Historical redlining associated with lower breast cancer screening across urban neighborhoods
1. In this retrospective cohort study, historically redlined grade C and D Census tracts had lower breast cancer screening rates than grade A tracts.
2. Screening disparities remained geographically clustered over time, with poverty and lower educational attainment being key drivers of this association.
Evidence Rating Level: 2 (Good)
Study Rundown: Mammography is an important component of breast cancer detection, but screening prevalence remains uneven across communities, suggesting that structural and socioeconomic barriers continue to influence access to preventive care. Historical redlining refers to the Homeowners’ Loan Corporation (HOLC) system that graded neighborhoods from A, considered most desirable for investment, to D, considered most hazardous. These classifications contributed to sustained neighborhood disinvestment and may continue to affect contemporary health outcomes and health care use. Although prior studies have linked redlining with cancer screening disparities, many were cross-sectional and did not account for geographic clustering or changes over time. Hence, this longitudinal ecological study examined breast cancer screening patterns in historically graded neighborhoods across the University of Kansas Cancer Center catchment area. Overall, grade C and D neighborhoods had lower adjusted screening prevalence than grade A neighborhoods, independent of present-day socioeconomic conditions, housing characteristics, and distance to mammography facilities. Lower-screening neighborhoods remained geographically clustered, and most tracts remained below the national Healthy People 2030 target. Poverty and lower educational attainment were found to explain substantial portions of the association, whereas geographic distance contributed relatively little. The study was limited by its use of Census tract-level and model-based estimates rather than individual-level behavior, which may have attenuated associations. Further, the use of straight-line distance may have been an incomplete measure of access. Nonetheless, these findings support place-based strategies to address persistent inequities and socioeconomic barriers to screening.
Click to read the study in JAMA
Relevant Reading: Association of Historical Redlining and Present-Day Social Vulnerability with Cancer Screening
In-Depth [retrospective cohort]: This study analyzed annual breast cancer screening prevalence from 2016 through 2024 in 1,152 historically HOLC-graded urban Census tracts across Kansas and adjacent Missouri counties. The sample included 27 grade A, 99 grade B, 423 grade C, and 603 grade D tracts. The primary outcome was the Centers for Disease Control estimate of the proportion of women aged 50 to 74 years who reported receiving mammography within the recommended interval. Exposures included HOLC grade, Social Vulnerability Index quintile, socioeconomic, housing, and transportation characteristics, and distance to the nearest certified mammography facility. Median screening prevalence was 79.6% in grade A tracts versus 75.2% in grade D tracts. After adjustment, grade C (odds ratio [OR], 0.94; 95% credible interval [CrI], 0.90 to 0.99) and D (OR, 0.94; 95% CrI, 0.89 to 0.99) tracts each had lower odds of screening than grade A tracts. Lower educational attainment was also associated with lower screening prevalence (OR, 0.94; 95% CrI, 0.92 to 0.96), while distance to the nearest mammography facility was not independently associated with screening (OR, 0.97; 95% CrI, 0.93 to 1.01). Geographic disparities persisted after adjustment, and 84.4% of tracts remained below the Healthy People 2030 screening target of 80.3%. In the mediation analysis, poverty accounted for an estimated 44.5% of the association between redlining and screening prevalence (95% confidence interval [CI], 22.7% to 76.1%), while lower educational attainment accounted for 25.5% (95% CI, 6.7% to 54.0%). Overall, these results highlight lasting inequities from historical residential segregation.
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