Barriers to Trial Diversity

Like studies assessing breast cancer risk factors, trials of lifestyle interventions are often lacking in diversity, according to Dr Bandera and colleagues.

One barrier to trial diversity is that many cancer trials are conducted at academic medical centers or large universities with cancer centers that serve mostly non-Hispanic White patient populations, said Rachel J. Meadows, PhD, MPH, assistant member of the faculty at the Center for Epidemiology & Healthcare Delivery Research at JPS Health Network in Fort Worth, Texas.

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“If that is where the trial is and where it is recruiting, then often you are not even reaching racial/ethnic minority populations who are often more likely to go to federally qualified health centers or county safety-net health systems,” Dr Meadows said.

Another barrier is that even when members of underserved communities are invited to participate, participation might not be feasible.

“Individuals with low income, which unfortunately tend to be racial/ethnic minorities, are less likely to have paid time off or days off during the week to go participate in a research trial,” Dr Meadows said. “For trials looking at diet or exercise, they might not have access to a gym membership, exercise equipment, places to buy healthy foods, or the extra money required to participate.”

However, research has shown that participation and retention in trials targeting underserved participants can be high, which counters the notion that underserved populations are unwilling to participate in trials.4

“Researchers and funders of trials need to work on minimizing barriers to participation, especially for racial/ethnic minorities, those with low income, and beyond,” Dr Meadows said.

Tailoring Interventions

There are a number of ways to adapt or tailor lifestyle interventions or programs for underserved minorities in general and for women specifically, Dr Mama said. For example, she and her colleagues previously published a study of faith-based mind-body interventions in Black adults.5

“We tailored lifestyle interventions by incorporating scripture into the intervention to better appeal to and engage African-American adult churchgoers,” Dr Mama said.

Participants were randomly assigned to a movement-based mind-body intervention or control. The intervention was developed in partnership with a pastor and senior member of the church. Trends showed greater improvements in physical activity and psychosocial well-being among participants in the mind-body intervention group.

“Importantly though, at the end, 100% of the intervention participants said they would recommend it to a friend or family,” Dr Mama said.

Researchers at MD Anderson also developed the “Tu Salud ¡Sí Cuenta! Your Health Matters!” campaign, which was intended to improve eating behaviors and anthropometric outcomes in Hispanic communities.

The campaign included TV and radio segments as well as newsletters and discussions with community health workers that disseminated culturally and language-appropriate messages about physical activity and eating behaviors.

A study of the campaign’s efficacy showed that any exposure to a campaign component was associated with a lower rate of unhealthy food consumption.6

Dr Meadows emphasized that when designing studies, it is important for researchers to remember that different people have different preferences when it comes to diet and exercise.

“There can be healthy diets that reflect different cultural groups and include food that is similar to what they are already used to eating,” she said. “For example, not everyone is going to adopt a Mediterranean diet because it includes foods they have never eaten before or are not used to.”

The same is true for physical activity interventions, Dr Mama said.

She and her colleagues studied the use of culturally adapted and standard home-based exercise interventions in a group of Hispanic breast cancer survivors in Project VIVA!7 The researchers used culturally tailored phone calls and newsletters to support home-based exercise and observed good rates of participation and adherence.

Another study of Black breast cancer survivors tested a community-based walking intervention and showed significant increases in steps per day and attitudes toward exercise as well as decreases in BMI, body weight, percentage of body fat, and other measures, including blood pressure.8

Despite these positive results, “there is a lot of work left to do to achieve better health equity in cancer prevention and control,” Dr Mama said.

“We have to do a better job generally of assessing social determinants of health that contribute to cancer disparities,” she noted. “Additionally, we need to do more to include community members and stakeholders in these efforts.”


  1. Bandera EV, Alfano CM, Qin B, et al. Harnessing nutrition and physical activity for breast cancer prevention and control to reduce racial/ethnic cancer health disparities. Am Soc Clin Oncol Educ Book. 2021;41:1-17. doi:10.1200/EDBK_321315
  2. American Cancer Society. Cancer Facts & Figures for Hispanics/Latinos 2018-2020. Accessed July 13, 2021.
  3. Chan DSM, Abar L, Cariolou M, et al. World Cancer Research Fund International: Continuous Update Project—systematic literature review and meta-analysis of observational cohort studies on physical activity, sedentary behavior, adiposity, and weight change and breast cancer risk. Cancer Causes Control. 2019;30:1183-1200. doi:10.1007/s10552-019-01223-w
  4. Ojha RP, Jackson BE, Lu Y, et al. Participation and retention can be high in randomized controlled trials targeting underserved populations: a systematic review and meta-analysis. J Clin Epidemiol. 2018;98:154-157. doi:10.1016/j.jclinepi.2017.11.014
  5. Mama SK, Bhuiyan N, Chaoul A, et al. Feasibility and acceptability of a faith-based mind-body intervention among African American adults. Transl Behav Med. 2020;10(4):928-937. doi:10.1093/tbm/iby114
  6. Heredia NI, Lee MJ, Mitchell-Bennett L, Reininger BM. Tu Salud ¡Sí Cuenta! Your Health Matters!: a quasi-experimental design to assess the contribution of a community-wide campaign to eating behaviors and anthropometric outcomes in a Hispanic border community in Texas. J Nutr Educ Behav. 2017;49(10):801-809.e1. doi:10.1016/j.jneb.2017.06.008
  7. Mama SK, Song J, Ortiz A, et al. Longitudinal social cognitive influences on physical activity and sedentary time in Hispanic breast cancer survivors. Psychooncology. 2017;26(2):214-221. doi:10.1002/pon.4026
  8. Wilson DB, Porter JS, Parker G, Kilpatrick J, et al. Anthropometric changes using a walking intervention in African American breast cancer survivors: A pilot study. Prev Chronic Dis. 2005;2(2):A16.