Good Morning. I am Dr. Nancy Lee, Director of the Division of Cancer Prevention and
Control of the National Centers for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention (CDC). I am pleased to be here this morning to
discuss CDC's National Breast and Cervical
Cancer Early Detection Program.
Recognizing the value of appropriate cancer screening, Congress passed the Breast and
Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354). CDC is in the ninth
year of the National Breast and Cervical Cancer Early Detection Program, which brings
critical breast and cervical cancer screening services to underserved women, including
older women, women with low incomes, and women of racial and ethnic minorities. While
successes and advances have been made with the help of this program, challenges still
exist.
CDC supports early detection programs in all 50 states, five U.S. territories, the
District of Columbia, and 15 American Indian and Alaska Native organizations. The program
establishes, expands, and improves community-based screening services for women to reduce
breast and cervical cancer mortality. The success of the breast and cervical cancer
program depends on screening, education and outreach, partnership development, case
management, and mechanisms to assure the quality of tests and procedures.
Through September of 1998, more than 2 million screening tests have been provided to
over 1.3 million women. That number includes 1 million Pap tests and 950,000 mammograms.
Almost half of these screenings were to minority women, who have traditionally had less
access to these services. Over 5,000 women have been diagnosed with breast cancer, more
than 30,000 women were diagnosed with precancerous cervical lesions, and 411 women had
invasive cervical cancer.
CDC collects data from all funded programs to monitor and evaluate each program's provision of clinical services. For each woman
enrolled in the program, information is collected on demographic characteristics, results
from mammograms, breast exams, and Pap tests, diagnostic procedures and outcomes, cancer
diagnoses, and for women diagnosed with cancer, whether treatment was initiated.
The program's success is due in part, from a
large network of professionals, coalitions and national organizations dedicated to the
early detection of breast and cervical cancer.
- An estimated 27,000 health professionals are involved in providing breast and cervical
cancer screening services to underserved women.
- More than 18,000 health educators and outreach workers are educating women on the
importance of early detection and helping them access critical screening and follow-up
services.
- More than 7,000 individuals are now members of a national network of coalitions that
have joined together with State health departments in support of this program.
- One of CDC's partners in the program, Avon,
has raised more than $32 million in additional dollars to educate women about breast
cancer and to provide underserved women with access to early detection services.
There has been a 20 percent increase in screening mammography rates among all
women 50 years and older since 1991, when the program was formally established. For both
mammograms and Pap tests, the disparity rates for most of the minority groups have either
been eliminated or reduced. There has been a recent decline in the rate of breast cancer
mortality. And while there remains much to be done, our most recent mortality data from
1996 indicates that we have met the Healthy People 2000 goal of reduced mortality from
breast cancer.
Insuring that all women with abnormal screening results receive adequate follow-up and
a definitive diagnosis is a crucial component of this program. Thus, breast diagnostic
services funded by federal dollars include diagnostic mammography, breast ultrasound, fine
needle aspiration and breast biopsy and for the cervix, colposcopy and colposcopy-directed
biopsy.
The legislation that authorizes the National Program does not allow federal resources
appropriated for the program to be used for treatment. However, States are required, under
terms of the grants they receive, to assure that women who are screened and need cancer
treatment, receive care.
Data through March 1998 show that 92 percent of the women diagnosed with breast cancer
and invasive cervical cancer have initiated treatment. The rest refused treatment, have
not yet initiated treatment, or are lost to follow-up. For women diagnosed with breast
cancer, data show a median of 8 days between the cancer diagnosis and the initiation of
treatment.
A detailed study of seven state screening programs conducted by Battelle Centers for
Public Health Research and Evaluation and the University of Michigan, funded by the CDC,
documents the innovative approaches that have been implemented to identify and secure
resources for treatment services. The study confirmed what we see in our Program data that
arrangements for treatment were made for almost all clients who received a diagnosis of
breast or cervical cancer. States' efforts to
secure treatment for women screened through the Program have been further documented in a
separate study conducted by the Susan G. Komen Breast Cancer Foundation.
State programs and their partners have invested significant amounts of time and effort
to develop systems of care for diagnostic follow-up and treatment; these systems appear to
be working. However, tremendous effort is involved in developing, implementing, and
maintaining strategies and systems for these services. Rarely is there a standardized way
that a State, tribe or territory obtains treatment services women need that are not
covered by the program. Efforts typically are tailored to an individual client's needs and resources.
State programs have developed sophisticated, creative and successful strategies to deal
with the tremendous challenge of payment for cancer treatment. The following are some of
the strategies that are employed by States to secure treatment services for women:
- Providers assist eligible clients in applying for Medicaid, Hill Burton funds, or other
types of public assistance.
- Clients may be referred to public hospitals, or receive care though hospital community
benefit programs, donated services, or other charitable care.
- Contracts with screening providers require
that agreements with treatment providers be established before screening commences.
- The Program appeals to treatment providers,
through state and county medical societies and professional associations, to offer free or
reduced-cost services to program clients.
Case management was identified in the Battelle study as one strategy that could assist
programs in their efforts to ensure the follow-up and treatment of clients. CDC has
developed a comprehensive policy on case management for the program. Increases in CDC's FY 1999 appropriation will be used to expand
critical case management services in States that strengthen the fragile system for
securing treatment services. With these funds, each program will enhance case management
activities to assist clients navigate through the system to obtain treatment services that
are not covered by the program.
Both North Carolina and Arkansas have appropriated State resources to the Cancer
Control Programs to provide for cancer diagnostic and treatment services for all state
citizens who meet eligibility criteria. California utilized a one-time allocation of $12.8
million from the Blue Cross Foundation to create a Breast Cancer Treatment Fund, which
paid for treatment during the first year after diagnosis for any uninsured California
women who met eligibility requirements. Unfortunately, this fund is nearly depleted.
Although States are currently meeting their commitment to help women access treatment
services, several of the programs reviewed in the Battelle study expressed concerns
regarding their ability to expand screening services to more women in need because the
systems in place for obtaining charitable treatment are becoming overburdened. These
programs stated that as long as the numbers of cancers diagnosed through the program
remain near the current level, the burden should not be too great or too threatening.
However, increased screening -- which is our goal -- is accompanied by increased
numbers of cancers diagnosed, and many physicians who contract with programs are concerned
about bringing more uninsured patients into their care, because of the need to provide
treatment. Lack of sources for treatment can lead to screening problems in states where
screening providers must have standing treatment referral options in order to screen.
States are finding it more and more challenging to ensure that these women get the
treatment they need. The labor-intensive and piecemeal approach needed to secure treatment
services diverts human and financial resources away from the screening services. The
overall goal of this program is to reduce mortality from breast and cervical cancers, and
the success of this effort hinges on the identification and treatment of early stage
cancers and precancers. As they have in the past, CDC and its state partners will continue
to give priority to this critical aspect of the early detection effort.
Let me relay to you how one woman felt about the program:
I was forty years of age, a recently divorced women with no health insurance and
working for peanuts when I discovered a lump in my breast. It was a very traumatic
experience, to say the least. My fears that accompanied this finding were overwhelming. In
my present financial position, I would have never received the medical attention I needed,
if it wasn't for your program. I am healthy, the
lump was benign. Through this entire ordeal, I was able to focus all my energies on my
medical problem, while your office proficiently attended the bills.
CDC's National Breast and Cervical Cancer
Early Detection Program does not change whether or not a women has cancer. However, it can
help women by improving their chances of detecting cancer earlier and getting treatment
for it. And by finding and treating precancerous cervical lesions, the Program prevents
thousands of women from ever developing cervical cancer.
Thank you, and I would be happy to answer any questions you may have.
