The social determinants no one talks about
When we think about cancer risk, we tend to think about lifestyle factors — diet, physical activity, smoking. These matter. But there is a layer of determinants that sits beneath individual behaviour and shapes it: income, education, geography, and social support.
People with lower incomes are less likely to participate in screening programmes, more likely to delay seeking care, and more likely to be diagnosed at an advanced stage, when treatment is both less effective and significantly more expensive. In Greece, where out-of-pocket health expenditure remains among the highest in Europe, this dynamic is particularly acute.
Where you live shapes your cancer risk. Residents of remote or underserved areas face not just geographic barriers to screening, but a compounding disadvantage: fewer specialists, longer waiting times, and limited digital access to book appointments.
Education plays a similarly structural role. Lower health literacy is associated with reduced participation in screening programmes and delayed recognition of symptoms. This is not about intelligence — it is about whether people have had the opportunity to develop the knowledge and confidence to navigate a health system that is often complex and poorly communicated.
Occupational exposure adds yet another dimension. Workers in agriculture and other physically demanding sectors face elevated CRC risk factors, while precarious employment and irregular hours reduce both the time and the incentive to engage with preventive health services.
Finally, social support matters in ways that are often overlooked. Patients with strong family or community networks are more likely to participate in screening and to complete treatment once diagnosed. For those living alone, particularly elderly people and migrants, the absence of this support can be the factor that tips the balance toward late diagnosis.
The screening paradox
Since 2022, Greece has been implementing “PROLAMVANO”, a national CRC screening programme offering free faecal immunochemical tests (FIT) to people aged 50–69, with automatic referral for colonoscopy following a positive result. This is a significant and welcome step forward.
But the numbers tell a sobering story. Greece’s screening participation rate stands at just 28%, compared to an EU average of 36%, itself far below the 90% target set by Europe’s Beating Cancer Plan. The gap is not random: it maps closely onto the social and geographic fault lines described above.
Universal programmes tend to be taken up disproportionately by those who are already more health-literate, more mobile, and better connected to the health system. The people who need screening most, those in remote areas, those in precarious employment, migrants, elderly people without family support, are precisely the ones least likely to use it.
This is the screening paradox: a well-designed public health intervention that, without accompanying equity measures, risks widening the gap it was meant to close.
Who is falling through the cracks?
Research consistently identifies several groups at heightened risk of being missed by standard screening approaches. People living in rural or island communities face genuine geographic barriers, like for example pharmacies, the primary point of FIT distribution, are often far away or inaccessible. Agricultural and industrial workers have lower rates of participation in preventive health activities, compounded by elevated occupational risk. Migrants and cultural minorities face additional barriers of language, trust, and systemic exclusion and consistently show lower survival rates. And men, despite having a higher CRC incidence than women, participate in screening at lower rates.
For each of these groups, the issue is not unwillingness. It is structural disadvantage and it requires structural solutions.
What does an equitable response look like?
Equity in CRC prevention requires moving beyond the assumption that making a service available is the same as making it accessible. Postal delivery of FIT kits to people with limited pharmacy access, outreach through mobile health units in remote communities, workplace-based prevention programmes in high-risk occupational settings, and culturally adapted communication strategies are not add-ons to a screening programme, since they are its precondition for effectiveness.
Primary care has a particularly important role to play. The personal physician, recently reintroduced in Greece, is well placed to actively follow up with patients who have not participated in screening, to address concerns, and to refer appropriately. Evidence consistently shows that direct, trusted outreach by a known healthcare professional significantly increases uptake among hard-to-reach populations.
Digital tools also offer an underutilised opportunity. Targeted SMS reminders, online appointment booking, and integrated digital pathways connecting PROLAMVANO to primary care records can reduce the friction that prevents participation, particularly for younger adults and those in urban areas with time constraints.
Equity in cancer screening is not achieved by offering the same thing to everyone. It is achieved by recognising that people start from different places — and designing interventions accordingly.
A system-level responsibility
The economic case for equitable screening is compelling. In the EU, CRC costs an estimated €19 billion annually, with 61% attributed to lost productivity rather than direct healthcare expenditure. In Spain alone, CRC is responsible for over €510 million in annual productivity losses and more than 25,000 lost working years. Early detection does not just save lives — it protects economic capacity and reduces long-term system costs.
Addressing social inequalities in CRC is ultimately a political choice. It requires acknowledging that health outcomes are shaped by conditions that lie largely outside the clinic, housing, employment, education, income, and that health policy must engage with these conditions, not just with clinical pathways.
Greece has the framework, the programme, and increasingly the political will. What is needed now is the deliberate, evidence-based integration of equity into every layer of CRC prevention from how screening kits are distributed, to how referrals are followed up, to how patients are supported once they receive a diagnosis.
Because the question is not just whether Greece has a colorectal cancer screening programme. The question is: who does it actually reach?
References
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