Equity, diversity, and inclusion in the Multinational Association for Supportive Care in Cancer: a global membership survey.

Equity, diversity, and inclusion (EDI) are essential for healthcare organizations since they allow for the development of programs and initiatives that bring together diverse perspectives and knowledge. Global multidisciplinary organizations, such as the Multinational Association for Supportive Care in Cancer (MASCC), need to understand the perspective of their members regarding EDI to identify opportunities to enhance diversity and inclusiveness and to better meet the needs of members from different backgrounds and resources. The MASCC Health Disparities Committee designed a survey to identify issues related to disparities faced by MASCC members when providing supportive care to patients with cancer and to examine the EDI landscape within the organization. Here, we report results related to EDI initiatives within the organization. Two-hundred and eighteen MASCC members responded to the survey (response rate 10.2%). The results indicated that respondents were generally satisfied with how MASCC manages leadership, membership, and organization-related EDI issues. Opportunities for improvement noted by respondents included developing strategies to foster a more diverse membership, improving communication regarding diversity in the organization, and increasing EDI content in educational sessions and publications. The results of this survey represent the first attempt at understanding how to improve EDI within MASCC and will be utilized to guide further initiatives and programs.

Factors contributing to differences in cervical cancer screening in rural and urban community health centers.

INTRODUCTION: Community health centers (CHCs) provide historically marginalized populations with primary care, including cancer screening. Previous studies have reported that women living in rural areas are less likely to be up to date with cervical cancer screening than women living in urban areas. However, little is known about rural-urban differences in cervical cancer screening in CHCs and the contributing factors, and whether such differences changed during the COVID-19 pandemic. METHODS: Using 8-year pooled Uniform Data System (2014-2021) data and Oaxaca-Blinder decomposition, the extent to which CHC- and catchment area-level characteristics explained rural-urban differences in up-to-date cervical cancer screening was estimated. RESULTS: Up-to-date cervical cancer screening was lower in rural CHCs than urban CHCs (38.2% vs 43.0% during 2014-2019), and this difference increased during the pandemic (43.5% vs 49.0%). The rural-urban difference in cervical cancer screening in 2014-2019 was mostly explained by differences in CHC-level proportions of patients with limited English proficiency (55.9%) or income below the poverty level (12.3%) and females aged 21 to 64 years (9.8%), and catchment area-level's unemployment (3.4%) and primary care physician density (3.2%). However, Medicaid (-48.5%) or no insurance (-19.6%) counterbalanced the differences between rural-urban CHCs. The contribution of these factors to rural-urban differences in cervical cancer screening generally increased in 2020-2021. CONCLUSIONS: Rural-urban differences in cervical cancer screening were mostly explained by multiple CHC-level and catchment area-level characteristics. The findings call for tailored interventions, such as providing resources and language services, to improve cancer screening utilization among uninsured, Medicaid, and patients with limited English proficiency in rural CHCs.

American Cancer Society's report on the status of cancer disparities in the United States, 2023.

In 2021, the American Cancer Society published its first biennial report on the status of cancer disparities in the United States. In this second report, the authors provide updated data on racial, ethnic, socioeconomic (educational attainment as a marker), and geographic (metropolitan status) disparities in cancer occurrence and outcomes and contributing factors to these disparities in the country. The authors also review programs that have reduced cancer disparities and provide policy recommendations to further mitigate these inequalities. There are substantial variations in risk factors, stage at diagnosis, receipt of care, survival, and mortality for many cancers by race/ethnicity, educational attainment, and metropolitan status. During 2016 through 2020, Black and American Indian/Alaska Native people continued to bear a disproportionately higher burden of cancer deaths, both overall and from major cancers. By educational attainment, overall cancer mortality rates were about 1.6-2.8 times higher in individuals with ≤12 years of education than in those with ≥16 years of education among Black and White men and women. These disparities by educational attainment within each race were considerably larger than the Black-White disparities in overall cancer mortality within each educational attainment, ranging from 1.03 to 1.5 times higher among Black people, suggesting a major role for socioeconomic status disparities in racial disparities in cancer mortality given the disproportionally larger representation of Black people in lower socioeconomic status groups. Of note, the largest Black-White disparities in overall cancer mortality were among those who had ≥16 years of education. By area of residence, mortality from all cancer and from leading causes of cancer death were substantially higher in nonmetropolitan areas than in large metropolitan areas. For colorectal cancer, for example, mortality rates in nonmetropolitan areas versus large metropolitan areas were 23% higher among males and 21% higher among females. By age group, the racial and geographic disparities in cancer mortality were greater among individuals younger than 65 years than among those aged 65 years and older. Many of the observed racial, socioeconomic, and geographic disparities in cancer mortality align with disparities in exposure to risk factors and access to cancer prevention, early detection, and treatment, which are largely rooted in fundamental inequities in social determinants of health. Equitable policies at all levels of government, broad interdisciplinary engagement to address these inequities, and equitable implementation of evidence-based interventions, such as increasing health insurance coverage, are needed to reduce cancer disparities.

Government Housing Assistance and Cancer Screening Among Adults With Low Income.

INTRODUCTION: Access to affordable housing may support cancer control for adults with low income by alleviating financial barriers to preventive care. This study examines relationships between cancer screening and receipt of government housing assistance among adults with low income. METHODS: Data are from the 2019 and 2021 National Health Interview Survey. Eligible respondents were classified as up-to-date or not with breast cancer (BC), cervical cancer (CVC) and colorectal cancer (CRC) screening guidelines. Multivariable logistic regression was used to model guideline-concordant screening by receipt of government housing assistance, overall and stratified by urban-rural status, race/ethnicity, and age. Analyses were performed in 2023. RESULTS: Analyses for BC, CVC and CRC screening included 2,258, 3,132, and 3,233 respondents, respectively. There was no difference in CVC screening by housing assistance status, but screening for BC and CRC was higher among those who received assistance compared to those who did not (59.7% vs. 50.8%, p<0.01 for BC; 57.1% vs. 44.1%, p<0.01 for CRC). In models adjusted for sociodemographic characteristics, health status and insurance, these differences were not statistically significant for either BC or CRC screening. In stratified adjusted models, housing assistance was statistically significantly associated with increased BC screening in urban areas (aOR=1.35, 95% CI=1.00-1.82) and among Hispanic women (aOR=2.20, 95% CI=1.01-4.78) and women 45-54 years of age (aOR=2.10, 95% CI=1.17-3.75). CONCLUSIONS: Policies that address housing affordability may enhance access to BC screening for some subgroups, including women in urban areas, Hispanic women, and younger women. More research on the mechanisms that link housing assistance to BC screening is needed.

Living alone and cancer mortality by race/ethnicity and socioeconomic status among US working-age adults.

BACKGROUND: Previous studies have shown an association between living alone and cancer mortality; however, findings by sex and race/ethnicity have generally been inconsistent, and data by socioeconomic status are sparse. The association between living alone and cancer mortality by sex, race/ethnicity, and socioeconomic status in a nationally representative US cohort was examined. METHODS: Pooled 1998-2019 data for adults aged 18-64 years at enrollment from the National Health Interview Survey linked to the National Death Index (N = 473,648) with up to 22 years of follow-up were used to calculate hazard ratios (HRs) for the association between living alone and cancer mortality. RESULTS: Compared to adults living with others, adults living alone were at a higher risk of cancer death in the age-adjusted model (HR, 1.32; 95% CI, 1.25-1.39) and after additional adjustments for multiple sociodemographic characteristics and cancer risk factors (HR, 1.10; 95% CI, 1.04-1.16). Age-adjusted models stratified by sex, poverty level, and educational attainment showed similar associations between living alone and cancer mortality, but the association was stronger among non-Hispanic White adults (HR, 1.33; 95% CI, 1.25-1.42) than non-Hispanic Black adults (HR, 1.18; 95% CI, 1.05-1.32; p value for difference < .05) and did not exist in other racial/ethnic groups. These associations were attenuated but persisted in fully adjusted models among men (HR, 1.13; 95% CI, 1.05-1.23), women (HR, 1.09; 95% CI, 1.01-1.18), non-Hispanic White adults (HR, 1.13; 95% CI, 1.05-1.20), and adults with a college degree (HR, 1.22; 95% CI, 1.07-1.39). CONCLUSIONS: In this nationally representative study in the United States, adults living alone were at a higher risk of cancer death in several sociodemographic groups.

Association of Smoking Cessation and Cardiovascular, Cancer, and Respiratory Mortality.

This study examines the association between years since quitting smoking and mortality in the US from 1997 to 2018.

Changes in cancer incidence rates by stage during the COVID-19 pandemic in the US.

The coronavirus disease 2019 (COVID-19) pandemic led to health care disruptions and declines in cancer diagnoses in the United States. However, the impact of the pandemic on cancer incidence rates by stage at diagnosis and race and ethnicity is unknown. This cross-sectional study calculated delay- and age-adjusted incidence rates, stratified by stage at diagnosis and race and ethnicity, and rate ratios (RRs) comparing changes in year-over-year incidence rates (eg, 2020 vs 2019) from 2016 to 2020 for 22 cancer types based on data obtained from the Surveillance, Epidemiology, and End Results 22-registry database. From 2019 to 2020, the incidence of local-stage disease statistically significantly declined for 19 of the 22 cancer types, ranging from 4% (RR = 0.96; 95%CI, 0.93-0.98) for urinary bladder cancer to 18% for colorectal (RR = 0.82; 95%CI, 0.81-0.84) and laryngeal (RR = 0.82; 95%CI, 0.78-0.88) cancers, deviating from pre-COVID stable year-over-year changes. Incidence during the corresponding period also declined for 16 cancer types for regional-stage and six cancer types for distant-stage disease. By race and ethnicity, the decline in local-stage incidence for screening-detectable cancers was generally greater in historically marginalized populations. The decline in cancer incidence rates during the first year of the COVID-19 pandemic occurred mainly for local- and regional-stage diseases across racial and ethnic groups. Whether these declines will lead to increases in advanced-stage disease and mortality rates remain to be investigated with additional data years. Nevertheless, the findings reinforce the importance of strengthening the return to preventive care campaigns and outreach for detecting cancers at early and more treatable stages.

Incident cancers attributable to using opium and smoking cigarettes in the Golestan cohort study.

Background: Opium consumption has recently been identified as a carcinogen, but the impact of opium use on cancer burden is unknown. We aimed to evaluate the fraction of cancers that could be attributed to opium use alone and in combination with cigarette smoking in a region where opium is widely used. Methods: 50,045 Iranian adults were recruited to this prospective cohort study between 2004 and 2008 and were followed through January 2022. We assessed the association between using opium and/or cigarette smoking and various cancers using proportional hazards regression models. We then calculated population attributable fractions (PAFs) for all cancers and for groups of cancers causally linked to opium and cigarette smoking. Findings: Of the total participants, 8% only used opium, 8.3% only smoked cigarettes, and 9% used both substances. During a median 14 years of follow-up, 2195 individuals were diagnosed with cancer, including 215 opium-related cancers (lung, larynx, and bladder) and 1609 tobacco-related cancers (20 types). Opium use alone was estimated to cause 35% (95% CI: 26%-45%) of opium-related cancers, while smoking cigarettes alone was estimated to cause 9% (6%-12%) of tobacco-related cancers in this population. Using opium and/or cigarettes was estimated to cause 13% (9%-16%) of all cancers, 58% (49%-66%) of opium-related cancers, and 15% (11%-18%) of tobacco-related cancers. Moreover, joint exposure to opium and cigarettes had the greatest impact on cancers of the larynx, pharynx, lung, and bladder, with PAFs ranging from 50% to 77%. Interpretation: Using opium and smoking cigarettes account for a large proportion of cancers in this population. To reduce the cancer burden, prevention policies should aim to decrease the use of both substances through public awareness campaigns and interventional efforts. Funding: The Golestan Cohort Study work was funded by the Tehran University of Medical Sciences, Cancer Research UK, U.S. National Cancer Institute, International Agency for Research on Cancer. The presented analysis was supported by the International HundredK+ Cohorts Consortium (IHCC).

The Burden of Lung Cancer in Women Compared With Men in the US.

This cross-sectional study examines the incidence rates of lung cancer in women compared with men from 2000 to 2019.

Educational Attainment and Cancer Incidence in a Large Nationwide Prospective Cohort.

BACKGROUND: Educational attainment is a social determinant of health and frequently used as an indicator of socioeconomic status. Educational attainment is a predictor of cancer mortality, but associations with site-specific cancer incidence are variable. The aim of this study was to evaluate the association of educational attainment and site-specific cancer incidence adjusting for known risk factors in a large prospective cohort. METHODS: Men and women enrolled in the American Cancer Society's Cancer Prevention Study-II Nutrition Cohort who were cancer free at baseline were included in this study (n = 148,965). Between 1992 and 2017, 22,810 men and 17,556 women were diagnosed with incident cancer. Cox proportional hazards regression models were used to estimate age- and multivariable-adjusted risk and 95% confidence intervals of total and site-specific cancer incidence in persons with lower versus higher educational attainment. RESULTS: Educational attainment was inversely associated with age-adjusted cancer incidence among men but not women. For specific cancer sites, the multivariable-adjusted risk of cancer in the least versus most educated individuals remained significant for colon, rectum, and lung cancer among men and lung and breast cancer among women. CONCLUSIONS: Educational attainment is associated with overall and site-specific cancer risk though adjusting for cancer risk factors attenuates the association for most cancer sites. IMPACT: This study provides further evidence that educational attainment is an important social determinant of cancer but that its effects are driven by associated behavioral risk factors suggesting that targeting interventions toward those with lower educational attainment is an important policy consideration.

Racial and Ethnic Disparities in Survival Among People With Second Primary Cancer in the US.

Importance: Comprehensive data for racial and ethnic disparities after second primary cancers (SPCs) are lacking despite the growing burden of SPCs. Objective: To quantify racial and ethnic disparities in survival among persons with SPCs. Design, Setting, and Participants: This population-based, retrospective cohort study used data from 18 Surveillance, Epidemiology, and End Results registries in the US for persons diagnosed with the most common SPCs at age 20 years or older from January 1, 2000, to December 31, 2013 (with follow-up through December 31, 2018). Data were analyzed between January and April 2023. Exposure: Race and ethnicity (Hispanic, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, and non-Hispanic White). Main Outcomes and Measures: The main outcomes were 5-year relative survival and cause-specific survival. Cause-specific hazard ratios (HRs) were calculated for death from cancer or cardiovascular disease (CVD) in each racial and ethnic minority population compared with the White population overall and stratified by SPC type, with adjustment for sex, year and age at SPC diagnosis, and prior cancer type and stage (baseline model) and additionally for county attributes (household income, urbanicity), SPC characteristics (stage, subtype), and treatment. Results: Among 230 370 persons with SPCs (58.4% male), 4.5% were Asian or Pacific Islander, 9.6% were Black, 6.4% were Hispanic, and 79.5% were White. A total of 109 757 cancer-related deaths (47.6%) and 18 283 CVD-related deaths (7.9%) occurred during a median follow-up of 54 months (IQR, 12-93 months). In baseline models, compared with the White population, the risk of cancer-related death overall was higher in the Black (HR, 1.21; 95% CI, 1.18-1.23) and Hispanic (HR, 1.10; 95% CI, 1.07-1.13) populations but lower in the Asian or Pacific Islander population (HR, 0.93; 95% CI, 0.90-0.96). When stratified by 13 SPC types, the risk of cancer-related death was higher for 10 SPCs in the Black population, with the highest HR for uterine cancer (HR, 1.87; 95% CI, 1.63-2.15), and for 7 SPCs in the Hispanic population, most notably for melanoma (HR, 1.46; 95% CI, 1.21-1.76). For CVD-related death, the overall HR was higher in the Black population (HR, 1.41; 95% CI, 1.34-1.49), with elevated risks evident for 11 SPCs, but lower in the Asian or Pacific Islander (HR, 0.75; 95% CI, 0.69-0.81) and Hispanic (HR, 0.90; 95% CI, 0.84-0.96) populations than in the White population. After further adjustments for county attributes and SPC characteristics and treatment, HRs were reduced for cancer-related death and for CVD-related death and associations in the same direction remained. Conclusions and Relevance: In this cohort study of SPC survivors, the Black population had the highest risk of both death from cancer and death from CVD, and the Hispanic population had a higher risk of death from cancer than the White population. Attenuations in HRs after adjustment for potentially modifiable factors highlight opportunities to reduce survival disparities among persons with multiple primary cancers.

The Association Between Census Tract Healthy Food Accessibility and Life Expectancy in the United States.

Accessibility of healthy food is an important predictor for several health outcomes, but its association with life expectancy is unclear. We evaluated the association between U.S. Department of Agriculture's Food Research Atlas measures of healthy food accessibility and life expectancy at birth across contiguous U.S. census tracts using spatial modeling analysis. Both income and healthy food accessibility were associated with life expectancy at birth, as indicated by shorter life expectancy in low-income census tracts when comparing tracts with similar healthy food accessibility level, and in low-access tracts when comparing tracts with similar income level. Compared to high-income/high-access census tracts, life expectancy at birth was lower in high-income/low-access (- 0.33 years; 95% confidence interval - 0.42, - 0.28), low-income/high-access (- 1.45 years; - 1.52, - 1.38), and low-income/low-access (- 2.29 years; - 2.38, - 2.21) tracts after adjusting for socio-demographic characteristics and incorporating vehicle availability. Effective interventions to increase healthy food accessibility may improve life expectancy.

Progress in reducing cancer mortality in the United States by congressional district, 1996-2003 to 2012-2020.

BACKGROUND: United States cancer death rates have been steadily declining since the early 1990s, but information on disparities in progress against cancer mortality across congressional districts is lacking. This study examined trends in cancer death rates, overall and for lung, colorectal, female breast, and prostate cancer by congressional district. METHODS: County level cancer death counts and population data from the National Center for Health Statistics were used to estimate relative change in age-standardized cancer death rates from 1996-2003 to 2012-2020 by sex and congressional district. RESULTS: From 1996-2003 to 2012-2020, overall cancer death rates declined in every congressional district, with most congressional districts showing a 20%-45% decline among males and a 10%-40% decline among females. In general, the smallest percent of relative declines were found in the Midwest and Appalachia, whereas the largest declines were found in the South along the East Coast and the southern border. As a result, the highest cancer death rates generally shifted from congressional districts across the South in 1996-2003 to districts in the Midwest and central divisions of the South (including Appalachia) in 2012-2020. Death rates for lung, colorectal, female breast, and prostate cancers also declined in almost all congressional districts, although with some variation in relative changes and geographical patterns. CONCLUSIONS: Progress in reducing cancer death rates during the past 25 years considerably vary by congressional district, underscoring the need for strengthening existing and implementing new public health policies for broad and equitable application of proven interventions such as raising tax on tobacco and Medicaid expansion.

Updated Review of Major Cancer Risk Factors and Screening Test use in the United States, with a Focus on Changes During the COVID-19 Pandemic.

We present national and state representative prevalence estimates of modifiable cancer risk factors, preventive behaviors and services, and screening, with a focus on changes during the COVID-19 pandemic. Between 2019 and 2021, current smoking, physical inactivity, and heavy alcohol consumption declined, and human papillomavirus vaccination and stool testing for colorectal cancer screening uptake increased. In contrast, obesity prevalence increased, while fruit consumption and cervical cancer screening declined during the same timeframe. Favorable and unfavorable trends were evident during the second year of the COVID-19 pandemic that must be monitored as more years of consistent data are collected. Yet disparities by racial/ethnic and socioeconomic status persisted, highlighting the continued need for interventions to address suboptimal levels among these population subgroups.

Association of the COVID-19 Pandemic and Changes in Patterns of Cancer-Related Mortality in the United States.

PURPOSE: This study examined changes in patterns of cancer-related deaths during the first year of the coronavirus disease 2019 pandemic in the United States. METHODS: We identified cancer-related deaths, defined as deaths attributable to cancer as the primary cause (underlying cause) or deaths with cancer documented as one of the multiple contributing factors (contributing cause) from the Multiple Cause of Death database (2015-2020). We compared age-standardized cancer-related annual and monthly mortality rates for January-December 2020 (first pandemic year) to January-December 2015-2019 (prepandemic) overall and stratified by sex, race/ethnicity, urban rural residence, and place of death. RESULTS: We found that the death rate (per 100,000 person-years) with cancer as the underlying cause was lower in 2020 compared with 2019 (144.1 v 146.2), continuing the past trend observed in 2015-2019. By contrast, the death rate with cancer as a contributing cause was higher in 2020 than in 2019 (164.1 v 162.0), reversing the continuously decreasing trend from 2015 to 2019. We projected 19,703 more deaths with cancer as a contributing cause than expected on the basis of historical trends. Mirroring pandemic peaks, the monthly death rates with cancer as a contributing cause first increased in April 2020 (rate ratio [RR], 1.03; 95% CI, 1.02 to 1.04), subsequently declined in May and June 2020, and then increased again each month from July through December 2020 compared with 2019, with the highest RR in December (RR, 1.07; 95% CI, 1.06 to 1.08). CONCLUSION: Death rates with cancer as the underlying cause continued to decrease in 2020 despite the increase in death rates with cancer as a contributing cause in 2020. Ongoing monitoring of long-term cancer-related mortality trends is warranted to assess effects of delays in cancer diagnosis and receipt of care during the pandemic.

Geographic diffusion of digital mammography in the United States.

BACKGROUND: Examining temporal and spatial diffusion of a new technology, such as digital mammography, can provide important insights into potential disparities associated with access to new medical technologies and how quickly these technologies are adopted. Although digital mammography is currently a standard technology in the United States for breast cancer screening, its adoption and geographic diffusion, as medical facilities transitioned from film to digital units, has not been explored well. METHODS: This study evaluated the geographic diffusion of digital mammography facilities from 2001 to 2014 in the contiguous United States (excluding Alaska and Hawaii) and estimated the geographic accessibility to this new technology for women aged ≥45 years at the census tract level within a 20-minute drivetime by population density, rural/urban residence, and race/ethnicity. The number of mammography units by technology type (film or digital) and density per 10,000 women were also summarized. RESULTS: The adoption of digital mammography advanced first in densely populated regions and last in remote rural areas. Overall, proportion of digital mammography units increased from 1.4% in 2001 to 94.6% in 2014, but since 2008, there was a decline in density of units from 2.31 per 10,000 women aged ≥45 years to 1.97 in 2014. In 2014, approximately 87% of women aged ≥45 years in the contiguous United States had accessibility to digital mammography, but this proportion was substantially lower for Native American women (67%) and rural residents (32%). CONCLUSION: Understanding the diffusion of and accessibility to digital mammography may help predict future medical technology diffusion and assess its role in geographic differences in cancer diagnosis and treatment.

Mortality by Education Before and During the COVID-19 Pandemic, U.S., 2017-2020.

INTRODUCTION: Mortality disparities by SES, including education, have steadily increased in the U.S. over the past decades. This study examined whether these disparities overall and for 7 major causes of death were exacerbated in 2020, coincident with the emergence of the COVID-19 pandemic. METHODS: Using data on 7,123,254 U.S. deaths from 2017 to 2020, age-standardized death rates and mortality rate differences per 100,000 population and rate ratios comparing least with most educated were calculated by sex and race/ethnicity. RESULTS: All-cause death rates were approximately 2 times higher among adults with least than among those with most education. Disparities in all-cause mortality by educational attainment slightly increased from 2017 (rate ratio=1.97; 95% CI=1.95, 1.98; rate difference=739.9) to 2019 (rate ratio=2.04; 95% CI=2.03, 2.06; rate difference=761.3) and then greatly increased in 2020 overall (rate ratio=2.32; 95% CI=2.30, 2.33; rate difference=1,042.9) and when excluding COVID-19 deaths (rate ratio=2.27; 95% CI=2.25, 2.28; rate difference=912.3). Similar patterns occurred across race/ethnicity and sex, although Hispanic individuals had the greatest relative increase in disparities for all-cause mortality from 2019 (rate ratio=1.47; 95% CI=1.43, 1.51; rate difference=282.4) to 2020 overall (rate ratio=2.00; 95% CI=1.94, 2.06; rate difference=652.3) and when excluding COVID-19 deaths (rate ratio=1.84; 95% CI=1.79, 1.90; rate difference=458.7). Disparities in cause-specific mortality by education were generally stable from 2017 to 2019, followed by a considerable increase from 2019 to 2020 for heart disease, cancer, cerebrovascular disease, and unintentional injury. Among these causes of death, the relative increase in rate ratio from 2019 to 2020 was greatest for unintentional injury (24.8%; from 3.41 [95% CI=3.23, 3.60] to 4.26 [95% CI=3.99, 4.53]). CONCLUSIONS: Mortality disparities by education widened in the U.S. in 2020, during the COVID-19 pandemic. Further research is warranted to understand the reasons for these widened disparities.

Changes in geographic accessibility to mammography by state and rural-urban status, United States, 2006-2022.

Although mammography is widely available in the United States, differences in accessibility in rural and urban areas and changes over time are not well described. In this study, we estimated the number and proportion of women aged 45-84 years who had limited travel time-based geographic accessibility to mammography by urban-rural status and state in the contiguous United States in 2006 and 2022. The proportion of women aged 45-84 years with limited accessibility to mammography did not substantially change from 2006 (12.7%; representing 7.5 million women) to 2022 (12.2%; 8.2 million women). Accessibility to mammography varied by state, but in 10 states, more than 26% of the statewide female population aged 45-84 years had limited accessibility in 2022. This proportion was substantially higher in rural areas (50.6% overall; ≥50% in 28 states in 2022) than in urban areas (3.0% overall). Increasing accessibility to mammography could increase utilization of breast cancer screening and, potentially, improve breast cancer survival.