EDITORIAL

Screening for Cancer: Progress, but More Can Be Done

Paul S. Frame

Affiliations of author: Tri-County Family Medicine, Cohocton, NY, and University of Rochester School of Medicine and Dentistry, NY.

Correspondence to: Paul S. Frame, M.D., Tri-County Family Medicine, 25 Park Ave., Cohocton, NY 14826 (e-mail: psframe{at}frontiernet.net).

Cancer is the second leading cause of death in the United States, after heart and vascular disease. It is, therefore, natural that prevention of cancer should be a major national health priority. With the exception of lung cancer, for which the major strategy for primary prevention is avoidance of tobacco products, screening for the early detection of cancers and cancer precursors is the primary method for preventing death and morbidity from other cancers, specifically cervical, breast, and colorectal cancers. By contrast with primary prevention, screening requires repeated interactions between patients and health care providers, which are sometimes costly, sometimes uncomfortable, and frequently inconvenient for the patient. Furthermore, screening requires an ongoing commitment by patients, providers, and the health care system.

How successful are efforts to screen for major cancers in the United States? In a special article in this issue of the Journal, Breen et al. (1) compare data on rates of screening for cervical, breast, and colorectal cancers from the 1987, 1992, and 1998 National Health Interview Surveys (NHISs). Their results are important and, in my opinion, are generally optimistic. They do, however, leave plenty of room for improvement.

In 1987, rates for Pap smear screening for the detection of cervical cancer were good and, by 1998, had improved to 80% of women reporting a Pap smear in the last 3 years. It is not clear from the article by Breen et al. that the NHIS methodology accounted for the fact that women who have had a hysterectomy or women older than 65 years, who have had repeatedly normal Pap smears, do not need continued screening. Therefore, compliance with appropriate cervical cancer-screening practices may have been even higher than 80%.

Mammography-screening rates for the detection of breast cancer were not as good as the screening rates for the detection of cervical cancer, but they have shown dramatic improvement, from 30% of women reporting having had a mammographic examination in the past 2 years in 1987 to 67% of women in 1998. If this trend continues, mammography-screening rates will soon be comparable to the screening rates for Pap smears.

In contrast to the generally good rates of screening for breast and cervical cancers, colorectal cancer screening rates remain low. Only about 30% of women and 37% of men had had a recent fecal occult blood test or sigmoidoscopy in the 1998 survey. The NHIS did not include data on use of screening colonoscopy, but although use of this modality is increasing rapidly, it still accounts for only a small portion of colorectal cancer screening. One reason for the lower rates of colorectal cancer screening is that advocacy for colorectal cancer screening is relatively recent compared with that for breast and cervical cancer screening. Pap smears have been recommended since the 1950s and screening mammography since the 1970s. It was only in 1997, after publication of the second edition of the U.S. Preventive Services Task Force guidelines (2) and the American Gastroenterological Association's (AGA's) gastrointestinal (GI) consortium guidelines (3), that there was expert consensus on colorectal cancer screening methods. Widespread campaigns to increase public awareness of colorectal cancer screening are an even more recent phenomenon.

In addition to the reluctance of patients to undergo sigmoidoscopy, a specific physician barrier to use of sigmoidoscopy is the low reimbursement from health care organizations. Medicare currently pays only $101 for a screening sigmoidoscopy, approximately two thirds of the overall screening cost. The equipment costs approximately $10 000 and requires routine maintenance, and the procedure takes a minimum of 20 minutes of the physician's time and 30 minutes of the nurse's time. Many physicians find in-office sigmoidoscopy to be a money-losing procedure (4).

The data presented showing that 40% of women in 1998 had a recent digital rectal examination (DRE) (1) is an example of excessive screening. Neither the U.S. Preventive Services Task Force (2), the American Cancer Society (5), or the AGA's GI consortium (3) currently recommends DRE for colorectal cancer screening. It could be argued the DRE is being done in men to screen for prostate cancer. However, to the extent DRE is reported to be used to screen for colorectal cancer, it is unnecessary.

It was encouraging to note in the data presented by Breen et al. (1) that African-Americans were actually screened more often than whites for cancer. Although screening rates for colorectal cancer were less for Hispanic populations than for whites, screening rates for breast or cervical cancer were equivalent between the two populations. It would appear that the racial/ethnic barriers to cancer prevention are being overcome.

Not surprisingly, lack of a usual provider and lack of health insurance were the major patient barriers to cancer prevention (1). With declining student interest in primary care and the lower prestige and incomes seen for primary care providers compared with specialists, primary care is under stress. If patients do not have access to a competent primary care provider, they are unlikely to receive appropriate preventive care. Clearly, having an ongoing relationship with a primary care provider is crucial to the efficient delivery of preventive services. However, within primary care, the continuity of care is being challenged by the trend toward large group practices with many part-time providers, which frequently results in the patient seeing a different provider at each visit. Furthermore, continuity between physician and patient is also disrupted by patients having to change providers because of frequent changes in their health insurance coverage.

It is rational that patients without health insurance choose to spend precious dollars on food, shelter, and transportation rather than on Pap smears, mammographic examinations, and sigmoidoscopies. The solution is obvious but seems elusive in the current politics of U.S. health care. There should be universal coverage for basic health care needs, especially proven preventive services.

To improve overall rates of cancer screening, system changes are needed at the levels of both national public policy and local practice. Some positive changes have already been made. Medicare and most managed care organizations now pay for basic preventive services, including Pap smears, mammographic examinations, and sigmoidoscopies. Medicare and many insurers pay for screening colonoscopy. The advent of report cards for managed care organizations (MCOs) developed by the National Committee on Quality Assurance has greatly increased the interest of MCOs in achieving high rates of delivery of preventive services.

However, more needs to be done. Most pressing is the need for universal health insurance coverage. Screening levels will be inadequate as long as the people most at risk for disease do not have health insurance.

Although Medicare now pays for most preventive services, its reimbursement for sigmoidoscopy is inadequate, and it does not pay for "health maintenance visits." Such lack of reimbursement means that the primary care physician seeing a patient for health maintenance, and perhaps referring for mammography, explaining the colorectal screening options before referring for sigmoidoscopy or colonoscopy, and dealing with non-cancer-related health maintenance issues, cannot get paid unless he or she creates an illness-related diagnosis.

At the local practice level, computer-based health maintenance tracking and quality-assurance tools need to be more widely used. Such tools can be used to prompt or to remind providers at each patient visit if preventive services are due, can create reminders to be directly sent to patients, and can facilitate audits of health maintenance compliance (6). Computer-based tracking systems are still evolving, however, and easy-to-use products are not available to all practices. Barriers to adoption of these tracking systems include the following: 1) the variety of different computer systems in use, which often are proprietary or not compatible with other software; 2) many systems that do not include all of the features needed to make health maintenance tracking work efficiently; and 3) the substantial costs of installation and maintenance.

The data reported by Breen et al. (1) demonstrate both that considerable progress in cancer screening has been made and that more needs to be done. All of the people associated with the health care profession, at the national and local levels, must work to improve the system so that optimal cancer screening can become a reality.

REFERENCES

1 Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbush R. Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer Inst 2001;93:1704–13.[Abstract/Free Full Text]

2 U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore (MD): Williams & Wilkins; 1996.

3 Winawer SJ, Fletcher RH, Miller L, Godlee F, Stolar MH, Mulrow CD, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594–642.[Medline]

4 Lewis JD, Asch DA. Barriers to office-based screening sigmoidoscopy: does reimbursement cover costs? Ann Intern Med 1999;130:525–30.[Abstract/Free Full Text]

5 Smith RA, Mettlin CJ, Davis KJ, Eyre H. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin 2000;50:34–49.[Abstract/Free Full Text]

6 Frame PS, Zimmer JG, Werth PL, Martens WB. Description of a computerized health maintenance tracking system for primary care practice. Am J Prev Med 1991;7:311–8.[Medline]



             
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