ACR Bulletin

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Diversifying Clinical Research to Improve Health Equity

Improving representation in clinical research can be done through a recruitment strategy that includes direct outreach to facilities in underserved communities.
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Ensuring a diverse research cohort is an underutilized mechanism that should be used more frequently to further the cause of health equity.

—Jinel A. Scott, MD, MBA
May 26, 2022

An important and often overlooked mechanism to improve health equity is making clinical research more inclusive to ensure that potential improvements are realized across all population groups. In this case, I am referring to care for Black Americans and other underserved communities, who often experience worse outcomes for many diseases, illnesses, and injuries.

Newly developed diagnostic technology or treatment may enable better patient outcomes but without broad representation of population groups within research cohorts, specific benefits or nuances cannot be studied, which ultimately hinders the progress of medicine and health equity. For example, initial eligibility criteria for lung cancer screening did not consider important racial differences in smoking patterns and lung cancer development between racial groups because Black individuals comprised only 4.4% of participants in the National Lung Screening Trial. As a result, a large number of Black patients were ineligible for lung cancer screening because Black patients tend to be intermittent or light smokers with fewer accumulated pack-years and are more likely to start smoking later in life compared to White patients. Unfortunately, Black smokers who are at greater risk of developing lung cancer at an earlier age were not eligible for screening based on the age criteria.1,2,3

One way to facilitate improved representation of underrepresented groups into clinical research is to have a recruitment strategy that includes direct outreach to facilities serving and based in underserved communities. During the course of my work with the Radiology Health Equity Coalition, I recently connected with leaders of the Tomosynthesis Mammographic Imaging Screening Trial (TMIST) to explore whether TMIST participation is right for my department. More than 20% of U.S. women in the study are Black. This growing rate is double the 9% average Black cohort in National Cancer Institute (NCI)–funded trials. Yet, more sites and patients are needed.4

The primary reason for enhanced Black participation appears to be simple: TMIST is reaching out to imaging providers and practices that serve large Black communities — and those sites are responding. In addition, TMIST is making it easier for practices to take part by:

  • Paying for mammography screening for women who qualify for free care at a participating site, enabling screening of more low-income and underserved women.
  • Allowing sites to apply for advance payment to facilities to hire a dedicated research assistant — which, if approved, can make it easier to get the study up and running on site.

Once registered with a cancer research group (which ACR can help with), sites can readily participate in future trials, creating a virtuous cycle that advances health equity. Ensuring a diverse research cohort is an underutilized mechanism that should be used more frequently to further the cause of health equity. I encourage research groups in well-resourced institutions to reach out to those of us practicing in underserved and marginalized communities. With the right levels of support, we can together make significant strides towards health equity.


1. Aberle DR, DeMello S, Berg CD, et al. Results of the Two Incidence Screenings in the National Lung Screening Trial. New Engl J Med. 2013;369(10):920–931.
2. Aldrich MC, Mercaldo SF, Sandler KL, Blot WJ, Grogan EL, Blume JD. Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers. JAMA Oncol. 2019;5(9):1318–1324.
3. Prosper A, Brown K, Schussel B, Aberle D. Lung Cancer Screening in African Americans: The Time to Act Is Now. Radiol Imaging Cancer. 2020;2(5):e200107.
4. Stevens WM. “Accrual of Minorities into NCTN and NCORP Clinical Trials: A Twenty-Year View.” National Cancer Institute. Published June 15, 2020.

Author Jinel A. Scott, MD, MBA  Member of the ACR General Radiology Improvement Database Committee and RSNA member representative to the Radiology Health Equity Coalition