Scoping Review Maps Steep Barriers to Cancer Care Across Alabama

Alabama sits at the center of one of the most stubborn cancer inequity crises in the United States. A new scoping review published in the Journal of Cancer Survivorship has synthesized nearly three decades of peer-reviewed research to map, with unusual precision, why residents of the state face some of the nation’s highest cancer mortality rates despite incidence rates that are actually slightly below the national average. The answer, the researchers conclude, lies not in a single failing but in the interlocking grip of geography, finances, insurance gaps, and fragmented healthcare delivery that falls hardest on Black and rural Alabamians.

The paradox at the heart of the findings is striking. Alabama’s overall cancer incidence rate of 432.6 cases per 100,000 population trails the national figure of 448.6, yet the state’s mortality rate of 159.1 per 100,000 substantially exceeds the US rate of 145.4. The American Cancer Society projected roughly 30,030 new cancer diagnoses and 10,210 cancer deaths among Alabamians in 2025 alone. The most common cancers in the state are breast, prostate, and lung. Something between diagnosis and death is going catastrophically wrong, and the review argues that access to care is the thread connecting the numbers.

Led by Nicole Caviness-Ashe and Timiya S. Nolan of the University of Alabama at Birmingham’s Heersink School of Medicine, the research team followed PRISMA-ScR reporting guidelines and Joanna Briggs Institute methodology. Working with an information specialist, they searched MEDLINE, Embase, Scopus, CINAHL, and APA PsycINFO for studies published between January 1, 1995, and December 30, 2024. Of 3,556 records uploaded for screening, 28 studies ultimately met the criteria, spanning qualitative interviews, quantitative and secondary data analyses, retrospective cohorts, and one implementation science study. Two independent reviewers screened and extracted data through a four-stage verification process, and critical appraisal was performed with JBI checklists, though no studies were excluded on the basis of appraisal scores.

To organize the evidence, the team adapted Robinson and Hudson’s Inter-relationships Framework, a model that treats cancer outcomes as the product of relationships among patients, providers, and healthcare systems rather than the consequence of any single factor. The framework had not previously been applied to cancer outcomes in Alabama, and the review demonstrates its explanatory power: barriers that appear personal, such as a missed screening appointment, are often rooted in system-level failures such as the absence of Medicaid expansion or the concentration of oncology services in distant urban centers.

The structural context the review describes is sobering. Alabama lies within the Black Belt, a region whose economic development was built on the forced labor of enslaved Africans and later shaped by Jim Crow segregation, the collapse of the cotton industry, boll weevil infestation, and chronic underinvestment in education, healthcare, and infrastructure. Approximately 42 percent of the state’s residents live in rural areas designated as health professional shortage areas, and of Alabama’s 67 counties, 58 are rural, served by just 54 rural county hospitals. Average emergency response times in rural counties range from 11 to 30 minutes, substantially longer than the sub-15-minute averages typical of many urban areas. Counties including Lowndes, Perry, Sumter, and Choctaw carry long histories of limited or no healthcare access, and many overlap with persistent poverty counties, defined as places where at least 20 percent of residents have lived below the federal poverty level for at least 30 consecutive years.

Across the 28 studies, geographic barriers emerged in nearly a third of the literature. Long travel distances from home to healthcare facilities, rural residency, and living in under-resourced areas were consistently correlated with delayed treatment, compromised treatment plans, interrupted survivorship care, and poorer prognoses. Transportation itself surfaced as a distinct obstacle in several studies: survivors described reluctance to travel to urban hospitals for surgical care, finding unfamiliar city environments difficult to navigate. Intriguingly, one study reported that living closer to a healthcare facility was associated with lower socioeconomic status and lower odds of attending colonoscopy follow-up, a reminder that proximity alone does not guarantee access.

Financial hardship was the most pervasive barrier of all, examined in 54 percent of the included studies. It touched cancer survivors from pediatric to geriatric ages, compounding medication non-adherence, delaying care, and degrading psychological well-being. Black participants, rural residents, people in high-deprivation areas, and those on fixed incomes were disproportionately affected. Insurance status, examined in five studies, compounded rather than resolved the problem: uninsured and underinsured survivors experienced longer screening delays, interrupted treatment, and poorer survival, and even those covered by Medicare or Medicaid remained burdened by financial strain. The review emphasizes that Alabama is one of the states that has not expanded Medicaid under the Affordable Care Act, leaving many low-income adults without adequate coverage, a policy gap linked in national evidence to later detection and worse survival across multiple cancer types.

Provider and system-level factors wove through the literature as well. Poor communication, medical mistrust, experiences of discrimination, complex billing, and a lack of culturally competent care all impeded screening follow-up and continuity of care, with particularly damaging effects reported among Black cancer survivors. Scheduling and referral practices further complicated navigation. Conversely, studies consistently found that positive patient-clinician communication reduced fear, built trust, and encouraged timely care seeking, and that survivors wanted more proactive conversations about treatment options, costs, and supportive services rather than less. Sixteen of the 28 studies, more than half, documented how these system-level determinants shaped outcomes.

Amid the bleak findings, the review identifies interventions that work. Lay navigation programs reduced financial strain among Black and rural residents and cut expenses related to hospitalizations and outpatient visits among older adults with Medicare. Remote symptom monitoring fostered proactive care management, expanded access, and improved patient-clinician relationships for survivors in under-resourced areas. Educational interventions eased insurance-related fears and encouraged care seeking, and among survivors of childhood cancers, adequate insurance coverage buffered the harmful effects of geographic distance and age on outcomes.

The authors argue that sustainable progress will require coordinated, multilevel action: expanding insurance coverage, strengthening rural healthcare infrastructure, deploying telehealth and satellite oncology clinics, funding transportation assistance, scaling patient and financial navigation, and adopting culturally responsive models of care. They hope the findings will inform the Alabama Comprehensive Cancer Control Plan and the development of the Alabama Cancer Plan 2028-2033. The review also acknowledges its own limits, including the exclusion of grey literature, sparse data on hematologic cancers such as the multiple myeloma that disproportionately affects Black patients, and a shortage of longitudinal and qualitative studies. Even so, it stands as the first comprehensive, state-specific synthesis of access to cancer care in Alabama, and a data-driven blueprint for dismantling the unequal paths that have cost so many lives.

Subject of Research: Barriers to cancer care access and their impact on cancer outcomes among Black and rural residents of Alabama

Article Title: Unequal paths to care: a scoping review of access and cancer outcomes in Alabama

Article References: Caviness-Ashe, N., Means, C., Aaron-Wade, L., Ninson, A., Aboagye, A., Sodeke, S., Miles, M., Fowler, M. E., Hagan, E. O., Akinyele, O., Aboagye, M., Anderson, L., Kaiser, K. A., & Nolan, T. S. (2026). Unequal paths to care: a scoping review of access and cancer outcomes in Alabama. Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02115-0

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02115-0

Keywords: cancer care access, health disparities, Alabama, rural health, Black Belt, financial hardship, Medicaid expansion, patient navigation, telehealth, cancer mortality, healthcare infrastructure, scoping review