How a century-old policy still shapes cancer survival today

Imagine being diagnosed with cancer. Now suppose that the likelihood of your survival might be determined by nearly a century-old housing policy that preceded your birth. Unlikely, isn't it? But that is exactly what researchers learned about the impact of historical redlining— discriminatory maps that systematically labeled neighborhoods disfavorabely due to their perceived mortgage risk—and cancer survival rates for children and young adults (AYAs) with cancer from a recent study published in Cancer. The study by Drs. Kristine Karvonen, Eric Chow and colleagues found that people under 40 years old, living in formerly redlined areas, had worse survival rates compared with those from neighborhoods never subjected to redlining.

This speaks of something fundamental—the health of the present day determined by decisions that were taken years ago. Why, and more crucially, what are the solutions?

In order to better understand the impact of redlining properly, let us travel back to the 1920s‐1930s. The U.S. federal government under the Home Owners' Loan Corporation (HOLC) prepared maps that rated the areas by the degree of perceived investment risk. The areas with concentrated populations of Black people, immigrants, and the poor were labeled "hazardous" for lending purposes by the HOLC. While it remains debated how widely these specific HOLC maps were used by banks, it is hypothesized that they influenced subsequent mapping tools and institutional practices that perpetuated disinvestment. These in turn may have contributed to patterns of discriminatory practices that stuned economic development in these neighborhoods.

Fast forward to the present day, and the legacy of this institutional racism lingers. Today, formerly redlined areas tend to have higher poverty rates, fewer healthcare facilities, and greater environmental hazards, contributing to worse health outcomes. This study looked at cancer incidence between 2000 and 2019 in Seattle and Tacoma and geotagged the locations of the patients with HOLC maps of the past. The researchers used Kaplan-Meier survival analysis and Cox proportional hazard models to compare five- and ten-year survival rates while controlling for cancer type, age, and socioeconomic status.

The outcomes were striking. Five-year survival rates for individuals with cancer residing in redlined communities were 85.1%, whereas 90.3% of individuals with cancer residing outside redlined communities survived for that period. Ten years down the line, the rates decreased again—81.1% versus 88.1%. Even after adjusting for poverty rates and cancer-specific status, individuals from redlined communities were 32% more likely to die from cancer. The study also found that modern neighborhood poverty did not significantly change this association, further supporting that historical segregation continues to drive disparities even today.

Interestingly, the impact of redlining did vary by age cohort. Survival rates for pediatric individuals under 18 years of age were no different. A probable reason for this is that children are more likely to be enrolled in government-funded health coverage such as Medicaid and CHIP. But for 18–39-year-olds, the survival rate disparity was stark. Once individuals age out of pediatric coverage, their healthcare access is increasingly shaped by economic inequalities rooted in redlining’s legacy.

Why does redlining remain a factor for cancer survival rates today? Several reasons are proposed by researchers. Historically redlined areas' restricted health care access may cause diagnoses to be delayed or of inferior quality. Higher levels of pollution exposure are another kind of hazard that may be present. Financial insecurity—connected with constant stress—has also been found to be related to worse health consequences.

In Dr. Karvonen’s opinion, the findings of this study “suggest historical redlining, a form of structural racism, is associated with higher mortality in patients under the age of 40." That is, the institutional racism embedded within these maps isn't just something that happened years ago—it's a present-day public health epidemic. “These maps were racist, and although the extent of the use of these maps is debated, they represent the racially charged attitudes and beliefs held at the time and therefore serve as a measure of structural racism.”

The research team stresses the need for further studies: “further studies are needed to build upon this historical example and examine more proximal measures of structural racism relevant to patients today.” This means looking beyond historical policies to assess how modern factors—such as hospital locations, insurance access, and socioeconomic barriers—continue to shape health outcomes.

Addressing these systemic inequalities requires action from health professionals and policymakers. In addition to improving health coverage and expanding early cancer screenings in marginalized communities, the study underscores the need to investigate modern structural barriers—such as disparities in hospital access, insurance coverage, and economic mobility. Solutions should also include investments in historically redlined areas to reduce the long-term effects of segregation on health outcomes.

For most of us, redlining is a chapter in history books—a shameful policy of the past. But this study makes clear that its consequences are still shaping health outcomes today. Let us be troubled by the hard questions. If it is acceptable that almost a century of unethical policy should determine life and death outcomes, what are we willing to do about it?

This study was supported by grants from the American Society of Clinical Oncology Conquer Cancer, the National Institutes of Health, National Cancer Institute, and Seattle Children’s Hospital.

Fred Hutch/UW/Seattle Children’s Cancer Consortium members Drs. Eric Chow, Kristine Karvonen and Stephen Schwartz contributed to this work.

Karvonen, K. A., Doody, D. R., Barry, D., Bona, K., Winestone, L. E., Rosenberg, A. R., Mendoza, J. A., Schwartz, S. M., & Chow, E. J. 2025. Historical redlining and survival among children, adolescents, and young adults with cancer diagnosed between 2000-2019 in Seattle and Tacoma, Washington. Cancer, 131(3), e35677.