Colorectal cancer (CRC) screening saves lives, yet screening rates among underserved populations, such as the uninsured and minorities, are low.^1-4 The best CRC screening strategy for underserved populations is unclear. Colonoscopy is known to be the most sensitive test for colorectal neoplasia.⁵ However, it is unclear on a population level whether colonoscopy should the primary test promoted for boosting screening for all groups for several reasons. Colonoscopy may not be as acceptable as noninvasive tests such as the fecal immunochemical test (FIT) to all populations.^6-8 If associated with higher participation rates, programmatic screening with less-invasive tests may result in similar or even better population effectiveness than population colonoscopy screening.^5,9 Financial resources and infrastructure required for colonoscopy vs noninvasive screening are markedly different.¹⁰ These issues are especially germane for underserved populations because prior work suggests screening participation may differ by type of test offered⁸ and because safety-net health systems that typically care for underserved populations face financial challenges and have limited colonoscopy capacity.^11,12

Background: Although numerous studies have examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES, findings have been inconsistent. A systematic review of existing studies is timely to identify conceptual and methodologic limitations and to provide a basis for future research directions and policy. Objective: The objectives were to (a) describe the study designs, constructs, methods, and measures; (b) describe the independent association of area SES and cancer screening; and (c) identify neglected areas of research. Methods: We searched six electronic databases and manually searched cited and citing articles. Eligible studies were published before 2008 in peer-reviewed journals in English, represented primary data on individuals ages ≥18 years from developed countries, and measured the association of area and individual SES with breast, cervical, or colorectal cancer screening. Results: Of 19 eligible studies, most measured breast cancer screening. Studies varied widely in research design, definitions, and measures of SES, cancer screening behaviors, and covariates. Eight employed multilevel logistic regression, whereas the remainder analyzed data with standard single-level logistic regression. The majority measured one or two indicators of area and individual SES; common indicators at both levels were poverty, income, and education. There was no consistent pattern in the association between area SES and cancer screening. Discussion: The gaps and conceptual and methodologic heterogeneity in the literature to date limit definitive conclusions about an underlying association between area SES and cancer screening. We identify five areas of research deserving greater attention in the literature. (Cancer Epidemiol Biomarkers Prev 2009;18(10):2579–99)

BACKGROUND: The authors investigated whether residential segregation (the degree to which racial/ethnic groups live separately from one another in a geographic area) 1) was associated with mortality among urban women with breast cancer, 2) explained racial/ethnic disparities in mortality, and 3) whether its association with mortality varied by race/ethnicity.METHODS: Using Texas Cancer Registry data, all‐cause mortality and breast‐cancer mortality were examined among 109,749 urban black, Hispanic, and white women aged ≥50 years who were diagnosed with breast cancer from 1995 to 2009. Racial (black) segregation and ethnic (Hispanic) segregation of patient's neighborhoods were measured and were compared with the larger metropolitan statistical area using the location quotient measure. Shared frailty Cox proportional hazard models were used to nest patients within residential neighborhoods (census tract) and were controlled for race/ethnicity, age, diagnosis year, tumor stage, grade, histology, neighborhood poverty, and county‐level mammography availability.RESULTS: Greater black segregation and Hispanic segregation were adversely associated with cause‐specific mortality and all‐cause mortality. For example, in adjusted models, Hispanic segregation was associated with cause‐specific mortality (adjusted hazard ratio, 1.24; 95% confidence interval, 1.05‐1.46). Compared with whites, blacks had higher mortality for both outcomes, whereas Hispanics demonstrated equivalent (cause‐specific) or lower (all‐cause) mortality. Segregation did not explain racial/ethnic disparities in mortality. Within each race/ethnicity strata, segregation was either adversely associated with mortality or was not significant.CONCLUSIONS: Among urban women with breast cancer in Texas, segregation has an independent, adverse association with mortality, and the effect of segregation varies by patient race/ethnicity. The novel application of a small‐area measure of relative racial segregation should be examined in other cancer types with documented racial/ethnic disparities across varied geographic areas. Cancer 2015;121:1845–1855. © 2015 American Cancer Society.

This study sought to characterize racial and ethnic disparities in cervical cancer screening and follow-up of abnormal findings across 3 U.S. healthcare settings. Data were from 2016 to 2019 and were analyzed in 2022, reflecting sites within the Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings & Populations Research Center, part of the Population-based Research to Optimize the Screening Process consortium, including a safety-net system in the southwestern U.S., a northwestern mixed-model system, and a northeastern integrated healthcare system. Screening uptake was evaluated among average-risk patients (i.e., no previous abnormalities) by race and ethnicity as captured in the electronic health record, using chi-square tests. Among patients with abnormal findings requiring follow-up, the proportion receiving colposcopy or biopsy within 6 months was reported. Multivariable regression was conducted to assess how clinical, socioeconomic, and structural characteristics mediate observed differences. Among 188,415 eligible patients, 62.8% received cervical cancer screening during the 3-year study period. Screening use was lower among non-Hispanic Black patients (53.2%) and higher among Hispanic (65.4%,) and Asian/Pacific Islander (66.5%) than among non-Hispanic White patients (63.5%, all p<0.001). Most differences were explained by the distribution of patients across sites and differences in insurance. Hispanic patients remained more likely to screen after controlling for a variety of clinical and sociodemographic factors (risk ratio=1.14, CI=1.12, 1.16). Among those receiving any screening test, Black and Hispanic patients were more likely to receive Pap-only testing (versus receiving co-testing). Follow-up from abnormal results was low for all groups (72.5%) but highest among Hispanic participants (78.8%, p<0.001). In a large cohort receiving care across 3 diverse healthcare settings, cervical cancer screening and follow-up were below 80% coverage targets. Lower screening for Black patients was attenuated by controlling for insurance and site of care, underscoring the role of systemic inequity. In addition, it is crucial to improve follow-up after abnormalities are identified, which was low for all populations.