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The detection of breast cancer in its latent stages through mammography screening can improve patient's chances of recovery. However, geographic variation in mammography participation remains. Our objectives were first to assess whether the geographic accessibility of mammography-screening services influences mammography-screening participation and second to estimate the extent to which geographic variation in the use of cancer screening can be explained by spillover effects between adjacent areas, while controlling for covariates. Methods Mammography-screening services participation rates were calculated, for women aged 50-74 years who live in Lyon metropolitan area and did a mammography between 2015-2016 after being invited with a letter by the mammography screening program. We used spatial autoregressive models to estimate the extent of spatial spillover effects by applying spatial lag models. The geographic accessibility (availability, distance and affordability) on participation was evaluated adjusting on socioeconomic characteristics of census blocks. Results We found evidence of urban rural paradox. The mammography screening participation was 53.2% in residential and rural areas and 46.6% in urban and active areas, p &amp;lt; 0.001. Conversely to rural areas, women living in urban census blocks had high availability, lower distance to the closest mammography services, and lower mammography screening participation. Moreover, the coefficients for the spatial lag are significant and positive. The positive spatial lags indicate that screening utilization rates are determined by knowledge spillovers and geographic proximity between adjacent areas. Conclusions This study makes an important methodological contribution to measure access to services and better understand the variety of community contextual factors that drive mammography use decisions; which is a critical component of health care planning and equity almost everywhere. Key messages Evidence of urban rural paradox in mammography screening participation. Screening utilization rates are determined by knowledge spillovers and geographic proximity between adjacent areas.

Urban rural paradox -when easy access to mammography services does not mean active participation