Safety-net primary care access and screening-amenable cancer outcomes: A national county-level analysis.

Abstract

156 Background: Federally Qualified Health Centers (FQHCs) form a critical component of the U.S. safety net and provide preventive care in underserved communities. However, whether greater local FQHC availability is associated with improved screening-amenable cancer outcomes remains unclear. We examined the association between county-level FQHC density and late-stage colorectal (CRC) and breast cancer incidence. Methods: We constructed a national cross-sectional county-level dataset combining HRSA FQHC service-site data, State Cancer Profiles late-stage incidence rates (2018–2022), and American Community Survey estimates (2017–2021). FQHC density was defined as sites per 100,000 residents living below 200% of the federal poverty level and categorized as no FQHC or quartiles of nonzero density. Outcomes were age-adjusted late-stage incidence rates per 100,000. Counties with suppressed rates were excluded (CRC, n=2,461; breast, n=2,281). Multivariable linear regression with robust standard errors adjusted for poverty, uninsured rate, racial/ethnic composition, median household income, rurality, and state fixed effects. Results: Nearly one-third of U.S. counties had no FQHC, representing approximately 25 million residents. Compared with counties without FQHCs, counties in the first three quartiles of FQHC density had significantly lower late-stage CRC incidence, with adjusted differences of 1.03-1.74 fewer cases per 100,000, and lower late-stage breast cancer incidence, with differences of 1.42-1.99 fewer cases per 100,000 (all P<.05). If counties without FQHCs experienced rates comparable to low-density counties, these differences would correspond to approximately 400 fewer late-stage CRC cases and 400 fewer late-stage breast cancer cases annually. Associations were attenuated in the highest-density quartile, potentially reflecting greater underlying need. Findings remained consistent after excluding small counties and restricting analyses to urban counties. Secondary analyses showed similar associations with CRC and breast cancer mortality. Conclusions: Greater county-level FQHC availability was consistently associated with lower late-stage CRC and breast cancer incidence after adjustment for measured socioeconomic and geographic factors. The absence of FQHCs in nearly one-third of U.S. counties highlights a substantial gap in safety-net primary care infrastructure. Expanding FQHC access may represent a scalable cancer equity strategy, particularly when paired with targeted outreach and interventions addressing social barriers to screening and follow-up.