Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer deaths among women in the United States. During 1992, breast cancer will be diagnosed in 180,000 women, and an estimated 46,000 women will die from the disease (1). In addition, invasive cervical cancer will be diagnosed in an estimated 13,500 women and will cause approximately 4400 deaths (1). Many of these deaths could be prevented through routine, high-quality mammography screening and use of the Papanicolaou (Pap) test (2,3). This report describes cancer screening in three women who received these services through CDC's National Breast and Cervical Cancer Early Detection Program and the implementation of this comprehensive screening program for low-income women through cooperative agreements with state health agencies during July 1991- July 1992. Case Reports Case 1. A 56-year-old woman, who lives with her disabled husband on a low (i.e., <$600) monthly income, received a screening mammogram through a screening program sponsored by the Texas Department of Health. The mammogram was abnormal; follow-up detected a 5-mm malignancy that was surgically removed by lumpectomy. Because the malignancy was detected early, she did not require chemotherapy and was advised to return for follow-up examination in July 1993. Case 2. A 45-year-old woman did not have health insurance, was living on a limited income following a divorce, and had no source for medical care. Through the Minnesota Department of Health's screening program, she received a pelvic exam, Pap test, clinical breast examination, and mammogram; results were normal. She indicated she would return for annual exams. Case 3. An American Indian woman with a family history of breast cancer had been unable to afford a screening mammogram. She received a screening mammogram from the California Department of Health Services screening program funded through CDC's National Breast and Cervical Cancer Early Detection Program. The results of her screening mammogram were abnormal, and she was immediately scheduled for a breast biopsy. Analysis of Program Implementation

The Breast and Cervical Cancer Mortality Prevention Act of 1990 authorizes grants to state health agencies to make screening tests for breast and cervical cancer available to low-income women. From July 16, 1991, through July 31, 1992, $64 million was awarded to state health agencies in 12 states* through the National Breast and Cervical Cancer Early Detection Program; annual awards to each state averaged $3 million. Grantees are required to match each $3 of federal funds with $1 of state funds or in-kind funds. By law, 60% of the funds must be used to provide screening and follow-up services to women of low income. In addition, outreach programs were initiated specifically to serve older women and women in racial/ethnic minority groups.

Service delivery must begin within the first year of a 5-year project period. Other program components that must be in place by the end of the second grant year include 1) public health surveillance systems to assist in planning and evaluating program activities; 2) public information and education programs to increase use of screening services; 3) education for health professionals to improve the screening process; 4) required standards (e.g., Health Care Financing Administration [HCFA] and American College of Radiology [ACR] guidelines) to ensure high-quality screening tests; and 5) state cancer coalitions and control plans to identify statewide resources and specify program objectives.

Program services include Pap tests (for screening and follow-up), pelvic examinations, colposcopy, colposcopy-directed biopsy, screening mammography, clinical breast examination, and diagnostic mammography. Because the law prohibits federal funds to be used to pay for treatment, state funds are used to ensure that appropriate follow-up and medical treatment are provided. To assure the quality of mammography services delivered to program participants, facilities providing mammography services as part of these cooperative agreements must be accredited by the ACR.** In addition, laboratories that provide cytology services are required by HCFA to comply with proposed rules from the Clinical Laboratory Improvement Amendments of 1988 (4).

As of July 15, 1992, a total of 13,178 eligible women in eight states had been screened for breast cancer by mammography (Figure 1), and 20,733 women had been screened for cervical cancer by Pap test (Figure 2). Breast cancer was diagnosed in 49 women, and 963 women with abnormal mammogram results had been referred for diagnostic follow-up. Invasive cervical cancer was diagnosed in five women, and cervical intraepithelial neoplasia (a precancerous lesion that is curable in up to 90% of women when treated at this stage [5]) was diagnosed in 1701 women. In addition, 2935 women received diagnostic follow-up, including colposcopy-directed biopsy, for abnormalities.

Reported by: Epidemiology and Statistics Br and Office of Program Advancement, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In addition to increasing the number of women screened each year for breast and cervical cancers, CDC's National Breast and Cervical Cancer Early Detection Program has 1) improved collaborative planning between states and public- and private-sector organizations; and 2) mobilized partnerships between CDC and the American Cancer Society, the American College of Physicians, the ACR, the National Medical Association (NMA), and other government organizations, such as the Indian Health Service, to develop coalitions for planning and implementing interventions.

All grantees collect and report information on screening location, patient demographic characteristics, screening results, and diagnostic procedures. These data will be used to help state health agencies implement, direct, evaluate, and monitor their screening programs; provide state and national legislators with data on the progress and results of the program; and direct and improve CDC's program efforts.

Participating state health departments have developed service delivery models that assist local agencies in designing screening programs based on the needs of the community and its health-care resources. In addition, state health departments and private health organizations have developed curricula to educate health-care providers about the importance and effectiveness of screening and the need to make referrals for follow-up and treatment. For example, the NMA developed a workshop, "Breast and Cervical Cancer: Recognition, Management, and Screening Strategies," that was offered at four regional sites during 1992 for NMA members and other professionals. In South Carolina and West Virginia, two state population-based breast and cervical cancer registries were initiated.

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 aged greater than or equal to 18 years with uterine cervix who have ever received a Pap test (objectives 16.11b and 16.12d) (6). Because successful breast and cervical cancer programs require a strong state health infrastructure, during 1992 CDC has provided financial and technical assistance to 18 additional state health agencies *** to initiate capacity-building programs in preparation for implementing comprehensive statewide breast and cervical cancer early-detection programs. In mid-1993, CDC proposes to fund three additional states for the comprehensive breast and cervical cancer control programs and to increase awards to the 12 states previously funded so additional low-income women can be screened for breast and cervical cancer.

References

1. American Cancer Society. Cancer facts and figures -- 1992. Atlanta: American Cancer Society, 1992; publication no. 5008.920LE.

2. Devesa SS, Young JL, Brinton LA, Fraumeni JF. Recent trends in cervix uteri cancer. Cancer 1989;64:2184-90.

3. 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. MMWR 1992;41(no. SS-2):17-34.

4. CDC. Regulations for implementing the Clinical Laboratory Improvement Amendments of 1988: a summary. MMWR 1992;41(no. RR-2).

5. Eddy DM. Screening for cervical cancer. Ann Intern Med 1990;113:214-26.

6. 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. ** CDC directly supports training and salaries for personnel in the radiation health offices of some grantees to monitor the quality of mammography services in the state. *** Grants ranging from $250,000 to $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.

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