Disparities in screening mammography

OBJECTIVE: This paper describes trends in screening mammography utilization over the past decade and assesses the remaining disparities in mammography use among medically underserved women. We also describe the barriers to mammography and report effective interventions to enhance utilization. DESIGN: We reviewed medline and other databases as well as relevant bibliographies. MAIN RESULTS: The United States has dramatically improved its use of screening mammography over the past decade, with increased rates observed in every demographic group. Disparities in screening mammography are decreasing among medically underserved populations but still persist among racial/ethnic minorities and low-income women. Additionally, uninsured women and those with no usual care have the lowest rates of reported mammogram use. However, despite apparent increases in mammogram utilization, there is growing evidence that limitations in the national survey databases lead to overestimations of mammogram use, particularly among low-income racial and ethnic minorities. CONCLUSIONS: The United States may be farther from its national goals of screening mammography, particularly among underserved women, than current data suggests. We should continue to support those interventions that increase mammography use among the medically underserved by addressing the barriers such as cost, language and acculturation limitations, deficits in knowledge and cultural beliefs, literacy and health system barriers such as insurance and having a source regular of medical care. Addressing disparities in the diagnostic and cancer treatment process should also be a priority in order to affect significant change in health outcomes among the underserved.     

Increased patient concern after false-positive mammograms

OBJECTIVE: To measure how often a breast-related concern was documented in medical records after screening mammography according to the mammogram result (normal, or true-negative vs false-positive) and to measure changes in health care utilization in the year after the mammogram. DESIGN: Cohort study. SETTING: Large health maintenance organization in New England. PATIENTS: Group of 496 women with false-positive screening mammograms and a comparison group of 496 women with normal screening mammograms, matched for location and year of mammogram. MEASUREMENTS AND MAIN RESULTS: 1) Documentation in clinicians' notes of patient concern about the breast and 2) ambulatory health care utilization, both breast-related and non-breast-related, in the year after the mammogram. Fifty (10%) of 496 women with false-positive mammograms had documentation of breast-related concern during the 12 months after the mammogram, compared to 1 (0.2%) woman with a normal mammogram (P =.001). Documented concern increased with the intensity of recommended follow-up (P =.009). Subsequent ambulatory visits, not related to the screening mammogram, increased in the year after the mammogram among women with false-positive mammograms, both in terms of breast-related visits (incidence ratio, 3.07; 95% confidence interval [CI], 1.69 to 5.93) and non-breast-related visits (incidence ratio, 1.14; 95% CI, 1.03 to 1.25). CONCLUSIONS: Clinicians document concern about breast cancer in 10% of women who have false-positive mammograms, and subsequent use of health care services are increased among women with false-positive mammogram results.     

Improving Colorectal Cancer Screening Among the Medically Underserved: A Pilot Study within a Federally Qualified Health Center

Background Colorectal cancer screening rates remain low, especially among low-income and racial/ethnic minority groups. Objective We pilot-tested a physician-directed strategy aimed at improving rates of recommendation and patient colorectal cancer screening completion at 1 federally qualified health center serving low-income, African-American and Hispanic patients. Colonoscopy was specifically targeted. Design Single arm, pretest–posttest design. Setting Urban. Patients 154 screening-eligible, yet nonadherent primary care patients receiving care at an urban, federally qualified health center. Intervention 1) manually tracking screening-eligible patients, 2) mailing patients a physician letter and brochure before medical visits, 3) health literacy training to help physicians improve their communication with patients to work to resolution, and 4) establishing a “feedback loop” to routinely monitor patient compliance. Measurement Chart review of whether patients received a physician recommendation for screening, and completion of any colorectal cancer screening test 12 months after intervention. Physicians recorded patients’ qualitative reasons for noncompliance, and a preliminary cost-effectiveness analysis for screening promotion was also conducted. Results The baseline screening rate was 11.5%, with 31.6% of patients having received a recommendation from their physician. At 1-year follow-up, rates of screening completion had increased to 27.9 percent (p < .001), and physician recommendation had increased to 92.9% (p < .001). Common reasons for nonadherence included patient readiness (60.7%), competing health problems (11.9%), and fear or anxiety concerning the procedure (8.3%). The total cost for implementing the intervention was $4,676 and the incremental cost-effectiveness ratio for the intervention was $106 per additional patient screened by colonoscopy. Conclusions The intervention appears to be a feasible means to improve colorectal cancer screening rates among patients served by community health centers. However, more attention to patient decision making and education may be needed to further increase screening rates.     

Adherence of low-income women to cancer screening recommendations

BACKGROUND: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts. OBJECTIVE: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold. PARTICIPANTS: Included in the survey were 1,205 women over age 40, 82% of whom were African American. MAIN OUTCOME MEASURES: Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age. RESULTS: The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.) CONCLUSIONS: Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women's adherence to cancer screening recommendations.     

A Culturally Tailored Navigator Program for Colorectal Cancer Screening in a Community Health Center: A Randomized, Controlled Trial

Background  Minority racial/ethnic groups have low colorectal cancer (CRC) screening rates. Objective  To evaluate a culturally tailored intervention to increase CRC screening, primarily using colonoscopy, among low income and non-English speaking patients. Design  Randomized controlled trial conducted from January to October of 2007. Setting  Single, urban community health center serving a low-income, ethnically diverse population. Patients  A total of 1,223 patients 52-79 years of age overdue for CRC screening, randomized to intervention (n = 409) vs. usual care control (n = 814) groups. Intervention  Intervention patients received an introductory letter with educational material followed by phone or in-person contact by a language-concordant “navigator.” Navigators (n = 5) were community health workers trained to identify and address patient-reported barriers to CRC screening. Individually tailored interventions included patient education, procedure scheduling, translation and explanation of bowel preparation, and help with transportation and insurance coverage. Rates of colorectal cancer screening were assessed for intervention and usual care control patients. Results  Over a 9-month period, intervention patients were more likely to undergo CRC screening than control patients (27% vs. 12% for any CRC screening, p < 0.001; 21% vs. 10% for colonoscopy completion, p < 0.001). The higher screening rate resulted in the identification of 10.5 polyps per 100 patients in the intervention group vs. 6.8 in the control group (p = 0.04). Limitations  Patients were from one health center. Some patients may have obtained CRC screening outside our system. Conclusions  A culturally tailored, language-concordant navigator program designed to identify and overcome barriers to colorectal cancer screening can significantly improve colonoscopy rates for low income, ethnically and linguistically diverse patients. ClinicalTrials.gov registration number: NCT00476970     

Breast cancer screening use by African Americans and whites in an HMO

OBJECTIVE: To examine racial differences in breast cancer screening in an HMO that provides screening at no cost. DESIGN: Retrospective cohort study of breast cancer screening among African-American and white women. Breast cancer screening information was extracted from computerized medical records. SETTING: A large HMO in New England. PATIENTS/PARTICIPANTS: White and African-American women (N=2,072) enrolled for at least 10 years in the HMO. MAIN RESULTS: Primary care clinicians documented recommending a screening mammogram significantly more often for African Americans than whites (70% vs 64%; P<.001). During the 10-year period, on average, white women obtained more mammograms (4.49 vs 3.93; P<.0001) and clinical breast examinations (5.35 vs 4.92; P<.01) than African-American women. However, a woman’s race was no longer a statistically significant predictor of breast cancer screening after adjustment for differences in age, estimated household income, estrogen use, and body mass index (adjusted number of mammograms, 4.47 vs 4.25, P=.17; and adjusted number of clinical breast examinations, 5.35 vs 5.31, P=.87). CONCLUSIONS: In this HMO, African-American and white women obtained breast cancer screening at similar rates. Comparisons with national data showed much higher screening rates in this HMO for both white and African-American women. This project was supported by a grant from the American Cancer Society (JGE), by a Robert Wood Johnson Generalist Faculty Scholar Award (JGE), and by the Harvard Pilgrim Health Care Foundation (SF, MB)     

Mammography and Papanicolaou smear use by elderly poor black women. The Harlem Study Team.

OBJECTIVE: To describe factors related to the use of mammography and Papanicolaou smears in low-income women aged 65 or more years to guide development of future interventions. DESIGN: A cross-sectional survey. SETTING AND PATIENTS: Elderly Black women attending a public hospital medical clinic. MEASUREMENTS: Information obtained in a face-to-face interview of a random sample of patients. RESULTS: Four-hundred and forty-five women (94%) consented to be interviewed; 74% reported a mammogram, and 85% reported a Papanicolaou smear in the past, although these early-detection tests were not obtained with any regularity after age 65. Concordance between self-reported screening use and blind chart review was more than 90%. The major reasons for non-use of both screening tests were that a physician hadn't recommended them or that the women didn't know they needed them. Levels of knowledge about breast and cervix cancer were low; 68% believed bumping or bruising the breast caused cancer, and only 25% knew that cancer risk increased with advancing age. In logistic regression models, health status, provider type, perceived benefit, life satisfaction, and knowledge of test intervals were each significantly associated with mammogram use. Age, health status, education, perceived susceptibility and benefit, life satisfaction, and knowledge of test intervals were independently related to Pap use (P < .05). CONCLUSION: This study illustrates that elderly, poor, minority women who are regular health-care users do use mammography and Pap smear screening services. Incorporating screening into routine primary care and physician and patient education could enhance the use of early cancer detection procedures in this age group.     

When a Usual Source of Care and Usual Provider Matter: Adult Prevention and Screening Services

OBJECTIVE  To examine whether the usual source of preventive care, (having a usual place for care only or the combination of a usual place and provider compared with no usual source of preventive care) is associated with adults receiving recommended screening and prevention services. DESIGN  Using cross-sectional survey data for 24,138 adults (ages 18–64) from the 1999 National Health Interview Survey (NHIS), we estimated adjusted odds ratios using separate logistic regression models for receipt of five preventive services: influenza vaccine, Pap smear, mammogram, clinical breast exam, and prostate specific antigen. RESULTS  Having both a usual place and a usual provider was consistently associated with increased odds for receiving preventive care/screening services compared to having a place only or neither. Adults ages 50–64 with a usual place/provider had 2.8 times greater odds of receiving a past year flu shot compared with those who had neither. Men ages 50–64 with a usual place/provider had nearly 10 times higher odds of receiving a PSA test compared with men who had neither. Having a usual place/provider compared with having neither was associated with 3.9 times higher odds of clinical breast exam among women ages 20–64, 4.1 times higher odds of Pap testing among women ages 21–64, and 4.8 times higher odds of mammogram among women ages 40–64. CONCLUSIONS  Having both a usual place and usual provider is a key variable in determining whether adults receive recommended screening and prevention services and should be considered a fundamental component of any medical home model for adults.     

Patient and clinical site factors associated with rescreening behavior among older multiethnic, low-income women

PURPOSE: Our goal was to identify factors predictive of mammography rescreening within 18 months of baseline screening in multiethnic, low-income older women. DESIGN AND METHODS: We interviewed a cross-sectional survey of staff of 102 randomly selected clinics that provided screening and diagnostic services. We also surveyed a random sample of 391 older women served by these clinics to retrospectively assess their experiences of the screening process. RESULTS: We found that 59% of the sample returned for a repeat mammogram. Education level and the belief it is important to get an annual mammogram were significant patient-level predictors of rescreening. Offering pap smears and using hands-on demonstrations with breast models were significant clinic-level variables predictive of rescreening. Of note, among the variables that did not prove significant in the final model were those reflecting ethnicity and income. IMPLICATIONS: Individual and health-care-delivery-system factors play important roles in the obtaining of regular mammograms by low-income women. These findings highlight the importance of both factors in improving rescreening rates among older women.     

Determinants of NCI Cancer Center Attendance in Medicare Patients with Lung, Breast, Colorectal, or Prostate Cancer

BACKGROUND  Geographic access to NCI-Cancer Centers varies by region, race/ethnicity, and place of residence, but utilization of these specialized centers has not been examined at the national level in the U.S. This study identified determinants of NCI-Cancer Center attendance in Medicare cancer patients. METHODS  SEER-Medicare (Surveillance Epidemiology and End Results) data were used to identify individuals with an incident cancer of the breast, lung, colon/rectum, or prostate from 1998–2002. NCI-Cancer Center attendance was determined based on utilization claims from 1998–2003. Demographic, clinical, and geographic factors were examined in multilevel models. We performed sensitivity analyses for the NCI-Cancer Center attendance definition. RESULTS  Overall, 7.3% of this SEER-Medicare cohort (N = 211,048) attended an NCI-Cancer Center. Travel-time to the nearest NCI-Cancer Center was inversely related to attendance, showing 11% decreased likelihood of attendance for every 10 minutes of additional travel-time (OR = 0.89, 95%CI 0.88–0.90). Receiving predominantly generalist care prior to diagnosis was associated with a lower likelihood of attendance (OR = 0.79, 95%CI 0.77–0.82). The other factors associated with greater NCI-Cancer attendance were later stage at diagnosis, fewer comorbidities, and urban residence in conjunction with African-American race. CONCLUSIONS  Attendance at NCI-Cancer Centers is low among Medicare beneficiaries, but is strongly influenced by proximity and general provider care prior to diagnosis. Other patient factors are predictive of NCI-Cancer Center attendance and may be important in better understanding cancer care utilization.     

Perceived Discrimination and Adherence to Medical Care in a Racially Integrated Community

Background Past research indicates that access to health care and utilization of services varies by sociodemographic characteristics, but little is known about racial differences in health care utilization within racially integrated communities. Objective To determine whether perceived discrimination was associated with delays in seeking medical care and adherence to medical care recommendations among African Americans and whites living in a socioeconomically homogenous and racially integrated community. Design A cross-sectional analysis from the Exploring Health Disparities in Integrated Communities Study. Participants Study participants include 1,408 African-American (59.3%) and white (40.7%) adults (≥18 years) in Baltimore, Md. Measurements An interviewer-administered questionnaire was used to assess the associations of perceived discrimination with help-seeking behavior for and adherence to medical care. Results For both African Americans and whites, a report of 1–2 and >2 discrimination experiences in one’s lifetime were associated with more medical care delays and nonadherence compared to those with no experiences after adjustment for need, enabling, and predisposing factors (odds ratio [OR] = 1.8, 2.6; OR = 2.2, 3.3, respectively; all P < .05). Results were similar for perceived discrimination occurring in the past year. Conclusions Experiences with discrimination were associated with delays in seeking medical care and poor adherence to medical care recommendations INDEPENDENT OF NEED, ENABLING, AND PREDISPOSING FACTORS, INCLUDING MEDICAL MISTRUST; however, a prospective study is needed. Further research in this area should include exploration of other potential mechanisms for the association between perceived discrimination and health service utilization.     

Beliefs and expectations of women under 50 years old regarding screening mammography

OBJECTIVE: Because shared decision making has been recommended for screening mammography by women under age 50, we studied women's decision-making process regarding the procedure. DESIGN: Qualitative research design using in-depth semi-structured interviews. PATIENTS: Sixteen white and African-American women aged 38 to 45 receiving care at a large New England medical practice. MEASUREMENTS AND MAIN RESULTS: We identified the following content areas in women's decision-making process: intentions for screening, motivating factors to undergo screening, attitudes toward screening mammography, attitudes toward breast cancer, and preferences for information and shared decision making. In our sample, all women had or intended to have a screening mammogram before age 50. They were motivated by the awareness of the recommendation to begin screening at age 40, knowing others with breast cancer, and a sense of personal responsibility for their health. Participants feared breast cancer and thought the benefits of screening mammography far outweighed its risks. Women's preferences for involvement in decision making varied from wanting full responsibility for screening decisions to deferring to their medical providers. All preferred the primary care provider to be the main source of information, yet the participants stated that their own providers played a limited role in educating them about the risks and benefits of screening and the mammography procedure itself. Most of their information was derived from the media. CONCLUSIONS: The women in this study demonstrated little ambivalence in their desire for mammography screening prior to age 50. They reported minimal communication with their medical providers about the risks and benefits of screening. Better information flow regarding mammography screening is necessary. Given the lack of uncertainty among women's perceptions regarding screening mammography, shared decision making in this area may be difficult to achieve.     

Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization.

BACKGROUND: Despite the mortality benefits of breast cancer screening, not all women receive regular mammography. Such factors as age, socioeconomic status, and physician recommendation have been associated with greater use of screening. However, we do not know whether having an abnormal mammogram affects future screening. OBJECTIVE: To examine the effect of a false-positive mammogram on adherence to the next recommended screening mammogram. DESIGN: Prospective cohort study. SETTING: The breast cancer screening program at Group Health Cooperative, a health maintenance organization in Washington state. PATIENTS: 5059 women 40 years of age or older with no history of breast cancer or breast surgery who had false-positive (n = 813) or true-negative (n = 4246) index screening mammograms between 1 August 1990 and 31 July 1992. MEASUREMENTS: Screening rates and odds ratios for recommended interval screening up to 42 months after the index mammogram. RESULTS: After adjustment for differences in age; previous use of mammography; family history of breast cancer; exogenous hormone use; and age at menarche, first childbirth, and menopause, women with false-positive index mammograms were more likely than those with true-negative index mammograms to obtain their next recommended screening mammogram (odds ratio, 1.21 [95% CI, 1.01 to 1.45]). The relation between a false-positive mammogram and the likelihood of adherence to screening in the next recommended interval was strongest among women who had not previously undergone mammography (odds ratio, 1.66 [CI, 1.26 to 2.17]). CONCLUSIONS: Having a false-positive mammogram did not adversely affect screening behavior in the next recommended interval. Women with false-positive mammograms, especially those without previous mammography, were more likely to return for the next scheduled screening.     

Perceptions of barriers and facilitators to cervical cancer screening among low-income,HIV-infected women from an integrated HIV clinic

Significantly elevated rates of cervical cancer and low rates of Papanicolaou (Pap) smear screening have been documented among HIV-infected women. However, little is known about women's perceptions of cervical cancer screening utilization. Hence, this study describes barriers and facilitators related to cervical cancer screening in a sample of HIV-infected women seeking care at an integrated HIV clinic in Houston, Texas. Using an inductive qualitative methodological approach, data were obtained from five focus group discussions with a total of 33, HIV-infected women. The majority of the study sample consisted of women who self-identified as Black (69.7%), and reported heterosexual contact as the mode of HIV acquisition (75.8%). Barriers to cervical cancer screening were described as pain and discomfort associated with receiving Pap smears and subsequent procedures; lack of awareness of cervical cancer as a preventable disease; limited transportation access; and systemic issues as it relates to scheduling gynecological appointments. Facilitators were described as awareness of HIV-infected women's increased risk of cervical cancer and strong provider–patient relationships. To address disparities in cervical cancer screening among low-income HIV-infected women, programs should capitalize on the identified facilitators and alleviate modifiable barriers using multilevel strategies.     

Missed Opportunities: Family History and Behavioral Risk Factors in Breast Cancer Risk Assessment Among a Multiethnic Group of Women

Background Clinician’s knowledge of a woman’s cancer family history (CFH) and counseling about health-related behaviors (HRB) is necessary for appropriate breast cancer care. Objective To evaluate whether clinicians solicit CFH and counsel women on HRB; to assess relationship of well visits and patient risk perception or worry with clinician’s behavior. Design Cross-sectional population-based telephone survey. Participants Multiethnic sample; 1,700 women from San Francisco Mammography Registry with a screening mammogram in 2001–2002. Measurements Predictors: well visit in prior year, self-perception of 10-year breast cancer risk, worry scale. Outcomes: Patient report of clinician asking about CFH in prior year, or ever counseling about HRB in relation to breast cancer risk. Multivariate models included age, ethnicity, education, language of interview, insurance/mammography facility, well visit, ever having a breast biopsy/follow-up mammography, Gail-Model risk, Jewish heritage, and body mass index. Results 58% reported clinicians asked about CFH; 33% reported clinicians ever discussed HRB. In multivariate analysis, regardless of actual risk, perceived risk, or level of worry, having had a well visit in prior year was associated with increased odds (OR = 2.3; 95% CI 1.6, 3.3) that a clinician asked about CFH. Regardless of actual risk of breast cancer, a higher level of worry (OR = 1.9; 95% CI 1.4, 2.6) was associated with increased odds that a clinician ever discussed HRB. Conclusions Clinicians are missing opportunities to elicit family cancer histories and counsel about health-related behaviors and breast cancer risk. Preventive health visits offer opportunities for clinicians to address family history, risk behaviors, and patients’ worries about breast cancer. This research was presented in part at the Society of General Internal Medicine meeting, May 2005, New Orleans.     

Prevalence and Trends of Receipt of Cancer Screenings Among US Women with Diagnosed Diabetes

BACKGROUND  Diabetes increases the risk of breast and colorectal cancers and has an undetermined relationship to cervical cancer. Improved screenings for these cancers are effective in reducing cancer mortality. OBJECTIVES  To examine the prevalence of receiving recommended screenings for these cancers and to assess the trends in the screening rates over time among US women with diagnosed diabetes in comparison with women without diabetes. DESIGN  Cross-sectional. PARTICIPANTS  A total of 63,650 to 182,168 adult women participated in the 1996−2006 (biennially) Behavioral Risk Factor Surveillance System. METHODS  The prevalence of receiving cancer screenings was age-standardized to the 2000 US population. The adjusted prevalence and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated using logistic regression analyses. The linear trends in the screening rates were tested using orthogonal polynomial contrasts. RESULTS  In 2006, women with diabetes had a lower adjusted prevalence (74% versus 79%, P < 0.05) and the AOR (0.73, 95% CI: 0.66−0.81) for receiving cervical cancer screenings, but had a higher adjusted prevalence (63% versus 60%, P < 0.05) and the AOR (1.14, 95% CI: 1.04−1.24) for receiving colorectal cancer screenings compared to those without. In both women with diabetes and those without, the screening rate for colorectal cancer increased linearly during 2002−2006, whereas the screening rates for breast and cervical cancers changed little during 1996−2006. CONCLUSION  Women with diabetes were equally likely to be screened for breast cancer, less likely to be screened for cervical cancer, but more likely to be screened for colorectal cancer compared to those without. Overall, the screening rates in both groups remain below the recommended levels.     

Impact of U.S. Citizenship status on cancer screening among immigrant women

OBJECTIVES: We evaluated the relationship between U.S. citizenship status and the receipt of Pap smears and mammograms among immigrant women in California. DESIGN: Cross-sectional study using data from the 2001 California Health Interview Survey. PATIENTS/PARTICIPANTS: Noninstitutionalized, civilian women, aged 18 years and older living in California. MEASUREMENTS AND MAIN RESULTS: We analyzed data from the 2001 California Health Interview Survey and used logistic regression models to adjust for sociodemographic factors and for access and utilization of health services. After adjusting we found that U.S. citizen immigrants were significantly more likely to report receiving a Pap smear ever (adjusted prevalence ratio [aPR], 1.05; 95% confidence interval [CI], 1.01 to 1.08), a recent Pap smear (aPR, 1.07; 95% CI, 1.03 to 1.11), a mammogram ever (aPR, 1.17; 95% CI, 1.12 to 1.21), and a recent mammogram (aPR, 1.38; 95% CI, 1.26 to 1.49) as compared to immigrants who are not U.S. citizens. Also associated with receiving cancer screening were income, having a usual source of care, and having health insurance. Hispanic women were more likely to receive Pap smears as compared to whites and Asians. CONCLUSIONS: Not being a U.S. citizen is a barrier to receiving cervical and breast cancer screening. Additional research is needed to explore causal factors for differences in cancer screening rates between citizens and noncitizens.