Social risks impede cancer screening, even with access to care

Researchers at University of California San Diego and collaborating institutions have shed light on the ways that social risks, such as housing or food insecurity, pose barriers to routine cancer screenings. The study, published in JNCI Cancer Spectrum, found that patients experiencing social risks were less likely to receive orders for cancer screenings and even less likely to complete screenings when ordered. The study also found that patients experiencing social risks had higher rates of primary care visits, suggesting that access to care is not the main barrier to cancer screening in this population.

“It’s well established that social risks are associated with numerous negative health outcomes, including cancer risk, but we wanted to look more closely at how these risks affect specific aspects of cancer prevention,” said study first author Matthew P. Banegas, Ph.D., M.P.H, associate professor and co-director of the Center for Health Equity Education and Research in the Department of Radiation Medicine and Applied Sciences at UC San Diego School of Medicine. “By tailoring interventions to address specific social risks and ensuring that patients are able to complete routine screenings, we can provide better quality care and improve health outcomes more effectively.”

The team used electronic health record data from OCHIN, a national nonprofit health IT consultancy and provider of electronic health record services for community health centers and rural hospitals, to study the associations between social risks and receipt of screening for three common cancers — cervical, colorectal and breast cancers — among patients at 186 community-based health care organizations (CBHCOs) across 13 states. CBHCOs provide essential care to underserved communities at no or little cost. For low-income, rural and immigrant populations, CBHCOs are often the only way for patients to access cancer screenings and other essential preventative care. However, despite having access to care through a CBHCO, these patients still experience a greater burden of social risks than the general U.S. population.

"This study shows that social drivers of health impact patients' ability to receive needed cancer screenings, through very complex pathways," said senior author Rachel Gold, Ph.D., M.P.H., director of the implementation science program at OCHIN. "It's very important to understand this, because cancer screenings save lives, and should be equitably accessible to all patients."

"Access to care is just one of many social risks that affect marginalized populations, and our study highlights the complex pathways between these varied social risks and cancer early detection services,” added Banegas, who is also a member of the Cancer Control Program at UC San Diego’s Moores Cancer Center. "We found that patients with food insecurity, housing instability and transportation insecurity all face barriers to receiving and completing cancer screening orders, but that these effects varied by risk and cancer type.”

The study’s key findings include:

• Health care providers were less likely to order all three types of cancer screenings for patients with food insecurity, and cervical cancer screenings were ordered less often for patients with transportation insecurity.
• Patients with food insecurity were less likely to complete ordered screenings for cervical and colorectal cancer, but patients with transportation insecurity were less likely to complete ordered screenings for colorectal cancer only.
• The likelihood of completing an ordered breast cancer screening did not differ significantly in patients with social risks compared to those without.

While further research is needed to identify the root cause of these varied trends, the researchers hypothesize that patients with food insecurity may be less likely to be ordered cancer screenings because the urgency of food insecurity may shift the focus of primary care visits toward addressing more acute health risks, leading to delays in preventive care. Additionally, once cancer screenings are ordered, it may be difficult for patients to follow through and complete screenings that require additional appointments or procedures, such as a colonoscopy or a Papanicolaou (Pap) test. In contrast, mammograms are relatively easy for patients to complete, in part because outreach programs like mobile mammography clinics support mammogram access.

Banegas noted that the study's findings are particularly relevant in the context of recent policy changes aimed at addressing social determinants of health. "The Centers for Medicare and Medicaid Services (CMS) has recently mandated that health systems screen patients for social risks, and has also started connecting patients with identified unmet social risk to services," he said. "This is a huge step forward for health equity.”

However, the findings also highlight the need for health care providers to take a more holistic approach to patient care in order to appropriately address social risk proactively in the clinic.

"We need to continue to study the pathways between social risks and health outcomes and develop strategies for addressing these challenges in a way that is meaningful and practical for patients," Banegas said. “By investing in prevention and early intervention, we can save significantly on healthcare spending and, more importantly, improve health outcomes for patients.”

Additional coauthors on the study include Jean O’Malley at OCHIN, Jorge Kaufmann, Miguel Marino and Nathalie Huguet at Oregon Health & Science University, Laura M. Gottlieb at UC San Francisco, and Adjoa Anyane-Yeboa at Massachusetts General Hospital.

This work was supported by the National Cancer Institute of the National Institutes of Health (grant P50CA244289). This P50 program was launched by NCI as part of the Cancer Moonshot.

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