their care. Clearly, efforts to improve cancer prevention and early detection practices will have to focus on these ambulatory care settings.

Assessments of whom to train also require answers to questions about the number of providers who need to be trained and the appropriate roles for which physician and nonphysician providers of prevention services need to be prepared. The specter of a lack of provider capacity has arisen as the large baby boom cohort ages and falls into the age groups for whom regular screening is recommended. The need for qualified mammography providers, for example, will likely increase as the population ages and as more providers and women adopt screening recommendations. The number of women eligible for breast cancer screening is expected to increase by 46 percent from 2000 to 2020 (U.S. Census middle projections, The 2001 Institute of Medicine (IOM, 2001b) report Mammography and Beyond cites anecdotal reports that inadequate numbers of mammographers and mammography technologists are being trained to fill current and future needs, but it also notes that good data to support such claims are lacking. The IOM committee that prepared that report recommended that a study be conducted to assess provider supply.

Likewise, the demand for colorectal cancer screening could easily outpace the number of physicians trained to conduct the tests recommended in colorectal cancer screening guidelines (e.g., sigmoidoscopy and colonoscopy) if gains in the rate of acceptance of such screening tests are coupled with the aging of the baby boom cohort (Schoenfeld, 1999). Increased demand for tests could renew long-standing calls for greater involvement of nonphysician providers in screening programs. However, despite evidence suggesting that appropriately trained nurses can perform flexible sigmoidoscopy with the same degrees of accuracy and safety as physicians (Fletcher and Farraye, 1999; Maule, 1994; Schoenfeld, 1999; Schoenfeld et al., 1999), they have not uniformly been accepted as providers within health care systems (Floch, 1999). Nevertheless, several professional societies (e.g., the American Society for Gastrointestinal Endoscopy and the British Society of Gastroenterology) have endorsed the performance of flexible sigmoidoscopy by nurses, but 16 of 50 U.S. state boards of nursing expressly prohibit registered nurses from performing screening flexible sigmoidoscopy (Cash et al., 1999).1 In 1996 the U.S. Preventive Services Task Force included a recommendation that flexible sigmoidoscopy be used to screen asymptomatic adults age 50 and older, and since 1998 Medicare has provided reimbursement for screening flexible sigmoidoscopy, but only physicians are


Fifteen of 16 of these states allow nurse practitioners, but not registered nurses, to perform screening flexible sigmoidoscopy (Cash, 1999). Among U.S. institutions with gastroenterology fellowship programs, 15 percent (24 of 164 programs) were using paramedical personnel to perform flexible sigmoidoscopy (Cash, 1999).

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