September 03, 2026
7 min read
Key takeaways:
- Noncitizens had substantially lower rates of breast, cervical and colorectal cancer screening.
- Many of the barriers to screening may only be solvable with systemic intervention or improved public health policy.
Patients in the United States who are not U.S. citizens are much less likely to get screened for breast, cervical and colorectal cancers, highlighting structural barriers to care, according to experts.
Jenny S. Guadamuz, MSPH, PhD, an assistant professor of health policy and management at University of California, Berkeley, School of Public Health, and colleagues recently published a cross-sectional study in JAMA Network Open to evaluate cancer screening equity associated with citizenship status.
Using nationally representative data and USPSTF guidelines, Guadamuz, also the health equity program director for UC Berkeley’s Center for Health Management and Policy Research screening services, and colleagues measured how often immigrants without U.S. citizenship received breast, colorectal and cervical cancer screening services.
They found that noncitizens had significantly lower cancer screenings for all three types studied than U.S.-born citizens:
- breast cancer rates — 73% (95% CI; 66.4%-78.7%) for noncitizens and 80.1% (95% CI; 78.8%-81.3%) for citizens;
- cervical cancer rates — 57.1% (95% CI; 53.1%-61%) for noncitizens and 71.6% (95% CI; 70.3%-72.8%) for citizens; and
- colorectal cancer rates — 43.6% for noncitizens (95% CI; 38.7%-48.4%) and 75.5% for citizens (95% CI; 74.6%-76.5%).
The researchers wrote that the disparities occurred in many states and throughout the study period.
Noncitizens also saw significantly lower odds for receiving the screenings than citizens born in the U.S.:
- OR = 0.57 (95% CI; 0.52-0.62) for breast cancer screening;
- OR = 0.41 (95% CI; 0.38-0.44) for cervical cancer screening; and
- OR = 0.35 (95% CI; 0.32-0.38) for colorectal cancer screening.
Together, healthcare and socioeconomic factors mediated those inequities (proportion mediated rates were 97.1% [95% CI, 87.1%-107.1%] for breast cancer; 39.6% [95% CI, 32.3%-47%] for cervical cancer; and 56.6% [95% CI, 49.1%-64.2% for colorectal cancer).
Healio spoke with Guadamuz to learn about the study, what can be done to close the screening gap and more.
Healio: Why did you decide to research this subject? Why is it important for healthcare professionals to know about?
Guadamuz: I decided to focus on citizenship and ask what it means for access to cancer screening because — and specifically in these three types of cancers — over the last couple decades, deaths in these cancers have declined sharply. This is primarily driven not only by new treatments, but by the fact that they’re being diagnosed at earlier stages when they are more treatable.
But we also know that because of the health and immigration systems we have in the U.S., certain populations don’t have equitable access to these screening services, which have really clear implications for how people are diagnosed with cancer, when they’re diagnosed with cancer, and, ultimately, when they die, how they die. If someone is diagnosed at a late stage of any of these three types of cancer, their survival drops, and they end up dying a very unjust death because oftentimes these catches are very treatable.
Healio: What are the barriers to access here? What are the consequences?
Guadamuz: It’s a bit of a gimme. Once you know how healthcare for citizens and noncitizen works in the U.S., it was pretty evident that you would find this inequity consistently and of this magnitude.
That being said, the No. 1 cause is the fact that noncitizens have much lower access to health insurance and much less access to a usual source of care, like a primary care provider or some other type of regular provider who can notice that someone has a history of certain types of diseases that need screening, or who simply just follows the clinical guidelines and says, “Oh, this person reached 45, they need to go get the screening.” Those are the No. 2 biggest causes. And this is the mediation analysis that led to these inequities that we observed.
But the other things that were really important were economic barriers, so having lower incomes. I talk about this in the discussion of my manuscript as I’m trying to interpret the findings: these screenings, even if you’re insured, can be time-consuming and expensive because you have to take off work. For example, a colonoscopy requires you to take off the whole day, and we know from the literature that noncitizens, on average, have jobs with limited flexibility in terms of taking paid time off. So, the barriers to these screenings were really structural barriers. We didn’t really find that things like language proficiency or years in the U.S. — these measures of how well a person has integrated into the U.S. society — led to the differences. They are important for clinicians to think about, but it was really caused by lower health insurance, lower healthcare access and worse socioeconomic conditions for noncitizens.
Healio: What can be done to improve cancer screening (and other preventive healthcare) in this population?
Guadamuz: The No. 1 thing we can do — we being the medical community, the public health community — is advocate for more inclusive health coverage policies. For example, California, albeit temporarily, expanded health insurance for undocumented immigrant adults. About 50% of noncitizens are undocumented or have some status that boots them from health insurance. They could be, for example, on a work visa — a noncitizen but not undocumented — and they still don’t have access to health coverage from the public system. So, that’s No. 1.
There’s also healthcare access programs that can be implemented. As one example, essentially the county government, instead of the state or federal government, has set up a program where people can get most primary care and a lot of specialty care funded by the county government. It is specifically targeting people who are excluded from other forms of health insurance. So, that’s another thing that we can do.
These are all system-level things that we should be thinking about doing. I also talk a little bit in the manuscript about other policies that are helpful to other the broader community. For example, paid leave for cancer screenings or other kinds of essential healthcare services would be helpful in terms of getting people to actually be able to take the time to go and do this type of screening. So, I would, No. 1, focus on what can we as a clinical or public health community think about in terms of advocacy, in terms of policy making, to make sure that we’re serving and protecting the health of everyone? What can we do to try to actually reach that goal? And that’s not even to talk about immigration policy. There’s plenty that can be done on that end.
Healio: Considering Immigration and Customs Enforcement (ICE) and the political turmoil in the U.S. right now, do you have any advice or best practices for providers on interacting with immigrant patients?
Guadamuz: For noncitizens to worry about ICE at healthcare facilities is a completely reasonable fear. Work from other scholars has shown that when there’s more ICE activity, people are less likely to go access healthcare, even emergency healthcare, for the fear of being exposed to that type of violence in in your community.
So, from a clinical perspective … one thing that we can think about is how do we make sure that we, as a healthcare system, like a hospital system or a clinical setting, ensure that the community feels safe going here? There are best practices that others have published about how do we communicate to the public and, therefore, also the federal government and ICE, that people cannot just enter these private facilities without permission or without a warrant? Some clinical settings have done that for areas that are not publicly facing. So, that is something that a broader health system or even a smaller clinic can think about, like can we look up these best practices and can we implement them so that our community feels like, “I might not be safe out there but in here I know that this clinical setting is trying to protect me as best as they can?”
Again, this is a structural problem. We can’t put this on the backs of clinicians to fix. It is the policymakers who are allowing this to happen. But going back to the clinical side, providing things like community health workers who are from immigrant communities, maybe communities that are language concordant — that could also help signal that this place is designed for you and welcomes you.
But, again, we have to go back on what the medical community wants to advocate for in terms of ICE being allowed to be near their healthcare facilities, sometimes in their healthcare facilities. How do they manage that? And if they choose to advocate, what would they want to advocate for?
Healio: If nothing else, what would you like PCPs to get out of this Q&A?
Guadamuz: As a primary care provider, as a clinician, as a public health professional, we do want to consistently keep in mind the policies that are in place federally and how that affects our community. And, again, thinking about these structural barriers and what can be done to address the fact that a certain population in the U.S. is systematically excluded from healthcare, therefore can’t even access some of the most basic healthcare services in the U.S. that can help them live a healthier life.
This is a huge difference between citizens and noncitizens in terms of getting very basic guideline-accordant cancer screenings. If you want to think about the financing of it all, getting someone cancer screening, ensuring that, if something’s wrong, they are diagnosed at an early stage and treated and potentially cured, is a lot more affordable than letting people not get the treatment that they need when they do, and then have a long, painful death in the U.S. Even from a financial perspective, it is obvious that excluding people like this is not saving anything. It is just kind of cruelty for cruelty’s sake. So, I would say to primary care physicians: think about who you vote for, think about what policies you want to advocate for, get involved with public health advocacy and public health policy making, and just make sure that you’re always thinking about that because you can’t put that on the back of your own primary care practice and paddle against structures that are designed by our society and by our government. That is unfathomable to put on an individual clinician.
For more information:
Jenny S. Guadamuz, MSPH, PhD, can be reached at primarycare@healio.com.
Sources/Disclosures
Source:
Healio Interviews
Reference:
Disclosures:
Guadamuz reports receiving grants from the Robert Wood Johnson Foundation during the conduct of the study and personal fees from Flatiron Health outside the submitted work.
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