Major Gaps in Cancer Screening at Federally Qualified Health Centers

Breast, cervical, and colorectal cancer screening use at federally qualified health centers (FQHCs) was substantially lower than that seen in overall general populations, according to results from a national cross-sectional study.

Nationally, the percentages of screening-eligible patients who were up-to-date with screening at FQHCs were 45.4% for breast cancer, 51% for cervical cancer, and 40.2% for colorectal cancer compared with 78.2%, 82.9%, and 72.3%, respectively, in the U.S. general population, reported Prajakta Adsul, MBBS, MPH, PhD, of the University of New Mexico Comprehensive Cancer Center in Albuquerque, and colleagues.

The contribution of the underscreened population served by FQHCs to the national underscreened general population was 16.9%, 29.7%, and 14.7% for breast, cervical, and colorectal cancers, respectively.

“These findings highlight a major screening gap among minoritized populations and could have important implications for addressing disparities,” Adsul and team wrote in JAMA Internal Medicine.

FQHCs are federally funded nonprofit health centers that provide primary care services, regardless of ability to pay, to medically underserved populations. In 2020, a total of 28,590,897 persons were served by FQHCs, 62.2% of whom were from racial and ethnic minority groups.

Of these individuals, 90.6% were at or below the 200% federal poverty level (FPL), while 68% were at or below 100% FPL. About one in five had no health insurance, 46.9% had Medicaid or were in the Children’s Health Insurance Program, 10.4% had Medicare, 4.5% were experiencing homelessness, and 18.1% were residents of public housing.

Thus, FQHCs are disproportionately responsible for the care of low-income, marginalized, and uninsured patients, Jennifer C. Spencer, PhD, of the University of Texas at Austin, and Michael P. Pignone, MD, of Duke University School of Medicine in Durham, North Carolina, pointed out in a commentary accompanying the study. “Improving screening at FQHCs is therefore critical for both increasing the screening rates overall and for reducing existing inequities in screening by race, ethnicity, and income.”

Spencer and Pignone suggested steps to improve screening rates at FQHCs, including completing expansion of Medicaid in states where it has not been implemented and improving Medicaid reimbursement in all states; expanding funding for the CDC’s breast, cervical, and colorectal cancer screening initiatives; and increasing existing federal funding or creating novel financing to support greater FQHC adoption of team-based comprehensive care.

For this study, Adsul and colleagues obtained data from the Health Center Program Uniform Data System to assess screening use among 1,364 FQHCs that served a total of 3,162,882 breast, 7,444,465 cervical, and 6,089,345 colorectal screening-eligible individuals in 2020. They also used the Behavioral Risk Factor Surveillance System (BRFSS) to estimate national and state-specific screening use.

When broken down by state, breast cancer screening use in FQHCs ranged from 29.1% in Utah to 65.2% in Maine, while in the general population, rates ranged from 65.5% in Wyoming to 86.5% in Massachusetts.

Cervical cancer screening in FQHCs ranged from 33.7% in Wyoming to 67.9% in New Hampshire, and from 76.3% in Utah to 86.9% in Mississippi in the general population.

Colorectal cancer screening use in FQHCs ranged from 25.3% in Alabama to 60.9% in Maine, and 62.3% in California to 81.3% in Maine in the general population.

Adsul and colleagues also calculated that if screening use was optimized to 100% in FQHCs, it could increase overall screening among racial and ethnic minority groups by 7.7% for breast cancer, 7.3% for cervical cancer, and 8.5% for colorectal cancer.

If screening for all three cancers increased in FQHCs to meet the Healthy People 2030 goals (80% for breast, 79% for cervical, and 68% for colorectal cancer), overall screening among racial and ethnic minority groups would increase by 4.9% for breast cancer, 4.2% for cervical cancer, and 4% for colorectal cancer.

Why the discrepancy in cancer screening rates? The authors suggested lower screening use in FQHCs could reflect limited resources, while the low rates in some states with large uninsured populations (due to a lack of Medicaid expansion) could be the result of these centers caring for patients for whom screening tests — as well as other preventive services — aren’t covered by insurance.

Adsul and colleagues acknowledged several limitations to their study. For example, the BRFSS dataset is a self-reported national survey that could overestimate screening use, while using medical record-derived screening data could underestimate screening use in FQHCs, since it is possible some patients only sporadically seeking care in FQHCs may have undergone cancer screening elsewhere.

Nevertheless, the findings “highlight the urgency of scaling up screening use in FQHCs,” they wrote.

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