Breast & Cervical Cancer Screening
Federal/State Program Aims to Lower Mortality Among Poor Women
Nitsa Allen-Barash
Veronica Foster
William H. Mitchell
Robert Fletcher
Death from cervical cancer should be completely
preventable. Both incidence and mortality rates from cervical cancer are
highest among women of minority groups. While white women experience the
highest incidence of breast cancer, African-American women have the highest
mortality rate because fewer are diagnosed at an early stage. Screening
for breast and cervical cancer lowers mortality, but poor women are less
likely to be screened than those at higher income levels (Figure 1).
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In Washington in 1994, 29% of poor women aged 51 and
older had never had a mammogram, and nearly 6% had never had a Pap smear.
By contrast, only 9% of more affluent women in this age group had never
had a mammogram and approximately 2% had never had a Pap smear. Among women
in this age group who had been screened previously, only about 22% of poor
women had received a mammogram in the past year, compared to about 78%
of more affluent women. About 52% of poor women reported having a Pap smear
in the previous two years, compared to 80% of more affluent women.
The federal Breast and Cervical Cancer Mortality Prevention Act of 1990
addresses this problem by providing federal funds for cancer screening
and related services for poor women who are uninsured or whose medical
insurance does not provide full screening coverage. This act and subsequent
congressional appropriations provided both the impetus and resources for
the establishment of the national Breast and Cervical Cancer Early Detection
Program by the Centers for Disease Control and Prevention. Its aim is to
minimize mortality among uninsured and underinsured women who are 40 years
and older, and particularly among those 50 and older. The program's provision
of free breast and cervical |
cancer screening and confirmatory diagnostic tests should contribute
to the removal of financial barriers to screening and should result in
higher screening rates for the target population. Washington and five other
states began receiving funds for screening in 1993. Additional appropriations
have provided funding to all states, the District of Columbia, and to several
territories.
Washington's Program
In 1994, mortality from breast cancer in Washington State was highest among
African-American women at 35 deaths per 100,000 -- 50% higher than the general
rate. The death rate from cervical cancer was highest among Native Americans,
and at 5.5 deaths per 100,000 was more than twice the general rate. In
September 1993, Washington initiated a five-year Breast and Cervical Health
Program (BCHP). Sixty percent of the $12 million granted by the CDC are
designated for the provision of screening services; 40% are dedicated to
the development and implementation of program activities that support the
goal of early detection. Clinics are paid to coordinate and provide services.
Local health jurisdictions and community agencies were contracted to coordinate
services. The Washington State Department of Health promotes screening
of the target population.
Program Services
The program provides free regular screening mammograms, cervical cytology,
and confirmatory diagnostic tests for women of low income (at or below
200% of the federal poverty level) who are un- or underinsured. While women
as young as 40 years of age are eligible for services, the focus has been
on those aged 50 and older. This policy is consistent with CDCs goal of
dedicating 90% of the funds to screen this older group, for whom mammograms
are most effective in detecting early cancers and reducing mortality.
The program has a special mandate to work with the federally funded
community and migrant health centers. While they may not be able to provide
all needed medical services, these clinics take responsibility for coordinating
them for their patients. Twenty-four of the 26 centers operating in Washington
State, several of which especially serve minorities, participate in the
BCHR The program provides screening resources and training to 10 Native
American tribes and to 140 private clinics and providers who administer
care to poor women in counties lacking public care clinics. To date, 76
mammography facilities are participating in the program.
Partnerships with the YWCA, American Cancer Society, Cancer Information
Service, Susan G. Komen Foundation, local health departments, community
care clinics, lesbian community groups, and many other groups have promoted
screening services. Other program components include public education and
outreach, professional education, quality assurance, surveillance, and
evaluation.
Outreach: Data from previous studies and from similar programs
and the results of ethnic-specific focus groups conducted with African-American,
Native American, Hispanic, European-American, and Southeast Asian women
contributed to the development of strategies for contacting women and for
addressing potential barriers to initial screening. Outreach channels include
social meetings, worksites, health fairs, beauty salons, newspaper, radio,
and local television ads. Community women were hired by local health departments
and community organizations to spread the word about the availability of
the program's services to increase initial and repeat use by the target
population.
 Figure
2: Examples of posters used to reach women in specific ethnic groups.
The top poster is aimed at Native Americans, the lower one at Vietnamese
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Factors identified as barriers to free screening include
lack of transportation, fear of cancer, distrust of doctors (particularly
of male doctors), and spousal objection. Strategies include the provision
of transportation fares and the inclusion of mobile mammography units in
remote rural areas, and recruitment of eligible and previously screened
women to explain the value of early diagnosis and to bring women to clinics
for exams. Educational sessions for objecting spouses are conducted in
some counties. While the program has developed and disseminated some ethnic-specific
posters and materials (Figure 2), most of the activities are county-specific
and are initiated and implemented by local agencies. The Cancer Information
Service, a regional office of the National Cancer Institute, has a contract
with BCHP to develop outreach activities specific to four of the participating
tribes, and Group Health Cooperative is developing strategies relevant
to uninsured women served by HMOs.
Professional Education: Staff at most of the federally funded
community and migrant health centers in Washington were trained in the
development and use of a reminder system to maximize repeated, regular
screening. Staff of 11 randomly selected clinics received enhanced training
to identify and address women's barriers to rescreening and received information
on the risk factors for breast and cervix cancer, on screening guidelines,
and on the value of regular screening.
Quality Assurance: Quality assurance focuses on the clinics,
cytology labs, and mammography facilities, and includes clinic and facility
audits and accuracy evaluation of cytologic interpretations. To date, agreement
has been close to 100%. |
The program monitors standardized reporting procedures to ensure timely
evaluation of abnormal results and the sensitivity and specificity rates
of program mammograms; and cervical cytology. Factors affecting mammography
sensitivity and specificity will be examined.
Program Surveillance: All medical services funded by the program
are documented by all participating clinics, providers, facilities, and
the lab. BCHP staff monitor program activities and provide periodic reports
to clinics, facilities, and the CDC, which monitors the national program.
Program Evaluation: Mammography screening of large population
groups is expected to save lives but not money Program evaluation focuses
on the effect of outreach activities on initial program use, the effect
of an enhanced clinic-based training on rescreening, the identification
of barriers to rescreening, and the effect of the program on stage of cancer
diagnosis. Surveys are used to evaluate outreach activities, the effect
of clinic training, and other outcomes. Cancer registry data will be used
to assess the program's effect on stage of diagnosis.
 |
Program Results
From May 1994 through fall 1996, approx imately 10,000 women have received
BCHP services - about one-sixth of the estimated eligible target population.
Forty-seven percent of the program women are nonwhite 46 (Table 1) and
47% are 50 years and older. The rates of prior cancer screening reported
by BCHP patients were less than half those reported by more affluent Washingtonians
of the same age range who participated in the 1994 Behavioral Risk Factor
Survey. |
As of October 1996, BCHP paid for 9,644 clinical breast exams, 7,854
mammograms, and 9,109 cervical cytologies. Among 9,278 women enrolled,
91% were referred for a mammograrn at the first visit and 93% of these
complied. Eight percent of all first BCHP mammograms; were abnormal and
54 8.6% of these were diagnosed as breast cancer (12 in-situ, 31 invasive,
and 11 pending diagnosis). Twenty-four cervical cancers (14 in-situ, 7
invasive, and 3 pending) were identified through the program. Among BCHP
participants 50 years or older whose first BCHP mammogram was normal,
40% came to the clinic for a rescreening exam within 18 months of their
initial mammogram.
Future Directions
The program expects to screen 15,000 women at least once by the end of
the 1997 fiscal year and another 5,000 by September 1998. Current screening
data suggest the need to identify and remove remaining barriers to program
use, and to increase repeated, regular screening to reduce mortality among
the target population. Training of outreach workers may emphasize skills
needed to address specific barriers to increase the likelihood of contacting
and affecting women who are harder to reach and possibly less motivated
than those screened to date. Internal activities include improving clinic
reminder systems and expanding patient education to help increase rescreening
by 10-15%. Such expansion of the BCHP requires further development of local
systems, including the involvement of additional private providers in the
care of uninsured women, and the identification of local funding sources
for screening and for treatment. These challenges are the focus of current
program activities and those planned for the near future.
Recommended Reading
Brooks SE: Cervical cancer screening and the older woman: Obstacles
and opportunities. Cancer Prac 1996; 4(3):125-129.
Burns RB, Freund KM, Ash A, et al: Who gets repeat screening mammography:
The role of the physician. J Gen Intern Med 1995; 10:520-522.
Eastman P: Task force issues new screening guide lines. J Natl
Cancer Inst 1996, 88(2):74-78.
Harper M: Mammography utilization in the poor and medically underserved.
Cancer 1993; 72(4 Suppl): 1478-82.
Kerlikowske K, Grady D, Rubin SM et al: Efficacy of screening
mammography: A meta-analysis. JAMA 1995; 273:149-154.
Lemkau J, Grady K, Carlson S: Maximizing the referral of older
women for screening mammography. Arch Fam Med 1996; 5:174-178.
SEER Cancer Statistics Review, 1973-1992. NIH Publication No.
96-2789. Bethesda, MD: National Institutes of Health, National Cancer Institute,
1995.
Authors
Nitsa Allen-Barash, Ph.D., is the director of Breast and Cervical
Health Program Evaluation, Washington State Department of Health, and affiliate
assistant professor of epidemiology at the UW School of Public Health and
Community Medicine.
Veronica Foster, M.B.A., B.S.N., is the manager of the
Breast and Cervical Health Program, Washington State Department of Health.
William H. Mitchell, B.A., was the public health advisor
assigned by the Centers for Disease Control and Prevention to the Breast
and Cervical Health Program.
Robert Fletcher, M.S., is the data manager for the Breast
and Cervical Health Program.
Funded by a grant from the National Breast and Cervical
Cancer Early Detection Program, Centers for Disease Control and Prevention.
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Created: 5/7/98 Updated: 7/14/99
