Cancer Screening

Refugee Health Domestic Guidance

Key points

  • Refugees or foreign-born persons in the United States experience significantly lower cancer screening rates, compared to the general U.S. population.
  • Refugees may have limited or no history of cancer screening prior to arrival in the United States.
  • This guidance outlines cancer screening recommendations for newly arrived refugees during the domestic medical exam (DME) and is based on the United States Preventive Services Taskforce (USPSTF) Recommendations for Cancer Screening in the general U.S. population.
  • The DME visit provides a valuable opportunity to educate patients about their cancer risks and discuss cancer screening recommendations.
  • It is acceptable for DME providers to refer refugees to primary care providers for cancer screening visits since cancer screening may require longer-term follow-up and coordination.

Background

Studies show that foreign-born persons have lower cancer screening rates particularly for colorectal, cervical, and breast cancers 1234. Additionally, foreign-born persons are more likely to be diagnosed with late-stage cancers overall, compared to U.S.-born persons 56. Lower screening rates among foreign-born persons, which may lead to delayed diagnoses, have been attributed to several factors, including limited access to care, financial constraints, transportation issues, lack of health insurance, insufficient knowledge about cancer screening, cultural or religious beliefs, language barriers, prior trauma, mistrust of the healthcare system, and differing health perceptions 78910.

While studies suggest the risk of all cancers overall is lower in foreign-born persons than in U.S.-born persons, foreign-born persons have higher risk for infection-related cancers than U.S.-born persons 111213. Foreign-born persons have also been found to have higher mortality rates for certain cancers than U.S.-born persons 11. A study comparing cancer mortality rates between U.S.-born and foreign-born persons from 2005 to 2014 found that overall, foreign-born persons had a 31% lower cancer mortality rate, but higher mortality rates for infection-related cancers (nasopharyngeal, stomach, Kaposi sarcoma, gallbladder, and liver and intrahepatic bile duct cancers) and certain non-infection-related cancers (acute lymphocytic leukemia and thyroid) 11. This study also found that stomach, and liver and intrahepatic bile duct cancers made up the majority of cancer deaths among foreign-born persons 11.

Cancer Screening During the Domestic Medical Examination

Awareness of risk factors, timely referrals, and appropriate screening measures are essential for the early detection and management of cancers in refugees. Table 1 lists key risk factors for infection-related cancers to consider in newly arrived refugees.

Table 1. Key Risk Factors Associated with Infection-Related Cancers to Consider in Newly Arrived Refugees

Table 1. Key Risk Factors Associated with Infection-Related Cancers to Consider in Newly Arrived Refugees
Cancer Type Risk Factors
Liver cancer14,15,16
  • Chronic hepatitis B virus (HBV) infection
  • Chronic hepatitis C virus (HCV) infection
  • Exposure to aflatoxins (fungi found on maize, peanuts, cottonseed, and tree nuts)
  • Schistosoma mansoni or Schistosoma japonicum infection
Gastric cancer17
  • Chronic Helicobacter pylori infection
  • First-generation immigrants from regions with high-incidence of gastric cancer (defined as gastric cancer incidence ≥10–12 per 100,000 people; includes Eastern Europe, Andean Latin America, and East Asia)
Bladder cancer16, 18, 19
  • Schistosoma haematobium infection
  • Patients from S. haematobium–endemic areas (Africa, the Middle East, and Corsica (France)) with unexplained hematuria
  • Occupational exposure (for example, rubber, chemical, and leather industries)
  • Smoking
Nasopharyngeal, oral, oropharyngeal, and laryngeal cancers20,21
  • Use of betel quid, gutka, or tobacco products
  • Bacterial or Candida infections
  • Immunocompromise
  • Oral human papillomavirus (HPV) infection
Cholangiocarcinoma3,16, 18,22
  • Chronic liver fluke infection with Clonorchis sinensis, Opisthorcis viverrine, or Opisthorcis felineus
  • Chronic liver disease
  • History of bile duct stones
  • History of primary sclerosing cholangitis

Recommendations

Given that refugees often have not received and may not be aware of cancer screening recommendations, CDC recommends the following:

  • Clinicians should use the DME visit to educate newly arrived refugees about cancer risks and to discuss the age-based USPSTF Recommendations for Cancer Screening carefully.
  • Clinicians should also discuss important risk factors and counsel patients on not starting tobacco or the cessation of tobacco, and other substances.
  • Clinicians may consider extending cancer screening beyond the USPSTF recommended age ranges for refugees with inadequate or unknown screening histories, or those at high risk for certain cancers (see Table 2).
  • In addition to a detailed medical history, clinicians should provide a thorough head-to-toe physical examination during the DME (see History and Physical) to evaluate for signs or risk factors for cancers. The examination should include a thorough oral examination for people with risk factors for nasopharyngeal, oral, oropharyngeal, and laryngeal cancers.
  • Clinicians should refer patients with significant risk factors and abnormal physical examination findings, such as suspicious oral lesions or unexplained hematuria, to a specialist for further evaluation and management.
  • It is acceptable for DME providers to refer refugees to primary care providers for cancer screening visits since cancer screening may require longer-term follow-up and coordination.

Table 2. Special Considerations for Cancer Screening in Refugees

Table 2. Special Considerations for Cancer Screening in Refugees
Cancer Type Risk Factors
Colorectal Cancer
Cervical Cancer

*Follow USPSTF's recommendations for other age groups.

Additional Information

  1. CDC's Cancer Risk Factors
  2. CDC's Cancer Screening Tests
  3. CDC's National Comprehensive Cancer Control Program
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Content Source:
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
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