9
Federal Programs That Support Cancer Prevention and Early Detection

Opportunitiestopromotecancer prevention and early detection span several sectors of society including health systems and providers, educational institutions, social services agencies, employer and labor organizations, and consumer groups. From a public policy perspective, actions to foster change can be taken by the federal government, states, and local entities (e.g., county and city governments and school boards). This chapter briefly describes the federal role in support of cancer-related prevention services in five important areas:

  1. national objectives and guideline development,

  2. information dissemination,

  3. monitoring and surveillance,

  4. facilitation of statewide program planning and evaluation, and

  5. provision of and payment for services.

The federal government’s role in education and training is described in Chapter 8, and its role in research is described in Chapter 10. Previous chapters highlight the significant roles of state and local entities (both public and private) in carrying out important functions to incorporate cancer prevention and early detection programs into community-based programs (Chapters 4 and 6).

NATIONAL OBJECTIVES AND GUIDELINE DEVELOPMENT

Explicit national health-related goals and objectives have been set as part of the Healthy People 2010 initiative (U.S. DHHS, Office of Disease



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Fulfilling the Potential of Cancer Prevention and Early Detection 9 Federal Programs That Support Cancer Prevention and Early Detection Opportunitiestopromotecancer prevention and early detection span several sectors of society including health systems and providers, educational institutions, social services agencies, employer and labor organizations, and consumer groups. From a public policy perspective, actions to foster change can be taken by the federal government, states, and local entities (e.g., county and city governments and school boards). This chapter briefly describes the federal role in support of cancer-related prevention services in five important areas: national objectives and guideline development, information dissemination, monitoring and surveillance, facilitation of statewide program planning and evaluation, and provision of and payment for services. The federal government’s role in education and training is described in Chapter 8, and its role in research is described in Chapter 10. Previous chapters highlight the significant roles of state and local entities (both public and private) in carrying out important functions to incorporate cancer prevention and early detection programs into community-based programs (Chapters 4 and 6). NATIONAL OBJECTIVES AND GUIDELINE DEVELOPMENT Explicit national health-related goals and objectives have been set as part of the Healthy People 2010 initiative (U.S. DHHS, Office of Disease

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Fulfilling the Potential of Cancer Prevention and Early Detection Prevention and Health Promotion, 2000), and efforts are under way to chart the nation’s progress toward those goals. Such objectives provide invaluable guidance to policy makers, and assessments of the achievement of these objectives often provide the impetus needed to stimulate systematic changes. Cancer-related objectives from Healthy People 2010 are shown in Box 9.1. Evidence-based guidelines for clinical and community practice also provide maps for action. The U.S. Preventive Services Task Force (USPSTF) periodically conducts rigorous assessments of the effectiveness of clinical BOX 9.1 Cancer-Related Healthy People 2010 Objectives Reduce the overall cancer death rate and death rates for lung cancer, breast cancer, cancer of the uterine cervix, colorectal cancer, oropharyngeal cancer, prostate cancer, and melanoma (Objectives 3-1 to 3-8). Increase the proportion of persons who use at least one of the following protective measures that may reduce the risk of skin cancer: avoid the sun between 10 a.m. and 4 p.m., wear sun-protective clothing when exposed to sunlight, use sunscreen with a sun-protective factor (SPF) of 15 or higher, avoid artificial sources of ultraviolet light (Objective 3-9). Increase the proportion of physicians and dentists who counsel their at-risk patients about tobacco use cessation, physical activity, and cancer screening (Objective 3-10). Increase the proportion of women who receive a Pap test (Objective 3-11). Increase the proportion of adults who receive a colorectal cancer screening examination (Objective 3-12). Increase the proportion of women aged 40 years and older who have received a mammogram within the preceding 2 years (Objective 3-13). Increase the number of states that have a statewide population-based registry that captures case information on at least 95 percent of the estimated number of reportable cancers (Objective 3-14). Increase the proportion of cancer survivors who are living 5 years or longer after diagnosis (Objective 3-15). Increase the proportion of local health departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs (Objective 7-11) Increase the proportion of adults who are at a healthy weight (Objective 19-1). Reduce the proportion of adults who are obese (Objective 19-2). Increase the proportion of oral and pharyngeal cancers detected at the earliest stage (Objective 21-6). Increase the proportion of adults who, in the past 12 months, report having had an examination to detect oral and pharyngeal cancers (Objective 21-7). Reduce the proportion of adults who engage in no leisure-time physical activity (Objective 22-1). SOURCE: US DHHS and Office of Disease Prevention and Health Promotion, 2000 (www.health.gov/healthypeople).

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Fulfilling the Potential of Cancer Prevention and Early Detection prevention services, and the U.S. Task Force on Community Preventive Services is assessing the effectiveness of interventions aimed at communities. USPSTF is an ad hoc independent panel of private-sector experts in primary care and prevention convened by the U.S. Public Health Service’s Agency for Healthcare Research and Quality (AHRQ). USPSTF evaluates scientific evidence of the effectiveness of clinical prevention services (e.g., screening tests, counseling, immunization, and chemoprophylaxis) and produces age- and risk factor-specific recommendations for the services that should be included in a periodic health examination. USPSTF is supported by outside experts, two Evidence-Based Practice Centers (groups that systematically synthesize available literature), and liaisons from the major primary care societies and from U.S. Public Health Service agencies. Currently, the third USPSTF, convened in 1998, is issuing recommendations updating its 1996 Guide to Clinical Preventive Services (www.ahrq.gov/clinic/cps3dix.htm). The 15-member independent, nonfederal Task Force on Community Preventive Services first met in 1996 and issued a number of reports, among them Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke (Task Force on Community Preventive Services, 2001). Other agencies within the federal government such as the Centers for Disease Control and Prevention (CDC) and AHRQ have been at the forefront in identifying effective prevention intervention strategies. CDC, for example, has issued three guidelines aimed at improving the health of school-age children: (1) CDC’s Guidelines for School Health Programs: Promoting Lifelong Healthy Eating (www.cdc.gov/nccdphp/dash/nutguide.htm), (2) Guidelines for School and Community Programs to Promote Lifelong Physical Activity Among Young People (CDC, 1997a), and (3) Guidelines for School and Community Health Programs Preventing Tobacco Use and Addiction (www.cdc.gov/nccdphp/dash/ptuaaag.htm). In 2000 AHRQ helped issue an update of its 1996 smoking cessation guideline that provides exhaustive information on best practices for clinicians (http://www.surgeongeneral.gov/tobacco/systems.htm). Another activity that has provided guidance regarding certain cancer prevention interventions is the National Cancer Institute’s (NCI’s) Consensus Development Conference process. Here, expert panels convene for a few days to review a synthesis of the literature and produce a consensus statement. In the area of cancer prevention and early detection, recent statements are available for breast cancer screening for women ages 40 to 49 (1997),1 cervical cancer (1996), and ovarian cancer screening, treatment, and follow-up (1994) (http://odp.od.nih.gov/consensus/cons/cancer.htm). 1   The controversy surrounding this statement is described in Chapter 4.

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Fulfilling the Potential of Cancer Prevention and Early Detection The federal government also plays an active role in guideline dissemination. The AHRQ Put Prevention into Practice (PPIP) initiative is designed to help implement the recommendations of USPSTF by supplying health care providers with easy-to-use materials to prompt adherence to the guidelines (http://www.ahrq.gov/clinic/ppipix.htm). Roughly 20 percent of the services considered by USPSTF and PPIP relate to cancer detection or prevention. Another federally sponsored guideline dissemination activity is CONQUEST (Computerized Needs-Oriented Quality Measurement Evaluation System), which consists of a database of performance measures (conditions, diseases, and procedures), measure sets (measures with a common purpose and developer), and conditions (with detailed epidemiological information). CONQUEST includes measures related to the management of several cancers (i.e., colorectal, lung, prostate, and breast cancer), the use of screening tests (i.e., mammography and Pap smear), and cigarette use (www.ahrq.gov/qual/conquest.htm). INFORMATION DISSEMINATION NCI is at the center of federal efforts to disseminate cancer-specific information to individuals and health care providers. By telephone, individuals can receive up-to-date cancer information in English or Spanish through the Cancer Information Service (1-800-4-CANCER). Over 390,000 calls are received each year, with 79 percent from cancer patients and their families and the balance from the general public and health care professionals (http://cis.nci.nih.gov/about/underserved.html, accessed January 30, 2002). Through the World Wide Web (www.nci.nih.gov/cancerinfo/index.html), individuals can get information about the basics of cancer; treatment options; clinical trials; genetics, causes, risk factors, and prevention; screening; and information about support and other resources. Information about cancer trials and how to access them is available through a dedicated clinical trial website (http://cancertrials.nci.nih.gov). In an effort to learn more about the public’s access to and use of cancer-related health information, the NCI is conducting a national survey, the Health Information National Trends Survey. Other research-oriented activities that are a part of NCI’s cancer communications initiative are described in Chapter 10. PDQ (Physician Data Query) is NCI’s comprehensive cancer database originally designed for use by physicians. The database contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, and supportive care. These summaries are updated monthly by specialized editorial boards. There are two versions of the screening and detection summaries. One is for health professionals and contains current data, by cancer site, on screening interventions, levels of evidence for statements regarding screening, and the significance and evidence of benefit for the

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Fulfilling the Potential of Cancer Prevention and Early Detection statements. Another version is available for patients and is written in non-technical language (http://cancernet.nci.nih.gov/pdqfull.html). Provider- and consumer-oriented prevention summaries are also available. In addition to these summaries, PDQ includes an online registry of approximately 1,800 open and 10,300 closed clinical trials from around the world. An additional resource is directories of health professionals and organizations involved in cancer care, and professionals who provide genetics services (e.g., cancer risk assessment, genetic counseling, genetic susceptibility testing). The Centers for Disease Control and Prevention also supports information dissemination, often targeted to states and localities. Tobacco Information and Prevention Source (TIPS) is a Web portal that provides an array of tobacco control information and links to resources (http://www.cdc.gov/tobacco/issue.htm). The site provides access to guides to tobacco cessation; educational materials for parents, educators, professional and youth leaders; state information, such as best practices; and information of interest to children and young adults (sports initiatives, celebrities against smoking). Also online at CDC’s site is information about obesity and overweight, including guidelines and recommended strategies to prevent chronic diseases and obesity, and programs to support state health departments and their partners (www.cdc.gov/nccdphp/dnpa/obesity/index.htm). In October 2000, CDC’s Division of Nutrition and Physical Activity initiated a program to support state health departments and their partners in developing and implementing targeted nutrition and physical activity interventions in an effort to prevent chronic diseases, especially obesity. Twelve states funded in FY 2000 and 2001 were encouraged to use a social marketing approach in designing their population-based strategies, particularly policy-level and environmental interventions. Information about cancer screening is also available at CDC’s website, including a series of “At-a-Glance” publications focusing on the importance of early detection (www.cdc.gov/health/cancer.htm). The Office of the Surgeon General has issued a series of reports regarding the health consequences of tobacco (Box 9.2). MONITORING AND SURVEILLANCE Several federally supported surveys and administrative record systems provide the data needed to assess progress toward reaching the nation’s cancer prevention and early detection goals (Box 9.3). The National Health Interview Survey (NHIS) is the principal source of information on the health of the civilian noninstitutionalized population of the United States (http://www.cdc.gov/nchs/about/major/nhis/hisdesc.htm) and provides national estimates of a number of cancer-related health behaviors including tobacco use and use of cancer screening tests. The NCI supports periodic supplements to the NHIS on cancer control (most re-

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Fulfilling the Potential of Cancer Prevention and Early Detection BOX 9.2 Surgeon General’s Reports on Tobacco Control Date Topic 1964 Reducing the Health Consequences of Smoking 1981 The Health Consequences of Smoking: The Changing Cigarette 1982 The Health Consequences of Smoking: Cancer 1986 The Health Consequences of Involuntary Smoking 1988 The Health Consequences of Smoking: Nicotine Addiction 1989 Reducing the Health Consequences of Smoking 1990 The Health Benefits of Smoking Cessation 1994 Preventing Tobacco Use Among Young People 1998 Tobacco Use Among U.S. Racial/Ethnic Minority Groups 2000 Reducing Tobacco Use 2001 Women and Smoking cently, in 2000) to assess knowledge, attitudes, and practices concerning cancer-related health behaviors and cancer screening (Stacey Vandor, Planning Officer, NCI, personal communication to Maria Hewitt, February 11, 2002). The NHIS involves personal interviews in homes to gather information on household members. The NCI also supports a smoking supplement to the Current Population Survey (CPS), a household survey of 60,000 households conducted by the Bureau of Census for the Bureau of Labor Statistics. The CPS provides data on the U.S. labor force and employment statistics (http://www.bls.gov/cps/cps_over.htm#overview). State-based estimates of preventive health behaviors, knowledge, and attitudes are available through CDC’s Behavioral Risk Factor Surveillance BOX 9.3 Selected Examples of Cancer Prevention and Early Detection Surveillance Tools Sponsor Surveillance Tool Centers for Disease Control and Prevention • National Health Interview Survey (national estimates) • Behavioral Risk Factor Surveillance System (state-based estimates) • Youth Risk Behavior Surveillance System • National Ambulatory Medical Care Surveys (provider practices) • National Health and Nutrition Examination Survey (clinical measures and assessments) Centers for Medicare and Medicaid Services • Medicare Beneficiary Survey • Claims analyses (estimates of use of services) U.S. Department of Veterans Affairs • Veterans surveys • Medical records and administrative records

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Fulfilling the Potential of Cancer Prevention and Early Detection System. This telephone survey is conducted by states among adults age 18 and older. States generally use a core survey instrument and may add additional items to meet local informational needs. A number of data systems provide information on important subpopulations. Estimates of rates of tobacco use and levels of access to cigarettes among youth, for example, are available through CDC’s Youth Risk Behavior Surveillance System (CDC, Division of Adolescent and School Health, http://www.cdc.gov/nccdphp/dash/yrbs/), and estimates of cancer screening practices among Medicare beneficiaries are available through the Medicare Beneficiary Survey. National surveys of ambulatory care practices help gauge the extent to which physicians are delivering preventive health services such as counseling on diet, nutrition, and exercise. Two surveys sponsored by CDC, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, collect data from a representative sample of physicians’ offices and hospital outpatient departments and provide national estimates of the number of ambulatory care visits, reasons for visits (e.g., diagnoses associated with visits and use of selected preventive health interventions), and actions taken during visits (e.g., counseling, ordering of tests, prescriptions for medication). The National Health and Nutrition Examination Survey, sponsored by CDC, collects information about the health and diet of people in the United States. NHANES is unique in that it combines a home interview with health tests that are done in a mobile examination center (www.cdc.gov/nchs/nhanes.htm). Results of the survey have been used to monitor trends in overweight and obesity (see Chapter 3, figure 3.1). Some data systems are unique to a system of care. The U.S. Department of Veterans Affairs (VA), for example, uses both survey data and formal audits of medical records to assess progress in cancer prevention and early detection (see Tables 9.3 and 9.4). FACILITATING STATEWIDE PROGRAM PLANNING AND EVALUATION National organizations may set guidelines and policy for cancer prevention and control, but implementation of public health measures to reduce the burden of cancer largely falls to state and local health departments, along with their partners, which include consumer and advocacy organizations, universities, and area health care providers. Wide state-level variations in the prevalence of cancer-related risk factors are alarming but provide opportunities to target interventions and achieve gains in health (Box 9.4). CDC would like to build the capacities of states—and, in turn, their local partners—to both develop and implement comprehensive cancer control plans. As part of CDC’s National Comprehensive Cancer Control

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Fulfilling the Potential of Cancer Prevention and Early Detection BOX 9.4 State-Level Variations in Cancer Risk Factors Tobacco smoking. The rates of smoking among adults in the 10 states with the lowest smoking rates and the 10 states with the highest smoking rates were 19 and 28 percent, respectively, in 1999. Closing this gap, alone, could reduce lung cancer rates by a third in the 10 states with the highest smoking rates. Breast cancer screening. The rate of adherence to current recommendations for screening mammography by women age 50 and older was 84 percent in the 10 states with the highest screening rates in 1999, but the rate was only 70 percent in the 10 states with the lowest rates. Closing this gap could reduce breast cancer mortality rates by 5 percent in the 10 states with the lowest rates. Colorectal cancer screening. The gap between the 10 states with the highest colorectal cancer screening rates and the 10 states with the lowest screening rates is wide (39 versus 30 percent), but much more important is the observation that screening rates are low in all states. Screening for colorectal cancer has a very high potential for saving lives, as it has proven effectiveness, yet it is being applied to only a small proportion of the population. SOURCE: Byers, University of Colorado School of Medicine, unpublished analyses of data from CDC’s Behavioral Risk Factor Surveillance System. Program, such plans have been defined as those with an integrated and coordinated approach to reducing the incidence and the rates of morbidity and mortality from cancer through prevention, early detection, treatment, rehabilitation, and palliation (CDC, 2001a; www.cdc.gov/cancer/ncccp/index.htm). CDC has identified a useful framework for the establishment of a state cancer control program and has provided various models for comprehensive planning and evaluation. Essential elements of a comprehensive plan include (Abed et al., 2000a,b) the following: strategies and mechanisms for developing and maintaining partnerships, assessments and surveillance, infrastructure development, public education, professional education, policy and legislative activities, and evaluation and monitoring. Phases of implementation of a comprehensive state plan include setting optimal objectives that are data-driven, determining optimal strategies that are science-driven, establishing feasible priorities given the capacity, and implementing effective strategies that are assessed by evaluations of outcomes (Abed et al., 2000b).

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Fulfilling the Potential of Cancer Prevention and Early Detection Many states have in place some of the essential elements of a comprehensive program. Nearly half of the states, for example, have cancer registries that achieve the standards of completeness, timeliness, and coverage to provide accurate cancer incidence data for planning and evaluation. State data on the prevalence of cancer-related risk factors such as smoking are available through the Behavioral Risk Factor Surveillance System (CDC, Division of Adult and Community Health, http://www.cdc.gov/nccdphp/brfss/) and the Youth Risk Behavior Surveillance System (CDC, Division of Adolescent and School Health, 1999, http://www.cdc.gov/nccdphp/dash/yrbs/index.htm). In the area of early detection, all states have in place CDC-funded breast and cervical cancer screening programs targeted to low-income and underserved women (CDC, The National Breast and Cervical Cancer Early Detection Program, http://www.cdc.gov/cancer/nbccedp/about.htm). NCI has also promoted the development of state cancer control capacity through its Surveillance, Epidemiology, and End Results Program and through special grants (see the discussion of research initiatives in Chapter 10). According to a recent CDC assessment, however, only 13 states have comprehensive state plans that are being implemented (or that are ready to be implemented), 14 states and the District of Columbia are creating a new plan (or are updating an old plan), and 23 states have no plan or one that is outdated (Figure 9.1). FIGURE 9.1 Comprehensive cancer control plans, 2001.

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Fulfilling the Potential of Cancer Prevention and Early Detection Although considerable variations in state capacities have been observed and certain barriers to implementation have been identified, it is unclear what levels and types of investments are needed to build state and local capacities and how these needs may vary across the nation. CDC’s Division of Cancer Prevention and Control spends an estimated $250 million on cancer control and prevention annually, but much of the money is categorically targeted to specific activities (e.g., cancer registries), populations, or cancer sites (see Chapter 10). Since 1998, 19 states and 1 tribal organization have received grant support totalling approximately $37 million from CDC to develop and implement a comprehensive cancer control (CCC) plan. In addition, states and tribal organizations have been provided technical assistance regarding CCC plans with $1 million from the CDC (Leslie Given, Division of Cancer Prevention and Control, CDC, personal communication to Maria Hewitt, IOM, September 9, 2002). The CDC-funded states are developing programs that are varied, depending on the needs and organizational preferences of each state. The key to each program is, however, the same: fostering collaborative efforts among many sectors within the states to increase individual and organizational awareness of the state’s cancer burden and achieve objectives that will lead to future reductions in that burden (Byers, University of Colorado School of Medicine, unpublished). Resources appear to be inadequate to meet the need for CCC plan development and implementation. In 2002, for example, CDC had resources to support only half of the requests for assistance from states, territories, and Indian tribes in response to its National Cancer Prevention and Control Program Announcement (Leslie Given, Division of Cancer Prevention and Control, CDC, personal communication to Maria Hewitt, IOM, August 26, 2002). The CDC estimates that $30 million per year would be needed before states would have plans developed and implementation in progress by 2005 (Leslie Given, Division of Cancer Prevention and Control, CDC, personal communication to Maria Hewitt, IOM, August 26, 2002). CDC also provides guidance to states regarding comprehensive approaches to risk reduction. The CDC’s Office on Smoking and Health, for example has described essential elements of a comprehensive tobacco control program (CDC, 1999d). The extent to which states have such comprehensive programs is discussed in Chapter 11. Guidelines for comprehensive state programs to promote healthy eating and physical activity are forthcoming. The National Governors Association has launched a website, State Best Practices in Cancer Prevention and Control, to help states communicate their successes and learn from the experience of other states (National Governors Association, http://www.nga.org/center/divisions/1,1188,C_ISSUE_BRIEF^D_1913,00.html). The website also provides basic cancer statistics by state, and summaries of relevant state legislation.

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Fulfilling the Potential of Cancer Prevention and Early Detection PROVIDING AND PAYING FOR SERVICES This section reviews the role of the following selected federal programs in the provision of (or reimbursement for) prevention services: Direct Providers of Services Health Resources and Services Administration programs (Community and Migrant Health Centers) Veterans Health Administration Indian Health Service Centers for Disease Control and Prevention (National Breast and Cervical Cancer Early Detection Program) Office of Family Planning, US DHHS Indirect Providers of Services (Payers) Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) Medicaid Office of Management and Budget (which oversees federal employee health benefits) Direct Providers of Services Health Resources and Services Administration Sometimes called the “access” agency, the Health Resources and Services Administration (HRSA) oversees a number of direct service and training programs that provide primary care and other services to vulnerable and underserved populations. HRSA’s Bureau of Primary Health Care (BPHC) programs serve more than 12 million people in roughly 4,000 primary care sites including Community and Migrant Health Centers, Black Lung Clinics, and clinics along the United States-Mexico border. BPHC programs further bolster the public health infrastructure through training and educational programs, placement of clinicians in areas with shortages of health care professionals, and support of primary care offices in state health departments and independent primary care associations that attempt to build statewide coalitions for primary care health delivery systems. In 1999, BPHC launched the “100% Access and 0 Health Disparities Campaign” to support community leaders in setting and achieving access and disparity goals (Health Resources and Services Administration, 2000a). Community and Migrant Health Centers HRSA’s largest direct service program is the Community Health Center (CHC) and Migrant Health Center (MHC) Program. In 1998 the program had approximately 700 health centers

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Fulfilling the Potential of Cancer Prevention and Early Detection include Medicare, Medicaid, the State Children’s Health Insurance Program, and the End-Stage Renal Disease Program. This section focuses on prevention services provided as part of Medicare and Medicaid. Medicare Medicare enrollment in 2001 was estimated to be 40.3 million individuals, most (86 percent) of whom are age 65 and older. Most Medicare beneficiaries (94 percent) have both hospital insurance and supplemental insurance coverage and report relatively high levels of access to routine care. Having had a routine checkup in the past year, for example, was reported by from 74 to 92 percent of Medicare beneficiaries, according to surveys conducted in all 50 states and the District of Columbia (Health Care Financing Administration, 2000a). Most Medicare beneficiaries obtain care in the traditional fee-for-service system. As of 1999 only 18 percent of Medicare beneficiaries were enrolled in managed care plans. Total outlays for Medicare benefit payments were $210.1 billion in 1998, representing an estimated 13 percent of the total federal budget (Health Care Financing Administration, 2000b). CMS has several mechanisms in place to ensure the quality of care for the beneficiaries it serves. In 1992, CMS initiated the Health Care Quality Improvement Program to address shortcomings in the health care received by its beneficiaries. Although the quality improvement program was initially focused on acute myocardial infarction, CMS has expanded its quality improvement efforts to include five other clinical priority areas (breast cancer, diabetes, heart failure, pneumonia, and stroke) and reductions in disparities in health care (www.cms.hhs.gov/qio/1a1.asp). Much of CMS’s quality improvement work is carried out by its national network of 53 Quality Improvement Organizations (formerly called peer review organizations or PROs) (http://www.cms.hhs.gov/qio/default.asp). A number of national performance goals, including increased rates of receipt of a screening mammography, have been set to hold CMS accountable for improvements in care pursuant to the Government Performance and Results Act of 1993 (PL 103-62). Medicare managed care organizations are required to adopt the quality, access, and utilization performance measures of the National Committee for Quality Assurance’s Health Plan Employer Data and Information Set (http://www.ncqa.org/Programs/HEDIS/), and CMS is in the process of developing performance measures in its fee-for-service program that serves the majority of beneficiaries. Preliminary results of research in this area suggest that measures of screening for breast cancer by mammography could be applied at the national, small geographic, and large group practice levels (www.hcfa.gov/quality/docs/ffs2-es.htm). The Balanced Budget Act of 1997 (PL 105-33) required CMS to provide comparable information regarding performance in both fee-for-service and managed care settings.

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Fulfilling the Potential of Cancer Prevention and Early Detection Medicare Screening Benefits Until recently, preventive services were explicitly excluded from Medicare coverage. As it was originally conceived, the Medicare program was to limit its coverage to hospital, physician, and certain other services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” (section 1862 of the Social Security Act). Since the program’s inception in 1965, the U.S. Congress has expanded coverage to screening for breast, cervical, colorectal, and prostate cancer (Table 9.6). The coverage is not entirely consistent with recommendations of the U.S. Department of Health and Human Service’s USPSTF. For example, prostate cancer screening by digital rectal examinations or by detection of tumor markers in serum (e.g., prostate-specific antigen) is a Medicare benefit, but screening is not recommended by USPSTF (U.S. Preventive Services Task Force, 1996). Some of the out-of-pocket costs associated with cancer screening are defrayed by some sort of supplemental coverage through the Medicaid program, private insurance, or an employer-sponsored benefit program. Medicare beneficiaries who receive their care through managed care plans may obtain additional benefits that include prevention services (Centers for Medicare and Medicaid Services, 2002). Estimates of mammography use among female Medicare beneficiaries are shown in Table 9.7 The Mammography Campaign was launched by CMS in 1995 to improve female beneficiaries’ knowledge of breast cancer screening and awareness of Medicare’s annual screening mammography benefit (before 1998, the benefit covered mammography every 2 years). Educational materials for distribution to beneficiaries have been developed in partnership with NCI’s Office of Communications. Both beneficiaries and providers have been targeted for outreach by CMS’s peer review organizations. The overall rate of use of colorectal cancer screening and diagnostic services among Medicare beneficiaries is generally low, even though more than 70 percent of new cases of colorectal cancer occur among those age 65 and older (Ries et al., 2000b). The rate of use has not changed significantly since 1995, despite the issuance of a clinical practice guideline in 1997 and the expanded Medicare benefit that became effective in 1998. In 1999, only 14.1 percent of beneficiaries age 50 and older used one or more of the covered services for screening or diagnosis of colorectal cancer. The overall rate of use in 1999 was roughly equivalent to the rate in 1995, when 13.6 percent of beneficiaries used any of these services (U.S. General Accounting Office, 2000). In 1999, the rates of use of colorectal cancer screening tests among beneficiaries age 50 and older were 9.1 percent for the fecal occult blood test, 1.9 percent for sigmoidoscopy, 1.9 percent for flexible sigmoidoscopy, and 3.8 percent for colonoscopy. These low levels of screening occur even though nearly all older Americans report having a regular source of health care and a large majority report receiving routine checkups. In

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Fulfilling the Potential of Cancer Prevention and Early Detection TABLE 9.6 Coverage for Cancer Screening Tests Under Original Medicare Plan, Centers for Medicare and Medicaid Services   Extent of Coverage Cancer Test Individuals Covered Test Frequency Coinsurance (percent) Deductiblea Breast Mammogramb Women age 40 and older Annual 20 None Women ages 35 to 39 One-time baseline exam 20 None   Clinical breast exam All women Every 2 years 20 None Cervical Pap test All women Every 2 years, annual for high-risk women None for lab, 20 for collection None   Pelvic exam All women Every 2 years, annual for high-risk women 20 None Prostate Digital rectal exam Men age 50 and older Annual 20 Yes   Prostate-specific antigen (PSA) Men age 50 and older Annual None None Colorectal Colonoscopy Individuals age 50 and older; at high risk, no minimum age Every 10 years, but not within 4 years of a screening flexible sigmoidoscopy. Every 2 years for high-risk individuals 20c Yes   Fecal occult blood test Individuals age 50 and older Annual None None   Flexible sigmoidos-copy Individuals age 50 and older Every 4 years 20c Yes   Barium enema Alternative to sigmoidoscopy or colonoscopy   20 Yes aThe Part B deductible is $100 per year. bMedicare also covers new digital technologies for mammogram screening. cBeneficiary pays 25% of the Medicare-approved amount if sigmoidoscopy or colonoscopy is performed in an ambulatory surgical center or hospital outpatient department. SOURCE: Centers for Medicare and Medicaid Services (2002).

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Fulfilling the Potential of Cancer Prevention and Early Detection TABLE 9.7 Mammography Use Within Past 2 Years   Survey-Based Estimates 1997 (Women Age 65 and Older)% (95% confidence interval) Claims-Based Estimate 1997–1999 (Women Ages 52 to 69)% Rate in median state 70 56 Rate range 57–83 47–66 Alabama 76 (70–81) 55 Alaska 72 (57–87) 52 Arizona 76 (69–83) 57 Arkansas 57 (51–64) 50 California 78 (74–83) 54 Colorado 72 (65–79) 55 Connecticut 75 (69–81) 60 Delaware 74 (69–80) 59 District of Columbia 82 (75–89) 52 Florida 80 (76–83) 62 Georgia 72 (65–79) 52 Hawaii 79 (73–85) 52 Idaho 63 (58–67) 53 Illinois 67 (61–73) 54 Indiana 58 (51–65) 54 Iowa 61 (57–66) 60 Kansas 68 (62–74) 58 Kentucky 66 (62–70) 53 Louisiana 70 (63–78) 50 Maine 76 (70–83) 66 Maryland 76 (70–81) 58 Massachusetts 75 (68–82) 63 Michigan 77 (72–82) 64 Minnesota 68 (64–72) 61 Mississippi 62 (56–69) 47 Missouri 68 (61–74) 54 Montana 71 (65–77) 59 Nebraska 60 (55–66) 56 Nevada 64 (50–77) 50 New Hampshire 75 (67–82) 63 New Jersey 69 (63–75) 50 New Mexico 67 (60–74) 51 New York 75 (70–80) 56 North Carolina 72 (67–76) 57 North Dakota 71 (65–77) 64 Ohio 69 (64–75) 56 Oklahoma 59 (52–65) 49 Oregon 77 (73–82) 59 Pennsylvania 70 (65–75) 56 Rhode Island 83 (78–88) 58 South Carolina 76 (71–81) 55 South Dakota 70 (64–75) 57 Tennessee 69 (64–74) 53 Texas 65 (58–72) 51

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Fulfilling the Potential of Cancer Prevention and Early Detection   Survey-Based Estimates 1997 (Women Age 65 and Older)% (95% confidence interval) Claims-Based Estimate 1997–1999 (Women Ages 52 to 69)% Utah 70 (63–77) 55 Vermont 70 (65–76) 63 Virginia 68 (62–75) 55 Washington 69 (64–74) 59 West Virginia 66 (61–71) 55 Wisconsin 69 (63–75) 60 Wyoming 70 (64–76) 55   SOURCES: Jencks et al. (2000) and Health Care Financing Administration, state-specific estimates (2000a). general, higher rates of colorectal screening test use were seen among women than among men, higher rates were seen among whites than among members of racial or ethnic minority groups, and higher rates were seen among beneficiaries ages 70 to 79 than among younger and older beneficiaries (Table 9.8). Uncertainty remains regarding the benefits of screening for breast cancer at older ages. Resolving these uncertainties is of paramount importance to the Medicare program because nearly half (47 percent) of beneficiaries are age 75 and older. Smoking Cessation Benefits Within the Medicare Program The rate of current smoking among Medicare beneficiaries age 65 and older varies markedly by state, with the range being from 3.7 percent in Utah to 20.6 in Nevada. Estimates of the share of smokers who have attempted to quit smoking range from 16.7 percent in Arizona to 59.3 percent in Alabama (Health Care Financing Administration, 2000a). According to one estimate, a person who smokes more than 20 cigarettes a day and who quits at age 65 can expect to increase his or her life expectancy by 2 to 3 years (Sachs, 1986). Even though evidence supports the health and quality-of-life benefits of smoking cessation at older ages, Medicare does not provide coverage for smoking cessation programs or products. As part of CMS’s Healthy Aging Initiative, a literature review of the evidence of the effectiveness of interventions to promote smoking cessation in the Medicare population has been completed (DHHS, HCFA, undated). In addition, a demonstration program testing the effects of various benefit enhancements on smoking cessation is in progress. The three benefit options being compared with usual care (smoking cessation information) in the seven-state Medicare Stop Smoking Program are (www.hcfa.gov/healthyaging/1b.htm):

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Fulfilling the Potential of Cancer Prevention and Early Detection TABLE 9.8 Medicare Beneficiaries’ Rates of Use (Percent) of Tests for Colorectal Cancer Screening and Diagnostic Services, 1995–1999a Characteristic 1995 1996 1997 1998 1999 Total 13.6 13.2 12.6 13.1 14.1 Sex   Male 12.8 12.4 11.9 12.1 13.2 Female 14.2 13.8 13.2 13.8 14.8 Race or ethnicity   White 14.2 13.8 13.3 13.9 14.9 Black 9.0 8.9 8.5 8.4 9.1 Asian 11.8 11.2 8.9 11.2 12.6 Hispanic 8.0 8.2 5.9 7.7 8.1 Other and unknown 10.5 10.5 11.9 9.0 10.6 Age   Younger than 65 4.6 4.6 4.5 4.5 4.9 65–69 15.0 14.6 13.7 14.7 15.6 70–74 16.6 16.2 15.6 16.3 17.6 75–79 16.8 16.4 15.7 16.4 17.9 80–84 15.2 14.8 14.4 14.8 15.9 85 and older 10.9 10.5 10.3 10.0 11.0 aRates represent the percentage of Medicare beneficiaries who had a fecal occult blood test, flexible sigmoidoscopy, colonoscopy, or barium enema for screening, diagnostic, and, in the case of colonoscopy, treatment purposes. Rates are based on analyses of Medicare claims. SOURCE: McMullan M, HCFA Center for Beneficiary Services, Testimony before the Special Committee on Aging, U.S. Senate (March 6, 2000). reimbursement for provider counseling only, reimbursement for provider counseling and Food and Drug Administration-approved prescription or nicotine replacement pharmacotherapy, and a telephone counseling quit line and reimbursement for nicotine replacement therapy. The program commenced in the summer of 2001 and is expected to be completed in 2003. Medicaid Medicaid is a joint federal and state program that provides essential medical and medically related services to the nation’s most vulnerable populations (HCFA, 2000d). Three types of health protection are available through Medicaid: health insurance for low-income families with children and people with disabilities; long-term care for older Americans and individuals with disabilities; and

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Fulfilling the Potential of Cancer Prevention and Early Detection supplemental coverage for low-income Medicare beneficiaries for services not covered by Medicare and Medicare premiums, deductibles, and cost sharing.3 Each state establishes its own eligibility standards, benefits package, payment rates, and program administration under broad federal guidelines. Many variations exist among state Medicaid programs regarding not only which services are covered but also the amount, duration, and scope of services. Each state Medicaid program must cover “mandatory services” identified by statute and have the discretion to cover additional “optional services.” Early and Periodic Screening, Diagnosis, and Treatment services are mandatory for individuals under age 21, whereas screening and prevention services are optional for older enrollees (Health Care Financing Administration, 2000d). The population enrolled in the Medicaid program is dynamic, with individuals entering and leaving the program at fairly high rates, but at any point in time an estimated 12 percent of the U.S. population is enrolled, with most of these individuals consisting of low-income women and children. In 1998, Medicaid enrollment was 41.4 million, with children under age 21 making up 54 percent of Medicaid enrollment (HCFA, 2000d). In 1998 it was estimated that one in five U.S. children was served by the Medicaid program.4 Total outlays for Medicaid medical assistance payments were $96.4 billion in 1998. Throughout the 1990s states significantly expanded the enrollments in Medicaid managed care programs.5 By 1998, more than half (54 percent) of the Medicaid population was enrolled in some type of managed care plan. Medicaid managed care penetration varies greatly by state: 2 states (Alaska, Wyoming) have no beneficiaries enrolled in managed care plans, whereas 12 states (Arizona, Colorado, Delaware, Georgia, Hawaii, Iowa, Montana, New Mexico, Oregon, Tennessee, Utah, and Washington) have more than 75 percent of their beneficiaries enrolled in such plans. As of 1998, 35 states and the District of Columbia operated Freedom of Choice 3   In 1998 about 6 million persons were enrolled in both Medicare and Medicaid. 4   In 1997, the U.S. Congress created the State Children’s Health Insurance Program (SCHIP) to address the growing number of uninsured children. By 1999 nearly 2 million children were enrolled in one of the 53 SCHIP plans (3 plans were not yet in operation). Most states use a Medicaid expansion as part of the SCHIP plans, either solely or in combination with a separate program. 5   Medicaid managed care contractors include comprehensive health maintenance organization (HMO) plans, Medicaid-only HMO plans, prepaid health plans (i.e., an entity that provides a noncomprehensive set of services on either a capitated risk basis or a nonrisk basis or an entity that provides comprehensive services on a nonrisk basis), and primary care case management plans (i.e., a program in which the state contracts directly with primary care providers who agree to be responsible for the provision or coordination of medical services to Medicaid beneficiaries under their care).

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Fulfilling the Potential of Cancer Prevention and Early Detection waivers [84 Section 1915(b)] to mandatorily enroll beneficiaries in managed care programs, provide additional services via the savings produced from managed care, or create a “carve-out” system for the delivery of specialty care (e.g., behavioral health).6 Smoking rates tend to be higher among the Medicaid population, and 5 million or more adult smokers were estimated to be covered by the program in 1999 (Schauffler et al., 2001a). Only half of the states, however, cover even one smoking cessation treatment for their Medicaid recipients, according to a review of Medicaid coverage for treatments for tobacco dependence in 1998 (Schauffler et al., 2001a). State Medicaid programs were most likely to cover pharmacotherapy for tobacco dependence, including bupropion, the nicotine patch, nicotine gum, and a nicotine nasal spray (Table 9.9). Six states (Delaware, Maine, Maryland, Minnesota, New Mexico, and Oregon) offered comprehensive Medicaid benefits for the treatment of tobacco dependence (all forms of nicotine replacement therapy, bupropion, and both group and individual counseling). Even in states whose Medicaid programs did provide coverage for treatments for tobacco dependence, the programs made little effort to inform smokers of the availability of these benefits or how to access and use them. Only four state Medicaid programs (those in Arizona, Maine, Rhode Island, and Wyoming) reported offering any special programs designed to assist women who are pregnant or breast-feeding to quit smoking, despite the strong evidence that the cessation of smoking during pregnancy reduces the incidence of low birth weight. Cancer screening rates among Medicaid beneficiaries appear to be similar to those among privately insured individuals, according to recent studies (Potosky et al., 1998; Hewitt et al., 2002). Office of Management and Budget In 1997, a presidential executive order established smoke-free environments for the more than 1.8 million civilian federal employees and members of the public visiting or using federal facilities. In 2001, federal departments and agencies were directed to establish a policy that provides up to 4 hours of excused absence each year, without a loss of pay or a charge to leave, for participation in preventive health screenings. Agencies were also directed to develop or expand programs offered at the worksite to help employees understand their risks for disease, obtain preventive health services, and make healthy lifestyle choices. The Office of Personnel Management has issued guidance for a model smoking cessation program and is 6   In addition, 17 states operated statewide comprehensive research and demonstration projects to test substantially new ideas with potential policy merit.

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Fulfilling the Potential of Cancer Prevention and Early Detection TABLE 9.9 Medicaid Program Coverage of Pharmacotherapy and Counseling—United States,a 2000   Over-the-counter medication Prescription Medication State Any treatment Gum Patch Any Spray Inhaler Arizona •b • •   Arkansas •   •   Californiac • • • • • • Coloradoc • • • • • • Delawarec • • • • • • District of Columbia •   • •   Florida • • • •   Hawaii •   • • • Illinoisc • • • • • • Indianac • • • • • • Kansas •   • •   Louisiana •   • • • Mainec • • • • • • Maryland •   • • • Massachusetts •   Michigan • • • •   Minnesotac • • • • • • Montana • • • •   Nevadac • • • • • • New Hampshirec • • • • • • New Jerseyc • • • • • • New Mexicoc • • • • • • New Yorkc • • • • • • North Carolina •   • • • North Dakota • • • •   Ohio • • • •   • Oklahoma •   •   Oregond • • • • • • Rhode Island •   Texasc • • • • • • Vermont • • • • • • Virginia •   • • • West Virginiac • • • • • • Wisconsin •   • • • No. states in 2000 34 22 23 31 23 23 % states in 2000 67 43 45 61 45 45 aCovered treatment. bStates offering no coverage were Alabama, Alaska, Connecticut, Georgia, Idaho, Iowa, Kentucky, Mississippi, Missouri, Nebraska, Pennsylvania, South Carolina, South Dakota, Tennessee, Utah, Washington, and Wyoming. cOffered all pharmacotherapy recommended in Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence. dOffered all treatments. eCovers pregnant women only. SOURCE: Adapted from CDC, 2001e.

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Fulfilling the Potential of Cancer Prevention and Early Detection Prescription Medication Counseling Zyban Wellbutrin Bupropion Any Group Individual Telephone   • • •   • •   • • •   • • •   • • •   • • •   •   • • •   • • •   • • • •   •   • • • • • •   • • •   • • • • • •   • • • •e •e •e     • • •   • •   • • • • • •   •   • • •   • • • • • •   • • •   • • • •e •e •e •e • • •   • • •   • • •   • • •   • • •   • • • • • • •   • • •   • • •   • • •   • • •   • • • •   • • • • • •   •   31 29 27 13 10 13 3 61 57 53 26 20 26 6

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Fulfilling the Potential of Cancer Prevention and Early Detection compiling a list of best practices to be shared with agencies. Agencies can pay the costs incurred by employees participating in agency-authorized smoking cessation programs, including payment for nicotine replacement therapy when it is purchased as part of an agency’s smoking cessation program (www.opm.gov/ehs). SUMMARY AND CONCLUSIONS The federal government provides many opportunities to further cancer prevention and early detection by promulgating national goals and objectives, issuing clinical guidelines, disseminating information, carrying out monitoring and surveillance activities, facilitating statewide program planning and evaluation, and providing or paying for services. Explicit national cancer-related goals and objectives have been set as part of the Healthy People 2010 initiative (US DHHS and Office of Disease Prevention and Health Promotion, 2000), and efforts are under way to chart the nation’s progress toward those goals. Federally sponsored evidence-based guidelines for clinical and community practice provide clinicians and public health providers with the information they need to achieve these goals. NCI is the lead federal agency in the dissemination of cancer-related information to clinicians, consumers, and the public health community through a number of channels including its telephone Cancer Information Service, its websites, and PDQ, a comprehensive cancer information database. Tracking the successes of these and other efforts in reaching cancer prevention and early detection goals often relies on federally sponsored surveys and surveillance systems that assess the prevalence of risk behaviors, levels of access to services, and health behaviors among the general and selected members of the U.S. population. Federal safety net providers including Community and Migrant Health Centers and Title X family planning clinics are key to closing the gap in service use and, ultimately, in reducing the unequal burden of cancer observed among poor and disadvantaged populations. Although some federal programs are at the forefront of promoting effective cancer prevention and early detection interventions, there appears to be much room for improvement. In particular, policies are needed to improve coverage of evidence-based smoking cessation interventions within the Medicare and Medicaid programs. Such policies could greatly reduce the burden of cancer. In addition, the significant variations in the rates of use of screening services among beneficiaries served by the Medicare and VHA programs suggest that interventions are needed to improve rates of adherence to evidence-based guidelines.