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

The research, led by Jamie L. Humphrey of RTI International together with Jason Williams, Sofia A. Oviedo, Bradley R. Ray, and Jessica D. Cance, addresses a question that has lingered as the synthetic opioid crisis deepened. Fentanyl and its analogs have driven unprecedented overdose mortality in the United States, but their effects extend beyond fatal poisoning. The drug’s extreme potency and rapid onset have altered injection frequency and syringe-sharing behavior in ways that heighten the risk of HIV transmission, and clusters of new infections in several states have underscored the urgency of embedding HIV testing, prevention, and treatment within settings where people who use drugs already seek care.

Integrated HIV services within substance use disorder treatment facilities have long been viewed as a critical intervention point for this syndemic of addiction, overdose, and infectious disease. Whether such services actually proliferated as fentanyl spread geographically, however, remained unknown. To find out, the research team assembled a longitudinal dataset of United States counties from 2015 through 2023, relying on geocoded facility listings from the National Survey of Substance Abuse Treatment Services and its successor, the National Substance Use and Mental Health Services Survey. The outcome of interest was the annual county-level proportion of substance use disorder treatment facilities reporting that they provided HIV services.

A central methodological challenge was defining when the fentanyl era began for any given county. Rather than relying on a single national date, the investigators derived state-specific onset points for rapid illicit fentanyl market penetration using data from the National Forensic Laboratory Information System, which tracks drug submissions to forensic laboratories across the country. This allowed the team to model each county’s trajectory of HIV service availability before and after the moment fentanyl effectively took over the local illicit drug supply, capturing the staggered diffusion of the synthetic opioid wave as it moved across the country.

The statistical approach was equally refined. The researchers employed longitudinal growth models with a beta distribution, a technique suited to modeling proportions bounded between zero and one, to estimate rates of change in HIV service availability across the study period. The models incorporated a set of time-varying covariates designed to isolate the effect of fentanyl’s arrival from other concurrent forces: county-level drug overdose mortality and HIV incidence rates, each lagged by two years to reflect plausible causal timing, as well as state-level policy factors including Medicaid expansion and prohibitions on prior authorization requirements for medications for opioid use disorder.

The headline result is striking in its simplicity. Between 2015 and 2023, the average proportion of substance use disorder treatment facilities providing HIV services doubled among counties that had treatment infrastructure in place. This was not a uniform trend, however. The geographic heterogeneity was considerable: following the introduction of fentanyl, HIV service availability increased in 38.8 percent of counties, remained stable in 14.0 percent, and decreased in 24.5 percent. Perhaps most sobering, 22.7 percent of counties had no measurable HIV service availability at all during the period because they lacked substance use disorder treatment facilities entirely, leaving residents of those areas without any local point of access to integrated care.

The adjusted models sharpened the temporal story. Before fentanyl’s arrival, the increase in HIV service provision within counties was modest and not statistically significant, with an estimated slope of 0.021 and a standard error of 0.013. After fentanyl was detected in a state’s drug market, integration accelerated markedly, with a post-fentanyl slope of 0.072 and a standard error of 0.009, a difference that was highly significant at P less than .001. A formal test of the interaction between the slope and fentanyl’s introduction confirmed that the acceleration was genuinely tied to the synthetic opioid’s arrival, with an interaction coefficient of 0.051 and a standard error of 0.014, also significant at P less than .001.

What these coefficients imply, in practical terms, is that the arrival of fentanyl appears to have functioned as a shock to the addiction treatment system, prompting facilities to adapt their service portfolios in response to a visibly escalating threat. The authors interpret this pattern as evidence of adaptive integration of HIV prevention and care within addiction treatment systems during the fentanyl era. Treatment organizations, confronting a drug supply that dramatically raised both overdose risk and injection-related HIV vulnerability, appear to have recognized that testing for HIV, linking patients to antiretroviral care, and offering preventive services were no longer optional adjuncts but core components of responsible care for a population facing compounded dangers.

Yet the study’s darker findings demand equal attention. Nearly one-quarter of United States counties had no in-person substance use disorder treatment infrastructure at all during the study window, a persistent service desert that no amount of integration within existing facilities can remedy. Moreover, even among counties with treatment capacity, the post-fentanyl period saw service availability decline in roughly one in four, indicating that the adaptive response was far from universal. Geographic disparities in access to integrated HIV and addiction services remain substantial, and the counties most vulnerable to overlapping overdose and HIV epidemics are often precisely those least equipped to respond.

The authors conclude that these patterns underscore the need for policies that expand substance use disorder treatment capacity and actively incentivize HIV service integration in underserved communities. As fentanyl, and increasingly its more potent analogs, continues to dominate the illicit drug supply, the window for preventive action narrows in the places least served. The research, which was supported by the National Institute on Drug Abuse under Award Number U24DA057611 and reviewed by the RTI International Institutional Review Board under protocol STUDY00022322, provides both a benchmark and a warning: the treatment system can respond to crisis, but only where treatment exists, and only when policy deliberately directs resources toward the communities where the syndemic burns hottest.

Subject of Research: Longitudinal county-level analysis of HIV service availability in US substance use disorder treatment facilities before and after the state-specific arrival of illicit fentanyl, 2015 to 2023.

Article Title: HIV service integration in substance use treatment facilities in the fentanyl era, 2015–2023

Article References: HIV service integration in substance use treatment facilities in the fentanyl era, 2015–2023. (n.d.). https://doi.org/10.1186/s12889-026-29460-0

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29460-0

Keywords: HIV services, fentanyl, substance use disorder treatment, integrated care, overdose crisis, health services accessibility, geospatial analysis, HIV prevention, Medicaid expansion, opioid epidemic, public health, service integration