crucial to have plans in place to help manage patients as they go through treatment, especially when these treatments cause serious complications, such as the systemic inflammation seen with cytokine release syndrome. To this end, having trained staff and well-defined admission protocols are essential.

Standardizing care through multidisciplinary collaboration is also vital, with embedded specialized care hubs and training programs being essential to facilitating community-based practices offering complex therapies, explained Dax Kurbegov, MD, senior vice president at Sarah Cannon Cancer Network. At the center of this is balancing accessibility with volume-driven proficiency to ensure that specialized centers can maintain their expertise by not becoming overburdened with excessive patient loads.

Dax Kurbegov, MD | Image credit: SCRI

“Ensuring that centers see enough cases to maintain proficiency is critical to balancing access with expertise,” he explained.

Sandhya Mudumbi, MD, palliative care physician and medical director of supportive care teams (psychosocial oncology, palliative care, and integrative health) at Tennessee Oncology, explained that with the increasing complexity of some cancer treatments, community practices need to invest time and resources in fostering bidirectional partnerships so that everyone benefits and can overcome organizational hurdles. Each party that comes to the table through these interactions must align on their core values and mission, have strong data capabilities for tracking outcomes, and be committed physician champions.

Precision Medicine in Value-Based Care
The third panel discussion of the evening explored the intersection of precision medicine and value-based care in oncology, focusing on the challenges and opportunities in implementing genomic testing and precision treatment strategies. Edward “Ted” Arrowsmith, MD, MPH, executive vice president of therapeutics at Tennessee Oncology and medical director for pathways at OneOncology, was joined by Wade Iams, MD, MSCI, director of lung cancer research at Tennessee Oncology, and Douglas Johnson, MD, MSCI, coleader of the Translational Research and Interventional Oncology Research Program at Vanderbilt-Ingram Cancer Center.

Edward "Ted" Arrowsmith, MD, MPH | Image credit: Tennessee Oncology

“One of the biggest breakthroughs we’ve had over the last 20 years has been the development of targeted, precise therapies for our patients,” Arrowsmith said. “But there are barriers to delivering that across the full spectrum of patient populations.”

The trio addressed several hot topics, such as reflex next-generation sequencing for non–small cell lung cancer (NSCLC)—the standardization of which remains a top challenge. This key component of precision medicine is when a pathologist automatically initiates additional genetic testing on a tumor sample after initial results reveal a predefined mutation, eliminating the need for orders from an oncologist.⁴ Universal testing is a top priority of many advocates, the panel noted, but debate is ongoing over its necessity in specific populations, such as patients with squamous NSCLC or a history of smoking. The development of guidelines to define its appropriate applications is crucial.

Another highlight of this discussion was the need for standardized molecular testing processes and the importance of timely, early-stage testing for high-risk patients—supported by payer-aligned guidelines—and longitudinal testing to help monitor resistance mutations. The panelists also discussed the complexities of minimal residual disease testing, which is quickly gaining traction as a surrogate treatment end point⁵ but still lacks robust prospective data to endorse its widespread adoption.

“I think systems and physicians are going to continue to get more and more pressure to use these tests before we have the ideal prospective data sets that we need,” Iams cautioned.

Beyond testing, the 3 experts highlighted the importance of communication and streamlining provider coordination, particularly in integrating genomic data into electronic medical records.

Like Mudumbi, Johnson emphasized the importance of bidirectional communication, “especially when patients go back and forth between academic and community sites or from one site to another. That communication piece is really important and can be lifesaving.”

Addressing access disparities is also crucial due to the impact of socioeconomic factors on testing availability and access. The discussants called for continued investment in clinical trials, health literacy efforts, and systematic solutions to ensure equitable access to precision oncology.

Pharmacy Decision-Making in Oncology
Jerrick White, PharmD, director of pharmacy services at Tennessee Oncology, moderated the final panel discussion of the evening, which focused on advancing oncology care with innovative delivery methods, multidisciplinary collaboration, and pharmacy-led initiatives. Angie Maynard, PharmD, MS, CPGx, assistant professor of pharmacy practice at Lipscomb University College of Pharmacy, and Amanda Cass, PharmD, BCSCP, clinical pharmacist specialist in thoracic oncology at Vanderbilt University Medical Center, were his copanelists.

The first key topic they addressed was outpatient delivery models for bispecific antibodies and CAR T. Vanderbilt is exploring outpatient administration with remote patient monitoring, and Tennessee Oncology is employing hub sites for step-up dosing and a thorough screening process for CAR T referrals.

“A lot of steps go into this, but so far, we’ve treated 8 patients,” White noted, “and we have another 4 in the pipeline.”

The panelists also discussed challenges with optimizing care from fragmented care models, especially for underinsured patients, and they emphasized the importance of strong nurse navigation and multidisciplinary collaboration for seamless patient transitions. “This has been a theme throughout the night from every panel that’s been up here. There needs to be some continuity and good communication between each place that’s involved in a patient’s care,” Maynard emphasized. “We do the best we can but having a good multidisciplinary care team and a good nurse navigator, [and] pharmacist, if they are involved in that [aspect] of care, is imperative.”

Specialty pharmacies also place a vital role in improving treatment access and affordability by finding novel solutions to facilitate medication dispensing while reducing waste. For example, Vanderbilt licensed automatic dispensing machines in clinics to facilitate the dispensing of chemotherapy medications and enable the restocking of unused medications in the case of dose changes.

Lastly, the experts highlighted the role of pharmacists in oncology clinics, noting they provide telehealth services, manage supportive care, and reduce physicians’ workloads. The panel praised telehealth for improving patient engagement, reducing travel time, and enhancing adherence.
“I think it’s helped expedite care for these patients and streamline care,” Cass noted,” as well as hopefully prevent some toxicities from some of these more high-risk therapies.”

Where to Go From Here
Health care is a deeply personal experience and one that extends beyond mere policy and procedure. Addressing systemic disparities and prioritizing patient-centered care can drive a more equitable system in which the future of community oncology will hinge on collaboration between community and academic centers, strong leadership, and coordinated care transitions as keys to safely delivering advanced therapies in nonacademic, diverse settings. Challenges include site-of-care mandates, use of telehealth in patient management, and the need for real-world data to inform cost-effectiveness. Expanding patient assistance programs, and addressing socioeconomic barriers are critical to ensuring equitable access to care.

References
1. Chatlani S. In the 10 states that didn’t expand Medicaid, 1.6M can’t afford health insurance. Stateline. July 19, 2024. Accessed February 20, 2025. https://stateline.org/2024/07/19/in-the-10-states-that-didnt-expand-medicaid-1-6m-cant-afford-health-insurance/
2. Norris L. Medicaid eligibility and enrollment in Tennessee. HealthInsurance.org. Accessed February 27, 2025. https://www.healthinsurance.org/medicaid/tennessee/
3. Shaw ML. Building trust through community engagement in cancer care. The American Journal of Managed Care. January 15, 2025. Accessed February 28, 2025. https://www.ajmc.com/view/building-trust-through-community-engagement-in-cancer-care
4. Gosney JR, Paz-Ares L, Kerr KM, et al. Pathologist-initiated reflex testing for biomarkers in non-small-cell lung cancer: expert consensus on the rationale and considerations for implementation. ESMO Open. 2023;8(4):101587. doi:10.1016/j.esmoop.2023.101587
5. Munz K. MRD negativity: a “robust” predictor of survival outcomes in MM. The American Journal of Managed Care. January 13, 2025. Accessed March 5, 2025. https://www.ajmc.com/view/mrd-negativity-a-robust-predictor-of-survival-outcomes-in-mm