Neighborhood-Level Food Insecurity and Colorectal Cancer Incidence in Texas: A Spatial Ecological Analysis.

Purpose: Colorectal cancer (CRC) remains a leading cause of cancer morbidity and mortality in the United States. Growing evidence suggests that neighborhood-level social drivers, including food insecurity and rurality, contribute to disparities in CRC burden, yet the joint effects of time-varying food insecurity and CRC remain understudied. Methods: We conducted a spatial ecological analysis of CRC incidence across 6,808 census tracts in Texas from 2017 to 2021. Tract-level CRC cases from the Texas Cancer Registry were linked with time-varying food insecurity estimates from Feeding America's Map the Meal Gap and rural and urban classifications based on 2020 Rural-Urban Commuting Area (RUCA) codes. Sequential spatial Poisson models were used to assess associations between food insecurity, rurality and urbanicity, and CRC screening prevalence with CRC incidence. Results: Higher food insecurity was consistently associated with increased CRC incidence. In the unadjusted model, each one-percentage point increase in food insecurity corresponded to a 1.7% increase in CRC risk (RR = 1.017; 95% CrI, 1.015-1.019). When additional covariates were included, food insecurity was attenuated (RR range: 1.011-1.016). Compared with metropolitan areas, CRC risk was higher in micropolitan, small town, and rural tracts. Screening prevalence among older adults was negatively associated with CRC incidence. Conclusion: Food insecurity is a significant contextual factor that is positively associated with higher risk of CRC, independent of geographic settings and screening patterns. These findings highlight the structural disadvantage of food insecurity in shaping CRC burden in Texas and call attention to public health and social interventions to reduce CRC disparities.