










































 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e1 Cancer Health Disparities 

RESEARCH 

Spatial Analysis of Clinical Trial Accrual 
Within an NCI Comprehensive Cancer 
Center Catchment Area by Race and 
Ethnicity 
Daniel Holguin 

Stanford University, 1206 Whitton Ave, San Jose, CA 95116 

*Corresponding author: Daniel Holguin,  dholguin@stanford.edu 

ABSTRACT 
Accrual into cancer clinical trials is concerningly low, approximately 5% of all U.S. adult cancer patients 
enroll into a trial, and racial/ethnic disparities in clinical trial accrual between White and minority patients, 
(i.e., Native American, Latino, Asian, and Black) are well documented 1-5. This paper uses Geographic 
Information System (GIS) spatial analysis to identify racial and ethnic disparities in clinical trial accrual 
within the Stanford Cancer Institute (SCI) Comprehensive Cancer Centers (CCC) catchment area between 
2012-2020 and compares drive times to the SCI by ethnicity overall and within each county it serves. 215 
studies in the adult gastrointestinal oncology clinic trials department were reviewed to collect patient data 
on race and ethnicity, zip code at registration, and the type of trial they enrolled in. ArcGIS was used to 
plot ethnicity and zip code, and to calculate drive times to the clinical trial site in Palo Alto within the 10-
county catchment area. 848 patients were available for analysis. The ethnicities of our trial patients were 
61% White (n=514), 25% Asian/Pacific Islander (n=210), 13% Latino (n=107), 2% Black (n=14), and <1% 
Native American (n=3). Most patients enrolled into non-interventional studies (54.83%), followed by 
treatment trials (33.13%) and non-therapeutic trials (12%). Latino patients had the longest drive on average 
(mean maximum drive time of 67 minutes) and minority patients faced longer drive times than White 
patients in 8/10 counties in the catchment area. This analysis showed racial disparities in clinical trial accrual 
at the SCI CCC as well as disparities in drive times to the clinical trial site. Counties closest to the SCI had 
minority patient accrual approximately equal to that of the general population and higher accrual in 
general compared to counties further away, suggesting the need for additional clinical trial sites within 
the catchment area. 

KEYWORDS: cancer clinical trial accrual, health disparity, race/ethnicity, nci, comprehensive cancer 
center, catchment area, spatial analysis, drive time, San Francisco  

Citation: Holguin D (2022) Spatial Analysis of Clinical Trial Accrual Within an NCI Comprehensive Cancer 
Center Catchment Area by Race and Ethnicity. Cancer Health Disparities 6:e1-10.doi:10.9777/chd.2022.1002  
 
 

mailto:dholguin@stanford.edu


 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e2 Cancer Health Disparities 

RESEARCH 

 



 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e3 Cancer Health Disparities 

RESEARCH 

Introduction 
Accrual into cancer clinical trials is concerningly low, 
approximately 5% of all U.S. adult cancer patients 
enroll into a trial and approximately 40% of 
National Cancer Institute (NCI) trials fail to attain 
their minimum accrual goals(Hamel et al., 2016). 
Since the 1970’s, studies have documented racial 
and ethnic disparities in clinical trial accrual between 
White and minority patients, (i.e., Native American, 
Latino, Asian, and Black)(Duma et al., 2018; Loree et 
al., 2019; Nazha et al., 2019; Siegel et al., 2020) 
despite other studies reporting that minorities are 
just as interested in engaging in cancer clinical trials 
as Whites(Katz et al., 2007), especially when 
controlling for previous knowledge of trials(Durant 
et al., 2011). In addition to disparities in accrual, 
there are also significant ethnic disparities in 
incidence and mortality rates of various 
cancers(Axtell and Myers, 1978; Cancer Prevention 
Institute of California and Greater Bay Area Cancer 
Registry, 2018; Zahnd et al., 2021). Increasing clinical 
trial accrual overall and achieving health equity 
among different ethnicities as outlined by the 
American Society of Clinical Oncology (ASCO)(Patel 
et al., 2020; Winkfield et al., 2021) will undoubtedly 
require an increase of minority enrollment in clinical 
trials. 

Racial segregation is one mechanism of systemic 
racism theory(Feagin, 2006) that has propagated 
various health disparities in the U.S., yet no studies 
have addressed its’ role on cancer clinical trial 
accrual(Kanarek et al., 2010). Segregation creates 
health disparities by excluding minority patients 
from communal resources limited to wealthy 
(mostly White) neighborhoods – including housing, 
schools, and hospitals(Coleman, 1992; Cornely, 
1956; Firebaugh and Acciai, 2016; Jha et al., 2011; 
National Academies of Sciences, Engineering, and 
Medicine et al., 2017; Rothstein, 2017) – and forcing 
them to live in areas with increased environmental 

and social risk factors linked to worse health 
outcomes, such as pollution, food desserts, lack of 
mental health resources, and crime, in order to 
maintain access to jobs in those areas(Alexander, 
2012; Cheng et al., 2020; Chhatre and Jayadevappa, 
2018; Hilmers et al., 2012; Krieger et al., 2020; 
McGuire and Miranda, 2008; McGuire et al., 2006; 
Nardone et al., 2020; New York Law School Racial 
Justice Project., 2012; Williams and Mohammed, 
2013). Racial segregation reflects the root cause of 
other factors associated with barriers to cancer 
clinical trials for minority patients(Hamel et al., 2016) 
by means of the disinvestment in their communities 
and the devaluation of their lives. Though most NCI 
comprehensive cancer centers (CCC) are in 
metropolitan areas where much of the patient 
population is White,(Onega et al., 2017) the 
association between ethnically segregated areas 
and proximity to treatment centers is confounded 
by covariates such as inadequate community 
engagement and attitudes towards clinical trials, as 
well as the availability of trials in hospitals that serve 
patients with similar socioeconomic factors such as 
low-income and public health insurance(McCaskill-
Stevens et al., 2005; Sutton et al., 2019; Wenzel et 
al., 2015). For example, the Sidney Kimmel CCC in 
Baltimore performed a spatial analysis of their 
catchment area and found that even though 
minorities constituted a majority of the ethnic 
demographic in that area, White patients that lived 
outside of Baltimore City in wealthy suburbs made 
up a majority of their clinical trial patients(Kanarek 
et al., 2010). On a national level, research suggests 
that the effects of segregation on clinical trial 
accrual may be more significant in other CCC 
catchment areas. Two decade after the National 
Institute of Health’s (NIH) Revitalization Act of 
1993(Institute of Medicine, 1994), which mandated 
the enrollment of women and minority race patients 
in NIH-funded research, approximately 2% of trials 



 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e4 Cancer Health Disparities 

RESEARCH 

have enrolled enough minority patients to meet the 
goals outlined by the Act(Chen et al., 2014). 

Racial segregation in the Stanford Cancer Institute 
(SCI) catchment area (i.e., the San Francisco Bay 
Area) began with the state-sanctioned genocide of 
Native American tribes from the 17th to 19th 
centuries – the Native American population in the 
Bay Area today is <1%(Madley, 2016). In the 20th 
century, discriminatory real estate practices only 
approved home loans for racial and ethnic 
minorities in less desirable neighborhoods within 
big cities like the Mission District in San Francisco, 
or adjacent to wealthy suburbs, like Palo Alto and 
East Palo Alto(Rothstein, 2017). The only clinical trial 
sites for Bay Area patients are in wealthy 
neighborhoods in the peninsula, at UCSF and 
Stanford (i.e., West Bay). This paper analyzes 
gastrointestinal cancer clinical trial patient accrual at 
the Stanford Cancer Institute (SCI) between 2012-
2020 by ethnicity and trial type and compares drive 
times to the SCI between patients of different 
ethnicities. It hypothesizes that the location of the 
SCI contributes to racial disparities in clinical trial 
accrual within its’ catchment area (as designated by 
the NCI) by requiring minority patients in historically 
segregated communities to travel to the clinical trial 
site to receive treatment on trial. 

Methods 
This cohort is derived of adult gastrointestinal (GI) 
oncology patients (i.e., colorectal, pancreatic, 
hepatic, bile duct, gastric, and esophageal) that 
enrolled in a clinical trial at the SCI between 2012 to 
2020. Data was made available through internal 
review and verified through OnCore (Forte 
Research Systems, Madison, WI). 215 studies were 
reviewed for demographic data – i.e., self-reported 
race, ethnicity, and zip code at time of enrollment 
(U.S. patients only) – and study type – therapeutic, 
non-therapeutic, and non-interventional (i.e., 
observational). Only patients with self-reported race 

and ethnicity were included in the final analysis. 
Under California state law, health insurers are 
required to cover routine or standard of care costs 
for all clinical trial patients, so the type of insurance 
a patient had (private, public, or uninsured) was not 
considered a relevant factor in deciding to enroll. 

Geographic analysis was limited to the SCI 
catchment area as designated by the NCI. The 10 
counties served by the SCI are Alameda, Contra 
Costa, Merced, Monterrey, San Benito, San Joaquin, 
San Mateo, Santa Clara, Santa Cruz, and Stanislaus 
Counties. San Francisco and the counties north of 
the Golden Gate Bridge are served by the UCSF 
Cancer Center and are not addressed in this analysis. 
Though patients from all over the world come to the 
SCI for cancer clinical trials, these patients were not 
appropriate for this analysis. 

ArcGIS Pro by Esri® was used to plot patients within 
our catchment area and generate descriptive 
statistics. Patients were plotted using their zip code 
at the time of enrollment. The ethnicity field of the 
patient was layer was joined to the SCI catchment 
area polygon using the Spatial Join tool. The 
Summarize Within tool was then used to generate 
the proportion of patient ethnicities by county. The 
location of the SCI in Palo Alto was geocoded to 
derive drive times to the clinical trial site. Drive times 
to the SCI were calculated by ethnicity overall and 
by county using the Network Analysis Service Area 
tool. Polygons with a radius of x minimum and 
maximum drive time to the SCI were used to 
compare drive times among patients by ethnicity. 
The minimum and maximum cutoff times chosen 
for this calculation are 5, 10, 15, 20, 25, 30, 35, 40, 
45, 50, 60, 70, 80, 90, 100, 110, 120, 140, 160, and 180 
minutes, based on expected drive times to the SCI 
without traffic. 

https://www.advarra.com/about-advarra/
https://www.advarra.com/about-advarra/


 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e5 Cancer Health Disparities 

RESEARCH 

Results 
848 patients were available for analysis. Overall, 
61% of patients were White, 25% Asian and Pacific 
Islander (AAPI), 13% Latino, 2% Black, and <1% 

Native American (Table 1). Most patients enrolled 
into non-interventional studies (54.83%), followed 
by treatment trials (33.13%) and non-therapeutic 
trials (12%). White patients were the most 
represented in each trial type. 

 
 

Table 1. GI Clinical Trial Patients by Ethnicity and Trial Type. 

Ethnicities Total  Therapeutic Trials  Non-Therapeutic Non-interventional 

White 514  176  64 274 

Black  14  3 1 10 

AAPI 210  66 26 118 

Latino 107  36 10 61 

Native American 3  0 1 2 

Total 848  281 102 465 

 
The approximate location of trial patients within the 
SCI’s catchment area are plotted in Figure 1. The 
breakdown of trial patient ethnicity by county within 
the catchment area was 44% White, 41% Asian, 11% 
Latino, and 4% Black in Alameda. 62% White, 19% 
Latino, 16% Asian, and 3% Black in Contra Costa. 
63% White, 31% Latinos, and 6% Asian in Merced. 
49% Latino and White, and 3% Asian in Monterrey. 

67% White and 33% Latino in San Benito. 73% 
White, 14% Black, 9% Asian, and 5% Latino in San 
Joaquin. 65% White, 23% Asian, 11% Latino, and 1% 
Native in San Mateo. 49% White, 40% Asian, 9% 
Latino, 2% Black, and <1% Native in Santa Clara. 
89% White, 8% Latino, and 3% Asian in Santa Cruz. 
And 77% White, 23% Latino in Stanislaus (Table 2). 

Figure 1. 

 



 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e6 Cancer Health Disparities 

RESEARCH 

Table 2. Comparison of trial patients’ ethnicity, and drive time to the cancer center by county. 

Ethnicities Alameda Contra 
Costa 

Merced Monterrey San 
Benito 

San 
Joaquin 

San 
Mateo 

Santa 
Clara 

Santa 
Cruz 

Stanislaus 

White 33 23 10 17 6 16 51 121 34 10 

Black  3 1 0 0 0 3 0 4 0 0 

AAPI 31 6 1 1 0 2 18 99 1 0 

Latino 8 7 5 17 3 1 9 21 3 3 

Native 
American 0 0 0 0 0 0 1 1 0 0 

Total  75 37 16 35 9 22 79 246 38 13 

Average Minimum/Maximum Drive Times to the SCI (minutes) 

White 41/47 68/78 125/144 89/100 70/80 96/107 16/21 26/31 55/65 117/134 

Black  43/52 90/100 0/0 0/0 0/0 93/103 0/0 20/25 0/0 0/0 

AAPI 35/40 60/70 140/160 80/90 0/0 90/100 17/22 26/31 70/80 0/0 

Latino 31/36 76/67 134/152 85/95 70/80 100/110 26/31 26/31 63/73 110/123 

Native 
American 0/0 0/0 0/0 0/0 0/0 0/0 25/30 30/35 0/0 0/0 

 
Overall, Latino patients had the longest drive on 
average (mean max drive time of 67 minutes), while 
the means for Black, White, Asian, and Native 
patients were 60, 53, 36, and 33 minutes, 
respectively. In Alameda and Contra Costa 
Counties, Black patients faced the longest 
commutes to the SCI of all ethnicities, 52 and 100 
minutes, respectively (Table 2). AAPI patients had 
the longest commutes in Merced and Santa Cruz 
Counties (160min. and 80min). Latino patients had 
the longest commutes in San Joaquin and San 
Mateo Counties. White patients had the longest 
commutes in Monterrey and Stanislaus Counties. 
One patient identifying as Native American in Santa 
Clara County had the longest commute of all 
ethnicities. 

Discussion 
This report demonstrated racial disparities in clinical 
trial accrual at the SCI CCC using a cohort of adult 
gastrointestinal cancer patients. Spatial analysis 

showed that the counties closest to the SCI had the 
highest accrual (Santa Clara and San Mateo) and 
there was an inverse relationship between distance 
the SCI and patient accrual overall. In Santa Clara 
and San Mateo Counties, the racial and ethnic 
demographics of trial patients was approximately 
equal to the racial and ethnic makeup of the 
general population. For example, approximately 2% 
of trial patients from Santa Clara County were Black 
compared to 3% in the general population, but the 
proportion of Black patients from Alameda County 
was much less than expected, approximately 4% 
compared to 11% in general(U.S Census Bureau 
Quickfacts, 2020). Drive time analysis suggested 
that accrual could be increased if trials were offered 
at satellite sites in counties further away, and 
minority accrual would reflect the demographics of 
the counties in general, as is the case for Santa Clara 
County. 



 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e7 Cancer Health Disparities 

RESEARCH 

Limitations to this study include a lack of 
demographic information on the cohort, studies 
have shown that variables such as sex (male/female, 
non-binary), cancer type, stage at diagnosis, 
socioeconomic status, type of insurance, and the 
patients’ referring hospital, are also associated with 
low minority patient accrual in clinical trials(Awidi 
and Al Hadidi, 2021; Krieger et al., 2020). These 
missing variables are partially due to deficiencies in 
the data collection processes at the SCI as well as 
the migration of data between the electronic 
medical record system and research databases. 
Demographic and sociological variables tend to be 
overlooked in cancer clinical trials research, one 
study found that 7.8% of trials leading to FDA 
oncology drug approvals between 2008-2018 
reported the main race and ethnicity categories 
used in the United States(Loree et al., 2019). 
Limitations of the spatial analysis are the use of 
patient zip codes rather than exact addresses’, and 
the exclusion of patients outside the SCI catchment 
area. Excluding non-catchment area patients from 
the analysis was justified to determine where a 
future clinical trial site would make the most impact 
on minority patient accrual. The calculated drive 
times assumed no traffic though this is rarely the 
case, and it also does not take into consideration 
the fact that East Bay patients face tolls that patients 
from most other counties in the catchment area do 
not. Though this report lacked the quantitative 
analysis to conclude that historical segregation 
played a role in minority patient trial enrollment 
patterns within the SCI catchment area, it did show 
ethnic disparities in accrual and drive times to trials 
within different counties. 

In the past decade the NCI mandated all CCC’s 
applying for P30 support grants to address racial 
disparities in their catchment area and increase 
community outreach and engagement (COE), 
leading to two approaches to increase minority 
patient enrollment. One approach is to invest 

resources into transportation programs that reduce 
out-of-pocket costs for low-income patients in 
underserved areas. For example, Massachusetts 
General Hospital (MGH) and the Lazarex Cancer 
Foundation started a patient navigation and sliding-
scale reimbursement program in 2013 which funds 
all transportation and lodging costs for clinical trial 
patients, but saw no increase in minority patient 
enrollment in the first two years(Nipp et al., 2016). 
Similarly, the SCI implemented a shuttle program to 
Palo Alto for clinical trial patients in East Bay, though 
this paper suggests these efforts were also met with 
limited results. The other approach, used by the 
NCI’s Community Oncology Research Program 
(NCORP) and several CCCs, has been to invest in 
new clinical trial sites within underserved minority 
and rural communities through partnerships with 
local healthcare providers. In 2014, NCORP tested 
whether community-based hospitals with little to no 
clinical research experience could develop and 
sustain clinical trial programs with guidance from a 
local, larger CCC(Wong et al., 2014). 3 of 6 hospitals 
received 10 years of funding through NIH U56 and 
U54 grants, increased their yearly patient accrual by 
~60% to NCI cooperative group trials, required 
approximately a year into their implementation 
phase to fully open their programs, and all were 
able to recruit principal investigators to help sustain 
their new programs. Though the trials offered to 
patients were limited in comparison to their mentor 
site, the study showed that investing resources in 
underserved communities is feasible and translates 
to a significant increase in clinical trial accrual. 

Regardless of the approach used, studies show that 
COE and staff cultural sensitivity training is pivotal 
to making underserved communities aware of 
clinical trial resources in their area and overcoming 
explicit and “implicit” racial biases that perpetuate 
feelings of mistrust by minority patients and create 
barriers to enrollment. For example, the 
Georgetown CCC increased enrollment of Black 



 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e8 Cancer Health Disparities 

RESEARCH 

patients to non-therapeutic clinical trials by 62% at 
two community sites in underserved areas by 
implementing staff cultural competence training at 
those sites(Wallington et al., 2016). In “Systemic 
Racism and U.S. Healthcare,”(Feagin and 
Bennefield, 2014) Feagin and Bennefield 
demonstrate that the degree to which a healthcare 
provider identifies with these biases positively 
correlates with preferential treatment of White 
patients and poor treatment of minority patients. 
One study among a group of healthcare 
professionals showed that people of color are seen 
as “less promising” candidates for trials, and in some 
cases, not considered for studies they may be 
eligible for(Niranjan et al., 2020). Though some 
studies report that Black and other minority race 
patients are just as willing to enroll in clinical trials 

as Whites when access and awareness are 
equivalent,(Durant et al., 2011, 2014) other patients 
are still skeptical due to past crimes against 
uninformed patients (e.g., the Tuskegee Syphilis 
Study(Katz et al., 2007)). To overcome this barrier, 
the Abramson Cancer Center formed partnerships 
with faith-based organizations and community 
health centers and achieved Black patient accrual 
representative of the percentage of Black cancer 
patients among all cancer cases in the catchment 
area over 5 years(Guerra et al., 2021). CCCs looking 
to increase minority patient accrual to clinical trials 
should begin by taking an honest look at accrual 
statistics within their catchment area and invest 
resources in the underserved areas that often lack 
clinical trials nearby, or are simply unaware of them. 

ACKNOWLEDGEMENT 
I would like to acknowledge Dr. George A. Fisher, 
Susan Segar, and the Stanford GI oncology 
research team for their support and 
encouragement of this project.  I would also like to 
acknowledge Madeline Comer for directing me 
towards relavent literature.   

 

Conflicts of interest 
The authors declare no conflict of interest. 

Authors' contributions 
The data review, literature search, manuscript 
development, and data analysis were done entirely 
by the author.   

REFERENCES 
Alexander, M. (2012). The New Jim Crow: Mass Incarceration in 

the Age of Colorblindness (New York: New Press). 

Awidi, M., and Al Hadidi, S. (2021). Participation of Black 
Americans in Cancer Clinical Trials: Current Challenges 
and Proposed Solutions. JCO Oncology Practice 17, 265–
271. 

Axtell, L.M., and Myers, M.H. (1978). Contrasts in survival of 
black and white cancer patients, 1960-73. J Natl Cancer 
Inst 60, 1209–1215. 

Cancer Prevention Institute of California, and Greater Bay Area 
Cancer Registry, (2018). The Greater Bay Area Cancer 
RegistryAnnual Report:Incidence and Mortality Review, 
1988-2015 (Cancer Prevention Institute of California). 

Chen, M.S., Lara, P.N., Dang, J.H.T., Paterniti, D.A., and Kelly, K. 
(2014). Twenty Years Post-NIH Revitalization Act: 
Renewing the Case for Enhancing Minority Participation in 
Cancer Clinical Trials. Cancer 120, 1091–1096. 

Cheng, I., Tseng, C., Wu, J., Yang, J., Conroy, S.M., Shariff-
Marco, S., Li, L., Hertz, A., Lin Gomez, S., Le Marchand, L., 
et al. (2020). Association between ambient air pollution 
and breast cancer risk: The Multiethnic Cohort Study. Int J 
Cancer 146, 699–711. 

Chhatre, S., and Jayadevappa, R. (2018). Racial and ethnic 
disparities in substance use disorders and outcomes in 
elderly prostate cancer patients. J Ethn Subst Abuse 17, 
135–149. 

Coleman, S.J. (1992). Savage Inequalities: Children in Americas 
Schools. Journal of Education 174, 136–139. 

Cornely, P.B. (1956). Segregation and Discrimination in Medical 
Care in the United States. Am J Public Health Nations 
Health 46, 1074–1081. 

Duma, N., Vera Aguilera, J., Paludo, J., Haddox, C.L., Gonzalez 
Velez, M., Wang, Y., Leventakos, K., Hubbard, J.M., 
Mansfield, A.S., Go, R.S., et al. (2018). Representation of 



 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e9 Cancer Health Disparities 

RESEARCH 

Minorities and Women in Oncology Clinical Trials: Review 
of the Past 14 Years. J Oncol Pract 14, e1–e10. 

Durant, R.W., Legedza, A.T., Marcantonio, E.R., Freeman, M.B., 
and Landon, B.E. (2011). Willingness to participate in clinical 
trials among African Americans and whites previously 
exposed to clinical research. J Cult Divers 18, 8–19. 

Durant, R.W., Wenzel, J.A., Scarinci, I.C., Paterniti, D.A., Fouad, 
M.N., Hurd, T.C., and Martin, M.Y. (2014). Perspectives on 
Barriers and Facilitators to Minority Recruitment for Clinical 
Trials among Cancer Center Leaders, Investigators, 
Research Staff and Referring Clinicians. Cancer 120, 1097–
1105. 

Feagin, J.R. (2006). Systemic racism: A theory of oppression 
(New York, NY, US: Routledge/Taylor & Francis Group). 

Feagin, J., and Bennefield, Z. (2014). Systemic racism and U.S. 
health care. Soc Sci Med 103, 7–14. 

Firebaugh, G., and Acciai, F. (2016). For blacks in America, the 
gap in neighborhood poverty has declined faster than 
segregation. Proc Natl Acad Sci U S A 113, 13372–13377. 

Guerra, C.E., Sallee, V., Hwang, W.-T., Bryant, B., Washington, 
A.L., Takvorian, S.U., Schnoll, R., Glanz, K., Cohen, R.B., 
Nathanson, K.L., et al. (2021). Accrual of Black participants 
to cancer clinical trials following a five-year prospective 
initiative of community outreach and engagement. JCO 
39, 100–100. 

Hamel, L.M., Penner, L.A., Albrecht, T.L., Heath, E., Gwede, C.K., 
and Eggly, S. (2016). Barriers to Clinical Trial Enrollment in 
Racial and Ethnic Minority Patients With Cancer. Cancer 
Control 23, 327–337. 

Hilmers, A., Hilmers, D.C., and Dave, J. (2012). Neighborhood 
Disparities in Access to Healthy Foods and Their Effects on 
Environmental Justice. Am J Public Health 102, 1644–1654. 

Jha, A.K., Orav, E.J., and Epstein, A.M. (2011). Low-quality, high-
cost hospitals, mainly in South, care for sharply higher 
shares of elderly black, Hispanic, and medicaid patients. 
Health Aff (Millwood) 30, 1904–1911. 

Kanarek, N.F., Tsai, H.-L., Metzger-Gaud, S., Damron, D., 
Guseynova, A., Klamerus, J.F., and Rudin, C.M. (2010). 
Geographic Proximity and Racial Disparities in Cancer 
Clinical Trial Participation. Journal of the National 
Comprehensive Cancer Network 8, 1343–1351. 

Katz, R.V., Green, B.L., Kressin, N.R., Claudio, C., Wang, M.Q., 
and Russell, S.L. (2007). Willingness of minorities to 
participate in biomedical studies: confirmatory findings 
from a follow-up study using the Tuskegee Legacy Project 
Questionnaire. J Natl Med Assoc 99, 1052–1060. 

Krieger, N., Wright, E., Chen, J.T., Waterman, P.D., Huntley, E.R., 
and Arcaya, M. (2020). Cancer Stage at Diagnosis, 
Historical Redlining, and Current Neighborhood 
Characteristics: Breast, Cervical, Lung, and Colorectal 

Cancers, Massachusetts, 2001-2015. Am J Epidemiol 189, 
1065–1075. 

Loree, J.M., Anand, S., Dasari, A., Unger, J.M., Gothwal, A., Ellis, 
L.M., Varadhachary, G., Kopetz, S., Overman, M.J., and 
Raghav, K. (2019). Disparity of Race Reporting and 
Representation in Clinical Trials Leading to Cancer Drug 
Approvals From 2008 to 2018. JAMA Oncol 5. 

Madley, B. (2016b). An American Genocide: The United States 
and the California Indian Catastrophe, 1846-1873 (Yale 
University Press). 

McCaskill-Stevens, W., McKinney, M.M., Whitman, C.G., and 
Minasian, L.M. (2005). Increasing Minority Participation in 
Cancer Clinical Trials: The Minority-Based Community 
Clinical Oncology Program Experience. JCO 23, 5247–
5254. 

McGuire, T.G., and Miranda, J. (2008). New evidence regarding 
racial and ethnic disparities in mental health: policy 
implications. Health Aff (Millwood) 27, 393–403. 

McGuire, T.G., Alegria, M., Cook, B.L., Wells, K.B., and Zaslavsky, 
A.M. (2006). Implementing the Institute of Medicine 
Definition of Disparities: An Application to Mental Health 
Care. Health Serv Res 41, 1979–2005. 

Nardone, A., Casey, J.A., Morello-Frosch, R., Mujahid, M., 
Balmes, J.R., and Thakur, N. (2020). Associations between 
historical residential redlining and current age-adjusted 
rates of emergency department visits due to asthma 
across eight cities in California: an ecological study. Lancet 
Planet Health 4, e24–e31. 

National Academies of Sciences, Engineering, and Medicine, 
Health and Medicine Division, Board on Population Health 
and Public Health Practice, and Committee on 
Community-Based Solutions to Promote Health Equity in 
the United States (2017). Communities in Action: Pathways 
to Health Equity (Washington (DC): National Academies 
Press (US)). 

Nazha, B., Mishra, M., Pentz, R., and Owonikoko, T.K. (2019). 
Enrollment of Racial Minorities in Clinical Trials: Old 
Problem Assumes New Urgency in the Age of 
Immunotherapy. American Society of Clinical Oncology 
Educational Book 3–10. 

New York Law School Racial Justice Project. (2012). Unshared 
Bounty: How Structural Racism Contributes to the Creation 
and Persistence of Food Deserts. (with American Civil 
Liberties Union). Racial Justice Project. 

Nipp, R.D., Lee, H., Powell, E., Birrer, N.E., Poles, E., Finkelstein, 
D., Winkfield, K., Percac-Lima, S., Chabner, B., and Moy, B. 
(2016). Financial Burden of Cancer Clinical Trial 
Participation and the Impact of a Cancer Care Equity 
Program. Oncologist 21, 467–474. 

Niranjan, S.J., Martin, M.Y., Fouad, M.N., Vickers, S.M., Wenzel, 
J.A., Cook, E.D., Konety, B.R., and Durant, R.W. (2020). Bias 



 
 
 
 
 

 
www.companyofscientists.com/index.php/chd e10 Cancer Health Disparities 

RESEARCH 

and stereotyping among research and clinical 
professionals: Perspectives on minority recruitment for 
oncology clinical trials. Cancer. 126, 1958–1968. 

Onega, T., Alford-Teaster, J., and Wang, F. (2017). Population-
based geographic access to parent and satellite National 
Cancer Institute Cancer Center Facilities. Cancer 123, 
3305–3311. 

Patel, M.I., Lopez, A.M., Blackstock, W., Reeder-Hayes, K., 
Moushey, E.A., Phillips, J., and Tap, W. (2020). Cancer 
Disparities and Health Equity: A Policy Statement From the 
American Society of Clinical Oncology. JCO 38, 3439–
3448. 

Rothstein, R. (2017). The color of law: a forgotten history of how 
our government segregated America (New York ; London: 
Liveright Publishing Corporation, a division of WWNorton 
& Company). 

Siegel, R.L., Miller, K.D., Goding Sauer, A., Fedewa, S.A., Butterly, 
L.F., Anderson, J.C., Cercek, A., Smith, R.A., and Jemal, A. 
(2020). Colorectal cancer statistics, 2020. CA Cancer J Clin 
70, 145–164. 

Sutton, A.L., He, J., Edmonds, M.C., and Sheppard, V.B. (2019). 
Medical Mistrust in Black Breast Cancer Patients: 
Acknowledging the Roles of the Trustor and the Trustee. J 
Cancer Educ 34, 600–607. 

Wallington, S.F., Dash, C., Sheppard, V.B., Goode, T.D., 
Oppong, B.A., Dodson, E.E., Hamilton, R.N., and Adams-
Campbell, L.L. (2016). Enrolling Minority and Underserved 
Populations in Cancer Clinical Research. Am J Prev Med 
50, 111–117. 

Wenzel, J.A., Mbah, O., Xu, J., Moscou-Jackson, G., Saleem, H., 
Sakyi, K., and Ford, J.G. (2015). A Model of Cancer Clinical 
Trial Decision-making Informed by African-American 
Cancer Patients. J Racial Ethn Health Disparities 2, 192–199. 

Williams, D.R., and Mohammed, S.A. (2013). Racism and Health 
I: Pathways and Scientific Evidence. Am Behav Sci 57. 

Winkfield, K.M., Regnante, J.M., Miller-Sonet, E., González, E.T., 
Freund, K.M., and Doykos, P.M. (2021). Development of an 
Actionable Framework to Address Cancer Care Disparities 
in Medically Underserved Populations in the United States: 
Expert Roundtable Recommendations. JCO Oncology 
Practice 17, e278–e293. 

Wong, R.S.L., Vikram, B., Govern, F.S., Petereit, D.G., Maguire, 
P.D., Clarkson, M.R., Heron, D.E., and Coleman, C.N. 
(2014). National Cancer Institute’s Cancer Disparities 
Research Partnership Program: Experience and Lessons 
Learned. Front. Oncol. 0. 

Zahnd, W.E., Gomez, S.L., Steck, S.E., Brown, M.J., Ganai, S., 
Zhang, J., Adams, S.A., Berger, F.G., and Eberth, J.M. 
(2021). Rural-urban and racial/ethnic trends and disparities 
in early-onset and average-onset colorectal cancer. 
Cancer 127, 239–248. 

U.S. Census Bureau QuickFacts: Santa Clara County, California; 
Alameda County, California; San Francisco County, 
California. 

Institute of Medicine (US) Committee on Ethical and Legal 
Issues Relating to the Inclusion of Women in Clinical, 
Mastroianni, A.C., Faden, R., and Federman, D. (1994). NIH 
Revitalization Act of 1993 Public Law 103-43 (National 
Academies Press (US)).  

 


	Introduction
	Methods
	Results
	Discussion
	ACKNOWLEDGEMENT
	Conflicts of interest
	Authors' contributions

