Association of Historical Redlining and Present-Day Social Vulnerability with Cancer Screening

The Healthy People 2030 initiative has set national cancer screening targets at 77.1%, 74.4%, and 84.3% for breast, colon, and cervical cancers, respectively. We sought to assess the association between historical redlining relative and present-day social vulnerability on screening targets for breast, colon, and cervical cancer.

Data on national census-tract level cancer screening prevalence and social vulnerability index in 2020 was extracted from the CDC PLACES and CDC social vulnerability index databases, respectively. Census tracts were then assigned Home-Owners Loan Corporation grades (A: "Best", B: "Still Desirable", C: "Definitely Declining," and D: "Hazardous/Redlined"). Mixed-effects logistic regression and mediation analyses were conducted to evaluate the association between Home-Owners Loan Corporation grades and achievement of cancer screening targets.

Among 11,831 census tracts, 3,712 were classified as redlined (A: n = 842, 7.1% vs B: n = 2,314, 19.6% vs C: n = 4,963, 42.0% vs D: n = 3,712, 31.4%). Notably, 62.8% (n = 7,427), 21.2% (n = 2,511), and 27.3% (n = 3,235) of tracts met screening targets for breast, colon, and cervical cancer, respectively. After adjusting for present-day social vulnerability index and access to care metrics (population to primary care physician ratio and distance to nearest healthcare facility), redlined tracts were markedly less likely to meet breast (odds ratio [OR] 0.76, 95% CI 0.64 to 0.91), colon (OR 0.34, 95% CI 0.28 to 0.41), and cervical (OR 0.21, 95% CI 0.16 to 0.27) cancer screening targets compared with the "Best" tracts. Notably, poverty, lack of education, and limited English proficiency, among others, mediated the adverse effect of historical redlining on cancer screening.

Redlining as a surrogate for structural racism continues to adversely impact cancer screening. Policies that aim to make access to preventive cancer care more equitable for historically marginalized communities should be a public priority.