1. EDITORIAL
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 territories, and 12 American Indian/Alaska Native (AI/AN)
colorectal cancer are prioritized clinical preventive services tribes or tribal groups. They, in turn, have contracted with
that can reduce the burden of cancer in the United States.1 individual providers, practice networks, hospital systems,
While significant progress has been made in this area, health centers, and local health departments to recruit and
screening rates for breast and cervical cancers have not screen medically underserved, low-income women aged 40
improved in almost a decade and rates for colorectal cancer to 64 years for breast cancer and women aged 18 to 64 years
are unacceptably low. Lack of insurance has traditionally for cervical cancer. In 2000, the Breast and Cervical Cancer
been the main factor preventing adults from obtaining Prevention and Treatment Act allowed states to provide
cancer screening.2 Components of the Patient Protection Medicaid coverage to women diagnosed with breast cancer
and Affordable Care Act will help address this through through the NBCCEDP.
Medicaid expansion, subsidized state insurance exchanges, A 2009 analysis by the Government Accounting Office
and the elimination of cost sharing. found that current funding for the NBCCEDP allowed it
However, access to health insurance and medical care to reach 15% of eligible, uninsured, low-income women
are not the only factors that limit participation in cancer for breast cancer screening. Approximately 26% of this
screening. Many people who currently have health insurance population receives screening through other mechanisms.
and regular access to medical care are not being screened. The remaining 60% may not be screened.6 Subsequent
Based on 2010 National Health Interview Survey data, analysis of the NBCCEDP’s effect on breast cancer morta-
among adults aged 50 to 75 years with a regular source of
lity found that the program saved 369,000 life-years
medical care, only 62% were up to date with screening for
compared with women who received no screening.7 The
colorectal cancer and only 75% of women in this age range
median medical costs of providing breast and cervical cancer
had received a mammogram within the preceding 2 years.3
screening services in the NBCCEDP are $120 and $59,
Analyses of national Medicare data revealed that, despite
respectively, which compares favorably with cost data from
coverage of cancer screening services, only 66% of eligible
other health care delivery systems. The outreach and service
women had undergone a mammogram within the past
delivery components of the NBCCEDP play an important
2 years4 and only 47% of adults had insurance claims
role in addressing health care disparities. Of the 1.6 million
documenting adequate screening for colorectal cancer.5 To
women screened for breast cancer by the program from
realize the full potential of anticipated improvements in
2005 through 2010, 17% were black, 27% were Hispanic,
access to care, public health must provide leadership to ensure
that cancer screening is proactive, organized, and equitable. and 3% were AI/AN.
The CDC has also developed a national system to ensure
Efforts Should Build on Existing Infrastructure the timely follow-up and treatment of patients with
and Capacity abnormal screening test results. The CDC requires funded
Existing public health infrastructure could be built upon to providers to collect and report state-based, standardized
increase cancer screening rates. In 1990, Congress passed data to the Minimum Data Elements registry. This registry
the Breast and Cervical Cancer Mortality Prevention Act, is the only national system that collects information to
which authorized the Centers for Disease Control and monitor attainment of screening quality. The NBCCEDP
Prevention (CDC) to implement the National Breast and has consistently met its quality standards on diagnostic
Cervical Cancer Early Detection Program (NBCCEDP). follow-up and treatment initiation since the inception of
The CDC funds 50 states, the District of Columbia, 5 US 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 Health
Promotion, 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 necessarily
represent 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
VOLUME 00 _ NUMBER 0 _ MONTH/MONTH 2012 1

2. New Roles for Public Health in Cancer Screening
EDITORIAL
diagnosis and treatment in state, tribal, and territorial Public Health Should Develop Organized
programs found that 80% of women were diagnosed Cancer Screening Systems
within 60 days of abnormal screening test results and almost Surveillance of cancer screening in the United States is
94% of women initiated treatment within 60 days currently based on self-reported population surveys that
after diagnosis. Comparison with a similar population monitor temporal trends in screening use. However, data on
of women in New Jersey reported median diagnostic current screening rates would be more accurate if they were
intervals that were almost 2 weeks longer than those for based on actual use of services. Public health agencies are
the NBCCEDP.8 uniquely positioned to lead the development of centralized
data systems for cancer screening because of their access
More Aggressive Approaches Are Needed to population data and their experience developing,
to Improve Cancer Screening implementing, and managing surveillance systems that
require patient confidentiality. These data could be used to
The infrastructure to promote and ensure cancer screening
develop more organized, systematic approaches to cancer
in the United States must be expanded to achieve desired
screening in the United States.
screening goals. While the medical care system is an impor-
For example, centralized lists from insurance company
tant partner in promoting and providing cancer screening
databases or emerging state insurance exchanges could be
services, efforts to increase screening rates in this setting are
developed and managed to prompt eligible adults, via
limited by the opportunistic nature of clinical services. Most
telephone, mail, or electronic reminders, to participate in
patients are offered screening tests when they visit a medical
screening. More resource-intensive approaches, such as case
provider for unrelated reasons. Evidence-based interven-
management and patient navigation, could be targeted to
tions, including reminders to clients and providers to ensure
that individuals are screened on time, have been shown to more effectively reach communities most affected by health
increase cancer screening rates.9 Screening registries have care disparities. In particular, public health departments will
been found to improve the follow-up of patients with have a tremendous opportunity to work collaboratively with
positive screening tests.8 However, the widespread state Medicaid programs to increase cancer screening as
implementation of these approaches has been challenging in previously uninsured adults become eligible. Public health
our fragmented health care system. In a recent study of agencies could work with state Medicaid programs to
primary care physicians’ practices, only 40% reported that identify populations eligible for screening from Medicaid
they had a system in place to remind patients to come in for enrollee data and actively link these individuals with available
breast or cervical cancer screenings.10 Compared with the screening services. Agencies could also develop data linkages
general population, minorities and those from lower and clinical registries to monitor participation, diagnostic
socioeconomic backgrounds receive less timely follow-up follow-up, treatment initiation, and long-term outcomes.
after an abnormal screening test.11 The patient-centered Provider systems must be fully integrated into these
medical home is an emerging model with which to improve efforts to ensure they do not create a demand that providers
the quality of medical practice. This approach could be are not ready to fulfill. Efforts currently are ongoing
applied to the delivery of clinical preventive services but, to increase the capacity of Federally Qualified Health
to date, efforts have focused primarily on achieving Centers (FQHCs) to provide clinical services. Public health
intermediate outcomes in the management of patients with departments could expand on their existing relationships
diabetes, asthma, and congestive heart failure.12 with FQHCs through the NBCCEDP. Collaborative
A more organized and comprehensive approach is needed approaches could include expedited screening referrals,
to increase cancer screening participation among individuals direct mailing of fecal occult blood test kits to patients,
who already have medical insurance or are likely to become and the use of practice-based outreach workers in tradition-
insured through the Patient Protection and Affordable Care ally underserved communities. Systems to improve the
Act. Lessons can be learned from other countries and from follow-up of patients with abnormal screening tests could
some managed care systems in the United States. They have be based on the experience of the CDC’s existing quality
actively developed systems to identify members who are eli- assurance system described above. Recent initiatives to
gible to participate in recommended screenings and have expand the implementation of electronic health records in
also developed practices to ensure appropriate follow-up of FQHCs could facilitate these efforts to ensure appropriate
patients with positive tests. These programs enhance diagnostic testing and treatment.
recruitment into organized screening programs through In an era of health care reform, public health has opportu-
direct personal invitations. Media advertising is used to nities to ensure that participation in cancer screening is
reinforce these personal invitations, and there is active widespread and equitable. Given the magnitude of cancer
surveillance of screening use. morbidity and mortality, and the considerable capacity that
2 CA: A Cancer Journal for Clinicians

3. EDITORIAL
has been developed throughout the 22-year history of the 5. Schenck AP, Peacock SC, Klabunde CN, Lapin P, Coan JF, Brown
ML. Trends in colorectal cancer test use in the Medicare population,
NBCCEDP, public health has a responsibility to lead a 1998-2005. Am J Prev Med. 2009;37:1-7.
national approach to cancer control that is comprehensive, 6. United States Government Accountability Office. Medicaid: Source
of Screening Affects Women’s Eligibility for Coverage of Breast and
strategic, and organized. An initial focus on developing an Cervical Cancer Treatment in Some States. http://gao.gov/products/
organized system to improve cancer screening could ulti- GAO-09-384. Accessed April 2, 2012.
7. Hoerger TJ, Ekwueme DU, Miller JW, et al. Estimated effects of the
mately be expanded to other clinical preventive services. n National Breast and Cervical Cancer Early Detection Program on
breast cancer mortality. Am J Prev Med. 2011;40:397-404.
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