This article is the ninth in a 10-part series highlighting the work of the Alliance for Equity in Cancer Care, a national initiative focused on expanding access to high-quality cancer care for underserved communities.
Each installment will spotlight a different Alliance grantee site, exploring how healthcare teams are partnering with community organizations to break down barriers to care and reimagine what navigation looks like on the ground.
Through these stories, we’ll see how tailored, community-informed solutions are making cancer care more accessible.
The Integrated Cancer Care Access Network (ICCAN) was created in New York City (NYC) in 2006 and has been housed at Memorial Sloan Kettering Cancer Center (MSK) since 2011. Over time, it has grown into a comprehensive, community-engaged cancer equity initiative designed to meet the needs of low-income, immigrant, limited English proficiency, and other historically marginalized groups who often face disproportionate barriers to care.1-3
The network operates through 2 interconnected arms working synergistically to increase patient access and connect patients with crucial support services. Through the work of the Alliance for Equity in Cancer Care (Alliance), ICCAN is systematically strengthening how social determinants of health (SDOH) needs are identified, addressed, and integrated across the care continuum.
The cancer care landscape in NYC encompasses substantial social, economic, linguistic, and cultural constructs that impact barriers to and facilitators of access to essential resources. Across 2 decades, continuous needs assessments and program evaluations have documented patient challenges, including unmet financial needs, food insecurity, transportation barriers, legal concerns, housing instability, and limited access to psychosocial care.
There are patients who reside in neighborhoods with some of the highest rates of food insecurity and resource scarcity in NYC. Approximately 80% of ICCAN patients live at or below the federal poverty level, and more than half report no income at all.
Often impacted by multiple SDOH, ICCAN patient needs vary widely across NYC boroughs. Notably, the impacts of SDOH can change over the course of treatment, requiring navigation approaches that are individually tailored yet have the capacity to operate across complex community and health systems. The diverse populations supported by the ICCAN Equity Platform, which serves more than 1600 unique individuals each year, reflect the program’s purpose.
MSK is expanding the platform through the Alliance to better meet these needs and improve health equity among urban, underserved patients. Prior to scaling, MSK evaluated institutional readiness and internal capacity. The longstanding history of the program, experienced multilingual team, structured training processes, active needs assessment tools, and robust partnerships all added to the confidence of expanding sustainably. Institutional support was strong and multifaceted. Executive leadership formally endorsed the expansion, with inclusion of SDOH screening in the MSK Epic electronic health record (EHR), with automated referrals to the ICCAN team demonstrating commitment at the highest levels.
ICCAN’s Access Facilitation arm is a multilingual, patient-centered navigation program where access facilitators work directly with individuals to assess their SDOH needs and help them overcome obstacles related to treatment completion, psychosocial support, and overall quality of life. More than 8 facilitators rotate across 15 cancer clinics in NYC, offering patient education and guidance, and connection to relevant resources.
The second arm, the ICCAN Network, brings together more than 360 partners, including community- and faith-based organizations, cancer clinics, healthcare providers, cancer support organizations, and social and legal service groups. These groups share resources, build knowledge, and collaborate on policy and systems-level strategies that improve equity in cancer outcomes. Critical to this work is addressing policy system barriers, social risks, and essential needs of marginalized patients.
The ICCAN Steering Committee oversees these 2 arms to ensure evidence-based, ongoing iterative changes to each arm and to share in the planning and effectuation of quarterly ICCAN all-network meetings. Shared leadership also ensures joint articulation of goals, analysis of impact, and contributions to strategic planning.
Despite the program’s strong foundation and extensive network, challenges persist. Resource scarcity has intensified as documentation of need grows, as demand continues to rise, as charitable organizations face funding cuts, and as federal resources shrink. Shifts in federal policies, for example, including more restrictive Supplemental Nutritional Assistance Program eligibility, have increased vulnerability for patients who already face significant financial strain.
Shifts in federal policies, including more restrictive Supplemental Nutritional Assistance Program eligibility, have increased vulnerability for patients who already face significant financial strain.
After MSK incorporated universal SDOH screening into its EHR in February 2025, referrals for food insecurity and utilities assistance rose by more than 2000%. This dramatic increase, stemming from both higher screening volume and improved identification, initially exceeded the ICCAN team’s capacity.
Challenges were addressed through a series of strategic solutions, national collaborations, and personalized approaches. Following the adoption of universal SDOH screening, new workflows were developed to standardize referrals, including triage dashboards to manage the sharp increase in referrals, and the development of patient pathways connecting eligible patients with tailored support services.
In 2023, MSK initiated a formal partnership with a search engine tailored to social needs care. Integration of the tool into MSK’s EHR is intended to streamline referrals and improve follow-up processes, enhancing adoptability across clinical teams.
In recognition of the heightened needs of immigrant populations, ICCAN launched BRIdge ALLiance: Building Resources & Inclusivity for ALL Immigrants, a collaborative initiative that identifies legal, healthcare, and financial resources tailored to help immigrants with cancer, including those without authorized immigration status.
Concurrently, ICCAN expanded patient-facing services to better meet the needs of linguistically and culturally diverse populations, including telehealth navigation, access to linguistically responsive care, advanced medical interpretation, and broader dissemination of the ICCAN Equity Platform.
ICCAN also hired 2 additional facilitators, allowing the team to reach nearly 200 additional patients each year. The expanded workforce has also enabled the team to broaden its needs assessment to include psychosocial care, clinical trial access, symptom management, and shared decision-making.
Community insight and engagement is central to the ICCAN Equity Platform model. A steering committee, comprising community partners (advocacy, social service, and community-based organizations) and healthcare facilities, together with the broader ICCAN Network, meets quarterly to guide ICCAN efforts, share resources, identify emerging issues (eg, resource scarcity, policy changes affecting patients, new community concerns), and codesign solutions that inform program priorities. Insights generated through these forums have directly informed programmatic innovation and institutional change. This ongoing collaboration ensures that ICCAN remains responsive to the lived realities of the communities it serves.
In parallel, ICCAN works to increase the capacity of communities and healthcare systems to promote equitable cancer outcomes. This is achieved through sustained partnerships with community-serving organizations, shared governance and decision-making, workforce training, and the development of policies, workflows, and resource infrastructures. Through its work with the Alliance, ICCAN has brought on 24 new partners and expanded its geographic reach, ensuring that resource recommendations remain accessible and culturally appropriate for local communities.
ICCAN has achieved several significant programmatic and systematic milestones since its expansion in 2022. With the addition of a search engine tailored to social needs care, thousands of additional community-based resources are now available to MSK patients. The partnership further supports clinicians, navigators, and patients through a searchable resource platform, with future plans to transition to a closed-loop referral system to enhance tracking and accountability across the care continuum.
The integration of automated screening and referrals created a more consistent and equitable process for identifying and addressing needs early in care when a patient first presents for treatment to the healthcare facility. With universal SDOH screening now available for all patients at MSK, referrals are directly routed to social work, patient financial services, or to the Immigrant Health and Cancer Disparities Center.
In parallel, ICCAN’s expanded navigation models are designed to meet the unique needs of specific patient groups requiring more intensive care, including those receiving immuno-oncology treatment or undergoing bone marrow transplant or neuro-oncology care.
Alliance participation has elevated ICCAN’s visibility and influence, strengthening its collective voice and that of its partners to advocate for systemic changes that support patients’ essential needs. These advances are evident in both policy and practice.
Program evaluation data indicate strong implementation fidelity and meaningful outcomes. The ICCAN Program has enrolled 1207 patients since joining the Alliance. Of these patients, 96% have received navigation services. Access facilitators continuously address needs and navigate patients through 6 months of case management.
They have assisted patients with 281 financial assistance applications totaling $176,857. Access facilitators have referred patients to resources for expressed needs, which addressed 99% of food access needs, 73% of legal issues, 79% of connections and emotional support needs, and 80% of transportation requirements.
Referrals for additional expressed needs included help for 56% of healthcare needs (eg, primary care physician/dental), support with oncology communication, information about genetic testing or immunotherapy, and 76% of expressed physical well-being needs (eg, physical safety; substance use issues; smoking cessation; quality-of-life aids such as wigs, prosthesis, cold caps, and assistance with activities of daily living).
Access facilitators have also referred patients to resources to address 74% of expressed financial assistance needs, 67% of expressed housing needs, 97% of expressed telehealth needs, and 60% of expressed financial counseling needs (Table).
Collectively, these results demonstrate that ICCAN is both feasible and scalable and remains highly responsive to the social and structural barriers shaping cancer care.
Through Alliance support, the ICCAN Equity Platform has refined its model, expanded its reach, and emerged as a national leader in SDOH-focused cancer navigation, demonstrating how community-driven, equity-centered systems of care can be sustained in practice.
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