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. 2026 Sep 10;132(18):e70557. doi: 10.1002/cncr.70557

Prevalence of breast, cervical, and colorectal cancer screening among adults according to disability type and difficulty level, United States, 2021 and 2023

Natalia Mazzitelli 1, Jessica Star 1, Kinsey Meggett 2, Xuesong Han 1, Priti Bandi 1,✉
PMCID: PMC13560939  PMID: 42720530

Abstract

Background

Adults with disabilities face multiple barriers to cancer screening services. Few studies have examined screening receipt across multiple disability domains via standardized measures in contemporary nationally representative samples.

Methods

Data were pooled from the 2021 and 2023 National Health Interview Survey. Prevalence of United States Preventive Services Task Force recommendation concordant breast, cervical, and colorectal cancer screening was estimated according to disability domain (vision, hearing, mobility, cognition, communication, and self‐care) and difficulty level (“substantial,” “some,” and “none”), which were defined according to the Washington Group Composite Disability Indicator.

Results

A total of 1712, 1147, and 3106 sample respondents eligible for breast, cervical, and colorectal screening had disabilities, respectively, which translates to 6.02 million, 5.10 million, and 11.17 million when population weighted. Breast and cervical screening prevalence decreased with increasing difficulty level for self‐care, vision, mobility, and cognition domains, with the lowest receipt among those reporting substantial versus no self‐care difficulties (breast: 52% vs. 79%; adjusted prevalence ratio [aPR], 0.69; 95% CI, 0.58–0.82; cervical: 37% vs. 78%; aPR, 0.63; 95% CI, 0.51–0.78). Communication disability was associated with lower cervical screening (35% substantial vs. 78% none; aPR, 0.65; 95% CI, 0.52–0.82) but not for other screenings. Conversely, stool testing for colorectal screening was higher among adults with substantial mobility difficulties (22% vs. 16% none; aPR, 1.24; 95% CI, 1.12–1.38) and some self‐care, mobility, and vision difficulties, compared to those with none.

Conclusions

Addressing barriers for individuals with self‐care limitations could improve suboptimal screening levels across multiple cancer screenings. Self‐sampling modalities, including stool testing, may mitigate accessibility issues, and warrant further evaluation.

Keywords: cancer screening, early detection of cancer, functional disability, health care disparities, United States

Short abstract

According to 2021 and 2023 national survey data, prevalence of both breast and cervical screening receipt generally decreased with increasing difficulty level for self‐care, vision, mobility, and cognition. Conversely, adults with disabilities reported higher receipt of stool testing for colorectal cancer screening compared to adults without disabilities.

INTRODUCTION

The Americans with Disabilities Act defines a disability as a physical or cognitive impairment that significantly limits an individual’s capacity to perform specific activities and fully participate in their environment. In the United States, more than 61 million adults report having a disability. 1 The spectrum of disabilities includes conditions affecting multiple domains of functioning, such as motor (mobility), sensory (hearing and vision), cognitive (concentration, decision‐making, and memory), communicative, psychological, and social interaction capabilities. Cognitive (14%) and mobility disabilities (12%) constitute the most prevalent disability types within the US adult population. 2 , 3 These individuals face more than double the risk of all‐cause mortality compared to those without disabilities, with higher mortality for chronic conditions such as cancer. 4 , 5 , 6

Although screening protocols for breast, cervical, and colorectal cancers can improve survival outcomes via early detection, 7 individuals with disabilities often face barriers related to health care access, geographic location, and other social determinants of health. 8 , 9 , 10 , 11 They also tend to experience socioeconomic challenges, including higher poverty rates, limited access to financial services, food insecurity, and additional expenses for personal assistance products and transportation. 12 Individuals with cognitive, mobility, and intellectual disabilities have lower adherence in cancer screenings. 13 , 14 , 15 Specifically, mammography and Papanicolaou (Pap) test rates are lower among females with disabilities compared to females without disabilities. 15 , 16 , 17 , 18 , 19 Studies comparing colorectal screening rates between adults with and without disabilities are inconsistent, with some showing lower 20 , 21 and others higher screening rates for those with a disability. 15 , 22

Despite existing evidence on cancer screening among individuals with disabilities, few studies fully captures the complexity of disability domains and difficulty levels across each screening type. Studies have infrequently assessed the spectrum of disability domains and difficulty levels in relation to screening receipt, and to our knowledge this information has yet to be addressed within a contemporary generalizable US sample. Such information is critical to demonstrating where interventions are most needed in this population. This study aims to analyze receipt of breast, cervical, and colorectal cancer screening across all six disability domains and their severity levels via recent nationally representative data.

MATERIALS AND METHODS

Data source and study population

Data were pooled from the 2021 and 2023 National Health Interview Survey (NHIS), a cross‐sectional survey of noninstitutionalized US adults. The survey included 29,482 adults in 2021 and 29,522 adults in 2023, with survey response rates of 53% and 47%, respectively.

The analytic sample consisted of respondents who met eligibility criteria for breast, cervical, and colorectal cancer screening according to the United States Preventive Services Task Force (USPSTF) guidelines in effect at the start of the measurement period (2021), with complete data on disability status and screening receipt. Participants with missing values on cancer screening (breast, n = 279 [2.04%]; cervical, n = 398 [2.18%]; colorectal, n = 336 [1.29%]) were excluded from the final analytic sample.

Outcomes and exposure

Primary outcomes were self‐reported receipt of up‐to‐date (UTD) cancer screening according to USPSTF recommendations. For breast screening, the 2016 USPSTF recommends 23 mammography within the past 2 years for females aged 50–74 years. For cervical screening, the 2018 USPSTF recommends 24 (1) Pap testing alone every 3 years for females aged 21–29 years, or either (2) Pap testing alone every 3 years or (3) human papillomavirus (HPV) testing alone or with a Pap test (cotesting) every 5 years for females aged 30–65 years. However, because of questionnaire limitations in survey year 2023, UTD cervical screening prevalence was estimated as having received any cervical cancer screening test within 3 years for females aged 21–29 years or within 5 years for females aged 30–65 years who have not had a hysterectomy consistent with prior literature. 25 Colorectal screening was defined according to the 2016 USPSTF recommendation 26 as an annual high‐sensitivity guaiac fecal occult blood test or fecal immunochemical test (FIT); multitarget stool DNA test (sDNA‐FIT) every 3 years; computed tomography colonography every 5 years; flexible sigmoidoscopy every 5 years; flexible sigmoidoscopy every 10 years plus annual FIT; or colonoscopy every 10 years among adults aged 50–75 years.

Our primary exposure was disability status, assessed via the Washington Group Composite Disability Indicator. 27 Disability status was defined by the reported level of difficulty (no difficulty, some difficulty, a lot of difficulty, or cannot do at all) across six functioning domains: vision (even if wearing glasses/lenses), hearing (even if wearing hearing aids), mobility (walking or climbing steps), communication (understanding or being understood by others), cognition (remembering or concentrating), and self‐care (such as washing all over or dressing). A dichotomous summary variable was provided that indicated that respondents reporting “a lot of difficulty” or “cannot do at all” to at least one question were classified as having a disability. On the basis of prior literature, disability was stratified along each domain by difficulty level: no difficulty, some difficulty, and substantial difficulty (which combined “a lot of difficulty” and “cannot do at all”). 14

Covariates

Covariates were previously reported to be associated with cancer screening, 10 , 28 , 29 , 30 , 31 and included survey year, sex (colorectal only), age group, race/ethnicity, health insurance status, education level, geographic region, marital status, and urbanicity. Medicare is only collected for individuals aged ≥65 years in the survey; therefore, for cervical screening, only the single year at age 65 years is captured. A multicollinearity assessment confirmed that all factors had variance inflation factors of <2.5.

Statistical analysis

Differences in covariate distribution were assessed according to disability status (with vs. without a disability) among screening‐eligible respondents, and χ2 tests assessed statistical significance. Crude prevalence of UTD screening receipt was estimated according to disability type and severity level. Multivariable logistic regression models with predicted marginal probabilities were used to estimate adjusted prevalence ratios (aPRs) comparing screening receipt (dependent variable) prevalence across disability severity levels (independent variable), with adjustment for covariates. Those without a disability served as the reference group.

In accordance with National Center for Health Statistics guidelines, estimates with denominator sizes of <50 or relative standard errors of ≥30% were suppressed. All analyses were weighted to be nationally representative, and accounted for complex survey sampling via SAS and SAS‐callable SUDAAN. Significance was assessed by p < .05 for bivariate comparisons and 95% confidence intervals (CIs) for prevalence ratios.

RESULTS

Respondent characteristics

The sample included 13,679 females eligible for breast screening (1712 with disabilities), 18,205 females eligible for cervical screening (1147 with disabilities), and 26,081 adults eligible for colorectal screening (3106 with disabilities). After population weighting, individuals with disabilities constituted 6.02 million (12.2%), 5.10 million (6.2%), and 11.17 million (11.4%) of those eligible for breast, cervical, and colorectal cancer screening, respectively. Compared to screening‐eligible adults without disabilities, those with disabilities included higher proportions of Hispanic and non‐Hispanic Black females (breast and cervical screening), individuals aged older than 65 years, with less than a high school education and a federal poverty level of <100%, who reported being single, and who live in nonmetropolitan areas (Table 1). Tables S1 and S2 provide sample and weighted population numbers of total and screening‐eligible individuals according to disability domain and severity level.

TABLE 1.

Characteristics of selected demographic factors among screening‐eligible adults by disability status, National Health Interview Survey, United States, 2021 and 2023.

Characteristic Eligible for breast cancer screening (females aged 50–74 years) p Eligible for cervical cancer screening (females aged 21–65 years, no hysterectomy) p Eligible for colorectal cancer screening (adults aged 50–75 years) p
With disability Without disability With disability Without disability With disability Without disability
Sample, No. Weighted, % Sample, No. Weighted, % Sample, No. Weighted, % Sample, No. Weighted, % Sample, No. Weighted, % Sample, No. Weighted, %
Total 1712 11,967 1147 17,058 3106 22,975
Weighted, millions 6.02 43.50 5.10 77.57 11.17 87.00
Sex <.0001
Male — — — — — — — — 1322 44.3 10,616 48.6
Female — — — — — — — — 1784 55.7 12,357 51.4
Age, years <.0001 <.0001 <.0001
21–29 — — — — 148 19.2 3014 23.5 — — — —
30–39 — — — — 213 18.9 4710 26.1 — — — —
40–49 — — — — 207 17.9 3697 21.5 — — — —
50–64 883 56.6 7032 64.8 533 41.2 5277 27.4 1541 55.7 13,202 64.0
65+ 829 43.4 4935 35.2 46 2.8 360 1.5 1565 44.3 9773 36.0
Race/ethnicity <.0001 <.0001 <.0001
Hispanic 209 15.6 1224 12.3 204 20.2 3101 20.0 356 14.1 2367 12.7
White 1177 65.3 8453 67.8 715 59.4 10,036 56.5 2210 68.5 16,498 68.6
Black 246 13.9 1427 11.8 159 14.9 2001 12.8 388 12.0 2561 11.2
Asian 26 2.3 615 6.2 13 1.0 1378 7.6 55 2.4 1112 5.8
AIAN 41 2.2 162 1.3 41 3.1 264 1.5 79 2.4 294 1.2
Other a 13 0.8 86 0.7 15 1.4 278 1.6 18 0.6 143 0.6
Education level <.0001 <.0001 <.0001
Less than HS 258 17.6 899 9.1 153 14.3 1075 7.6 475 18.0 1855 9.9
HS/GED 527 33.3 2755 25.3 345 34.6 3345 22.6 1031 35.3 5596 26.3
Some college 569 30.8 3559 28.9 395 32.4 4509 27.1 959 28.9 6507 27.5
College graduate or higher 346 18.2 4699 36.8 242 18.7 8059 42.6 620 17.8 8913 36.4
Health insurance <.0001 <.0001 <.0001
Uninsured 60 4.3 504 4.9 93 9.4 1569 10.4 118 4.4 1133 5.6
Private 568 36.3 7341 63.9 461 40.9 12,064 69.6 1019 35.8 13,772 62.9
Dual, Medicaid, other public 499 28.1 1143 9.8 461 40.7 2641 16.5 815 25.7 1944 8.6
Medicare 389 20.0 2400 17.1 18 1.0 136 0.6 683 19.7 4581 17.0
Other b 190 11.3 551 4.4 111 8.0 617 2.9 459 14.3 1484 6.0
Annual income <.0001 <.0001 <.0001
<100% of FPL 428 21.7 1029 7.9 320 24.8 1818 10.6 716 20.1 1824 7.2
100%–199% of FPL 515 29.8 1889 15.4 323 27.3 2859 17.9 893 28.3 3460 14.5
≥200% of FPL 769 48.6 9049 76.7 504 47.9 12,381 71.5 1497 51.7 17,691 78.3
Region .0002 .0134 <.0001
Northeast 241 15.4 2038 19.1 171 16.2 2830 18.0 420 15.0 3820 18.5
Midwest 338 19.0 2654 21.3 219 18.3 3575 20.5 637 19.5 5101 21.2
South 731 43.7 4329 37.1 483 43.0 6040 37.0 1315 43.5 8370 37.5
West 402 21.9 2946 22.5 274 22.4 4613 24.5 734 22.0 5684 22.8
Urbanicity <.0001 <.0001 <.0001
Large metro 448 28.2 3245 28.3 320 29.0 5738 34.0 781 26.7 6305 28.5
Fringe metro 329 20.2 2958 26.1 228 20.8 4170 25.6 585 19.8 5622 25.9
Medium/small metro 561 31.6 3884 30.9 376 32.6 5063 28.8 1026 32.4 7424 31.1
Nonmetropolitan 374 19.9 1880 14.8 223 17.5 2087 11.6 714 21.0 3624 14.5
Marital status <.0001 <.0001 <.0001
Married 574 45.6 5814 62.4 354 37.2 8251 53.4 1173 50.3 11,889 65.9
Living with a partner 64 5.0 381 4.2 93 10.6 1492 11.2 106 4.6 821 4.7
Single 1016 49.4 5360 33.5 670 52.3 6886 35.4 1728 45.1 9475 29.5
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Note: Adults who responded “a lot of difficulty” or “cannot do at all” to at least one question were considered to have a disability.

Abbreviations: AIAN, American Indian/Alaska Native; FPL, federal poverty level; GED, General Educational Development; HS, high school.

a

Other race refers to other single or multiple races.

b

Other insurance type refers to all other nonpublic insurance.

Breast cancer screening

Females reporting difficulties across multiple disability domains showed an overall lower breast cancer screening prevalence, compared to those with “none” (Table 2; Table S3). Those with substantial self‐care difficulties (52% vs. 79% with none; aPR, 0.69; 95% CI, 0.58–0.82) had the lowest prevalence, followed by vision (62% vs. 79% with none; aPR, 0.83; 95% CI, 0.75–0.91) and mobility (68% vs. 79% with none; aPR, 0.89; 95% CI, 0.85–0.93) difficulties. Significantly lower screening was also seen for those with “some” self‐care (71% vs. 79% with none; aPR, 0.93; 95% CI, 0.88–0.99), cognition (75% vs. 79% with none; aPR, 0.96; 95% CI, 0.94–0.99), and vision (75% vs. 79% with none; aPR, 0.96; 95% CI, 0.94–0.99) difficulties.

TABLE 2.

Crude prevalence estimates and adjusted prevalence ratios for up‐to‐date breast and cervical cancer screening by disability type and difficulty level, National Health Interview Survey, United States, 2021 and 2023.

Disability type Difficulty level Breast cancer screening Cervical cancer screening
Up to date % a 95% CI aPR (95% CI) Up to date % b 95% CI aPR (95% CI)
Vision None 79.4 (78.4–80.3) Reference 77.7 (76.6–78.7) Reference
Some 74.7 (72.8–76.6) 0.96 (0.94–0.99) 75.7 (73.6–77.6) 0.99 (0.96–1.01)
Substantial 62.3 (56–68.2) 0.83 (0.75–0.91) 63.5 (55.9–70.6) 0.89 (0.80–0.98)
Hearing None 78.4 (77.4–79.3) Reference 77.0 (76–78.1) Reference
Some 77.1 (74.9–79.1) 0.99 (0.96–1.02) 78.9 (76.4–81.2) 1.01 (0.98–1.05)
Substantial 67.6 (59.4–74.8) 0.91 (0.83–1.01) 70.1 (59.4–78.9) 0.93 (0.81–1.05)
Mobility None 79.3 (78.3–80.3) Reference 77.7 (76.6, 78.7) Reference
Some 77.6 (75.8–79.2) 0.98 (0.96–1.01) 75.7 (73.2–78.1) 0.98 (0.95–1.02)
Substantial 68.4 (65.2–71.5) 0.89 (0.85–0.93) 65.3 (60.2–70.1) 0.88 (0.82–0.94)
Communication None 78.4 (77.5–79.2) Reference 77.9 (76.9–78.9) Reference
Some 72.2 (67.8–76.2) 0.96 (0.91–1.01) 62.4 (57.2–67.3) 0.89 (0.83–0.95)
Substantial 64.4 (49.7–76.9) 0.89 (0.74–1.08) 35.0 (24.4–47.3) 0.65 (0.52–0.82)
Cognition None 79.2 (78.2–80.1) Reference 77.8 (76.7–78.8) Reference
Some 74.8 (72.8–76.6) 0.96 (0.94–0.99) 75.8 (73.9–77.6) 0.99 (0.97–1.02)
Substantial 69.2 (63–74.8) 0.93 (0.86–1.01) 63.5 (57.4–69.2) 0.91 (0.85–0.98)
Self‐care None 78.7 (77.8–79.5) Reference 77.5 (76.5–78.5) Reference
Some 70.8 (66.4–74.9) 0.93 (0.88–0.99) 71.8 (66.8–76.4) 0.97 (0.92–1.03)
Substantial 52.1 (42.4–61.6) 0.69 (0.58–0.82) 37.2 (27.6–47.9) 0.63 (0.51–0.78)
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Note: aPR is adjusted for survey year, age, sex, race/ethnicity, marital status, geographic region, education, urbanicity, and health insurance type.

Abbreviations: aPR, adjusted prevalence ratio; CI, confidence interval.

a

Mammogram within the past 2 years in females aged 50–74 years.

b

In females reporting no hysterectomy, cervical screening test within 3 years for those aged 21–29 years or within 5 years for those aged 30–65 years.

Females with some versus no mobility difficulty (78% vs. 79%; aPR, 0.98; 95% CI, 0.96–1.01) and substantial versus no cognitive difficulty (69% vs. 79%; aPR, 0.93; 95% CI, 0.86–1.01) showed lower receipt of breast cancer screening, along with both hearing and communication domains at all difficulty levels (Table S3); however, these differences were not statistically significant in adjusted analyses (Table 2).

Cervical cancer screening

Similar patterns were observed for cervical screening (Table 2; Table S3). Females reporting substantial self‐care (37% vs. 78% with none; aPR, 0.63; 95% CI, 0.51–0.78), vision (64% vs. 78% with none; aPR, 0.89; 95% CI, 0.80–0.98), mobility (65% vs. 78% with none; aPR, 0.88; 95% CI, 0.82–0.94), and cognitive (64% vs. 78% with none; aPR, 0.91; 95% CI, 0.85–0.98) difficulties had lower screening prevalence compared to those reporting none. Lower screening was also seen for females reporting communication disability difficulties (substantial, 35% vs. none, 78%; aPR, 0.65; 95% CI, 0.52–0.82; some, 62% vs. none, 78%; aPR, 0.89; 95% CI, 0.83–0.95).

Those reporting some self‐care (72% vs. 78% with none; aPR, 0.97; 95% CI, 0.92–1.03), cognition (76% vs. 78% with none; aPR, 0.99; 95% CI, 0.97–1.02), mobility (76% vs. 78% with none; aPR, 0.98; 95% CI, 0.95–1.02), and vision (76% vs. 78% with none; aPR, 0.99; 95% CI, 0.96–1.01) difficulties also had lower screening in unadjusted analyses (Table S3); however, these results were not significant after adjustment (Table 2). Hearing disabilities showed no significance across all levels of difficulty.

Colorectal cancer screening

In contrast to breast and cervical cancer screening, stool testing prevalence for colorectal cancer screening was higher in individuals with higher levels of difficulty across most disability domains, even after adjustment (Table 3; Table S3). Compared to adults reporting no difficulty, stool testing prevalence was higher in those reporting substantial mobility (22% vs. 16%; aPR, 1.24; 95% CI, 1.12–1.38) and some mobility (19% vs. 16%; aPR, 1.12; 95% CI, 1.03–1.21) difficulties, some self‐care difficulties (24% vs. 16%; aPR, 1.28; 95% CI, 1.11–1.47), and some vision difficulties (18% vs. 16%; aPR, 1.08; 95% CI, 1.00–1.17). Contrary to stool testing for colorectal cancer screening, colonoscopy prevalence did not significantly differ across most disability domains, except for a significantly higher prevalence among those with some versus no cognitive difficulties (67% vs. 63%; aPR, 1.07; 95% CI, 1.04–1.09).

TABLE 3.

Crude prevalence estimates and adjusted prevalence ratios for up‐to‐date colorectal cancer screening by disability type and difficulty level, National Health Interview Survey, United States, 2021 and 2023.

Disability type Difficulty level Colorectal cancer screening Stool testing Colonoscopy
Up to date % a 95% CI aPR (95% CI) Up to date % b 95% CI aPR (95% CI) Up to date % c 95% CI aPR (95% CI)
Vision None 72.8 (72–73.7) Reference 16.3 (15.6–17) Reference 64.6 (63.7–65.5) Reference
Some 70.3 (68.7–71.8) 1.01 (0.98–1.03) 18.0 (16.8–19.4) 1.08 (1.00–1.17) 61.2 (59.6–62.8) 1.00 (0.97–1.03)
Substantial 67.3 (62.1–72) 0.98 (0.92–1.05) 19.8 (15.8–24.5) 1.10 (0.88–1.38) 58.8 (53.7–63.7) 0.98 (0.91–1.06)
Hearing None 71.5 (70.6–72.3) Reference 16.4 (15.7–17.1) Reference 63.0 (62.1–63.9) Reference
Some 75.7 (74.3–77.2) 1.01 (0.99–1.04) 18.1 (16.9–19.4) 1.06 (0.99–1.15) 67.4 (65.8–69.1) 1.01 (0.99–1.04)
Substantial 72.5 (67.4–77) 1.02 (0.96–1.08) 16.6 (13.4–20.5) 0.98 (0.79–1.22) 66.6 (61.6–71.3) 1.06 (0.99–1.13)
Mobility None 71.8 (70.8–72.7) Reference 15.6 (14.9–16.3) Reference 63.4 (62.4–64.4) Reference
Some 74.2 (72.7–75.6) 1.02 (1.00–1.04) 18.9 (17.7–20.2) 1.12 (1.03–1.21) 65.6 (64–67.2) 1.02 (0.99–1.04)
Substantial 71.8 (69.5–73.9) 1.01 (0.97–1.04) 21.9 (19.9–24) 1.24 (1.12–1.38) 63.3 (60.8–65.7) 1.00 (0.96–1.05)
Communication None 72.5 (71.7–73.3) Reference 16.7 (16–17.3) Reference 64.1 (63.2–64.9) Reference
Some 67.3 (64.3–70.2) 0.96 (0.92–1.00) 17.0 (14.6–19.6) 0.96 (0.82–1.12) 59.3 (56.2–62.4) 0.96 (0.92–1.01)
Substantial 61.7 (52.9–69.7) 0.89 (0.78–1.01) 18.8 (13.3–26) 0.97 (0.67–1.41) 54.8 (46.1–63.2) 0.90 (0.78–1.05)
Cognition None 71.5 (70.6–72.3) Reference 16.2 (15.5–16.8) Reference 63.1 (62.2–64) Reference
Some 75.8 (74.3–77.3) 1.06 (1.03–1.08) 18.6 (17.4–20) 1.07 (0.99–1.16) 67.5 (65.8–69.1) 1.07 (1.04–1.09)
Substantial 68.7 (63.8–73.2) 1.03 (0.98–1.09) 20.2 (16.5–24.6) 1.15 (0.93–1.42) 59.2 (54.3–64) 1.04 (0.97–1.11)
Self‐care None 72.4 (71.6–73.2) Reference 16.4 (15.8–17.1) Reference 64.0 (63.2–64.8) Reference
Some 71.0 (67.4–74.4) 1.00 (0.95–1.04) 23.6 (20.7–26.9) 1.28 (1.11–1.47) 61.1 (57.3–64.9) 0.98 (0.92–1.04)
Substantial 59.9 (52.7–66.7) 0.85 (0.76–0.95) 16.5 (12.1–21.9) 0.78 (0.57–1.06) 55.2 (48–62.2) 0.89 (0.79–1.01)
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Note: aPR adjusted for survey year, age, sex, race/ethnicity, marital status, geographic region, education, urbanicity, and health insurance type.

Abbreviations: aPR, adjusted prevalence ratio; CI, confidence interval.

a

Adults aged 50–75 years. High‐sensitivity guaiac fecal occult blood test or fecal immunochemical test (FIT) every year; multitarget stool DNA test (sDNA‐FIT) every 3 years; computed tomography colonography every 5 years; flexible sigmoidoscopy every 5 years; flexible sigmoidoscopy every 10 years + FIT every year; or colonoscopy every 10 years.

b

High‐sensitivity guaiac fecal occult blood test or fecal immunochemical test (FIT) every year; or sDNA‐FIT every 3 years.

c

Colonoscopy every 10 years.

Overall colorectal screening (stool testing or colonoscopy) prevalence was lower for those with substantial versus no self‐care difficulties (60% vs. 72%; aPR, 0.85; 95% CI, 0.76–0.95), and higher among those reporting some versus no cognitive difficulties (76% vs. 71%; aPR, 1.06; 95% CI, 1.03–1.08) and some versus no mobility difficulties (74% vs. 72%; aPR, 1.02; 95% CI, 1.00–1.04).

DISCUSSION

This study compared receipt of breast, cervical, and colorectal cancer screening across six disability domains according to difficulty level in a nationally representative contemporary sample of US adults. Results show that prevalence of both breast and cervical screening receipt generally decreased with increasing difficulty levels for self‐care, vision, mobility, and cognition, with larger differences consistently observed for the self‐care domain. Conversely, adults with disabilities reported higher receipt of stool testing for colorectal cancer screening compared to adults without disabilities across self‐care, mobility, and vision domains. Communication disability was uniquely associated with lower cervical screening.

These findings are consistent with previously reported disparities between having a disability and receipt of cancer screening. 13 , 14 , 15 , 16 , 18 , 22 Although it has been reported that lower screening is prevalent in this population, previous literature used historical NHIS data without examining the degree of difficulty 15 or examined a single cancer screening type or disability domain. 14 , 32 , 33 This study adds to the literature by highlighting the several commonalities and differences that exist across disability domains and severity levels, which can be used to target disability‐related screening disparities.

Across all studied screenings, substantial self‐care limitations were consistently associated with the largest gap in adherence when compared to those without disabilities. To our knowledge, there is no prior literature that examines self‐care limitations and cancer screening, with one study excluding self‐care respondents if they did not report other disabilities. 15 This decision was likely because of the potential overlap that exists between the six functional domains. For example, those reporting self‐care limitations are likely to also report difficulties across other domains such as mobility, vision, and cognition disabilities. To account for this, the degree of difficulty for each disability domain was analyzed because it can offer a way to better identify those most at risk of not receiving recommended screenings. Other domains, such as vision, mobility, and cognition, were also similarly associated with lower breast and cervical screening prevalence among females with disabilities, which aligns with prior research. 11 , 14 , 15 , 34

Communication disability differences were observed for cervical screening prevalence alone but not with other screenings. Evidence on why this may be the case is incomplete, given that studies that highlight communication impairment define it as a visual, auditory, or linguistic disability, and do not examine it in relation to receipt of cervical cancer screening. 5 , 6 However, the literature extensively reports the various communication obstacles that continue to exist for this subgroup, which have remained unsolved at the patient–clinician level. 35

Interestingly, whereas screening decreased with increased severity for breast and cervical cancer, opposite gradients were observed for stool testing for colorectal cancer screening. Particularly, use was higher in those with higher difficulty levels across vision, self‐care, and mobility domains. Stool testing, specifically “at‐home” testing, has been generally available since the late 1980s, 36 and although it reduces certain barriers, particularly those related to transportation, it does not eliminate all barriers, such as return logistics or follow‐up colonoscopy testing after abnormal test results, which reinstates the burden at‐home testing intended to avoid. This finding, however, highlights the potential for improving screening access by direct‐mailing self‐collection testing kits for patients, which have been documented as a successful intervention to improve overall colorectal cancer screening. 37 , 38 , 39 , 40

Contrary to the patterns observed for stool testing, prevalence of colonoscopy and overall colorectal cancer screening (stool testing or colonoscopy) was higher in those with cognition‐related difficulties, a finding also observed across studies. 14 , 15 , 16 , 22 , 41 The contrast between stool testing and colonoscopy receipt may be due to the procedural burden involved with colonoscopy, which requires bowel preparation, transportation to a facility, sedation, and postprocedure instructions. 42 Stool testing, however, is a more flexible alternative because it can be completed at home without fasting or lengthy preparation. This suggests an interaction between testing modalities and disability domains, which highlights the need for tailored targeting of available testing options to specific disability domains. For example, although home‐based testing may improve access for those with physical impairments, such options need further refinement across other domains.

Another interesting finding was the observed differences by difficulty level across all cancer screening types. Compared to those with no difficulties, those reporting substantial difficulties had much lower screening levels, whereas those with some difficulties had marginally lower screening levels. Although more studies are needed to determine the contributing factors related to differences in screening across levels of difficulty, there is evidence supporting that severely impaired individuals are less likely to receive screening. 14 , 43 This may suggest that focusing on the severity of the impairment to tailor appropriate intervention programs could improve screening in this vulnerable population.

Documented barriers experienced by people with disabilities often include environmental (i.e., transportation and lack of support), person‐level (i.e., fear of embarrassment, distrust, and misinformation), provider‐level (i.e., lack of training and communication skills to accommodate the disability), and health care system–level factors (i.e., insurance costs and appointment wait times). 44 , 45 , 46 , 47 , 48 , 49 , 50 Lower screening prevalence among adults reporting self‐care difficulties may reflect current screening delivery systems and procedures, which are not designed to accommodate those with higher support needs, such as assistance with undressing, positioning, and communication with testing procedures. Therefore, improving screening disparities for this population requires a multilevel approach within the current health care system that considers the specifics of both the cancer screening type and disability domain.

Although self‐sampling methods can represent one approach (e.g., with some women reporting feeling more comfortable screening for cervical cancer at home), 45 this solution does not address factors such as the in‐person follow‐up care needed to establish a diagnosis or that Food and Drug Administration–approved HPV self‐sampling kits for cervical screening can only be obtained from a health care provider. 51 Additionally, meaningful barriers remain for females with cognitive difficulties (comprehending multistep screening instructions), communication difficulties (discussing results with a provider), and self‐care difficulties (performing sample collection). Self‐sampling is not a universally accessible solution, and implementation of innovative screening modalities needs to account for disability domain–specific challenges.

Limitations and strengths

The main strength of this study is the use of contemporary population‐based nationally representative data, which makes the results generalizable to noninstitutionalized eligible US adults. Also, although disability and cancer screening have been previously evaluated, this study goes a step further by examining multiple disability domains and their respective difficulty levels across three different cancer screening types via recent national survey data, which, to our knowledge, have not been evaluated. However, some limitations include answers being self‐reported and subject to recall and social desirability bias, with prior studies showing that self‐reported mammogram and colonoscopy are overestimated in national surveys. 52 , 53 However, other studies of self‐reported data for cervical, colorectal, and breast cancer screening have been found to be fairly accurate, and no differences were reported across sociodemographic factors. 54 , 55 Also, temporality could not be assessed because of the cross‐sectional nature of the study. The disability module, however, has been validated by the National Center for Health Statistics. 56 Last, the NHIS only includes noninstitutionalized adults; therefore, our findings are only generalizable to this population. Screening prevalence among adults living in institutional settings (e.g., assisted living spaces or prisons) could not be assessed. Disability and cancer mortality are known to be higher among institutionalized US adults. 57 , 58 Future research should evaluate how disability‐related screening disparities are likely further compounded by systemic factors such as poverty, rurality, and other health care system access.

AUTHOR CONTRIBUTIONS

Natalia Mazzitelli: Writing—original draft; writing—review and editing; formal analysis; investigation; conceptualization; methodology; software; data curation. Jessica Star: Writing—review and editing; formal analysis; methodology. Kinsey Meggett: Writing—review and editing; investigation. Xuesong Han: Writing—review and editing; investigation. Priti Bandi: Conceptualization; investigation; validation; supervision; project administration; writing—review and editing.

CONFLICT OF INTEREST STATEMENT

Natalia Mazzitelli, Jessica Star, Xuesong Han, and Priti Bandi are employed by the American Cancer Society, which receives grants from private and corporate foundations, including foundations associated with companies in the health sector, for research outside the submitted work; their salary is solely funded via American Cancer Society funds. The other author declares no conflicts of interest.

Supporting information

Supplementary Material

CNCR-132-e70557-s001.docx (32.9KB, docx)

ACKNOWLEDGMENTS

This work was supported by American Cancer Society intramural research.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are openly available from the National Center for Health Statistics of the Centers for Disease Control and Prevention at https://www.cdc.gov/nchs/nhis/documentation/?CDC_AAref_Val=https://www.cdc.gov/nchs/nhis/data‐questionnaires‐documentation.htm. These data were derived from https://www.cdc.gov/nchs/nhis/index.html, and are available in the public domain.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material

CNCR-132-e70557-s001.docx (32.9KB, docx)

Data Availability Statement

The data that support the findings of this study are openly available from the National Center for Health Statistics of the Centers for Disease Control and Prevention at https://www.cdc.gov/nchs/nhis/documentation/?CDC_AAref_Val=https://www.cdc.gov/nchs/nhis/data‐questionnaires‐documentation.htm. These data were derived from https://www.cdc.gov/nchs/nhis/index.html, and are available in the public domain.

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