Access Gaps: Breast Cancer Trial Participation Hindered by "Double Deserts"

In an interview with Targeted Oncology, Mariam Eskander, MD, surgical oncologist and assistant professor of surgery at the Rutgers Cancer Institute of New Jersey, discussed a study examining how structural barriers such as food insecurity and geographic access impact breast cancer clinical trial participation. These findings, drawn from a large, nationally representative data set, underscore how social determinants of health intersect to create compounding obstacles for vulnerable populations.^1,2

Targeted Oncology: What was the rationale for your study and the unmet needs it addressed?

Mariam Eskander, MD: We all agree that vulnerable populations must have access to clinical trials. Historically, oncology has focused on increasing representation among people of color—a critical effort that must continue. But we also need to understand and address socioeconomic barriers that can prevent trial participation. I'm particularly interested in how social determinants of health affect access to research for cancer patients.

Food insecurity is a major social determinant affecting millions. We know that people living in food deserts—areas without easy access to healthy food—have higher breast cancer mortality rates. These are precisely the individuals who could benefit from clinical trials, yet they may be systematically excluded. Our study aimed to examine the relationship between living in a food desert and enrollment in breast cancer clinical trials.

Can you summarize your methodology and findings?

We used the Vizient database, a nationally representative billing dataset that includes data from major academic and community hospitals across the United States. We defined food deserts as low-income census tracts where residents live more than 1 mile (urban) or 10 miles (rural) from a grocery store. Clinical trial deserts were defined as areas more than 2 hours from a hospital enrolling patients in trials. We excluded patients who traveled over 4 hours for care, assuming they likely sought destination treatment.

We also looked at neighborhood-level transportation vulnerability using a normalized Z score, based on households lacking access to vehicles or public transportation. These variables were assessed in quartiles.

Using multivariable analysis, we examined how each factor—living in a food desert, clinical trial desert, or transport-vulnerable neighborhood—was associated with clinical trial enrollment. Additionally, we analyzed the interaction between living in both a food desert and clinical trial desert.

We analyzed data from 1.3 million women treated for breast cancer between 2022 and 2024. About 8% lived in food deserts and 10% in clinical trial deserts; 41% of those in a food desert also lived in a clinical trial desert. Women living in food deserts were 13% less likely to enroll in trials. Those in clinical trial deserts were 11% less likely, and those from transport-vulnerable neighborhoods also showed reduced participation. The interaction analysis revealed a 27% lower enrollment rate for women living in both types of deserts—suggesting a compounding effect.

What are the takeaways for clinicians?

We need to understand our patients' social contexts. This study identified 3 independent barriers: food deserts, poor transportation, and geographic isolation from clinical trial sites. Clinicians and hospitals should assess their catchment areas: Where are the food deserts, the trial deserts, and the transportation-vulnerable neighborhoods?

We must bring clinical trials to these communities, support neighborhood initiatives addressing food insecurity, and strengthen public transit. At the clinical level, patient navigation programs can help support individuals facing these barriers.

How do clinicians begin to tackle that?

It’s daunting because these are system-level issues. But many solutions can be implemented locally. Hospitals and research institutions must shoulder some responsibility. If trials are not accessible, people won’t enroll. Satellite or telehealth trial sites in underserved neighborhoods could be transformative. Our study clearly shows the impact of double deserts: when barriers overlap, the effect is magnified.

Have you found challenges in bringing trials to more community-based sites?

Yes, absolutely. In our system across New Jersey, we've observed that trials requiring patients to travel to a main cancer center deter participation. Patients with Medicaid insurance have repeatedly cited reduced travel as a top priority. Studies with more flexible logistics like allowing labs or chemo at satellite sites are more accessible, but this requires planning at the stage of study design as well as the allocation of staff and resources. Restrictive designs disproportionately exclude vulnerable populations.

What’s next in your research?

We want to pinpoint where in the process vulnerable patients fall off—from eligibility screening to signing consent. Understanding these drop-off points can help us develop targeted, community-informed interventions. Each solution should be tailored to the local context. We need to move from identifying the problem to testing what works and for whom.

REFERENCES:

1. Sachs RA, Pamen L, Perati SR, et al. From food deserts to clinical trial deserts: Challenges in access to breast cancer trials. J Clin Oncol. 43, 1525-1525(2025). DOI:10.1200/JCO.2025.43.16_suppl.1525

2. RWJBarnabas Health and Rutgers Cancer Institute to Present Practice-Changing Research at 2025 ASCO Annual Meeting. News release. RWJBarnabas Health. May 22, 2025. https://tinyurl.com/2s45rbs5