March 4, 2025
Researchers from OCHIN partnered with colleagues at the University of California, San Diego, and Oregon Health & Science University to study the pathways connecting social risks with a lower likelihood of receiving clinically indicated cancer screening services among community health center patients.
This study was part of the BRIDGE-C2 project. The team recently published findings on how often community clinic patients with social risks were up to date on breast, cervical or colorectal cancer screenings. Among those due for a screening, the researchers assessed:
- Whether the provider placed an order for the recommended cancer screening.
- Whether the screening order was completed (meaning the test was performed).
These findings help determine how different social risks impact cancer screening completion.
The vital role of primary care in overcoming social barriers to cancer screening
Social risks, such as transportation instability, housing instability, and food insecurity—also known as adverse social determinants of health—can limit individuals’ ability to engage in preventive care, such as screening for early detection of breast, cervical and colorectal cancer. To improve cancer screening rates among individuals with social risk factors, researchers must better understand how these risks impede completion of preventive care measures like mammograms and colonoscopies.
Community-based health centers are often the primary source of cancer screening for the populations they serve, many of whom experience social risks. These health care providers need evidence on the pathways through which social risks prevent patients from receiving these life-saving preventive care measures.
Examining how social risks affect colorectal and cervical screenings
A research team from OCHIN, led by Rachel Gold, PHD, MPH, OCHIN’s program director of implementation science, collaborated on this study with colleagues from the University of California, San Diego, led by Mateo Banegas, PhD, and Oregon Health & Science University, led by Jennifer DeVoe, MD.
The researchers used data from July 2015 to February 2020 from 186 community-based health care organizations in the OCHIN network to compare cancer screening measures between patients who reported food, housing, financial or transportation insecurity and those who did not report these social risks.
The study team found that patients with social risks were less likely to be up to date on any cancer screening at the start of the study and, in most cases, spent fewer study months up to date on screenings compared to those without these risks. This was true even though patients with social risks had a higher rate of clinic visits during the study, suggesting that a lack of access to primary care was not the reason screenings did not occur.
All cancer screenings were ordered less often for food-insecure patients, and cervical cancer screenings were ordered less often for transportation-insecure patients. Patients with food insecurity were less likely to complete ordered cervical or colorectal cancer screenings, while those with transportation insecurity were less likely to complete ordered colorectal cancer screenings. No differences in breast cancer screening completion were observed in relation to social needs.
How these findings can improve cancer screenings
The study investigated whether lower cancer screening rates among community clinic patients result from differences in primary care access, receipt of screening orders, or screening completion. The results suggest these differences are not due to a lack of access to primary care but rather stem from other factors. The findings lay the foundation for further research into these pathways to aid in developing mitigation plans, including the following:
- Food insecurity: All three screenings were ordered less frequently for patients experiencing food insecurity, possibly because the urgency of their situation shifts the focus of the visit away from preventive care. A possible mitigation strategy is to allow longer appointments for patients with social needs, enabling providers to address both food insecurity and cancer screening.
- Transportation barriers and cervical cancer screening: Lower rates of cervical cancer screening orders among patients with transportation barriers may be due to their inability to stay at the clinic long enough to complete a Pap smear (Papanicolaou test, a procedure that examines cervical cells for signs of cancer), resulting in no order being issued.
- Housing instability and colorectal cancer screening: Lower rates of colorectal cancer screening orders among patients experiencing housing instability may be because providers assume or know that these patients lack reliable bathroom access for colonoscopy preparation or do not have a stable address to receive a fecal immunochemical test (FIT, a test that detects hidden blood in stool).
- Breast cancer screening completion: Completion rates for breast cancer screening (mammograms) did not differ among patients with social risks, possibly because mammograms are easier to complete than other screenings, aided by initiatives such as mobile mammography clinics. However, patients with transportation barriers were less likely to complete colorectal cancer screening, possibly because stable transportation home is required for the procedure.
By identifying which factors are and are not associated with decreased screening completion, this research helps guide the next steps in developing mitigation strategies. For example, to better understand how transportation insecurity affects screening rates, researchers could conduct focus groups with patients and providers. Their input could inform design of an intervention, such as a policy solution—funding longer visits for patients with social needs or expanding programs for affordable housing—or a clinical operations solution, such as more efficient referral processes for social needs.
“Social risks affect patients' ability to receive needed cancer screenings through complex pathways. It is important to understand this because cancer screenings save lives and should be accessible to all patients,” Gold said.
This study highlights how OCHIN’s research team works to improve health outcomes for patients served by community clinics by exploring ways these clinics can address barriers to cancer screening.
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. The BRIDGE-C2 center was one of seven Implementation Science Centers in Cancer Control funded by the National Cancer Institute.
The research reported in this work was powered by PCORnet®. PCORnet has been developed with funding from the Patient-Centered Outcomes Research Institute® (PCORI®) and conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network (CRN). ADVANCE is a Clinical Research Network in PCORnet® led by OCHIN in partnership with Health Choice Network, Fenway Health, University of Washington, and Oregon Health & Science University. ADVANCE’s participation in PCORnet® is funded through the PCORI Award RI-OCHIN-01-MC.
