Barriers to Health Care and Cancer Screening

Importance: Identification of health care access-related factors associated with lower rates of cancer screening may help inform targeted interventions to mitigate barriers and ameliorate screening disparities. Objective: To examine the multifaceted obstacles associated with screening for breast, cervical, colorectal, lung, and prostate cancer in a diverse population. Design, Setting, and Participants: This cohort study included longitudinal data from the National Institutes of Health's All of Us (AoU) Research Program (2017-2023). Nonincarcerated individuals aged 18 years or older residing in the US were eligible to participate by enrolling either online or through 1 of approximately 67 health care organizations. Identified participants within the AoU Research Program met US Preventive Services Task Force screening criteria for breast, colorectal, cervical, lung, or prostate cancer. Data were analyzed from October 2024 to January 2026. Main Outcomes and Measures: Participants self-reported whether 9 potential barriers delayed their medical care in the past year. Multivariable-adjusted odds ratios were estimated for the association between each barrier, the barrier burden, as well as for patterns of interrelated barriers identified using factor analysis and adherence to cancer screening recommendations. Results: In total, 160 691 participants were eligible for cancer screening including 42 908 participants in the breast (median age at last follow-up, 60 [IQR, 52-67] years; 100% female), 45 791 in the cervical (median age at last follow-up, 46 [IQR, 35-56] years; 100% female), 55 986 in the colorectal (median age at last follow-up, 66 [IQR, 57-73] years; 63% female), 3358 in the lung (median age at last follow-up, 66 [IQR, 59-72] years; 53% female), and 12 648 in the prostate cancer (median age at last follow-up, 63 [IQR, 59-66] years; 100% male) screening cohorts. Out-of-pocket costs, nervousness about seeing clinicians, and inability to get time off work were the most cited barriers. Participants reporting 3 or more barriers to care had significantly lower screening rates compared with those who reported no barriers for all cancer types, ranging from 18% (odds ratio [OR], 0.82; 95% CI, 0.76-0.88) for colorectal cancer to 32% (OR, 0.68; 95% CI, 0.46-0.97) for lung cancer. Three latent factors were consistently identified across cancer sites reflecting cost concerns, logistical barriers (eg, transportation), and competing obligations (eg, time off work). In multivariable analyses, cost concerns were associated with odds of screening for breast cancer (OR, 0.73; 95% CI, 0.66-0.80), cervical cancer (OR, 0.80; 95% CI, 0.73-0.87), and colorectal cancer (OR, 0.85; 95% CI, 0.77-0.94) and logistical barriers for breast cancer (OR, 0.75; 95% CI, 0.63-0.89), cervical cancer (OR, 0.78; 95% CI, 0.65- 0.93), and colorectal cancer (OR, 0.78; 95% CI, 0.65-0.94). Conclusions and Relevance: In this cohort study of participants eligible for cancer screening, barriers to access and barriers related to cost concerns and logistics were associated with lower screening rates. Policies and interventions must target multiple dimensions of access simultaneously to increase cancer screening.