June 1, 2022
Healthcare equity affects the well-being of a nation as a whole. Although surgeons aim to serve all our patients equally, healthcare has never been uniformly accessible to all populations in the US.
The differences in cancer incidence and outcomes between people of varying racial and socioeconomic backgrounds have been well documented. The Centers for Disease Control and Prevention (CDC) has delineated social determinants of health (SDOH) to include “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.”1 Healthy People 2030 categorizes SDOH into five key areas (see Table 1). Efforts to influence population health outcomes by enhancing quality of life, focusing on these five categories, have been under way, but more work is needed to achieve healthcare equity and equality. Previously published work in the Bulletin highlighted the role of surgery and SDOH and described strategies for surgeons to promote accessible, quality care for all patients.2
Cancer screening has been shown to reduce mortality from some of the most common cancers, including breast, cervical, colorectal, prostate, and lung cancer. In addition, screening enhances cancer prevention by identifying and removing precancerous lesions.3 Access to healthcare historically has been the driving factor in patients undergoing preventive screening. Health insurance coverage is associated with greater rates of screening. Uninsured and underinsured individuals have significantly lower rates of screening for cancers.4 It is imperative that we understand the obstacles that certain populations face in accessing breast, cervical, and colorectal cancer screening in order to optimize factors that allow for successful preventive care measures for all.
One in eight women in the US will be diagnosed with breast cancer during her lifetime, but mortality has been decreasing over the past 30 years, largely because of early detection by mammography.5 Although mammography has been associated with better outcomes, access to this screening modality varies among different populations. Uninsured women and recent immigrants reported the lowest prevalence of mammography use.6 Even after accounting for socioeconomic status, Black race has been shown to be an independent predictor of poor outcomes from breast cancer, highlighting the need for enhanced screening in this population.7
In 1990, the CDC created the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to provide uninsured and underinsured women with access to breast and cervical cancer screening and diagnostic and treatment services.8 However, up to 60% of all women who are eligible for the NBCCEDP were not screened for breast cancer. The reason for underuse of screening via this program likely is multifactorial.9 Eligibility guidelines and supplemental state funding to assist with the costs of delivering care vary considerably.
The costs of delivering care, including transportation and direct care (mammograms), also varies between localities, and the number of eligible women may outpace the capacity and funding to provide care. Some eligible women also may access mammogram screening via Medicaid. However, almost half of the states chose not to expand Medicaid access, which also increased disparities in eligibility between states.
In addition, a woman’s insurance status may change over the course of the year, depending on employment status. Confusion about the age group that should be screened and the frequency of screening also can lead to lower screening rates. Furthermore, women diagnosed with breast cancer through the NBCCEDP were diagnosed at a later stage compared with those diagnosed outside of the program.9
Disability also plays a role in access to cancer screening. Women with disabilities have been shown to be less likely to be up to date with breast cancer screening, although women both with and without disabilities fall short of the goal screening rate set in Healthy People 2020.10
Pathways to Improve Cancer Screening
Healthcare access and quality
Provide navigators and advocates with cultural competency training to interface with healthcare systems
Social and community context
Collaborate with community health centers, hospital clinics, and government programs to ensure access to screening such as CDC programs:
Ensure patients are screened for eligibility for appropriate programs to support healthcare (Medicaid, Medicare, Affordable Care Act)
Neighborhood and built environment
Provide case managers to assist with housing and food needs
Colorectal cancer (CRC) is the second most common cause of cancer-related deaths and the third most common form of cancer in the US.11 Screening is the most effective prevention method to decrease the burden of disease, and increased screening has been shown to reduce mortality.12 According to the CDC, one-quarter of adults have not received adequate screening for CRC.13 A variety of factors, including age, gender, ethnicity, insurance, and primary care clinic visits, affect access to and prevalence of screening. Both CRC screening and outcomes are influenced by socioeconomic and demographic factors, rural versus urban settings, and insurance coverage.14
Because primary care clinics are uniquely suited to promote health screening, there has been a push to amplify these efforts. The Colorectal Cancer Control Program, funded by the CDC, partners with clinics that serve populations from socioeconomically disadvantaged populations with the goal of increasing CRC screening rates and reducing disparities among these groups. Although these clinics had a lower overall screening rate (36.3%) than the overall US population, select evidence-based interventions, such as client and provider reminders, provider assessment and feedback, and reduction of structural barriers, have proven to increase screening rates.15
A significant reduction in the prostate cancer death rate has been shown in men who were offered prostate-specific antigen screening.16 Inequities in access to treatment are evident among certain racial and ethnic groups. Black and Hispanic men are less likely than White men to receive treatment for prostate cancer.17
The incidence of prostate cancer and mortality from the disease is significantly higher in Black men compared with the rest of the population.18 Previously, it was thought that biological differences could account for higher rates and worse outcomes in Black men. More recently, however, research has shown that after adjusting for nonbiologic differences, such as access to care, Black race was not associated with increased prostate cancer-specific mortality.19
However, using the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) data, researchers found that Black race was associated with statistically greater socioeconomic barriers to quality care.19 Li and colleagues identified differences in rates of modifiable factors in different ethnic groups with prostate cancer and demonstrated varying levels of alcohol consumption, obesity, and receipt of pneumococcal vaccination between Black and White patients. Such findings underscore the need to develop evidence-based interventions to mitigate these risks.20
The American Lung Association has shown that disparities in screening for lung cancer with low-dose computed tomography scanning as well as access to treatment have a direct effect on survival.21 It is clear that late diagnosis leads to worse outcomes. Black Americans with lung cancer are 18% less likely to be diagnosed early, 23% less likely to receive surgical treatment, 9% more likely to receive no treatment, and 21% less likely to survive 5 years compared with White Americans.21 Similar disparities were seen in Hispanic, Asian, and Native American populations.
To address disparities in lung cancer screening, the US Preventive Services Task Force (USPSTF) lowered eligibility thresholds. However, concerns remain that the revised guidelines simply perpetuate disparities by using age and pack-year criteria, which can limit referrals and access to screening facilities.22
The COVID-19 pandemic resulted in a significant decline in cancer screening. US studies have demonstrated that more than one-third of adults failed to receive recommended cancer screening during the pandemic.23 The virus has disproportionately affected Black and Hispanic/Latino populations, the same patients who experience a high burden of cancer.24
Asian-American populations also experience barriers to screening, which vary considerably depending on ethnic subgroup, language, socioeconomic status, and cultural norms.25 In addition, attacks on members of the Asian-American community during the COVID-19 pandemic likely have increased hesitancy to seek care.
Many mammography screening services were placed on hold during the pandemic, which adversely affected minorities in particular, as they already have more advanced-stage distribution of breast cancer. Furthermore, safety-net hospitals, where many socioeconomically disadvantaged patients receive their healthcare and cancer screenings, have been significantly burdened by the financial cost of treating COVID-19 patients and often were unable to support screening programs.26 An estimated 12 million individuals have lost their employer-sponsored health insurance coverage, with a disproportionate impact on Black and Hispanic people.27
To overcome the backlog of screening COVID presented, the American College of Surgeons Commission on Cancer (CoC) joined forces with the American Cancer Society and the National Accreditation Program for Breast Centers to create the PDSA (plan/do/study/act) Collaborative Project on Return to Screening, a quality improvement project and clinical study as described at here. This initiative encouraged cancer programs to prioritize safe, recommended screening for colorectal, breast, lung, and cervical cancer. The PDSA Collaborative enrolled 749 CoC-accredited programs in its study, and 814 quality improvement projects were initiated with the potential to achieve up to 70,000 additional screenings per month for 2021 if the screening targets were met, which helps to significantly move the needle toward prepandemic screening levels.
Despite the far-reaching and ever-present impact of SDOH, physicians can work to limit these effects on cancer care. As surgeons, one of our most important roles is to encourage and facilitate appropriate cancer screening. We should ensure that eligible patients are empowered to access programs such as Medicaid or Medicare, which can help to cover the costs of preventive services. We can address modifiable risk factors, such as smoking, lack of exercise, and unhealthy eating habits.28 Surgeons also can use their positions as experts in their fields and leaders in their communities to improve outreach and education efforts and to support and endorse policies and legislation that increase access to care.
Cancer screening has been linked to decreased incidence of cancer and associated mortality. Different racial and socioeconomic groups have varying rates of access to cancer screening and care, which has deleterious consequences. In addition, barriers to screening, such as reliable transportation, housing, food insecurity, language, and cultural differences, can affect the success of screening programs.29 Sexual orientation, gender minority group biases, low health literacy, mistrust of the medical system, time constraints, financial concerns, and lack of insurance also play a role.22
It is crucial that all cancer surgeons understand these disparities in access to cancer screening and the impact on cancer outcomes, so we can all work together to mitigate these inequities. As individuals, we can strive to increase awareness of disparities, confront our own implicit biases, and work closely with our hospitals and social services to increase access to care in our communities.22