detection. It can take many years to reap the benefits of behavioral change like smoking cessation. Significant reductions in breast cancer mortality rates as a result of screening programs have only recently been observed in the general population. The fascination of the American public with advanced technology and “getting tested,” the commercial and marketing interests in servicing this demand, and the sense of urgency to take action in combating cancer set the stage for the premature adoption of interventions that are potentially ineffective or harmful.

Increasingly, cancer screening guidelines incorporate the tenets of informed decision making. Rather than issuing prescriptive recommendations regarding prostate-specific antigen testing, for example, most organizations are suggesting that individuals discuss the relative benefits and harms of screening, weigh these factors according to their individual values and preferences, and decide whether or not to proceed with screening. Although this shared decision-making approach tends to be embraced by the well-educated health consumer, little is known regarding its acceptance among the general public and how best to incorporate it into the delivery of preventive services.

Improved understanding of cancer prevention by the general public is also critical to support for research in this area. Although the public is generally supportive of clinical medical innovation, it has less of an appreciation of the potential of public health interventions.

Recommendation 11: Public and private initiatives to reduce disparities in the cancer burden (e.g., initiatives of the National Cancer Institute and the American Cancer Society) should be supported.

There are glaring disparities in rates of morbidity and mortality from cancer among socioeconomic groups, insured and uninsured populations, and certain racial and ethnic groups (IOM, 1999b). The differences among these groups present both a challenge to understand the reasons and an opportunity to reduce the burden of cancer (U.S. Department of Health and Human Services and Office of Disease Prevention and Health Promotion, 2000). Lack of health insurance coverage is a key predictor of lower rates of use of cancer screening tests. Personal barriers can include cultural differences, language barriers, not knowing how or when to seek care, or concerns about confidentiality or discrimination (U.S. Department of Health and Human Services and Office of Disease Prevention and Health Promotion, 2000). In a nation of increasing diversity, interventions to improve cancer prevention and early detection must accommodate different languages, cultural values, and beliefs.

The elimination of racial and ethnic disparities in health is an over-arching goal of Healthy People 2010 (U.S. Department of Health and Human Services and Office of Disease Prevention and Health Promotion, 2000), and cancer screening and management is one of six focus areas of an

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