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Testimony on Screening Programs for Breast and Cervical Cancer by Nancy C. Lee, M.D.
Director, Division of Cancer Prevention and Control
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Before the House Committee on Commerce, Subcommittee on Health and Environment
July 21, 1999

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.

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