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Volume 1
Original Investigation
Equity, Diversity, and Inclusion
Historical Redlining and Spatiotemporal Patterns in Breast Cancer Screening
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JAMA Netw Open
Annual Census tract–level breast cancer screening prevalence estimates were obtained from the CDC PLACES database and linked to historical redlining and present-day neighborhood characteristics via the Census tract geographic identifier using publicly available datasets.20 The CDC PLACES breast cancer screening measure represents the estimated percentage of women aged 50 to 74 years who report receiving a
https://jamanetwork.com/
Published Online: September 2, 2026
2026;9;(9):e2630685. doi:10.1001/jamanetworkopen.2026.30685
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Key Points
Question Is historical redlining associated with breast cancer screening prevalence in a cancer center catchment area after accounting for social vulnerability, neighborhood socioeconomic conditions, and geographic access?
Findings In this cohort study of 1152 historically redlined Census tracts, tracts with Homeowners' Loan Corporation grades C and D (representing more redlining) had significantly lower odds of receiving breast cancer screening than grade A tracts (representing the least redlining). Substantial spatial clustering and temporal dependence persisted after adjustment, and most neighborhoods remained below national screening targets.
Meaning The finding that historical redlining was associated with breast cancer screening disparities supports place-based strategies that address persistent socioeconomic barriers.
Abstract
Importance Geographic variation in breast cancer screening may reflect persistent structural inequities in access to preventive care. Understanding whether historical redlining remains associated with screening, independent of contemporary social vulnerability, neighborhood conditions, and geographic access, is critical for targeting interventions within cancer center catchment areas.
Objectives To examine the association between historical redlining and breast cancer screening prevalence, accounting for social vulnerability, neighborhood characteristics, and geographic access, and to characterize spatiotemporal screening patterns.
Design, Setting, and Participants This cohort study used Census tract–level data from 2016 to 2024 across the University of Kansas Cancer Center catchment area, including communities in Kansas and adjacent Missouri counties. The analytic sample included Census tracts with available Homeowners' Loan Corporation (HOLC) grades A (indicating the least redlining) to D (indicating the most redlining). Statistical analysis was performed from July to December 2025.
Exposures HOLC grades; Social Vulnerability Index quintiles (with the first quintile indicating the lowest vulnerability and the fifth quintile indicating the highest); Census tract–level socioeconomic, housing, and transportation indicators; and distance to the nearest mammography facility.
Main Outcomes and Measures Census tract–level breast cancer screening prevalence from the Centers for Disease Control and Prevention's PLACES database, reported as odds ratios (ORs) with 95% credible intervals (CrIs).
Results A total of 1152 historically redlined Census tracts were analyzed. Tracts were categorized by HOLC grades A (n = 27), B (n = 99), C (n = 423), and D (n = 603). The median (IQR) screening prevalence was highest in grade A tracts (79.6% [79.0%-80.0%]) and lowest in grade D tracts (75.2% [71.7%-79.2%]). Models demonstrated substantial spatial and temporal dependence with geographic clustering and localized variability. Compared with grade A tracts, grade C (OR, 0.94; 95% CrI, 0.90-0.99) and grade D tracts (OR, 0.94; 95% CrI, 0.89-0.99) had lower screening prevalence after adjustment. The highest Social Vulnerability Index quintile was associated with increased screening odds (OR, 1.08; 95% CrI, 1.01-1.14). Lower educational attainment (OR, 0.94; 95% CrI, 0.92-0.96) and higher mobile home prevalence (OR, 0.98; 95% CrI, 0.97-1.00) were associated with lower screening odds. Residual spatial heterogeneity persisted (711 of 1152 tracts [61.7%] excluding the null). Screening peaked in 2018 to 2019, stabilized through 2023, and declined in 2024, with most areas remaining below the Healthy People 2030 target of 80.3%.
Conclusions and Relevance This study found that historical redlining was associated with lower breast cancer screening prevalence independent of contemporary social vulnerability, neighborhood conditions, and geographic access. These findings support sustained, place-based strategies addressing structural and socioeconomic barriers to improve screening uptake and progress toward national screening targets.
Introduction
Breast cancer is one of the most common cancers among women and remains a leading cause of cancer-related mortality. In the US, it is ranked as the second leading cause of cancer death among women, after lung cancer.1-3 Although the burden remains substantial, outcomes have improved considerably over time; breast cancer death rates declined by approximately 40% between 1989 and 2017, reflecting advances in treatment and earlier detection.4 Mammography screening is therefore considered a cornerstone of breast cancer control, supporting timely diagnosis and more effective intervention.5,6 However, screening prevalence is not evenly distributed across communities, and recent evidence has shown that social and structural barriers, such as transportation and other unmet social needs, continue to hinder screening utilization even when services are available.7-9
Historically produced inequities in neighborhood infrastructure and access to services may contribute to contemporary screening patterns. One key structural mechanism is the Homeowners' Loan Corporation (HOLC) residential security grading system, commonly referred to as historical redlining, which classifies neighborhoods from "best" (grade A) to "hazardous" (grade D) based on perceived mortgage lending risk and investment potential.10 These classifications contributed to long-term disinvestment and reduced neighborhood resources in communities labeled as declining or hazardous. These historical patterns are linked to persistent differences in cancer-related outcomes and contemporary inequities in health, including breast cancer outcomes.9-15 Contemporary neighborhood vulnerability is also shaped by present-day socioeconomic and demographic conditions and is commonly captured by the Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI), which is based on percentile rankings, with higher values indicating greater vulnerability.16-19 While the SVI captures current disadvantage across multiple domains, the enduring imprint of historical redlining may not be fully represented. In addition, geographic access to screening remains an important pathway, as distance to mammography facilities can influence preventive care use.20-22
National benchmarks highlight both progress and remaining gaps. Healthy People 2030 set a target of 80.3% for the proportion of women aged 50 to 74 years who are up to date with breast cancer screening, while the most recent (2023) national estimate was 79.8%.23 The 2024 Behavioral Risk Factor Surveillance System estimates from State Cancer Profiles showed that mammography use among women aged 50 to 74 years was 77.4% in Kansas and 79.5% in Missouri, compared with a US median of 78.5%.2,4 Thus, Kansas remains below both the 79.8% national estimate and the 80.3% Healthy People 2030 target, while Missouri is close to the 79.8% estimate but still below the 80.3% target.24 The Healthy People 2030 target is used as the primary national public health benchmark for the present analysis because it provides a federal population-level screening goal aligned with the eligible age group used in the breast cancer screening measure of the CDC PLACES project. These issues are particularly relevant for the University of Kansas Cancer Center (KUCC) catchment area, which spans communities across Kansas and adjoining counties in Missouri. For breast cancer prevention planning, it is important not only to evaluate whether historical redlining and social vulnerability are associated with screening but also to understand how screening prevalence is patterned across space and time. Census tract–level screening estimates commonly exhibit spatial dependence and year-to-year temporal correlation; analyses that ignore these features may underestimate uncertainty and miss meaningful geographic clustering.25 A preliminary analysis of the catchment area identified substantial geographic variation in breast cancer screening prevalence, with tract-level screening rates ranging from 56.9% to 84.5%, higher screening rates in urban centers, and lower screening rates in rural areas of southern and western Kansas. These geographic differences motivated our use of bayesian spatiotemporal modeling to account for spatial and temporal dependence in tract-level screening prevalence.
Despite increasing evidence linking historical redlining to cancer screening disparities, key gaps remain. Prior studies often had a cross-sectional design, and it remains unclear whether redlining is associated with breast cancer screening rates in the catchment area independent of present-day SVI, neighborhood conditions, and geographic access to mammography services. This study aimed to examine the association between historical redlining and breast cancer screening prevalence, accounting for social vulnerability, neighborhood characteristics, and geographic access, and to characterize spatiotemporal screening patterns. Specifically, we evaluated whether screening prevalence is lower in historically redlined Census tracts, particularly with HOLC grades C and D, and whether contemporary socioeconomic, housing, and transportation conditions help explain these disparities. The findings may generate place-based evidence to support cancer center outreach, community engagement, navigation, and resource allocation for neighborhoods where structural and socioeconomic barriers continue to limit progress toward national screening targets.
Methods
Study Design and Data Sources
A longitudinal ecological study was conducted to examine Census tract–level breast cancer screening rates in the KUCC catchment area (123 counties, including 105 in Kansas and 18 in Missouri) from 2016 to 2024. In accordance with University of Kansas Medical Center institutional policy, this study was exempt from ethics review and informed consent requirement because it used publicly available, deidentified, aggregate data. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies.
Annual Census tract–level breast cancer screening prevalence estimates were obtained from the CDC PLACES database and linked to historical redlining and present-day neighborhood characteristics via the Census tract geographic identifier using publicly available datasets.20 The CDC PLACES breast cancer screening measure represents the estimated percentage of women aged 50 to 74 years who report receiving a
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