Although redlining was outlawed more than 50 years ago, individuals who currently live in historically redlined areas may be less likely to be screened for breast cancer, colorectal cancer, and cervical cancer than individuals who live in areas not associated with redlining practices, according to a new study published by Zorays et al in the Journal of the American College of Surgeons.
Background
Redlining is a discriminatory practice in which financial institutions refuse to provide loans or insurance to individuals who live in areas deemed to have high financial risks. The practice predominately impacted Black individuals attempting to buy homes and contributed to segregation and inequality. Congress banned the practice under the Fair Housing Act of 1968; however, individuals who live in the areas that were once redlined continue to be negatively affected—as evidenced by low rates of cancer screenings.
Until this study, the impact of historical redlining on cancer screenings, regardless of contemporary social vulnerability, has been largely unexplored.
“Our study shows that the legacy of redlining has a long historical arc that still persists today [as a result of] chronic underinvestment in these areas,” explained senior study author Timothy Pawlik, MD, PhD, MPH, MTS, MBA, FACS, FRACS (Hon), Professor of Surgery and Chair of the Department of Surgery at the College of Medicine, Surgeon-in-Chief at the Wexner Medical Center, and the Urban Meyer III and Shelley Meyer Chair for Cancer Research at The Ohio State University Comprehensive Cancer Center–Arthur G. James Cancer Hospital and Richard J. Solove Research Institute. “Redlining serves as a surrogate for systemic racism, especially as it pertains to those who live in areas that lack adequate investment in education, employment, transportation, and healthcare,” he added.
Study Methods and Results
In the new study, investigators used national 2020 census-tract level data to examine cancer screening rates and historical redlining grades and discovered that:
- Among the 11,831 census-tracts incorporated in the study, 31.4% (n = 3,712) of them were redlined—with the greatest number of redlined tracts occurring in New York and California, particularly in the New York City and Los Angeles metropolitan areas.
- Areas with redlining were associated with lower odds of hitting screening targets for all three types of cancers—with a 24% lower rate for breast cancer, 64% lower rate for colorectal, and 79% lower rate for cervical cancer—compared with areas without redlining. This association persisted even after adjusting for contemporary social vulnerability and access to care.
- A large proportion of the total effect of redlining on cancer screenings was attributable to poverty, lack of education, and limited English proficiency.
“I find this study on the impact of historic redlining practices on current cancer screening rates to be incredibly important and sobering. The findings clearly demonstrate that the legacy of redlining continues to contribute to significant disparities in breast [cancer], colorectal [cancer], and cervical cancer screenings—highlighting the urgent need for targeted interventions and policy reforms to address underlying structural racism and improve health equity in our historically marginalized communities,” stressed David Tom Cooke, MD, FACS, Professor and Founding Chief of the Division of General Thoracic Surgery and Director of the General Thoracic Surgery Robotics Program at the University of California, Davis Health as well as President of the Thoracic Surgery Directors Association, who was not involved in this study. “[These findings] underscore the responsibility of health-care systems, including academic and non-academic medical centers, to proactively tackle social determinants of health, such as redlining, to achieve equitable access to cancer screenings and ultimately save lives,” he argued.
Next Steps to Eliminate Residual Redlining and Boost Cancer Screening Rates
By demonstrating the long-term implications of discriminatory practices, the new findings can help shape health-care and social policy reform to reduce health inequities.
The investigators emphasized that those efforts begin with specific, actionable initiatives. Determining how to improve cancer screening rates in specific areas may require resident questionnaires to determine the potential barriers. For instance, if transportation or English proficiency were barriers, travel vouchers or interpreters could be provided.
The investigators further identified approaches that could help improve cancer screening rates in historically redlined areas:
- New government policies could target the areas with social services aimed at poverty alleviation, affordable housing, and education.
- Initiatives could be introduced to improve access to preventive cancer care and mitigate cancer screening disparities—notably initiatives such as the Mobile Mammography Van by the Navajo Breast and Cervical Cancer Prevention Program.
- Alternative methods could be explored to make it easier for affected individuals to get screened for cancer. For example, since colonoscopies pose significant barriers to care, such as bowel prep and time required for the exam, tests to detect DNA mutations and blood in the stool may be more workable approaches.
“I think the fact that the cancer screenings [are] so disparate in these communities is a real wake up call to all of us,” Dr. Pawlik concluded.
Disclosure: For full disclosures of the study authors, visit journals.lww.com.
