Barriers and Facilitators to Delivering Cancer Care in US Prisons.

Abstract

Cancer is the leading cause of death in US prisons. Incarcerated patients with cancer have higher mortality than the general population, but little is known about barriers and facilitators to cancer care in prison. To describe barriers and facilitators to cancer care in US prisons from screening and diagnosis to end-of-life care. Semistructured qualitative interviews were conducted among clinicians involved in delivering cancer care in US prisons, including prison medical directors, primary care practitioners (PCPs), and oncologists in 16 US state and federal prison systems between September 2023 and April 2024, and a member-checking focus group was conducted in February 2025. Data were analyzed from September 2023 to February 2025. The main outcomes were identification of key themes regarding barriers and facilitators to delivering cancer care to incarcerated patients across US prison systems. Interview transcripts were analyzed using mixed inductive and deductive thematic content analysis to identify emerging themes. A total of 32 participants from 16 prison systems were interviewed, including 9 medical directors, 6 PCPs, and 15 oncologists, with a median (range) age of 49 (33 to ≥70) years. Participants predominantly self-identified as female (19 participants [59%]); 6 (18.8%) as Asian or Pacific Islander; 5 (15.6%) as Black, African, or African American; and 21 (65.6%) as White. Participants described 7 themes as barriers: (1) patients' acceptance of care; (2) population health and determinants of health; (3) care coordination between prisons and oncology practices; (4) communication between patients, oncologists, and prison clinicians; (5) symptom management; (6) transportation; and (7) humanity in care; as well as 3 cross-cutting themes of understaffing, prioritization of security over health, and nontransparent care within prisons. Participants described 2 themes regarding incarceration as a facilitator: increased access to health care for individuals with poor access in the community and help overcoming social determinant barriers. The 22-participant focus group affirmed these themes, added additional context, and identified no new themes. In this qualitative study of clinicians involved in cancer care delivery for individuals incarcerated in US prisons, participants identified numerous barriers to cancer care delivery in prisons. These barriers represent opportunities for targeted interventions to improve cancer outcomes.