New Roles for Public Health in Cancer Screening

Marcus Plescia, MD, MPH, Director, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention,Atlanta, GA; Lisa C. Richardson, MD, MPH, Associate Director for Science, Division of Cancer Prevention and Control,

Centers for Disease Control and Prevention, Atlanta, GA; Djenaba Joseph, MD, MPH, Medical Director,Colorectal Cancer Control Program, Centers for Disease Control and Prevention, Atlanta, GA

Screening tests for the early detection of breast, cervical, and

colorectal cancer are prioritized clinical preventive services

that can reduce the burden of cancer in the United States.1

While significant progress has been made in this area,

screening rates for breast and cervical cancers have not

improved in almost a decade and rates for colorectal cancer

are unacceptably low. Lack of insurance has traditionally

been the main factor preventing adults from obtaining

cancer screening.2 Components of the Patient Protection

and Affordable Care Act will help address this through

Medicaid expansion, subsidized state insurance exchanges,

and the elimination of cost sharing.

However, access to health insurance and medical care

are not the only factors that limit participation in cancer

screening. Many people who currently have health insurance

and regular access to medical care are not being screened.

Based on 2010 National Health Interview Survey data,

among adults aged 50 to 75 years with a regular source of

medical care, only 62% were up to date with screening for

colorectal cancer and only 75% of women in this age range

had received a mammogram within the preceding 2 years.3

Analyses of national Medicare data revealed that, despite

coverage of cancer screening services, only 66% of eligible

women had undergone a mammogram within the past

2 years4 and only 47% of adults had insurance claims

documenting adequate screening for colorectal cancer.5 To

realize the full potential of anticipated improvements in

access to care, public health must provide leadership to ensure

that cancer screening is proactive, organized, and equitable.

Efforts Should Build on Existing Infrastructureand Capacity

Existing public health infrastructure could be built upon to

increase cancer screening rates. In 1990, Congress passed

the Breast and Cervical Cancer Mortality Prevention Act,

which authorized the Centers for Disease Control and

Prevention (CDC) to implement the National Breast and

Cervical Cancer Early Detection Program (NBCCEDP).

The CDC funds 50 states, the District of Columbia, 5 US

territories, and 12 American Indian/Alaska Native (AI/AN)

tribes or tribal groups. They, in turn, have contracted with

individual providers, practice networks, hospital systems,

health centers, and local health departments to recruit and

screen medically underserved, low-income women aged 40

to 64 years for breast cancer and women aged 18 to 64 years

for cervical cancer. In 2000, the Breast and Cervical Cancer

Prevention and Treatment Act allowed states to provide

Medicaid coverage to women diagnosed with breast cancer

through the NBCCEDP.

A 2009 analysis by the Government Accounting Office

found that current funding for the NBCCEDP allowed it

to reach 15% of eligible, uninsured, low-income women

for breast cancer screening. Approximately 26% of this

population receives screening through other mechanisms.

The remaining 60% may not be screened.6 Subsequent

analysis of the NBCCEDP’s effect on breast cancer morta-

lity found that the program saved 369,000 life-years

compared with women who received no screening.7 The

median medical costs of providing breast and cervical cancer

screening services in the NBCCEDP are $120 and $59,

respectively, which compares favorably with cost data from

other health care delivery systems. The outreach and service

delivery components of the NBCCEDP play an important

role in addressing health care disparities. Of the 1.6 million

women screened for breast cancer by the program from

2005 through 2010, 17% were black, 27% were Hispanic,

and 3% were AI/AN.

The CDC has also developed a national system to ensure

the timely follow-up and treatment of patients with

abnormal screening test results. The CDC requires funded

providers to collect and report state-based, standardized

data to the Minimum Data Elements registry. This registry

is the only national system that collects information to

monitor attainment of screening quality. The NBCCEDP

has consistently met its quality standards on diagnostic

follow-up and treatment initiation since the inception of

the program. A study on the timeliness of breast cancer

Corresponding author: Marcus Plescia, MD, MPH, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and HealthPromotion, Centers for Disease Control and Prevention, 4770 Buford Highway, NEMS-K52, Atlanta, GA 30341; Ifs1@cdc.gov

DISCLOSURES: The authors report no conflicts of interest. The findings and conclusions in this report are those of the authors and do not necessarilyrepresent the official position of the Centers for Disease Control and Prevention.

Published 2012 American Cancer Society, Inc. †This article is a US Government work and, as such, is in the public domain in the United States of America.doi: 10.3322/caac.21147. Available online at cacancerjournal.com

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diagnosis and treatment in state, tribal, and territorial

programs found that 80% of women were diagnosed

within 60 days of abnormal screening test results and almost

94% of women initiated treatment within 60 days

after diagnosis. Comparison with a similar population

of women in New Jersey reported median diagnostic

intervals that were almost 2 weeks longer than those for

the NBCCEDP.8

More Aggressive Approaches Are Neededto Improve Cancer Screening

The infrastructure to promote and ensure cancer screening

in the United States must be expanded to achieve desired

screening goals. While the medical care system is an impor-

tant partner in promoting and providing cancer screening

services, efforts to increase screening rates in this setting are

limited by the opportunistic nature of clinical services. Most

patients are offered screening tests when they visit a medical

provider for unrelated reasons. Evidence-based interven-

tions, including reminders to clients and providers to ensure

that individuals are screened on time, have been shown to

increase cancer screening rates.9 Screening registries have

been found to improve the follow-up of patients with

positive screening tests.8 However, the widespread

implementation of these approaches has been challenging in

our fragmented health care system. In a recent study of

primary care physicians’ practices, only 40% reported that

they had a system in place to remind patients to come in for

breast or cervical cancer screenings.10 Compared with the

general population, minorities and those from lower

socioeconomic backgrounds receive less timely follow-up

after an abnormal screening test.11 The patient-centered

medical home is an emerging model with which to improve

the quality of medical practice. This approach could be

applied to the delivery of clinical preventive services but,

to date, efforts have focused primarily on achieving

intermediate outcomes in the management of patients with

diabetes, asthma, and congestive heart failure.12

A more organized and comprehensive approach is needed

to increase cancer screening participation among individuals

who already have medical insurance or are likely to become

insured through the Patient Protection and Affordable Care

Act. Lessons can be learned from other countries and from

some managed care systems in the United States. They have

actively developed systems to identify members who are eli-

gible to participate in recommended screenings and have

also developed practices to ensure appropriate follow-up of

patients with positive tests. These programs enhance

recruitment into organized screening programs through

direct personal invitations. Media advertising is used to

reinforce these personal invitations, and there is active

surveillance of screening use.

Public Health Should Develop OrganizedCancer Screening Systems

Surveillance of cancer screening in the United States is

currently based on self-reported population surveys that

monitor temporal trends in screening use. However, data on

current screening rates would be more accurate if they were

based on actual use of services. Public health agencies are

uniquely positioned to lead the development of centralized

data systems for cancer screening because of their access

to population data and their experience developing,

implementing, and managing surveillance systems that

require patient confidentiality. These data could be used to

develop more organized, systematic approaches to cancer

screening in the United States.

For example, centralized lists from insurance company

databases or emerging state insurance exchanges could be

developed and managed to prompt eligible adults, via

telephone, mail, or electronic reminders, to participate in

screening. More resource-intensive approaches, such as case

management and patient navigation, could be targeted to

more effectively reach communities most affected by health

care disparities. In particular, public health departments will

have a tremendous opportunity to work collaboratively with

state Medicaid programs to increase cancer screening as

previously uninsured adults become eligible. Public health

agencies could work with state Medicaid programs to

identify populations eligible for screening from Medicaid

enrollee data and actively link these individuals with available

screening services. Agencies could also develop data linkages

and clinical registries to monitor participation, diagnostic

follow-up, treatment initiation, and long-term outcomes.

Provider systems must be fully integrated into these

efforts to ensure they do not create a demand that providers

are not ready to fulfill. Efforts currently are ongoing

to increase the capacity of Federally Qualified Health

Centers (FQHCs) to provide clinical services. Public health

departments could expand on their existing relationships

with FQHCs through the NBCCEDP. Collaborative

approaches could include expedited screening referrals,

direct mailing of fecal occult blood test kits to patients,

and the use of practice-based outreach workers in tradition-

ally underserved communities. Systems to improve the

follow-up of patients with abnormal screening tests could

be based on the experience of the CDC’s existing quality

assurance system described above. Recent initiatives to

expand the implementation of electronic health records in

FQHCs could facilitate these efforts to ensure appropriate

diagnostic testing and treatment.

In an era of health care reform, public health has opportu-

nities to ensure that participation in cancer screening is

widespread and equitable. Given the magnitude of cancer

morbidity and mortality, and the considerable capacity that

2 CA: A Cancer Journal for Clinicians

New Roles for Public Health in Cancer Screening

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has been developed throughout the 22-year history of the

NBCCEDP, public health has a responsibility to lead a

national approach to cancer control that is comprehensive,

strategic, and organized. An initial focus on developing an

organized system to improve cancer screening could ulti-

mately be expanded to other clinical preventive services. n

References

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