Update: National Breast and Cervical Cancer Early Detection Program, 1992-1993

During the 1990s, an estimated 500,000 U.S. women will die from breast and cervical cancers (1). National efforts to prevent deaths from these cancers have included the implementation of the Breast and Cervical Cancer Mortality Prevention Act of 1990, which aims to increase the efficiency and effectiveness of screening. This program is directed toward women aged greater than or equal to 40 years and to women who have low incomes, are underinsured or uninsured, or are from racial/ethnic minority groups. This report describes cancer screening in two women in Michigan who received these services in 1992 through the CDC-funded National Breast and Cervical Cancer Early Detection Program and summarizes the assessment of the implementation of this program for low-income women.

In Michigan, the program targets urban and rural white, black, Hispanic, American Indian/Alaskan Native, Asian/Pacific Islander, and Arab women aged greater than or equal to 40 years. By the end of the program's second year (1992), the number of screening sites had increased by approximately 260%, from 24 to 62. Services are provided at a variety of locations, including public health departments, hospital-based clinics, churches, public housing complexes, and senior citizen centers. Case 1

In early January 1992, a woman requested assistance from the Michigan Department of Public Health in obtaining a mammogram. The woman, who had a family history of breast cancer, was examined by a physician in December 1991 and advised to have a mammogram because of a suspicious finding on examination. However, the woman lived in a group home with 13 other women, was unemployed, had no insurance, and was not receiving Medicaid. From a friend who learned of Michigan's breast and cervical cancer screening program through a multimedia campaign, she was informed of the services available. The woman subsequently received the appropriate diagnostic and treatment services (2). Case 2

A woman whose screening services were paid through program dollars at a program-sponsored site had a mammogram with highly suspicious findings. The report was sent simultaneously to the local health department and to the woman's primary-care physician. The program protocol required documentation of patient notification and immediate follow-up of abnormalities. When, within 2 days of receiving the report, the program nurse had not received information about a follow-up appointment, she contacted the primary-care physician; the physician's office had filed the report as "normal." The program nurse indicated to the physician the radiologist's findings of a suspicious lesion. The woman was immediately notified and a biopsy scheduled. The woman's physician is now a strong proponent of the breast and cervical cancer-control program and the need for tracking and follow-up (2). Assessment of Program Efforts

By July 1992, CDC had awarded $64 million to 12 state* health agencies to develop comprehensive programs for the early detection of breast and cervical cancers (1). Each state during its 5-year program period will 1) establish, expand, and/or improve screening services in communities with women at risk for breast and cervical cancers; 2) provide appropriate referrals for medical treatment of women screened through this program and ensure the provision of appropriate follow-up services; 3) develop and implement a public education program about the importance of screening in the early detection of breast and cervical cancers; 4) develop and implement a professional education program for physicians and other health-care providers to improve their skills in health education, screening, diagnosis, treatment, and follow-up services; 5) improve quality-assurance measures and ensure adherence to standards and guidelines in the screening and follow-up process; 6) establish a surveillance and evaluation system to monitor the program; and 7) establish and maintain a state-based cancer-control plan and coalition with representation from key private, voluntary, and public organizations and from consumers (1).

In September 1992, CDC awarded approximately $275,000 per state to an additional 18 state ** health agencies to begin capacity-building activities (1). Reported by: Cancer Section, Div of Programs, Michigan Dept of Public Health. Office of the Director, and Program Svcs Br, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Screening mammography followed by appropriate treatment reduces breast cancer mortality by as much as 30% in women aged greater than 50 years, and nearly all deaths from cervical cancer would be preventable if all women were screened according to guidelines (1). However, screening mammography is underutilized by women with fewer than 12 years of education and women earning less than $10,000 per year; intervals between Papanicolaou (Pap) smears are longer as women age and for women with lower household incomes (3,4). The two cases described in this report demonstrate the potential benefits of state-based comprehensive breast and cervical cancer screening programs that integrate outreach, screening, tracking, and clinical follow-up. To improve systematic, ongoing information collection efforts by state and federal program personnel and policy makers, CDC is undertaking a comprehensive evaluation of this program.

Benefits resulting from increased support of comprehensive programs have included 1) substantial increases in the number of screening sites (12 states); 2) implementation of 2900 public education programs designed to motivate women to seek screening services; 3) approximately 300 training programs for health-care providers delivered by the state programs; 4) collaboration between state health agencies and an estimated 440 organizations to plan, implement, and evaluate these programs; 5) establishment of coalitions among organizations essential to addressing control of these cancers (12 states); and 6) establishment or modification of cancer-control plans to address breast and cervical cancer specifically. During 1992, 1305 screening sites were available for women, compared with 575 in 1991.

The national health objectives for the year 2000 include increasing to at least 80% the proportion of low-income women aged greater than or equal to 40 years who have ever received a clinical breast examination and a mammogram and increasing to at least 95% the proportion of low-income women aged greater than or equal to 18 years with uterine cervix who have ever received a Pap smear (objectives 16.11b and 16.12d) (5). Because of the need for a concerted national strategy to reduce mortality from breast and cervical cancers, appropriations for the National Breast and Cervical Cancer Early Detection Program have continued to increase. Fiscal year 1993 appropriations of $72.5 million allowed CDC to expand the program: as of September 30, 1993, 18 states have comprehensive screening programs, *** and 27 have capacity-building programs ****.

References

1. CDC. Implementation of the Breast and Cervical Cancer Mortality Prevention Act: 1992 progress report to Congress. Atlanta: US Department of Health and Human Services, Public Health Service, 1993 (in press).

2. CDC. Anecdotes: National Breast and Cervical Cancer Early Detection Program. Atlanta: US Department of Health and Human Services, Public Health Service, 1993.

3. CDC. Mammography and clinical breast examinations among women aged 50 years and older -- Behavioral Risk Factor Surveillance System, 1992. MMWR 1993;42:737-41.

4. Ackermann SP, Brackbill RM, Bewerse BA, Cheal NE, Sanderson LM. Cancer screening behaviors among U.S. women: breast cancer, 1987- 1989, and cervical cancer, 1988-1989. In: CDC surveillance summaries (April). MMWR 1992;41(no. SS-2):17-34.

5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

* California, Colorado, Maryland, Michigan, Minnesota, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, Texas, and West Virginia. 

** Cooperative agreements ranging from $250,000-$300,000 were awarded to Alaska, Arizona, Arkansas, Connecticut, Georgia, Illinois, Indiana, Iowa, Maine, Massachusetts, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Washington, and Wisconsin. 

*** California, Colorado, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Mexico, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Texas, Washington, West Virginia, and Wisconsin. 

**** Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Mississippi, Montana, New Hampshire, New Jersey, North Dakota, Oklahoma, Oregon, Rhode Island, Utah, Vermont, Virginia, and Wyoming.

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