A large factor that impacts cancer prevention and treatment success is the use of regular cancer screenings. Three screenings have been known to successfully reduce morbidity and mortality rates among women: colon cancer, breast cancer, and cervical cancer. Yet, these screenings are not available to or utilized by everyone.
In a 2015-2016 survey offered to women in Chicago, accessibility (or lack thereof) to cancer screenings was placed in relation to race, with researchers hypothesizing that White women would have greater access to cancer screenings than women of color.
In total, 866 women participated in the survey. Of these participants, 12 percent were White, 36 percent were Black, 49 percent were Hispanic, and 3 percent identified as other races or ethnicities. The average age among participants was 43.5 years. Other important factors considered were that 60 percent of participants lived under the poverty level and 54 percent of participants had a high school education or less.
Holly Thomas, MD, MS, a women's health researcher with the University of Pittsburgh and first author of this study, explained how marginalized groups have limited access to cancer screenings, especially colonoscopies.
"One of the issues that comes up among our patients, if they need to get a colonoscopy, [is that] they need to take the day off of work and they need someone to pick them up after the procedure," Thomas said. "Some of our patients come from more underserved communities or certain areas where geographically it may be hard for them to physically get to the location where they would have the test done. Some of them may have to take two or three buses, or they may have to try to figure out a ride if they don't have a vehicle of their own."
Thomas urges the whole system to find ways to take the burden off patients. "They could ensure that they have locations for people to complete screening that are convenient for all different types of populations that are along bus routes, [and] geographically close to underserved areas," Thomas explained. "They could come up with programs to try to help those who don't have somebody to pick them up after the test, such as professional escorts."
The Logistics
First, participants were asked if their cancer screenings were up-to-date, falling within these parameters:
1. In women aged 21-65, Pap smears for cervical cancer screenings should be completed every 5 years.
2. In women aged 50-75, mammograms for breast cancer screenings should be completed every 2 years.
3. In women over the age of 50, colon cancer screenings should be done every 10 years (colonoscopy), every 5 years (sigmoidoscopy), and every 3 years (stool testing).
The authors then evaluated the relationship between the survey's primary predictor: race (which was defined as non-Hispanic White, non-Hispanic Black, Hispanic, and other) and whether cancer screenings were up-to-date. Other factors and covariates were considered in the survey, including "income, employment, education, use of a translator, disabilities, health insurance, age, BMI, comorbidities, smoking status, marital status, health care discrimination, and trust in health care practitioner." Any factors with a P value less than 0.05 were entered into multivariable analyses.
Cervical Cancer Screening
Of the 866 women surveyed for this study, 83 percent of participants, aged 21-65, were up-to-date on their 5-year Pap smear and cervical cancer screenings. Race does not appear to be a factor that influences the accessibility of this specific cancer screening. However, other factors were considered for this section of the survey. Women with no physical disabilities and no history of hysterectomy were more likely to have cervical cancer screening up-to-date (OR 2.25 [1.02, 4.95], p=0.043; OR 5.38 [2.94, 9.88] p<0.001]. However, these covariates did not influence the effect race has on the frequency of cervical cancer screenings.
Although trust in health care providers was not related to cervical cancer screening in this survey, Thomas asserts that this trust is especially important for women who have experienced sexual assault.
"For many women, the experience of the pelvic exam that is required to do cervical cancer screening can be a very vulnerable and triggering experience," she said. "Again, a trusting relationship with a health care provider can make it easier for people with those types of fears and worries to get their screening up-to-date."
Breast Cancer Screening
Unlike the results found in relation to cervical cancer screening, race does play a role in breast cancer screenings. In this part of the survey, 80 percent of participants had up-to-date mammograms. In a univariable analysis (p=0.070), race did not play a significant role in the accessibility to mammograms.
However, contrary to the researchers' hypothesis, when considered in a multivariable analyses, it was discovered that Black women were more likely to receive up-to-date breast cancer screenings than White women (OR 4.91 [1.46, 16.51], p=0.010) within this particular population. Other significant covariates considered in this portion of the survey are employer-based health insurance (OR 3.21 [1.06, 9.75], p=0.010), a diabetes diagnosis (OR 4.00 [1.20, 13.10], p=0.005), and experience of less racial discrimination from health care practitioners (OR 10.81 [2.06, 56.58], p=0.005).
Colon Cancer Screening
Unlike cervical cancer and breast cancer screenings, race plays a significant role in colon cancer screenings. Of the women aged 50 years or older participating in the survey, only 58 percent of women had up-to-date colonoscopies, sigmoidoscopy, or stool testing. Of this 58 percent, it was discovered that women of color-non-Hispanic Black women (OR 0.61 [0.28,1.35], p=0.049), Hispanic women (OR 0.38 [0.17, 0.84] p=0.049), and women of other races (OR 0.65 [0.16, 2.70] p=0.049)-were less likely to receive up-to-date colon cancer screening in comparison to White women.
However, when other factors were considered, there was no significant relationship between race and colon cancer screening. However, lack of physical disability (OR 3.22 [1.32, 7.940], p=0.010), a diabetes diagnosis (OR 3.10 [1.52, 6.31], p=0.002), and a higher trust in a practitioner (OR 2.24 [1.18, 4.79], p=0.029) were associated with up-to-date colon cancer screening.
"Trust comes up as a major issue in that some people forgo screening, because of the test itself," Thomas said, explaining women's distrust in medical professionals. "They're worried about if they have a complication with the colonoscopy. Patients get nervous about the anesthesia. And that fear of the test itself could be exacerbated if they're from a group that historically has been discriminated against or mistreated by the health care system."
Yet, as suggested by Thomas, there are ways to build doctor-patient trust, which in turn will lead to more women receiving cancer screenings.
"So, as health care providers, we should keep this in mind and make sure that we build trusting relationships with our patients from all different backgrounds," she noted. "And, we need to have good, open, honest, trusting conversations with our patients about the pros and cons of getting tested, because we did find in our study that patients who had a higher trust in their health care provider were more likely to be screened."
Quality Improvement Initiatives
This survey discovered discrepancies in a woman's access to preventative cancer screenings and how her race may affect this access. While White women are less likely to receive mammograms than women of color, Black women are less likely to receive tests linked to colon cancer screenings.
Although other factors (such as health insurance, disabilities, and [dis]trust in health care professionals) affect a woman's access to up-to-date cancer screenings, it is undeniable that race plays a large part in this access. By recognizing this, health care practitioners can focus their efforts on quality improvement initiatives that will better serve under-resourced communities and marginalized persons.
Elizabeth Rose Galamba is a contributing writer.