Social Determinants of Health Impact Cancer Screening Rates

Individuals living in areas of greater deprivation and rurality had lower rates of recommended cancer screening, reflecting the significant impact the social determinants of health have on care access, a study published in JAMA Network Open revealed.  

Although cancer mortality has declined over the past few decades, major disparities still impact cancer care and outcomes, the research team said.

Breast, colorectal, and cervical cancers are among the most frequently diagnosed cancers in the US. Providers can reduce the morbidity and mortality of these cancers with timely recommended screenings, but lower rates of preventive screening can exacerbate and contribute to disparities in outcomes for underserved populations.

While previous studies have examined the impact of social determinants on cancer screening practices, researchers noted that these studies tend to focus on select factors that may not capture the full complexity of a patient’s situation.

“Public health and clinical interventions aimed at improving cancer screening rates and reducing cancer-related mortality would benefit from identification of areas with greatest gaps in care access and use,” the team stated.

“Although cancer-related disparities based on income, rurality, and race/ethnicity have been individually described, it is not known how area-level deprivation alters recommended cancer screening practices independent of rurality.”

Researchers set out to examine the association between area deprivation, rurality, and screening for breast, cervical, and colorectal cancers. Using the area deprivation index (ADI), a composite measure of social determinants of health composed of 17 US Census indicators, researchers analyzed patient-level data from 75 primary care practices in Minnesota, Iowa, and Wisconsin.

The team found that the odds of completing recommended screening were decreased for individuals living in the most deprived census block group quintile compared to those living in the least deprived quintile. The odds ratios were 0.51 for breast cancer, 0.58 for cervical cancer, and 0.57 for colorectal cancer.

This finding shows that individuals living in the 20 percent most deprived census block groups were almost half as likely to undergo recommended cancer screening as those living in the 20 percent least deprived census block groups.

Individuals living in rural areas compared with urban areas also had lower rates of cancer screening, the results showed. The odds ratios were 0.76 for breast cancer, 0.81 for cervical cancer, and 0.93 for colorectal cancer, meaning rural residents were 7 to 24 percent less likely than their urban counterparts to undergo cancer screening.

These results demonstrate the significant impact community and neighborhood factors can have on care access and patient outcomes.

“In the case of cancer screening, community-based factors may intensify or supersede individual risk factors, including inadequate access to healthcare resources, poor community engagement with or distrust of the healthcare system, misperceptions about cancer screening, and other factors,” researchers said.

“Therefore, identifying disparities in cancer screening and other preventive health behaviors that stem from area-level deprivation and rurality signals the need for healthcare systems to form partnerships with local communities to enhance awareness, increase access, and improve overall health.”

Stakeholders and healthcare leaders have echoed these words, calling for partnerships and population-based approaches to address and close gaps in cancer care. In a 2019 report, the American Cancer Society stated that cross-sectoral collaborations will play a key role in reducing cancer care disparities.

“A long‐term goal should be to transform existing systems and approaches to achieve cancer health equity, rather than solely supporting individual patient needs or helping individuals to better navigate flawed systems (which are interim strategies),” the report authors wrote.

“Strategic coordination and collaboration with diverse sectors, in collaboration with researchers and in partnership with communities, are imperative to meet the needs of all population groups.”

Cross-sector and community partnerships have shown to be effective for improving screening rates for other prevalent conditions. In 2018, researchers at Cedars-Sinai Medical Center enlisted 52 barber shop owners in the LA area to offer blood pressure checks and pharmacist-led consultations to customers, increasing the availability of chronic disease management services in the community.

The initiative helped participating patrons cut their uncontrolled blood pressure within six months.

The findings from the cancer screening study could help providers improve cancer screening rates for underserved populations.

“By identifying areas where patients are most likely to forego recommended cancer screenings, these findings can instruct health systems and practices that serve patients at highest risk. This study can further inform staffing decisions associated with care coordination, social work, and outreach,” the team concluded.