and family practitioners, however, are specifically trained in these procedures during residency.) It could be argued that this is not an access problem or that structural deficiencies in the organization of care make it an access problem that reaches beyond the usual financial barriers.


Improved Survey Instruments. The committee believes that surveys about screening services, like the cancer control supplement of the NHIS, should include questions that explore in greater depth the reasons people do not obtain cancer screening services. Survey questions should focus on the effects of insurance coverage and cost issues.

More Frequent Reporting. In those years in which NHIS prevention or cancer supplements are not administered, the Behavioral Risk Factor Surveillance System (BRFSS) should be used to track trends in the data. To accomplish this, questions should be added to the BRFSS surveys to collect information about insurance status, income, and regular source of care.

Outcome Indicator: Incidence of Late-Stage Breast and Cervical Cancers

Late-stage cancers are those that have invaded contiguous tissues and organs or that have spread through the blood or lymphatic system to other parts of the body. Late-stage cancers present a more difficult clinical treatment challenge than those diagnosed at an earlier stage. Late-stage breast and cervical cancers are invariably fatal—therapy in these cases is palliative and not curative.

Discovery of late-stage cancers may indicate the underuse of an effective screening test. Alternatively, or in addition, late-stage cancer may also reflect inappropriate medical follow-up of a diagnosed disease or progression of the cancer in some cases despite appropriate therapy. A recent review article identifies the many steps at which the cervical cancer detection system may fail:

… starting with the initial clinical examination, continuing with the taking of the smear sample and laboratory errors in screening and interpretation, and ending with the clinician's failure to understand the report or take appropriate action and in some instances, with the patient's failure to follow the guidance of the physician. (Koss, 1989)

A large relative difference in late-stage cancer among different groups is an important clue to the existence of problems with access and, potentially, with subsequent treatment. In the case of breast cancer, the diagnosis of late-stage disease may indicate the failure of patients to undergo clinical

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