Even though cancer death rates have dropped “at an accelerated pace" nationwide in the past several decades, these gains have not been shared equally among all US. residents. The COVID-19 pandemic and the delays in preventative care that resulted only exacerbated many of these entrenched cancer screening and care inequities. A heightened focus on narrowing these gaps is necessary to reduce racial, ethnic, socioeconomic, and geographic inequities in cancer occurrences and outcomes.
Pandemic creates widespread cancer screening delays
At the onset of the pandemic, healthcare settings cancelled routine cancer screenings to keep people safe and to prioritize urgent medical needs. Even after facilities restarted preventive care, many people still avoided unnecessary healthcare visits, resulting in a dramatic decline in cancer screenings. In 2020, people missed about 9.4 million cancer screenings that would have typically occurred, according to findings published in JAMA Oncology.
The decline in screenings has led to a “significant drop" in the number of newly-diagnosed cancer across many disease types, points out oncologist Dr. Yuri Fesko, the vice president of medical affairs at Quest Diagnostics, in a recent video interview on Managed Healthcare Executive. That doesn't mean those cancers went away; people simply didn't get diagnosed.
As a result, oncologists are concerned about late-stage cancers that are harder to treat. The country hasn't returned to or surpassed the baseline of cancer diagnosis, something that was expected, he added.
Routine cancer screenings haven't rebounded
That could be a result of screening levels that still haven't rebounded. Despite some initial jumps, the rates of several key cancer screenings are still lower than pre-pandemic levels, researchers recently reported in JAMA Oncology.
“The findings suggest that screening quickly rebounded after the initial stages of the pandemic; however, the longer follow-up time reveals that gaps in preventive cancer screening returned and worsened," researchers wrote.
Approaching cancer differently
Initiatives such as the American Cancer Society's Return-to-Screening are trying to pinpoint these cancer screening gaps and identify who has been most impacted. That nationwide effort, which includes hundreds of accredited cancer facilities, is focused on:
- Increasing public awareness of screenings
- Improving healthcare provider emphasis on screenings
- Improving access to cancer screenings by extending hours or providing financial support
It's still uncertain how well these efforts will address gaps that existed before the pandemic. Even as some regions and people have made significant strides in returning to pre-pandemic screenings levels, some are still faring worse than others, points out Dr. Jennifer Croswell, of the Healthcare Research Delivery Program, in a recent National Cancer Institute post. The current moment may provide a good opportunity to double down on efforts to address these longstanding gaps.
"Disruptions to care due to the pandemic could represent an unparalleled opportunity to reassess early detection programs towards an explicit, thoughtful, and just prioritization of populations historically experiencing cancer disparities," writes Croswell and other researchers in the journal Preventative Medicine. "By focusing screening services on populations that have the most to gain, and by careful and deliberate planning for the period following the pandemic, we can positively affect cancer outcomes for all."
Despite positive strides, key inequities remain
US cancer death rates have been declining for decades, but there are still stark inequities in cancer occurrences and outcomes by race and ethnicity as well as factors such as geography, education level, and socioeconomic status. Here are just a few key examples of an imbalance of health equity that the American Cancer Society and other recent studies note:
- Black people have the highest death rate and shortest survival of any racial/ethnic group in the United States for most cancers.
- Black women have a 41% higher breast cancer death rate than White women even though their incidence of breast cancer is lower.
- Black men have 6% higher cancer incidence than White men but 19% higher cancer mortality.
- The cancer mortality among American Indian and Alaska Native individuals is 18% higher than among White individuals despite similar cancer incidence.
- In the United States, there are disparities in cancer mortality rates between people with a bachelor's degree or more and those with less education, a gap that is especially pronounced with lung cancer deaths.
- The incidence rates of colorectal, lung, and cervical cancers are much higher in rural Appalachia than in urban areas in the region.
Gaps in cancer screening rates widespread
Historically, cancer screening rates have been “substantially lower" among Black, Asian American, LatinX and American Indian/Alaska Native people when compared to White Americans, according to a systemic review published in 2020 in the Journal of Racial and Ethnic Health Disparities.
Across all cancer types, though, screening patterns can vary, with White people receiving less of certain cancer screenings, points out this Kaiser Family Foundation brief.
Along with race and ethnicity, other factors can influence these rates as well, including geography matters. For example, there are well-reported cancer screening and treatment gaps such cervical cancer disparities in the country's Appalachian region.
What's causing the inequities?
Factors that contribute to these differences in screening may include low health literacy, lack of health insurance and miscommunication between patients and providers. Along with access challenges, the Kaiser Family Foundation brief also describes other systemic factors such as discrimination and bias within the healthcare system.
There may also be heightened exposure to risk factors because of underlying social and economic inequities. Some research suggests hereditary risk and genetic determinants for some specific cancers. In addition, historically disadvantaged people might be less represented from clinical trials that determine screening guidelines.
Looking at the role of structural biases in cancer screening and prevention
The Centers for Disease Control and Prevention describes how structural racism can lead to healthcare access challenges for historically marginalized groups. A lack of convenient options for clinics providing colonoscopies could contribute to the higher rates of colorectal cancer among American Indian and Alaska Native groups.
Institutional racism in the form of less clinical follow-ups after screening may help explain why Black women are less likely to live five years after a cervical cancer diagnosis when compared to White women, the CDC notes.
Better understanding and exploring the role of these systems and lived experiences in creating heightened cancer risk is a key step in addressing them. To that extent, there have been numerous examples of multi-disciplinary efforts to better understand the intersection of structural racism and cancer.
Focusing on the community level
Acknowledging these inequities and better understanding the source is only the first step. Community-level engagement and action is essential in addressing and narrowing these health equity gaps.
One example of this approach comes from the San Francisco Cancer Initiative, a collaboration among residents, the city and community groups to reduce preventable cancers, especially among historically marginalized communities. The group and its community partners implement “culturally-sensitive, community education and outreach to improve screening rates for some of the city's most devastating cancers."
Exploring strategies to improve patient outcomes
Across the country, another well-known effort is addressing the high cancer rates in Appalachia, a region where many residents struggle to access healthcare resources. Central Appalachia has the highest cancer rate in the region at 32% higher than the national average, according to the Association of Community Cancer Centers.
In December 2021, that organization and several of its state chapters created the Appalachian Community Cancer Alliance with the goal of identifying evidence-based practices to improve patient outcomes throughout the region. For example, one initiative increases lung cancer screenings through a mobile effort, a move recognized by the White House in 2022.
Promoting diversity in clinical trials
Other groups such as Association for Clinical Oncology are working to improve diverse representation in clinical trials. In the Journal of Clinical Oncology, the group outlines specific recommendations and strategies for the research community to improve equity, diversity, and inclusion in cancer clinical trials. These steps include forming long-standing partnerships with patients, patient advocacy groups, and community leaders and their respective groups. The approach also involves reoccurring education and training to maintain the commitment.
Keeping health equity at the forefront
As the country addresses the lingering impact of these pandemic-related delays in cancer screenings and care, it's important to also address these longstanding inequities in cancer screenings and treatment. Sustained attention, research and resources are needed to close the gaps leading to cancer's uneven toll.
Let RTI Health Advance help you address inequities
RTI Health Advance helps clients address and identify and the root causes of health inequities. We use evidence-based health equity solutions that tailor interventions in an effort to address and narrow these cancer care gaps.